Socioeconomic Mediation of Racial Segregation in Pancreatic Cancer Treatment and Outcome Disparities.

OBJECTIVE: To understand the mediating effect of socioeconomic factors on the association between residential segregation and racial disparities in pancreatic cancer (PC). BACKGROUND: Black patients with PC present at a later stage and have worse mortality than White patients. These disparities have been explained by the level of residential segregation. METHODS: Data were obtained from Surveillance, Epidemiology, and End-Results (SEER) and included all Black and White patients who were diagnosed with PC between 2005 and 2015. The primary exposure variable was the Index of Dissimilarity, a validated measure of segregation. County-level socioeconomic variables from the US Census were assessed as mediators. The primary outcomes were advanced stage at diagnosis, surgical resection for localized disease, and overall mortality. Generalized structural equation modeling was used to assess the mediation of each of the socioeconomic variables. RESULTS: Black patients in the highest levels of segregation saw a 12% increased risk [relative risk=1.12; 95% confidence interval (CI): 1.08, 1.15] of presenting at an advanced stage, 11% decreased likelihood of undergoing surgery (relative risk=0.89; 95% CI: 0.83, 0.94), and 8% increased hazards of death (hazard ratio=1.08; 95% CI: 1.03, 1.14) compared with White patients in the lowest levels. The Black share of the population, insurance status, and income inequality mediated 58% of the total effect on the advanced stage. Poverty and Black income immobility mediated 51% of the total effect on surgical resection. Poverty and Black income immobility mediated 50% of the total effect on overall survival. CONCLUSIONS: These socioeconomic factors serve as intervention points for legislators to address the social determinants inherent to the structural racism that mediate poor outcomes for Black patients.

Treatment Inequity: Examining the Influence of Non-Hispanic Black Race and Ethnicity on Pancreatic Cancer Care and Survival in Wisconsin.

INTRODUCTION: We investigated race and ethnicity-based disparities in first course treatment and overall survival among Wisconsin pancreatic cancer patients. METHODS: We identified adults diagnosed with pancreatic adenocarcinoma in the Wisconsin Cancer Reporting System from 2004 through 2017. We assessed race and ethnicity-based disparities in first course of treatment via adjusted logistic regression and overall survival via 4 incremental Cox proportional hazards regression models. RESULTS: The study included 8,490 patients: 91.3% (n = 7,755) non-Hispanic White; 5.1% (n = 437) non-Hispanic Black, 1.8% (n = 151) Hispanic, 0.6% Native American (n = 53), and 0.6% Asian (n = 51) race and ethnicities. Non-Hispanic Black patients had lower odds of treatment than non-Hispanic White patients for full patient (OR, 0.52; 95% CI, 0.41-0.65) and Medicare cohorts (OR, 0.40; 95% CI, 0.29-0.55). Non-Hispanic Black patients had lower odds of receiving surgery than non-Hispanic White patients (full cohort OR, 0.67 [95% CI, 0.48-0.92]; Medicare cohort OR, 0.57 [95% CI, 0.34-0.93]). Non-Hispanic Black patients experienced worse survival than non-Hispanic White patients in the first 2 incremental Cox proportional hazard regression models (model II HR, 1.18; 95% CI, 1.06-1.31). After adding insurance and treatment course, non-Hispanic Black and non-Hispanic White patients experienced similar survival (HR, 0.98; 95% CI, 0.88-1.09). CONCLUSION: Non-Hispanic Black patients were almost 50% less likely to receive any treatment and 33% less likely to receive surgery than non-Hispanic White patients. After including treatment course, non-Hispanic Black and non-Hispanic White patient survival was similar. Increasing non-Hispanic Black patient treatment rates by addressing structural factors affecting treatment availability and employing culturally humble approaches to treatment discussions may mitigate these disparities.

It's more than just cancer biology: Health disparities in patients with pancreatic neuroendocrine tumors.

