Race versus place of service in mortality among medicare beneficiaries with cancer

Abstract

Background: Evidence suggests that excess mortality among African-American cancer patients is explained in part by the healthcare setting. The objective of this study was to compare mortality among African-American and Caucasian cancer patients and to evaluate the influence of attendance at a National Cancer Institute (NCI)-designated comprehensive or clinical cancer center.

Methods: The authors conducted a retrospective cohort analysis of Medicare beneficiaries with an incident diagnosis of lung, breast, colorectal, or prostate cancer between 1998 and 2002 who were identified from Surveillance, Epidemiology, and End Results data. Multivariate logistic regression models were used to assess the impact of NCI cancer center attendance and race on all-cause and cancer-specific mortality at 1 year and 3 years after diagnosis.

Results: The likelihood of 1-year and 3-year all-cause and cancer-specific mortality was higher for African Americans than for Caucasians in crude and adjusted models (cancer-specific adjusted: Caucasian referent, 1-year odds ratio [OR], 1.13; 95% confidence interval [CI], 1.07-1.19; 3-year OR, 1.23; 95% CI, 1.17-1.30). By cancer site, cancer-specific mortality was higher among African Americans at 1 year for breast and colorectal cancers and for all cancers at 3 years. NCI cancer center attendance was associated with significantly lower odds of mortality for African Americans (1-year OR, 0.63; 95% CI, 0.56-0.76; 3-year OR, 0.71; 95% CI, 0.62-0.81). With Caucasians as the referent group, the excess mortality risk among African Americans no longer was observed for all-cause or cancer-specific mortality risk among patients who attended NCI cancer centers (cancer-specific mortality:1-year OR, 0.95; 95% CI, 0.76-1.19; 3-year OR, 1.00; 95% CI, 0.82-1.21).

Conclusions: African-American Medicare beneficiaries with lung, breast, colorectal, and prostate cancers had higher mortality compared with their Caucasian counterparts; however, there were no significant differences in mortality by race among those who attended NCI cancer centers. The results of this study suggested that place of service may explain some of the cancer mortality excess observed in African Americans.

Figure 1

Predictive models of 1- and 3-year cancer-specific mortality as a function of cancer site in African American Medicare beneficiaries compared to Caucasian beneficiaries with an incident diagnosis of breast, lung, colon/rectal, or prostate cancer as identified in SEER-Medicare data from 1998–2002. * Adjusted models include the covariates: age at diagnosis, sex, travel time to nearest NCI Cancer Center, predominance of primary care prior to diagnosis, stage, rurality, comorbidities, median household income for ZIP of residence at diagnosis, SEER registry of residence at diagnosis, and year of diagnosis.

Figure 2

Predictive models of 1- and 3-year cancer-specific mortality as a function of NCI Cancer Center attendance in Medicare beneficiaries with an incident diagnosis of breast, lung, colon/rectal, or prostate cancer as identified in SEER-Medicare data from 1998–2002. * Adjusted models include the covariates: age at diagnosis, sex, travel time to nearest NCI Cancer Center, predominance of primary care prior to diagnosis, stage, rurality, comorbidities, median household income for ZIP of residence at diagnosis, SEER registry of residence at diagnosis, and year of diagnosis.