Racial and Ethnic Disparities in Cancer Care During the COVID-19 Pandemic | Health Disparities | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Racial and Ethnic Disparities in Cancer Care During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Did racial and ethnic minority adults with cancer in the United States experience more cancer care delays and adverse social and economic effects than White adults during the COVID-19 pandemic?

Findings  In this survey study of 1240 US adults with cancer, Black and Latinx adults reported experiencing higher rates of delayed cancer care and more adverse social and economic effects than White adults.

Meaning  This study suggests that the COVID-19 pandemic is associated with disparities in the receipt of timely cancer care among Black and Latinx adults.

Abstract

Importance  The full effect of the COVID-19 pandemic on cancer care disparities, particularly by race and ethnicity, remains unknown.

Objectives  To assess whether the race and ethnicity of patients with cancer was associated with disparities in cancer treatment delays, adverse social and economic effects, and concerns during the COVID-19 pandemic and to evaluate trusted sources of COVID-19 information by race and ethnicity.

Design, Setting, and Participants  This national survey study of US adults with cancer compared treatment delays, adverse social and economic effects, concerns, and trusted sources of COVID-19 information by race and ethnicity from September 1, 2020, to January 12, 2021.

Exposures  The COVID-19 pandemic.

Main Outcomes and Measures  The primary outcome was delay in cancer treatment by race and ethnicity. Secondary outcomes were duration of delay, adverse social and economic effects, concerns, and trusted sources of COVID-19 information.

Results  Of 1639 invited respondents, 1240 participated (75.7% response rate) from 50 US states, the District of Columbia, and 5 US territories (744 female respondents [60.0%]; median age, 60 years [range, 24-92 years]; 266 African American or Black [hereafter referred to as Black] respondents [21.5%]; 186 Asian respondents [15.0%]; 232 Hispanic or Latinx [hereafter referred to as Latinx] respondents [18.7%]; 29 American Indian or Alaska Native, Native Hawaiian, or multiple races [hereafter referred to as other] respondents [2.3%]; and 527 White respondents [42.5%]). Compared with White respondents, Black respondents (odds ratio [OR], 6.13 [95% CI, 3.50-10.74]) and Latinx respondents (OR, 2.77 [95% CI, 1.49-5.14]) had greater odds of involuntary treatment delays, and Black respondents had greater odds of treatment delays greater than 4 weeks (OR, 3.13 [95% CI, 1.11-8.81]). Compared with White respondents, Black respondents (OR, 4.32 [95% CI, 2.65-7.04]) and Latinx respondents (OR, 6.13 [95% CI, 3.57-10.53]) had greater odds of food insecurity and concerns regarding food security (Black respondents: OR, 2.02 [95% CI, 1.34-3.04]; Latinx respondents: OR, 2.94 [95% CI, [1.86-4.66]), financial stability (Black respondents: OR, 3.56 [95% CI, 1.79-7.08]; Latinx respondents: OR, 4.29 [95% CI, 1.98-9.29]), and affordability of cancer treatment (Black respondents: OR, 4.27 [95% CI, 2.20-8.28]; Latinx respondents: OR, 2.81 [95% CI, 1.48-5.36]). Trusted sources of COVID-19 information varied significantly by race and ethnicity.

Conclusions and Relevance  In this survey of US adults with cancer, the COVID-19 pandemic was associated with treatment delay disparities and adverse social and economic effects among Black and Latinx adults. Partnering with trusted sources may be an opportunity to overcome such disparities.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: May 14, 2022.

Published: July 14, 2022. doi:10.1001/jamanetworkopen.2022.22009

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Patel MI et al. JAMA Network Open.

Corresponding Author: Manali I. Patel, MD, MPH, MS, Division of Oncology, Department of Medicine, Stanford University, 875 Blake Wilbur Dr, Stanford CA 94305 (manalip@stanford.edu).

Author Contributions: Dr Patel had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Patel.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Patel, Ferguson, Duron, Hlubocky, Infantado, Julian, Maingi.

