Department of Surgery, University of Utah, Salt Lake City; Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT.
Department of Surgery, University of Utah, Salt Lake City.
Surgery. 2019 Apr;165(4):751-759. doi: 10.1016/j.surg.2018.10.035. Epub 2018 Dec 11.
Utilization of multimodality therapy for clinical stage I-II pancreatic ductal adenocarcinoma is associated with meaningful prolongation of survival. Although the qualitative existence of disparities in treatment utilization by socioeconomic status and race/ethnicity is well documented, the absolute magnitudes of these disparities have not been previously quantified.
The exposures in this retrospective cohort study of the 2010-2015 National Cancer Database were a 7-value area-level socioeconomic status index and race/ethnicity. Main outcomes were surgery, chemotherapy, and multimodality therapy (surgery and chemotherapy). Adjusted rate differences were calculated after logistic regression. Models excluded intermediate variables. Overall survival was evaluated in unadjusted and adjusted analyses.
Of 43,760 patients, 63.4% underwent surgery. Of 39,808 patients without chemotherapy contraindications, refusal, or missing data, 75.1% received chemotherapy and 51.4% received multimodality therapy. Adjusted rate differences for utilization of surgery, chemotherapy, and multimodality therapy in the lowest socioeconomic status patients were -10.0 (95% confidence interval [CI] -12.4 to -7.5), -12.7 (95% CI -16.3 to -9.1), and -15.4 (95% CI -18.8 to -12.0), respectively, versus the highest socioeconomic status patients. Adjusted rate differences for multimodality therapy utilization in non-Hispanic Black and Hispanic patients were -10.1 (95% CI -13.6 to -6.7) and -11.8 (95% CI -14.3 to -9.2), respectively, versus non-Hispanic White patients. Median overall survival increased in a graded fashion from 14.1 (95% CI 13.4-14.8) months in the lowest socioeconomic status patients to 20.2 months (95% CI 19.6-20.8) in the highest socioeconomic status patients. Survival differences were attenuated but not eliminated in multivariable Cox models.
Socioeconomic status and race/ethnicity are more powerful determinants of whether patients receive treatment for clinical stage I-II pancreatic ductal adenocarcinoma than previously appreciated. Nationwide quality improvement efforts aimed at addressing these inequities are warranted.
对于临床 I 期-II 期胰腺导管腺癌患者，采用多模态治疗与生存时间的显著延长相关。尽管社会经济地位和种族/民族差异在治疗利用方面存在定性差异已得到充分证实，但这些差异的绝对程度以前尚未量化。
本研究回顾性分析了 2010 年至 2015 年国家癌症数据库中的一个队列，将 7 级区域社会经济地位指数和种族/民族作为暴露因素。主要结局为手术、化疗和多模态治疗（手术和化疗）。逻辑回归后计算调整后的率差。模型排除了中间变量。未调整和调整后的分析评估了总生存情况。
在 43760 名患者中，63.4%接受了手术。在 39808 名没有化疗禁忌、拒绝或数据缺失的患者中，75.1%接受了化疗，51.4%接受了多模态治疗。在社会经济地位最低的患者中，手术、化疗和多模态治疗的利用率调整率差异分别为-10.0（95%置信区间[CI] -12.4 至-7.5）、-12.7（95% CI -16.3 至-9.1）和-15.4（95% CI -18.8 至-12.0），与社会经济地位最高的患者相比。非西班牙裔黑人和西班牙裔患者多模态治疗利用率的调整率差异分别为-10.1（95% CI -13.6 至-6.7）和-11.8（95% CI -14.3 至-9.2），与非西班牙裔白人患者相比。中位总生存期呈梯度增加，从社会经济地位最低的患者的 14.1 个月（95% CI 13.4-14.8）增加到社会经济地位最高的患者的 20.2 个月（95% CI 19.6-20.8）。多变量 Cox 模型中生存差异虽减弱但未消除。
社会经济地位和种族/民族是影响临床 I 期-II 期胰腺导管腺癌患者接受治疗的更有力决定因素，这比以前认识到的更为重要。需要开展全国范围的质量改进工作，以解决这些不公平问题。
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