Sociodemographic Barriers to the Timely Treatment of Pancreatic Cancer

Discussion

In this study, multiple factors were analyzed to uncover disparities in the time to first treatment, surgery, radiation, and chemotherapy. Age, sex, race, Hispanic origin, insurance status, income, facility type, geographical setting, and comorbid status were all found to be significantly associated with time to treatment variations within at least one treatment category.

Most notably, academic facilities and Carlson-Deyo Comorbidity (CDC) scores of 3 or more were associated with the longest times to treatment throughout all treatment categories. Naturally, a higher comorbidity score would be expected to lead to delays in treatment because these patients often need to be optimized or “cleared” prior to initiating treatment. Less intuitively, the delay in patients receiving treatment at academic facilities may be due to a possible greater influx of patients when compared to other hospital types which would ultimately make scheduling treatment more difficult. Sukniam et al. stated that referrals to tertiary academic centers likely play a role in patient’s untimely treatment (13). Given that academic facilities receive a high rate of referral cases, this could be another factor responsible for a delay in treatment. Academic facilities may also reanalyze the case before offering treatment.

Rural settings were consistently associated with the shortest time to treatments. Similar to access to care issues that may affect treatment facility type, this observation could be due to less dense populations within rural settings that translate to less saturated clinics and health facilities. Scheduling appointments would consequently be easier, and time to treatment would potentially be minimized. Conversely, metropolitan areas had the longest time to treatment, which likely also reflects population density as a factor associated with time to treatment.

Chemotherapy was the most frequent treatment within our cohort. Significant inequalities in times to chemotherapy were observed for black, Hispanic, and uninsured patients. Patients treated in academic facilities were also disadvantaged. On average, patients within these categories had treatment delays of approximately four days. While four days may not seem very significant, it is important to note that this only represents an average. Therefore, many patients unfortunately received their first chemotherapy treatment even later, which could jeopardize the patient’s outcomes.

Pancreatic cancer is mostly associated with older age. McGuigan et al. stated that 90% of patients are over the age of 55 when first diagnosed and most are in their 70’s and 80’s (2). This study particularly analyzed trends in times to treatment for age groups over 40. Among the various age groups, patients older than 70 had the longest time to receive their initial treatment and chemotherapy. Notably, this same age group showed the shortest time to treatment for surgery. This would be expected as many older patients would not be considered fit for systemic chemotherapy, therefore surgery may be their only option.

Sex was found to be an insignificant factor in times to first treatment, surgery, and radiation. However, time to chemotherapy was significantly longer in females than their male counterparts, which was particularly worrisome because pancreatic cancer has a disproportionately greater incidence in females (14). A factor contributing to this delay in treatment may be the side effects experienced by females undergoing chemotherapy. Unger et al. found that women have greater severity of symptomatic and hematologic adverse effects due to immunotherapy-targeted therapy and chemotherapy than men (15).

Noel and Fiscella have shown that African Americans and sometimes Hispanics receive suboptimal treatment for pancreatic cancers (11). Our data shows that minorities overall were always amongst the latest to receive treatment, particularly blacks and people of Hispanic origin. Whites were always first or second fastest to receive treatment. The disproportionally greater time to treatment for minorities might be rooted in socioeconomic status (SES) inequities. Lack of education might hinder patient-doctor relationships and hamper follow-up after diagnosis. Low income may obstruct access to healthcare altogether. In fact, having an income of less than $63,000 and being uninsured were delaying factors for times to first treatment and chemotherapy. Both factors obstruct access to healthcare services and treatment directly. Cheung et al. concurringly state that patients in lower SES are less likely to have pancreatic surgery, chemotherapy, and radiation (16). Surprisingly, uninsured patients had the fastest time to surgery. Surgery may also be the most comprehensible treatment and, therefore, the quickest to be performed on patients who have poor access to care the better (17).

It is important to note that while almost all factors studied were found to show statistically significant disparities, they may not be clinically significant. The large number of patients in the database would allow statistical significance to be achieved while the difference in days of the time to treatment do not amount to a difference in patient outcome among several treatment variables. Even though a large database improves study generalizability, it is also a noteworthy limitation. Due to the great volume of patient information, the database might have missing data and incorrectly documented information. Another limitation is the retrospective nature of this study because its data may no longer be representative of current practices and disparities.

Nonetheless, pancreatic cancer incidence is rising on a global level (18). This study provides large-scale evidence of the influence of sociodemographic factors on the time to treatment for pancreatic cancer. Understanding and acknowledging these disparities are very important in order to find ways to provide the best possible care to all communities affected by pancreatic cancer.