Critical revision of the manuscript for important intellectual content: Patel, Ferguson, Castro, Pereira-Estremera, Armaiz-Peña, Hlubocky, Nuqui, Nortey, Steck, Bondy, Maingi.

Statistical analysis: Patel, Ferguson, Hlubocky, Bondy.

Obtained funding: Patel.

Administrative, technical, or material support: Patel, Castro, Pereira-Estremera, Armaiz-Peña, Hlubocky, Infantado, Nuqui, Julian, Nortey, Steck, Maingi.

Supervision: Patel.

Conflict of Interest Disclosures: Dr Pereira-Estremera reported receiving salary from Tiber Health Public Benefit Corp during the conduct of the study. No other disclosures were reported.

Funding/Support: Dr Patel’s research in this publication was supported, in part, by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under award K23MD013474. Drs Castro and Armaiz-Peña were supported by the National Institutes of Health under award R21MD013674. Dr Patel and Ms Duron received research funding from the California Initiative to Advance Precision Medicine, which supported, in part, the research reported in this publication.

Role of the Funder/Sponsor: The National Institute on Minority Health and Health Disparities of the National Institutes of Health and the California Initiative to Advance Precision Medicine did not play a role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

References
1.
DeGroff  A , Miller  J , Sharma  K ,  et al.  COVID-19 impact on screening test volume through the National Breast and Cervical Cancer early detection program, January-June 2020, in the United States.   Prev Med. 2021;151:106559. doi:10.1016/j.ypmed.2021.106559 PubMedGoogle ScholarCrossref
2.
Chen  RC , Haynes  K , Du  S , Barron  J , Katz  AJ .  Association of cancer screening deficit in the United States with the COVID-19 pandemic.   JAMA Oncol. 2021;7(6):878-884. doi:10.1001/jamaoncol.2021.0884 PubMedGoogle ScholarCrossref
3.
COVIDSurg Collaborative.  Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study.   Lancet Oncol. 2021;22(11):1507-1517. doi:10.1016/S1470-2045(21)00493-9 PubMedGoogle ScholarCrossref
4.
Patel  MI , Ma  Y , Mitchell  B , Rhoads  KF .  How do differences in treatment impact racial and ethnic disparities in acute myeloid leukemia?   Cancer Epidemiol Biomarkers Prev. 2015;24(2):344-349. doi:10.1158/1055-9965.EPI-14-0963 PubMedGoogle ScholarCrossref
5.
Rhoads  KF , Patel  MI , Ma  Y , Schmidt  LA .  How do integrated health care systems address racial and ethnic disparities in colon cancer?   J Clin Oncol. 2015;33(8):854-860. doi:10.1200/JCO.2014.56.8642 PubMedGoogle ScholarCrossref
6.
Shavers  VL , Brown  ML .  Racial and ethnic disparities in the receipt of cancer treatment.   J Natl Cancer Inst. 2002;94(5):334-357. doi:10.1093/jnci/94.5.334 PubMedGoogle ScholarCrossref
7.
Cancer Action Network, American Cancer Society. Cancer disparities: a chartbook. Published 2018. Accessed August 27, 2021. https://www.fightcancer.org/sites/default/files/National%20Documents/Disparities-in-Cancer-Chartbook.pdf
9.
Bailey  ZD , Feldman  JM , Bassett  MT .  How structural racism works—racist policies as a root cause of U.S. racial health inequities.   N Engl J Med. 2021;384(8):768-773. doi:10.1056/NEJMms2025396 PubMedGoogle ScholarCrossref
10.
Bailey  ZD , Krieger  N , Agénor  M , Graves  J , Linos  N , Bassett  MT .  Structural racism and health inequities in the USA: evidence and interventions.   Lancet. 2017;389(10077):1453-1463. doi:10.1016/S0140-6736(17)30569-X PubMedGoogle ScholarCrossref