BACKGROUND AND OBJECTIVES: Pancreatic neuroendocrine tumors (PNETs) represent a rare form of pancreatic cancer. Racial/ethnic disparities have been documented in pancreatic ductal adenocarcinoma, but health disparities have not been well described in patients with PNETs. METHODS: A retrospective review of patients with PNETs in the National Cancer Database was performed for 2004-2014. Approximately 16 605 patients with PNETs and available vital status were identified. Survival was compared by race/ethnicity and socioeconomic status using Kaplan-Meier methods and Cox regression. RESULTS: There were no significant differences in survival between Non-Hispanic, White; Hispanic, White; or Non-Hispanic, Black patients on univariate analysis. Kaplan-Meier analysis showed that patients from communities with lower median household income and education level had worse survival (p < 0.001). Patients age less than 65 without insurance, similarly, had worse survival (p < 0.001). Multivariable modeling found no association between race/ethnicity and risk of mortality (p = 0.37). Lower median household income and lower education level were associated with increased mortality (p < 0.001). CONCLUSIONS: Unlike most other malignancies, race/ethnicity is not associated with survival differences in patients with PNETs. Patients with lower socioeconomic status had worse survival. The presence of identifiable health disparities in patients with PNETs represents a target for intervention and opportunity to improve survival in patients with this malignancy.

Racial Differences in Gastroenteropancreatic Neuroendocrine Tumor Treatment and Survival in the United States.

OBJECTIVES: The objective of this study was to evaluate racial differences in cancer treatment and survival in gastroenteropancreatic neuroendocrine tumor (GEP-NET) patients. METHODS: Using the Surveillance, Epidemiology, and End Results Registry, we identified patients with GEP-NETs of the stomach, small intestine (SI), colon, rectum, appendix, and pancreas diagnosed between 1973 and 2014. Demographic, cancer, and treatment information were collected and compared using χ2 tests. Multivariable logistic and Cox regression were used to determine disparities in receiving treatment and overall survival. RESULTS: We identified 19,031 GEP-NET patients: 2839 were non-Hispanic Blacks, 12,832 non-Hispanic Whites, 2098 Hispanics, and 1262 Asians. African Americans and Hispanics with SI and pancreatic NETs were less likely to be treated with surgery (odds ratio, 0.6; 95% confidence interval [CI], 0.46-0.69; odds ratio, 0.71; 95% CI, 0.51-0.99, respectively). African American race was not an independent predictor of survival; there was a strong trend in stomach, SI, and pancreas NETs (hazard ratio [HR], 1.31; 95% CI, 1-1.7; HR, 1.2; 95% CI, 0.99-1.45; HR, 1.22; 95% CI, 1-1.48, respectively). CONCLUSIONS: Our study provides evidence of racial disparities in treatment and survival across GEP-NET primary sites and racial groups. Further studies should be performed to improve our understanding of the reason for these disparities.

Racial and Socioeconomic Disparities in the Treatments and Outcomes of Pancreatic Cancer Among Different Treatment Facility Types.

OBJECTIVES: The aim of this study was to investigate racial and socioeconomic disparities for patients with pancreatic cancer across different facility types. METHODS: The National Cancer Database was queried for pancreatic cancer cases from 2004 to 2015. Along with propensity score matching analysis, multivariate logistic and Cox model were used to assess effects of facility type, race, elements of socioeconomics on receipt of treatment, time to treatment, and overall survival, separately. RESULTS: Among 223,465 patients, 44.6%, 42.1%, and 13.3% were treated at academic, community, and integrated facilities, respectively. Private insurance was associated with more treatment (odds ratio, 1.41; P < 0.001) and better survival [hazards ratio (HR), 0.84; P < 0.001]. Higher education was associated with earlier treatment (HR, 1.09; P < 0.001). African Americans had less treatment (odds ratio, 0.97; P = 0.04) and delayed treatment (HR, 0.89; P < 0.001) despite later stage at diagnosis. After adjusting for socioeconomic status, African Americans had similar survival (HR, 0.99; P = 0.11) overall and improved survival (HR, 0.95; P = 0.016) at integrated facilities. CONCLUSIONS: Higher socioeconomic status was associated with better treatment and survival. After adjusting for socioeconomic disparities, race did not affect survival. Less racial disparity was observed at integrated facilities.

Racial Disparities and Trends in Pancreatic Cancer Incidence and Mortality in the United States.

