Equitable access to cancer care remains a persistent problem in the United States. The National Institutes of Health (NIH) defines differences in health outcomes as measured by incidence, prevalence, mortality, or disease burden variation between population subgroups as health disparities.1 Among the varied American racial and ethnic groups, African Americans and Hispanics tend to have overall higher mortality rates from cancers compared to their White (non-Hispanic) counterparts.2 More specifically, patients of Hispanic descent tend to have higher rates of stomach, liver, and cervical cancer, whereas African American patients have a 10% higher incidence rate of cancer, overall, compared to Whites.2
Moreover, according to the 2019 US cancer statistics, African American patients have a higher rate of cancer-related mortality compared to all other ethnic subgroups (166.3 deaths per 100,000 people).3 The closest similar results are experienced by Whites, who have a lower rate of 147.1 deaths per 100,000 people, while comprising a much larger proportion of the population.
This disparity between African Americans and Whites is most prominent in prostate cancer, with African Americans having a nearly 2- to 3-fold greater rate of cancer-related mortality than all other ethnic subgroups.3 One interesting observation, however, is that despite the drastic difference in prostate cancer mortality, Whites continue to have higher rates of bladder cancer and kidney cancer mortality compared with all minority ethnic groups.3 In terms of genitourinary cancer, the only exception to these trends is testis cancer, where Hispanic males have a higher rate of mortality compared with all other ethnic groups.3
Apart from race and ethnicity, patients in lower socioeconomic classes have been shown to experience higher rates of cancer mortality, overall, compared with the wider population.2 This finding has been attributed to lack of equitable access to medical care in both preventive and treatment settings.2 This inequity includes screening for cancer, treatment of eventual diagnoses, and continued follow-up and surveillance to monitor for outcomes. In male patients, 3 of the top 10 cancers related to cancer-related mortality in the overall population are genitourinary (prostate, bladder, and kidney).2 This highlights the extreme importance of further research into health disparities in urologic cancer care.
Similar to last month, in this article we highlight key recent publications in Urology (focused on diversity, equity, and inclusion, and specifically related to both kidney and bladder cancers. Herein, we highlight 2 important articles exploring disparities in kidney and bladder cancer care in the United States.
Kidney Cancer
According to the latest data from the Centers for Disease Control and Prevention (CDC), in 2019 >68,000 patients were diagnosed with kidney cancer and >14,000 experienced kidney cancer–related mortality.3 In 2022, the estimated rate of new diagnoses is expected to rise to nearly 79,000 patients, with a similar proportion experiencing cancer-related mortality. In the United States, kidney cancer is the eighth most diagnosed malignancy. Yet, overall, despite a 0.6% year-over-year increase in diagnoses, mortality rates have been declining at a rate of 1.6% annually, suggesting that earlier diagnosis may be crucial to preventing cancer-related mortality.4
Meagher et al explored cancer-specific and overall survival (OS) outcomes for African American patients diagnosed with renal cell carcinoma (RCC).5 Among several important findings, the authors noted an increasing uneven incidence of the disease, with African Americans receiving a greater percentage of RCC diagnoses compared with other ethnic groups. Despite this, they noted that African Americans often receive diagnoses of lower oncologic potential compared with people in other ethnic groups; however, when compared with age-and- stage-matched subgroups, they experience higher rates of cancer-related mortality.5,6
Utilizing the INMARC (International Marker Consortium for Renal Cancer) database, Meagher et al analyzed patients undergoing partial or radical nephrectomy from January 2000 to June 2019 with the goal to evaluate all-cause mortality, OS, and certain secondary markers, including cancer-specific mortality and recurrence-free survival. The database contained a total of 3893 patients, with nearly 14.5% identified as ethnic African Americans. Several key demographic findings were of interest. The authors explained that African American patients were younger at time of surgery and had higher body mass indices compared to those in other cohorts. This group also had higher rates of comorbidities, including diabetes mellitus and coronary artery disease.
Regarding surgical outcomes, African American patients received radical nephrectomy more frequently (68.4%) while also having lower rates of clear cell histology on final pathology compared with other ethnic groups. Another finding of interest was lower rates of recurrence in the African American cohort compared with the population overall; however, the authors also identified that for those African Americans who did experience recurrence, the time to mortality was shorter. In further analyses, they also identified a difference in 5-year cancer-specific survival for African American patients with stage 3 and stage 4 disease. They suggest that worse outcomes in these patients may be reflective of lack of access to advanced oncologic care. Overall, despite the retrospective design, the study provided much needed insight into care disparities in RCC among American ethnic groups.