11.
Balogun  OD , Bea  VJ , Phillips  E .  Disparities in cancer outcomes due to COVID-19—a tale of 2 cities.   JAMA Oncol. 2020;6(10):1531-1532. doi:10.1001/jamaoncol.2020.3327 PubMedGoogle ScholarCrossref
12.
Obeng-Gyasi  S , Oppong  B , Paskett  ED , Lustberg  M .  Purposeful surgical delay and the coronavirus pandemic: how will Black breast cancer patients fare?   Breast Cancer Res Treat. 2020;182(3):527-530. doi:10.1007/s10549-020-05740-0 PubMedGoogle ScholarCrossref
13.
Centers for Disease Control and Prevention. Risk for COVID-19 infection, hospitalization, and death by race/ethnicity. Published 2021. Accessed August 11, 2021. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
14.
Shiels  MS , Haque  AT , Haozous  EA ,  et al.  Racial and ethnic disparities in excess deaths during the COVID-19 pandemic, March to December 2020.   Ann Intern Med. 2021;174(12):1693-1699. doi:10.7326/M21-2134 PubMedGoogle ScholarCrossref
15.
U.S. Bureau of Labor Statistics. Labor force statistics from the current population survey: E-13: employed persons by sex, occupation, class of worker, full- or part-time status, and race. Published 2020. Accessed September 8, 2021. https://www.bls.gov/web/empsit/cpsee_e13.htm
16.
Bernstein  AN , Talwar  R , Handorf  E ,  et al.  Assessment of prostate cancer treatment among black and white patients during the COVID-19 pandemic.   JAMA Oncol. 2021;7(10):1467-1473. doi:10.1001/jamaoncol.2021.2755 PubMedGoogle ScholarCrossref
17.
Satish  T , Raghunathan  R , Prigoff  JG ,  et al.  Care delivery impact of the COVID-19 pandemic on breast cancer care.   JCO Oncol Pract. 2021;17(8):e1215-e1224. doi:10.1200/OP.20.01062 PubMedGoogle ScholarCrossref
18.
Maringe  C , Spicer  J , Morris  M ,  et al.  The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study.   Lancet Oncol. 2020;21(8):1023-1034. doi:10.1016/S1470-2045(20)30388-0 PubMedGoogle ScholarCrossref
19.
Patt  D , Gordan  L , Diaz  M ,  et al.  Impact of COVID-19 on cancer care: how the pandemic is delaying cancer diagnosis and treatment for American seniors.   JCO Clin Cancer Inform. 2020;4:1059-1071. doi:10.1200/CCI.20.00134 PubMedGoogle ScholarCrossref
20.
Dinmohamed  AG , Visser  O , Verhoeven  RHA ,  et al.  Fewer cancer diagnoses during the COVID-19 epidemic in the Netherlands.   Lancet Oncol. 2020;21(6):750-751. doi:10.1016/S1470-2045(20)30265-5 PubMedGoogle ScholarCrossref
21.
American Association for Public Opinion Research. Standard definitions. Accessed April 1, 2022. https://www.aapor.org/Publications-Media/AAPOR-Journals/Standard-Definitions.aspx
22.
Zavala  VA , Bracci  PM , Carethers  JM ,  et al.  Cancer health disparities in racial/ethnic minorities in the United States.   Br J Cancer. 2021;124(2):315-332. doi:10.1038/s41416-020-01038-6 PubMedGoogle ScholarCrossref
23.
Emerson  MA , Golightly  YM , Aiello  AE ,  et al.  Breast cancer treatment delays by socioeconomic and health care access latent classes in Black and White women.   Cancer. 2020;126(22):4957-4966. doi:10.1002/cncr.33121 PubMedGoogle ScholarCrossref
24.
Rubin  DB .  Multiple Imputation for Nonresponse in Surveys. Wiley; 2004.
25.
Hanna  TP , King  WD , Thibodeau  S ,  et al.  Mortality due to cancer treatment delay: systematic review and meta-analysis.   BMJ. 2020;371:m4087. doi:10.1136/bmj.m4087 PubMedGoogle ScholarCrossref