BACKGROUND & AIMS: Pancreatic cancer is one of the few cancers in the United States that is increasing in incidence. Little is known about racial disparities in incidence and mortality. We characterized racial disparities in pancreatic cancer incidence and mortality in different locations, time periods, age groups, and disease stages. METHODS: We obtained data on the incidence of pancreatic cancer from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results program of cancer registries from 2001 through 2015 on incidence, demographics, tumor characteristics, and population estimates for all 50 states and the District of Columbia. We obtained data on mortality from pancreatic cancer from the National Center for Health Statistics during the same time period. We plotted incidence rates by 10-year age group (30-39 years through 70-79 years and 80 years or older) separately for white and black patients. We calculated incidence and mortality rate ratios with 95% CIs for categories of age and race. To determine racial disparities, we calculated incidence rate ratios (IRR) for black vs white patients and mortality rate ratios by state. RESULTS: Disparities in pancreatic cancer incidence and mortality in black vs white patients decreased over 5-year time periods from 2001 through 2015. However, among all age groups, from 2001 through 2015, pancreatic cancer incidence and mortality were higher among blacks than whites (incidence, 24.7 vs 19.4 per 100,000; IRR, 1.28; 95% CI, 1.26-1.29; mortality, 23.3 vs 18.4 per 100,000; IRR, 1.27; 95% CI, 1.26-1.28). Black patients had a higher incidence of distant pancreatic cancer (IRR, 1.32; 95% CI, 1.31-1.34) and a lower incidence of local cancer. Incidence increased in whites and blacks of younger age groups and was most prominent among persons 30-39 years old. Incidence increased by 57% among younger whites (IRR, 1.70; 95% CI, 1.43-2.02) and by 44% among blacks (IRR, 1.47; 95% CI, 1.01-2.15) from 2001 through 2015. Mortality remained stable among blacks and slightly increased among whites during this time period. CONCLUSIONS: In the United States, there are racial disparities in pancreatic incidence and mortality that vary with location, patient age, and cancer stage. Further research is needed to identify factors associated with increasing incidence and persistence of racial disparities in pancreatic cancer.

Impact of Race, Insurance Status, and Primary Language on Presentation, Treatment, and Outcomes of Patients with Pancreatic Adenocarcinoma at a Safety-Net Hospital.

BACKGROUND: Social determinants of health impact the delivery of care and outcomes in patients with pancreatic cancer. We explored the relationship between social determinants of health and presentation, treatment, and outcomes of patients with pancreatic adenocarcinoma at an urban safety-net medical center. DESIGN: A single-institution retrospective chart review of patients with pancreatic adenocarcinoma was conducted. Demographic, tumor, and treatment characteristics were obtained. Median overall survival, stage-specific survival, receipt of curative operation, and receipt of perioperative therapy were analyzed. Chi-square tests were used for categorical variables. Survival was determined by the Kaplan-Meier method. RESULTS: We identified 240 patients with pancreatic adenocarcinoma treated between January 2006 and December 2017. Median age was 66 years, 51% were female, 48% were non-white, 22% were non-English-speaking, 16% were Hispanic, and 40% were Medicaid/uninsured. There were 74 (31%) patients with early-stage (I/II) disease. There were no statistically significant differences between race, primary language, or ethnicity and receipt of surgical therapy or receipt of perioperative therapy. Relatively more patients with private insurance (100%) received perioperative therapy compared with Medicaid/uninsured (64%) and Medicare-insured (50%) patients (p = 0.018). Nearly 30% of patients with operable disease either declined having an intervention or were found to be too frail to undergo surgical intervention. CONCLUSIONS: There were no statistically significant relationships between examined social determinants of health and use of operation or perioperative therapy. Patients treated at an urban safety-net hospital with a focus on vulnerable patient populations are able to provide outcomes similar to national averages. Additional exploration of factors affecting outcomes for pancreatic cancer in these patients will be important, as many centers absorb higher immigrant and indigent populations.

Disparities in Care: Impact of Socioeconomic Factors on Pancreatic Surgery: Exploring the National Cancer Database.