Bladder Cancer
The 2019 US Cancer Statistics from the CDC reported >75,000 new diagnoses of bladder cancer resulting in nearly 16,800 bladder cancer-related deaths.3 With these numbers in mind, in 2022, an estimated ≥81,000 patients are expected to be newly diagnosed with bladder cancer, leading to >17,100 estimated deaths.4 Compared with kidney cancer, bladder cancer is an even more frequently diagnosed malignancy, ranked as sixth of the top 10 malignancies most commonly diagnosed.
In another key study, Knorr et al examined socioeconomic disadvantages following radical cystectomy. The authors explain that impact of medical risk factors, including comorbidities and their effect on radical cystectomy outcomes, has been well documented and studied. An area that remains underexplored is the effect of socioeconomics on patient outcomes after radical cystectomy. The authors employed the Area Deprivation Index (ADI), which is calculated using a variety of variables obtained from US Census data (eg, income, education, employment status), and sought to determine the relationship between ADI and patient outcomes.
Primary outcomes for the study included complications at 30 and 90 days, 90-day mortality, and OS. In their single-center study of prospectively collected data, the authors identified 906 patients who were eligible for inclusion in the analysis. Most patients had appreciable levels of follow-up care, with a median follow-up of 48 months for the entire cohort. The authors reported that after accounting for the ADI for all patients, higher ADI scores (indicative of higher inequality) were associated with Black race, smoking history, and other factors such as younger age. In terms of oncologic outcomes, higher ADI scores were associated with higher rates of muscle-invasive disease, node-positive disease, and presence of variant histology. In terms of complications, the authors identified that higher ADI scores were associated with higher rates of 30-day and 90-day mortality; however, complication rates were similar between all ADI quartiles.
By contrast, OS, another key indicator of patients with muscle-invasive bladder cancer undergoing radical cystectomy, was noted to decline substantially between ADI quartiles. For example, patients with the lowest ADI scores—indicative of lower levels of sociodemographic disparity—had the highest median OS, 8.25 years, compared with just 4.17 years in those in the quartile with higher levels of disparity. In summary, ADI was shown to be predictive of higher rates of worse cancer-specific outcomes as well as mortality.
The authors advocate for using ADI as a metric when conducting postdischarge counseling. These reports and more highlight how tumor biology is just one component of the multifaceted topic that is cancer care. Issues such as access to care and socioeconomics can significantly affect patient outcomes and should be investigated further.
References
- Dankwa-Mullan I, Rhee KB, Williams K, et al. The science of eliminating health disparities: summary and analysis of the NIH summit recommendations. Am J Public Health. 2010;100(suppl 1):S12-S18. doi: 10.2105/AJPH.2010.191619.
- Siminoff LA, Ross L. Access and equity to cancer care in the USA: a review and assessment. Postgrad Med J. 2005;81(961):674-679. doi: 10.1136/pgmj.2005.032813.
- Centers for Disease Control and Prevention. United States Cancer Statistics: Data Visualizations. Leading Cancers by Age, Sex, Race and Ethnicity; June 2022. Accessed August 16, 2022. https://gis.cdc.gov/Cancer/USCS/#/Demographics/.
- National Cancer Institute. Surveillance, Epidemiology, and End Results (SEER) Program. Cancer Stat Facts: Kidney and Renal Pelvis Cancer. Accessed August 16, 2022. https://seer.cancer.gov/statfacts/html/kidrp.html.
- Meagher MF, Patil D, Saito K, et al. Disparities in cancer specific and overall survival outcomes in African Americans with renal cell carcinoma: analysis from the International Marker Consortium for Renal Cancer (INMARC). Urology. 2022;163:164-176. doi: 10.1016/ j.urology.2021.12.022.
- Stafford HS, Saltzstein SL, Shimasaki S, Sanders C, Downs TM, Sadler GR. Racial/ethnic and gender disparities in renal cell carcinoma incidence and survival. J Urol. 2008;179(5):1704-1708. doi: 10.1016/j.juro.2008.01.027