26.
de Brey  C , Musu  L , McFarland  J ,  et al. Status and trends in the education of racial and ethnic groups 2018. US Department of Education. Published 2019. Accessed September 6, 2021. https://nces.ed.gov/pubs2019/2019038.pdf
27.
Ryan  CL , Bauman  K . Educational attainment in the United States: 2015. Published March 2016. Accessed September 6, 2021. https://www.census.gov/content/dam/Census/library/publications/2016/demo/p20-578.pdf
28.
Keisler-Starkey  K , Bunch  LN . Health insurance coverage in the United States: 2019. US Census Bureau. Published 2020. Accessed September 6, 2021. https://www.census.gov/content/dam/Census/library/publications/2020/demo/p60-271.pdf
29.
US Bureau of Labor Statistics. Labor force statistics from the current population survey: E-14: employed Hispanic or Latino workers by sex, occupation, class of worker, full- or part-time status, and detailed ethnic group. US Bureau of Labor Statistics. Published 2020. Accessed September 6, 2021. https://www.bls.gov/web/empsit/cpsee_e14.htm
30.
Gemelas  J , Davison  J , Keltner  C , Ing  S .  Inequities in employment by race, ethnicity, and sector during COVID-19.   J Racial Ethn Health Disparities. 2022;9(1):350-355. doi:10.1007/s40615-021-00963-3PubMedGoogle ScholarCrossref
31.
Chang  SW , Kerlikowske  K , Nápoles-Springer  A , Posner  SF , Sickles  EA , Pérez-Stable  EJ .  Racial differences in timeliness of follow-up after abnormal screening mammography.   Cancer. 1996;78(7):1395-1402. doi:10.1002/(SICI)1097-0142(19961001)78:7<1395::AID-CNCR5>3.0.CO;2-K PubMedGoogle Scholar
32.
Carey  P , Gjerdingen  DK .  Follow-up of abnormal Papanicolaou smears among women of different races.   J Fam Pract. 1993;37(6):583-587.PubMedGoogle Scholar
33.
Bleicher  RJ , Ruth  K , Sigurdson  ER ,  et al.  Time to surgery and breast cancer survival in the United States.   JAMA Oncol. 2016;2(3):330-339. doi:10.1001/jamaoncol.2015.4508 PubMedGoogle Scholar
34.
Fedewa  SA , Edge  SB , Stewart  AK , Halpern  MT , Marlow  NM , Ward  EM .  Race and ethnicity are associated with delays in breast cancer treatment (2003-2006).   J Health Care Poor Underserved. 2011;22(1):128-141.PubMedGoogle Scholar
35.
Borrayo  EA , Scott  KL , Drennen  AR , MacDonald  T , Nguyen  J .  Determinants of treatment delays among underserved Hispanics with lung and head and neck cancers.   Cancer Control. 2016;23(4):390-400. doi:10.1177/107327481602300410 PubMedGoogle Scholar
36.
Bandinelli  L , Ornell  F , von Diemen  L , Kessler  FHP .  The sum of fears in cancer patients inside the context of the COVID-19.   Front Psychiatry. 2021;12:557834. doi:10.3389/fpsyt.2021.557834 PubMedGoogle Scholar
37.
Islam  JY , Vidot  DC , Camacho-Rivera  M .  Evaluating mental health–related symptoms among cancer survivors during the COVID-19 pandemic: an analysis of the COVID impact survey.   JCO Oncol Pract. 2021;17(9):e1258-e1269. doi:10.1200/OP.20.00752 PubMedGoogle Scholar
38.
Hamlish  T , Papautsky  EL .  Differences in emotional distress among Black and White breast cancer survivors during the COVID-19 pandemic: a national survey.   J Racial Ethn Health Disparities. 2021;9(2):576-580. doi:10.1007/s40615-021-00990-0PubMedGoogle Scholar
39.
Goldmann  E , Hagen  D , Khoury  EE , Owens  M , Misra  S , Thrul  J .  An examination of racial and ethnic disparities in mental health during the COVID-19 pandemic in the U.S. South.   J Affect Disord. 2021;295:471-478. doi:10.1016/j.jad.2021.08.047 PubMedGoogle Scholar