Studies have shown high-volume institutions have decreased mortality and increased survival for pancreatectomy. However, not all patients can travel to high-volume centers. Socioeconomic factors may influence treatment decisions. The goal of this study is to examine socioeconomic factors that determine where a patient is treated and how that location affects outcome. This is a retrospective study of the National Cancer Database of patients diagnosed with pancreatic cancer from 2004 to 2014. The primary outcome was to examine socioeconomic factors that predicted where a patient underwent their pancreatectomy. Patients treated at academic programs (APs) had to travel a mean distance of 80.9 miles, whereas patients treated at community programs (CPs) had to travel 31.7 miles (P < 0.0001). Spanish and Hispanic patients were less likely to travel to an AP (69% had surgery at an AP versus 76% of non-Hispanic patients, P < 0.001). Patients with higher comorbidities were also more likely to have care at CPs. Patients who had pancreatic cancer surgery at CPs were more likely to be Hispanic or with higher medical comorbidities. Those who had surgery at AP traveled further distances but had better perioperative outcomes and had an improvement in overall survival.

Closing the Disparity in Pancreatic Cancer Outcomes: A Closer Look at Nonmodifiable Factors and Their Potential Use in Treatment.

OBJECTIVES: African Americans (AAs) have disproportionately higher incidence and lower survival rates from pancreatic cancer compared with whites. Historically, this disparity has been attributed to modifiable risk factors. Recent studies suggest that nonmodifiable aspects may also play an important role. We review these new contributions as potential targets for closing the disparity. METHODS: A PubMed search was conducted to review studies of nonmodifiable elements contributing to pancreatic cancer disparities in AAs. RESULTS: Several nonmodifiable risks are associated with the racial disparity in pancreatic cancer. SSTR5 P335L, Kaiso, and KDM4/JMJD2A demonstrate differential racial expression, increasing their potential as therapeutic targets. Many social determinants of health and their associations with diabetes, obesity, and the microbiome are partially modifiable risk factors that significantly contribute to outcomes in minorities. Barriers to progress include the low minority inclusion in research studies. CONCLUSIONS: Genomics, epigenetics, the microbiome, and social determinants of health are components that contribute to the pancreatic cancer disparity in AAs. These factors can be researched, targeted, and modified to improve mortality rates. Closing the disparity in pancreatic cancer will require an integrated approach of personalized medicine, increased minority recruitment to studies, and advanced health care/education access.

African-Americans and Indigenous Peoples Have Increased Burden of Diseases of the Exocrine Pancreas: A Systematic Review and Meta-Analysis.

Ethnic health disparity is a well-acknowledged issue in many disease settings, but not diseases of the exocrine pancreas. A systematic review and meta-analysis was conducted to explore the race- and ethnicity-specific burden of diseases of the exocrine pancreas. Studies that compared health-related endpoints between two or more ethnicities were eligible for inclusion. Proportion meta-analyses were conducted to compare burden between groups. A total of 42 studies (24 on pancreatic cancer, 17 on pancreatitis, and one on pancreatic cyst) were included in the systematic review, of which 19 studies were suitable for meta-analyses. The incidence of pancreatic cancer was 1.4-fold higher among African-Americans, while the incidence of acute pancreatitis was 4.8-fold higher among an indigenous population (New Zealand Maori) compared with Caucasians. The prevalence of post-pancreatitis diabetes mellitus was up to 3.0-fold higher among certain ethnicities, including Asians, Pacific Islanders, and indigenous populations compared with Caucasians. The burden of diseases of the exocrine pancreas differs between ethnicities, with African-Americans and certain indigenous populations being at the greatest risk of developing these diseases. Development of race- and ethnicity-specific screening as well as protocols for lifestyle modifications may need to be considered with a view to reducing the disparities in burden of diseases of the exocrine pancreas.

Determinants and prognostic value of quality of life in patients with pancreatic ductal adenocarcinoma.

BACKGROUND: Quality of life (QOL) is impaired in pancreatic cancer patients. Our aim was to investigate the determinants and prognostic value of QOL after diagnosis in a hospital-based cohort of racially/ethnically diverse patients with pancreatic ductal adenocarcinoma (PDAC). PATIENTS AND METHODS: QOL was prospectively assessed using the Short Form-12 in 2478 PDAC patients. The Physical Component Summary (PCS) and Mental Component Summary (MCS) were categorised into tertiles based on their distribution. Ordered logistic regression was adopted to compare the risk of having lower PCS and MCS by patient sociodemographic and clinical characteristics. The association of PCS and MCS with mortality was assessed by Cox regression. RESULTS: Compared with non-Hispanic whites, Hispanics were at significantly higher risk of having lower PCS (odds ratio [95% CI], 1.69 [1.26-2.26]; P < 0.001) and lower MCS (1.66 [1.24-2.23]; P < 0.001). Patients diagnosed with stage III (1.80 [1.10-2.94]; P = 0.02) and stage IV (2.32 [1.50-3.59]; P < 0.001) PDAC were more likely to have lower PCS than stage I patients. Other determinants of QOL included sex, age, drinking, smoking, education level, comorbidities and time since diagnosis. The low tertile of PCS (hazard ratio [95% CI], 1.94 [1.72-2.18]; P < 0.001) and MCS (1.42 [1.26-1.59]; P < 0.001) were each related to poor prognosis. Similar results were found for non-Hispanic whites as compared with African-Americans/Hispanics/others. CONCLUSION: QOL after diagnosis is a significant prognostic indicator for patients with PDAC. Multiple factors determine QOL, suggesting possible means of intervention to improve QOL and outcomes of PDAC patients.

