Black patients with brain tumors may be less likely to have surgery recommended to them than white patients are, according to a large U.S. study.
The research, which looked at two national databases, found that on average, Black patients were less likely to have surgery recommended for any of four types of brain tumor. That included three considered benign (non-cancerous) and one that is a deadly type of brain cancer.
Experts said the reasons for the disparity are unclear. But the nature of patients’ tumors — the size, stage or location in the brain — did not explain the gap. Nor did differences in health insurance coverage or any of the other factors the researchers were able to assess.
The findings are being published Dec. 10 in The Lancet, as part of a special issue on racial disparities in health care globally.
And they add to a body of research documenting gaps in U.S. health care, across medical specialties. Black people and Hispanic Americans often face more obstacles to accessing care, and often fare more poorly when they are diagnosed with a health condition, versus white Americans.
When it comes to cancerous brain tumors, like glioblastoma, surgery is the standard of care, said Dr. Andrew Venteicher, one of the senior researchers on the study.
Surgery may also be done to remove benign tumors, in order to relieve symptoms — like persistent headaches, hearing or vision problems, or dizziness and difficulty with balance.
But that decision is more of judgment call compared with cancerous tumors, said Venteicher, who is a neurosurgeon at the University of Minnesota in Minneapolis.
What has not been clear, he said, is whether minority patients are any more or less likely to have surgery recommended to them than white patients are.
To find out, his team used two large national databases, one maintained by the National Cancer Institute, the other by the American College of Surgeons. Together, they held decades’ worth of information on U.S. adults diagnosed with various types of brain tumors.
Overall, the study found, Black patients were 14% to 19% more likely to have a recommendation against surgery for glioblastoma, an aggressive form of brain cancer.
That was after the researchers accounted for “clinical” factors — like the size and location of the tumor — as well as patients’ overall health, insurance and whether they lived in a rural or urban area (an indicator for whether people are likely to live near a large medical center that performs a lot of surgeries).
Similarly, Black patients were anywhere from 13% to 48% more likely to have recommendations against surgery for three types of benign tumor: meningioma (the most common form of brain tumor), pituitary adenoma, and vestibular schwannoma.
“For each of four types of brain tumor, we saw a consistent result,” Venteicher said.
He did, however, point to what he called a promising finding. When researchers zeroed in on the most recent data (from 2010 to 2017), there was no longer a racial divide in recommendations for surgery to treat glioblastoma.
Venteicher noted that shortly before that period, treatment for the cancer became more standardized — with surgery, radiation and the drug temozolomide becoming the regimen of choice.
“This suggests that when you establish a treatment protocol, racial disparities may be diminished,” Venteicher said.
With benign tumors, however, the question of whether to perform surgery is more “gray,” and needs to be individualized, he said.
Dr. Julie Gralow, chief medical officer for the American Society of Clinical Oncology, pointed to a question the study cannot answer: When surgery wasn’t recommended, why was that?
It is possible that unconscious biases on the part of doctors played a role, Gralow said. But, she added, this study cannot show whether that’s the case.
Gralow said that especially in cases where the surgery decision is grayer, patients’ preferences hold a lot of weight in the discussion. Those nuances aren’t captured in a database, she noted, where a checked box indicates whether surgery was recommended.
“Do I think there could be implicit biases? Absolutely.” Gralow said. “This study should prompt more research into the ‘why.'”
In the meantime, she said, studies like this can give doctors something to think about in their own practices.
Both doctors pointed out that the study looked at broad national trends, and the findings do not mean that any one patient will be treated differently based on race.
But patients should always feel free to ask questions about any treatment recommendation, Venteicher said. That includes getting a second opinion — which, he noted, is common in the treatment of brain tumors.
The National Brain Tumor Society has more on treatment options.
SOURCES: Andrew Venteicher, MD, PhD, assistant professor, neurosurgery, and neurosurgical director, Center for Skull Base and Pituitary Surgery, University of Minnesota Medical School, Minneapolis; Julie Gralow, MD, chief medical officer, American Society of Clinical Oncology, Alexandria, Va.; The Lancet, Dec. 10, 2022
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