40.
Flowers  P , Riddell  J , Boydell  N , Teal  G , Coia  N , McDaid  L .  What are mass media interventions made of? exploring the active content of interventions designed to increase HIV testing in gay men within a systematic review.   Br J Health Psychol. 2019;24(3):704-737. doi:10.1111/bjhp.12377 PubMedGoogle Scholar
41.
Rubin  GJ , Amlôt  R , Page  L , Wessely  S .  Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey.   BMJ. 2009;339:b2651-b2651. doi:10.1136/bmj.b2651 PubMedGoogle Scholar
42.
Armstrong  K , Ravenell  KL , McMurphy  S , Putt  M .  Racial/ethnic differences in physician distrust in the United States.   Am J Public Health. 2007;97(7):1283-1289. doi:10.2105/AJPH.2005.080762 PubMedGoogle Scholar
43.
Robinson  RV , Jackson  EF .  Is trust in others declining in America? an age–period–cohort analysis.   Soc Sci Res. 2001;30(1):117-145. doi:10.1006/ssre.2000.0692 Google Scholar
44.
Abdul-Mutakabbir  JC , Casey  S , Jews  V ,  et al.  A three-tiered approach to address barriers to COVID-19 vaccine delivery in the Black community.   Lancet Glob Health. 2021;9(6):e749-e750. doi:10.1016/S2214-109X(21)00099-1 PubMedGoogle Scholar
45.
Hung  MC , Ekwueme  DU , Rim  SH , White  A .  Racial/ethnicity disparities in invasive breast cancer among younger and older women: an analysis using multiple measures of population health.   Cancer Epidemiol. 2016;45:112-118. doi:10.1016/j.canep.2016.10.013 PubMedGoogle Scholar
46.
Pinheiro  PS , Callahan  KE , Siegel  RL ,  et al.  Cancer mortality in Hispanic ethnic groups.   Cancer Epidemiol Biomarkers Prev. 2017;26(3):376-382. doi:10.1158/1055-9965.EPI-16-0684 PubMedGoogle Scholar
47.
Merrill  RM , Sloan  A , Anderson  AE , Ryker  K .  Unstaged cancer in the United States: a population-based study.   BMC Cancer. 2011;11:402-402. doi:10.1186/1471-2407-11-402 PubMedGoogle Scholar
48.
Adams  J , Audisio  RA , White  M , Forman  D .  Age-related variations in progression of cancer at diagnosis and completeness of cancer registry data.   Surg Oncol. 2004;13(4):175-179. doi:10.1016/j.suronc.2004.08.007 PubMedGoogle Scholar
49.
Worthington  JL , Koroukian  SM , Cooper  GS .  Examining the characteristics of unstaged colon and rectal cancer cases.   Cancer Detect Prev. 2008;32(3):251-258. doi:10.1016/j.cdp.2008.08.006 PubMedGoogle Scholar
50.
Bhaskaran  K , Smeeth  L .  What is the difference between missing completely at random and missing at random?   Int J Epidemiol. 2014;43(4):1336-1339. doi:10.1093/ije/dyu080 PubMedGoogle Scholar
51.
Sterne  JA , White  IR , Carlin  JB ,  et al.  Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls.   BMJ. 2009;338:b2393. doi:10.1136/bmj.b2393 PubMedGoogle Scholar
52.
O’Kelly  M .  Multiple Imputation and Its Application. Carpenter, James and Kenward, Michael (2013). Chichester: John Wiley & Sons. 345 pages, ISBN: 9780470740521.   Biom J. 2014;56(2):352-353. doi:10.1002/bimj.201300188 Google Scholar
53.
Toutenburg H, Rubin DB.  Multiple imputation for nonresponse in surveys.   Stat Hefte. 1990;31(1):180. Google Scholar
54.
Greenland  S , Finkle  WD .  A critical look at methods for handling missing covariates in epidemiologic regression analyses.   Am J Epidemiol. 1995;142(12):1255-1264. doi:10.1093/oxfordjournals.aje.a117592 PubMedGoogle Scholar
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close