Impact of Integrated Health Care Delivery on Racial and Ethnic Disparities in Pancreatic Cancer.

OBJECTIVES: The objective of this study was to evaluate whether disparities in pancreatic cancer diagnosis, treatment, and survival are reduced in an integrated health system. METHODS: We conducted a retrospective study (2006-2014) among patients with pancreatic cancer from Kaiser Permanente Southern California. Racial ethnic groups included non-Hispanic whites (NHW), non-Hispanic blacks (NHB), Hispanics, and Asians. We used multivariable and Cox regression analyses to evaluate disparities in diagnosis and treatment utilization (oncology care, surgery, time to surgery, chemotherapy) and overall survival, respectively. RESULTS: Among 2103 patients, 54% were diagnosed with stage IV disease, 80% received oncology consultation, 20% received surgery with mean time to surgery 27 days (standard deviation, 36.8), 50.4% received chemotherapy. Mean overall survival was 8.6 months (standard deviation, 11.5). There were no differences in odds of stage IV diagnosis, oncology consultation, surgery, or time to surgery by racial ethnic group. Asians were more likely to receive chemotherapy (odds ratio, 1.59; 95% confidence interval [CI], 1.09-2.32) compared to NHW. NHB (hazard ratio, 0.78; 95% CI, 0.67-0.91) and Asians (hazard ratio, 0.81; 95% CI, 0.66-1.00) had improved survival compared to NHW. CONCLUSIONS: Minorities were not disadvantaged in pancreatic cancer care. Improved health care coordination may improve current disparities.

Disparities in cancer outcomes across age, sex, and race/ethnicity among patients with pancreatic cancer.

Age, sex, and racial/ethnic disparities exist, but are understudied in pancreatic adenocarcinoma (PDAC). We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to determine whether survival and treatment disparities persist after adjusting for demographic and clinical characteristics. Our study included PDAC patients diagnosed between 1992 and 2011. We used Cox regression to compare survival across age, sex, and race/ethnicity within early-stage and late-stage cancer subgroups, adjusting for marital status, urban location, socioeconomics, SEER region, comorbidities, stage, lymph node status, tumor location, tumor grade, diagnosis year, and treatment received. We used logistic regression to compare differences in treatment received across age, sex, and race/ethnicity. Among 20,896 patients, 84% were White, 9% Black, 5% Asian, and 2% Hispanic. Median age was 75; 56% were female and 53% had late-stage cancer. Among early-stage patients in the adjusted Cox model, older patient subgroups had worse survival compared with ages 66-69 (HR > 1.1, P < 0.01 for groups >69); no survival differences existed between sexes. Black (HR = 1.1, P = 0.01) and Hispanic (HR = 1.2, P < 0.01) patients had worse survival compared with White. Among late-stage cancer patients, patients over age 84 had worse survival than those aged 66-69 (HR = 1.1, P < 0.01), and males (HR = 1.08, P < 0.01) had worse survival than females; there were no racial/ethnic differences. Older age and minority race/ethnicity were associated with lower likelihood of receiving chemotherapy, radiation, and/or surgery. Age and racial/ethnic disparities in survival outcomes and treatment received exist for PDAC patients; these disparities persist after adjusting for differences in demographic and clinical characteristics.

Racial disparities in pancreatic neuroendocrine tumors survival: a SEER study.

