Evaluation of Inequities in Cancer Treatment Delay or Discontinuation Following SARS-CoV-2 Infection

Abstract

ImportanceThere is a disproportionately greater burden of COVID-19 among Hispanic and non-Hispanic Black individuals, who also experience poorer cancer outcomes. Understanding individual-level and area-level factors contributing to inequities at the intersection of COVID-19 and cancer is critical.ObjectiveTo evaluate associations of individual-level and area-level social determinants of health (SDOH) with delayed or discontinued cancer treatment following SARS-CoV-2 infection.Design, Setting, and ParticipantsThis retrospective, registry-based cohort study used data from 4768 patients receiving cancer care who had positive test results for SARS-CoV-2 and were enrolled in the American Society for Clinical Oncology COVID-19 Registry. Data were collected from April 1, 2020, to September 26, 2022.ExposuresRace and ethnicity, sex, age, and area-level SDOH based on zip codes of residence at the time of cancer diagnosis.Main Outcomes and MeasuresDelayed (≥14 days) or discontinued cancer treatment (any cancer treatment, surgery, pharmacotherapy, or radiotherapy) and time (in days) to restart pharmacotherapy.ResultsA total of 4768 patients (2756 women [57.8%]; 1558 [32.7%] aged ≥70 years at diagnosis) were included in the analysis. There were 630 Hispanic (13.2%), 196 non-Hispanic Asian American or Pacific Islander (4.1%), 568 non-Hispanic Black (11.9%), and 3173 non-Hispanic White individuals (66.5%). Compared with non-Hispanic White individuals, Hispanic and non-Hispanic Black individuals were more likely to experience a delay of at least 14 days or discontinuation of any treatment and drug-based treatment; only estimates for non-Hispanic Black individuals were statistically significant, with correction for multiple comparisons (risk ratios [RRs], 1.35 [95% CI, 1.22-1.49] and 1.37 [95% CI, 1.23-1.52], respectively). Area-level SDOH (eg, geography, proportion of residents without health insurance or with only a high school education, lower median household income) were associated with delayed or discontinued treatment. In multivariable Cox proportinal hazards regression models, estimates suggested that Hispanic (hazard ratio [HR], 0.87 [95% CI, 0.71-1.05]), non-Hispanic Asian American or Pacific Islander (HR, 0.79 [95% CI, 0.46-1.35]), and non-Hispanic Black individuals (HR, 0.81 [95% CI, 0.67-0.97]) experienced longer delays to restarting pharmacotherapy compared with non-Hispanic White individuals.Conclusions and RelevanceThe findings of this cohort study suggest that race and ethnicity and area-level SDOH were associated with delayed or discontinued cancer treatment and longer delays to the restart of drug-based therapies following SARS-CoV-2 infection. Such treatment delays could exacerbate persistent cancer survival inequities in the United States.

Initiating Immunotherapy in the Treatment of Stage IV Cancers in the Month Before Death—A Health Care Disparities Lens

“…In the present historical context, SARS-CoV-2 continues to transmit at high rates, especially in winter months, and people with advanced cancer are among the most vulnerable . Supportive conversations that increase utilization of vaccines, masking, test-to-treat, and other mitigation may reduce the likelihood of severe COVID-19 outcomes, cancer treatment delays, and treatment discontinuities . We are aware of no data on variation in COVID-19–specific protocols and supports across health care centers but hypothesize that pandemic-related infrastructure may be more common at higher-resource academic and high-volume centers.…”

Evidence Base for Health Care Strategies to Protect Vulnerable Patients During the COVID-19 Pandemic—Reply

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COMMENT & RESPONSEIn Reply People with cancer experience an increased risk of SARS-CoV-2 vaccine nonresponse and infection, treatment delays from active infection, COVID-19 hospitalization, post-COVID-19 condition (long COVID), and COVID-19 mortality. [1][2][3] Accordingly, in our Editorial, 1 we encouraged cancer centers to provide more comprehensive pandemic support, suggested 10 evidence-based recommendations, and offered volunteer assistance.We appreciate Haslam and Prasad's comments on this evidence base. Foremost, our recommendations 1 focused on patient education about COVID-19, transmission, and mitigation.

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“…Second, SARS-CoV-2 poses cumulative harm from reinfections . An infection or a reinfection remains a notable concern in a population that may have a limited treatment window and limited life span. Third, reasonable mitigation can enhance rather than detract from social well-being by allowing friends and family to visit more safely with less concern toward disrupting a loved one’s oncology care.…”

“…Currently, to our knowledge, there are no randomized data on filtration systems in reducing COVID-19 transmission, although there are several randomized studies under way. 2,3 Randomized data on the efficacy of masks are limited to 2 studies 4,5 that either reported no benefit or were biased, making it difficult to determine whether the small benefit reported was real or confounded. Neither study tested N95 masks.…”

“…In Reply People with cancer experience an increased risk of SARS-CoV-2 vaccine nonresponse and infection, treatment delays from active infection, COVID-19 hospitalization, post-COVID-19 condition (long COVID), and COVID-19 mortality. [1][2][3] Accordingly, in our Editorial, 1 we encouraged cancer centers to provide more comprehensive pandemic support, suggested 10 evidence-based recommendations, and offered volunteer assistance.…”