Race, Age, Gender, and Insurance Status: A Comparative Analysis of Access to and Quality of Gastrointestinal Cancer Care

Background: Socioeconomics, demographics, and insurance status play roles in healthcare access. Considering the limited resources available, understanding the relative impact of disparities helps prioritize programs designed to overcome them. This study evaluates gastrointestinal cancer care disparity by comparing the impact of different patient factors across oncologic care metrices. Methods: A multi-institutional prospectively maintained cancer database was reviewed retrospectively for gastrointestinal cancers (esophagus, stomach, liver, pancreas, colorectal, and hepato-pancreato-biliary) from 2007 to 2017 to assess quality of care provided. Quality of care was defined by clinical course following national guidelines for the respective cancer. This included surgical intervention, chemotherapy, palliative care, and minimal delay to treatment/diagnosis. Logistic regression was used to adjust for confounders and identify factors associated with quality of care. Kaplan-Meier survival curves were compared using log-rank test. Results: One thousand seventy-two patients were identified. Survival improved in patients with private insurance compared to government-funded options [median overall survival (mOS) 57.8 vs. 21.2 months; P <.001]. Private insurance also correlated with earlier stage at diagnosis [stages I–II = 50.9% vs. 37.5%, stages III–IV = 37.7% vs. 49.1%, P <.001], increased chemotherapy use [44.2% vs. 37.1%, P <.001], and more surgical intervention [62.4% vs. 48.8%, P <.001]. Outcomes were inferior for Black Americans, including trend towards lower rate of surgical treatment [42% vs. 54%, P =.058] and worse survival in private insurance carriers [mOS 7.8 vs. 57.8 months, P =.021] and those with early stage disease [mOS 39.2 vs. 81.5 months, P =.045] compared to White counterparts. Conclusions: Insurance status has the strongest impact on the quality of gastrointestinal oncologic care with negative synergistic negative effect of race for Black Americans. While governmental programs aim to improve equality of care, there remains significant disparity compared to private insurance. Moreover, private insurance doesn’t correct disparity for Black Americans, suggesting the need to address racial imbalances in cancer care.