Pancreatic neuroendocrine tumor (pancreatic NETs), is an important cause of cancer-related death worldwide. No study has rigorously explored the impact of ethnicity on pancreatic NETs. We aimed to demonstrate the relationship between ethnicity and the survival of patients with pancreatic NETs. We used the SEER database to identify patients with pancreatic NETs from 2004 to 2013. Kaplan-Meier methods and Cox proportional hazard models were used to evaluate the impact of race on survival in pancreatic NETs patients. A total of 3850 patients were included: 3357 Non-Blacks, 493 Blacks. We stratified races as "Black" and "White/Other." Blacks were more likely to be diagnosed with later stages of tumors (P = 0.021). As for the treatment, the access to surgery seemed to be more limited in Blacks than non-Black patients (P = 0.012). Compared with non-Black patients, Black patients have worse overall survival (OS) (HR = 1.17, 95% CI: 1.00-1.37, P = 0.046) and pancreatic neuroendocrine tumors specific survival (PNSS) (HR = 1.22, 95% CI: 1.01-1.48, P = 0.044). Multivariate Cox analysis identified that disease extension at the time of diagnosis and surgical status contributed to the ethnical survival disparity. Black patients whose stages at diagnosis were localized had significantly worse OS (HR = 2.09, 95% CI: 1.18-3.71, P = 0.011) and PNSS (HR = 3.79, 95% CI: 1.62-8.82, P = 0.002). As for the patients who did not receive surgery, Blacks also have a worse OS (HR = 1.18, 95% CI: 1.00-1.41, P = 0.045). The Black patients had both worse OS and PNSS compared to non-Black patients. The restricted utilization of surgery, and the advanced disease extension at the time of diagnosis are the possible contributors to poorer survival of Blacks with pancreatic NETs.

Pancreatic cancer disparities in African Americans.

OBJECTIVES: Pancreatic cancer is the fourth leading cause of cancer-related deaths in the United States. The incidence of pancreatic cancer in African Americans is 50% to 90% higher than the incidence in other racial groups. African Americans also have the worst prognosis. This is an evidence-based review of pancreatic cancer in African Americans with particular emphasis on baseline characteristics, treatment, and survival. METHODS: We queried PubMed in search for articles describing racial disparities in pancreatic cancer. Two categories of terms were "anded" together: pancreatic cancer terms and race terms. The last search was performed on November 14, 2013. RESULTS: We summarized the data on pancreatic cancer baseline characteristics, treatment, and survival for African Americans that we obtained from the following databases: (1) Surveillance, Epidemiology, and End Results, 1988-2008; (2) California Cancer Registry 1988-1998; (3) Cancer Survivor Program of Orange County/San Diego Imperial Organization for Cancer Control, 1988-1998; and (4) Harris County, 1998-2010. CONCLUSIONS: Overall, pancreatic cancer survival of African Americans has not significantly improved over the past several decades despite advances in multimodality therapy; African Americans continue to face worse outcomes than whites. Although baseline characteristics, treatment, and biological factors offer some explanation, they do not completely explain the disparities in incidence and survival.

Racial and social economic factors impact on the cause specific survival of pancreatic cancer: a SEER survey.

BACKGROUND: This study used Surveillance, Epidemiology and End Results (SEER) pancreatic cancer data to identify predictive models and potential socio-economic disparities in pancreatic cancer outcome. MATERIALS AND METHODS: For risk modeling, Kaplan Meier method was used for cause specific survival analysis. The Kolmogorov-Smirnov's test was used to compare survival curves. The Cox proportional hazard method was applied for multivariate analysis. The area under the ROC curve was computed for predictors of absolute risk of death, optimized to improve efficiency. RESULTS: This study included 58,747 patients. The mean follow up time (S.D.) was 7.6 (10.6) months. SEER stage and grade were strongly predictive univariates. Sex, race, and three socio-economic factors (county level family income, rural-urban residence status, and county level education attainment) were independent multivariate predictors. Racial and socio-economic factors were associated with about 2% difference in absolute cause specific survival. CONCLUSIONS: This study s found significant effects of socio-economic factors on pancreas cancer outcome. These data may generate hypotheses for trials to eliminate these outcome disparities.

Selected cancers with increasing mortality rates by educational attainment in 26 states in the United States, 1993-2007.

