Originally published as JCO Early Release 10.1200/JCO.2008.20.8546 on May 26 2009

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Hospital Factors and Racial Disparities in Mortality After Surgery for Breast and Colon Cancer

From the Michigan Surgical Collaborative for Outcomes Research and Evaluation, Department of Surgery, University of Michigan, Ann Arbor, MI.

Corresponding author: Arden M. Morris, MD, MPH, 1500 E Medical Center Dr, TC-2124, Ann Arbor, MI 48109-5343; e-mail: ammsurg{at}umich.edu.

Purpose Black patients have worse prognoses than whites with breast or colorectal cancer. Mechanisms underlying such disparities have not been fully explored. We examined the role of hospital factors in racial differences in late mortality after surgery for breast or colon cancer.

Methods Patients undergoing surgery after new diagnosis of breast or colon cancer were identified using the Surveillance Epidemiology and End Results–Medicare linked database (1995 to 2005). The main outcome measure was mortality at 5 years. Proportional hazards models were used to assess relationships between race and late mortality, accounting for patient factors, socioeconomic measures, and hospital factors. Fixed and random effects models were used to account for quality differences across hospitals.

Results Black patients, compared with white patients, had lower 5-year overall survival rates after surgery for breast (62.1% v 70.4%, respectively; P < .001) and colon cancer (41.3% v 45.4%, respectively; P < .001). After controlling for age, comorbidity, and stage, black race remained an independent predictor of mortality for breast (adjusted hazard ratio [HR] = 1.25; 95% CI, 1.16 to 1.34) and colon cancer (adjusted HR = 1.13; 95% CI, 1.07 to 1.19). After risk adjustment, hospital factors explained 36% and 54% of the excess mortality for black patients with breast cancer and colon cancer, respectively. Hospitals with large minority populations had higher late mortality rates independent of race.

Conclusion Hospital factors, including quality, are important mediators of the association between race and mortality for breast and colon cancer. Hospital-level quality improvement should be a major component of efforts to reduce disparities in cancer outcomes.

Supported by Mentored Research Scholar Grant No. MRSGT06-076-01-CHPHS (A.M.M.) from the American Cancer Society, Atlanta, GA, and by Senior Scientist Award No. K05 CA115571-01 (J.D.B.) from the National Cancer Institute.

The views expressed herein do not necessarily represent the views of the American Cancer Society, the National Cancer Institute, Center for Medicare and Medicaid Services, or the US Government.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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