Analysis Reveals Racial Disparities in Timeliness of Treatment With IMRT Among Individuals With Cancer

Non-Hispanic Black (NHB), Hispanic, and Asian patients with cancer are significantly more likely to experience delays in receiving intensity-modulated radiotherapy (IMRT), according to findings from the Huntsman Cancer Institute at the University of Utah.¹

The median time to initiation of treatment (IIT) was 87 days (interquartile range [IQR], 52-135; P <.01) for NHB patients, 76 days (IQR 46-124; P <.01) for Hispanic patients, and 74 days (IQR, 43-120 days; P <.01) for Asian patients. The median IIT for White patients was 67 days (IQR, 40-110 days). Investigators found that the delays in IIT persisted across disease sites.

“Timeliness of initiating radiotherapy is a complex, multifactorial and multilevel issue,” lead author Ryan Hutten, MD, a chief radiation oncology resident at University of Utah Health, stated in a news release.² “We know there are enormous consequences to treatment delays, and we know minority groups have inferior oncologic outcomes. This work helps to identify an actionable area to improve equity in delivery of advanced radiation treatments.”

To determine disease sites to include in the analysis, Hutten and his team leveraged the most recent year of available data from the National Cancer Database. Utilizing this information, they identified the 10 sites with the highest total number of patients with cancer treated with definitive-intent IMRT in 2017; these sites included the prostate, lung, head and neck, rectum, esophagus, anus, pancreas, stomach, cervix, and uterus. The analysis included patients who received definitive-intent radiation to those sites between 2004 and 2017.

A total of 716,082 patients were included in the study; 350,425 received IMRT and 365,657 received 3DCRT. Investigators adjusted for a variety of factors including disease stage, age, race and ethnicity, and insurance status.

Overall use of IMRT increased from 20.3% in 2014 to 64.9% in 2017. Primary sites with the largest absolute change (∆) in IMRT utilization over the study period were cancers of the anus (∆ = 67.1%), esophagus (∆ = 62.2%), stomach (∆ = 58.3%), lung (∆ = 56.1%), and pancreas (∆ = 55.4%).

The percent of non-Hispanic White patients with delayed IIT ranged from 27.4% to 40.4% depending on site of disease, compared with 38.4% to 58.9% in Hispanic patients, 38.1% to 57.9% in NHB patients, and 27.3% to 49.1% in Asian patients.

Hispanic patients were more likely to have delayed IIT for 9 of 10 disease sites vs White patients after adjusting for clinical and sociodemographic covariates. NHB patients were significantly more likely to have delayed IIT for 7 of 10 disease sites, and Asian patients were significantly more likely to have delayed IIT for 8 of 10 disease sites.

Rates of public vs private insurance use was similar across racial/ethnic groups. Private insurance was associated with shorter median IIT compared with Medicare for White (62 days; IQR, 37-106), Asian (65 days, IQR, 40-113), and Hispanic (73 days; IQR, 44-124) patients. However, median IIT was longer for NHB patients with private insurance compared with those using Medicare (91 days; IQR, 54-139; P <.01).

“It’s a point of frustration for clinicians, when you have to delay treatment for patients due to insurance authorization processes,” Hutten said. “As the treatment planning process is the same regardless of insurance status, this research suggests that the observed disparity for NHB patients may be exacerbated by the prior-authorization process required by many private insurance companies.”

Investigators could not directly evaluate the role of prior authorization in privately insured patients in this dataset. However, Hutten noted that this work will guide further investigation into the prior-authorization process including denials, need for appeals, and approvals for advanced radiotherapy techniques.

Hutten added that the National Institute of Health (GMaP Program) has funded a research project that will allow his team to collect more granular information on the authorization process for IMRT for patients being treated specifically in Utah.

References

1. Hutten RJ, Weil CR, Gaffney DK, et al. Racial and ethnic health disparities in delay to initiation of intensity-modulated radiotherapy. JCO Oncol Pract. Published online August 5, 2022. doi:10.1200/OP.22.00104
2. New research shines light on racial disparities in cancer treatment. News release. Huntsman Cancer Institute. August 15, 2022. Accessed August 18, 2022. https://bit.ly/3PJ8Mz