BACKGROUND: Mortality rates continue to increase for liver, esophagus, and pancreatic cancers in non-Hispanic whites and for liver cancer in non-Hispanic blacks. However, the extent to which trends vary by socioeconomic status (SES) is unknown. METHODS: We calculated age-standardized death rates for liver, esophagus, and pancreas cancers for non-Hispanic whites and non-Hispanic blacks aged 25-64 years by sex and level of education (≤12, 13-15, and ≥16 years, as a SES proxy) during 1993-2007 using mortality data from 26 states with consistent education information on death certificates. Temporal trends were evaluated using log-linear regression, and rate ratios (RRs) with 95 % confidence intervals (CIs) compared death rates in persons with ≤12 versus ≥16 years of education. RESULTS: Generally, death rates increased for cancers of the liver, esophagus, and pancreas in non-Hispanic whites and non-Hispanic blacks (liver cancer only) with ≤12 and 13-15 years of education, with steeper increases in the least educated group. In contrast, rates remained stable in persons with ≥16 years of education. During 1993-2007, the RR (rates in ≤12 versus ≥16 years of education) increased for all three cancers, particularly for liver cancer among men which increased from 1.76 (95 % CI, 1.38-2.25) to 3.23 (95 % CI, 2.78-3.75) in non-Hispanic whites and from 1.28 (95 % CI, 0.71-2.30) to 3.64 (95 % CI, 2.44-5.44) in non-Hispanic blacks. CONCLUSIONS: The recent increase in mortality rates for liver, esophagus, and pancreatic cancers in non-Hispanic whites and for liver cancer in non-Hispanic blacks reflects increases among those with lower education levels.

Racial disparities in treatment for pancreatic cancer and impact on survival: a population-based analysis.

PURPOSE: Pancreatic adenocarcinoma is the fourth leading cause of cancer-related deaths in both men and women. Mortality from pancreatic cancer is higher amongst blacks compared to other races. We performed this analysis with the aim of examining racial disparity for receipt pancreatic cancer treatment and its association with survival. METHODS: Using the surveillance, epidemiology, and end results (SEER) database from 1988 to 2008, cases with locoregional pancreatic cancer were analysed. Kaplan-Meier survival curves were assessed to assess the survival amongst various races. Cox proportional hazard model was built to assess the impact of receipt of treatment on the racial disparity in survival. RESULTS: Of 16,282 cases with locoregional pancreatic cancer, 1,806 (11%) occurred in blacks. Median survival was 8-9 months with poorest survival in blacks. Blacks and Hispanics received radiation treatment less often compared to other races. On Cox regression logistic regression analysis, blacks had 20% poorer survival compared to whites. Treatment for pancreatic cancer explained only one-fourth of this poorer survival. CONCLUSION: Blacks have worst survival from locoregional pancreatic cancer. Receiving treatment for pancreatic cancer only explains 25% of the poorer survival amongst blacks, suggesting role of other factors. Studies are suggested to (a) identify barriers in receipt of treatment for pancreatic cancer amongst blacks and (b) to assess role of genetic and other factors to examine racial differences in survival.

Impact of race, age, and socioeconomic status on participation in pancreatic cancer clinical trials.

OBJECTIVES: Over 18 years, 7 phase 2 trials in advanced pancreatic cancer (APC) were conducted at Karmanos Cancer Institute (KCI). We sought factors that influenced the selection of patients for clinical trials and explored differences in overall survival (OS) of patients treated on clinical trials versus standard of care. METHODS: The target population was patients with APC diagnosed between January 1, 1986, and December 31, 2003. Patients were divided into 3 mutually exclusive groups: treated on clinical trials at KCI (t-KCI), treated at KCI but not on a clinical trial (KCI), or treated at non-KCI institutions (n-KCI). RESULTS: Eight thousand two hundred thirty patients met study criteria: 6470 n-KCI, 1642 KCI, and 118 t-KCI. Significant differences were observed across the 3 groups with respect to age, race, stage, grade, and socioeconomic status. Median OS was higher in t-KCI (8.5 months) than in KCI (5.0 months) or n-KCI (2.8 months) and could not be accounted for by variations in baseline characteristics. CONCLUSIONS: Patients enrolled on clinical trials were younger, had better socioeconomic status, and were less often African American. Patients with APC treated at academic institutions may have longer OS than patients treated in the community. Clinical trials seem to offer a survival advantage for patients with APC.