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Invited Commentary
June 9, 2021

Addressing Social Risk and Support as Adjuvants in Colorectal Cancer Treatment

Author Affiliations
  • 1Division of Gastroenterology and Hepatology, Department of Medicine, NYU Grossman School of Medicine, New York, New York
JAMA Netw Open. 2021;4(6):e2113651. doi:10.1001/jamanetworkopen.2021.13651

Although colorectal cancer (CRC) is one of the deadliest malignant entities in both men and women, it is also recognized as one of the most preventable through timely screening, yet disparities persist in screening. Beyond prevention, early detection of CRC provides an opportunity for appropriate treatment, as well as improved survival rates. Notably, following surgical resection of stage III (node-positive) disease, adjuvant chemotherapy has a substantial effect on disease-free survival rates beyond 5 years,1 yet disparities persist in treatment. Although CRC-associated death rates have been declining in the US, they remain highest among Black adults, who often receive a diagnosis at a later stage and have lower rates of chemotherapy treatment compared with non-Hispanic White patients.2 To decrease mortality, the factors contributing to these disparities need to be further understood and addressed, especially the extent to which social determinants of health (SDOH), as well as social needs, are associated with CRC treatment.

In their current study, Davis et al3 performed a population-based survey of 1087 patients with stage III CRC to evaluate whether cumulative social risk is associated with lower chemotherapy use. In addition, they assessed whether the presence of social support for such patients mitigated the deleterious associations of cumulative social risk. Black, female, or older participants had higher cumulative social risk compared with White, male, or younger participants. Moreover, those with 3 or more social risk factors were significantly less likely than those with 0 risk factors to undergo chemotherapy as planned. The social risks most likely to be associated with decreased use of chemotherapy included lower health literacy, lack of a spouse or partner, lower household income, and experiencing everyday discrimination. Social support reduced the association with cumulative social risk and was independently associated with chemotherapy use.

The findings from this study echo those from the Institute of Medicine (now the National Academy of Medicine) 2002 report,4 which found that differences in health care occurred in the background of broader social and economic inequality along with continuing racial and ethnic discrimination. The conditions in which people are born, live, and work can impact their health and are defined by the World Health Organization as SDOH.5 Davis et al3 provide a view of a significant dose-response association with SDOH, producing health inequity in CRC treatment. The study’s findings also contribute further evidence for a key Institute of Medicine report2 recommendation to help patients navigate the health care system with support structures as part of an innovative strategy to address health disparities. Why are certain groups potentially more susceptible to the lack of such support?

The promise of health equity is that it ensures conditions for the optimal health of all people by accounting for the differences in lived experiences. The stark realities of such differences were laid bare during the COVDI-19 pandemic in a manner that could not be ignored. Against the backdrop of racial and ethnic disparities in COVID-19 outcomes and the US national awakening of racial injustice, we arrived at a moment of clarity to reconcile that health equity cannot be regarded as a zero-sum game. In fact, we have been awakened to the intersectionalities of population health and the heavy cost of not implementing evidenced-based plans that seek to appropriately address SDOH.

For Black adults, the factors that allow for inequities across the CRC care continuum have metastatic roots beyond the clinical office that should be diagnosed and treated with a comprehensive care plan just as carefully as the malignant entity itself. Data have shown that in an equal access system, racial disparities in chemotherapy and surgery were not observed, highlighting that equalizing access to care will positively impact its quality.6 The environment that promotes these health inequities must, therefore, be modified and resources assigned according to need and requirement. Within the institution of medicine, it is imperative that we understand structural competence and the critical distinction between equality and equity. As Davis et al noted,3 low income and lack of steady employment accumulate as social risks. Income supplement programs in natural experiments have been found to be associated with health, whereas employment interventions for economically vulnerable groups suggest that they can be effective in reducing health disparities.7

The vision for the delivery of personalized medicine should go beyond the molecular realm by also aiming to systematically assess patients for increased social risks and addressing them as part of a holistic care plan, recognizing that many of these individuals will be members of historically marginalized groups. The potential of implementing social support interventions to mitigate cumulative social risks that adversely affect CRC treatment has therapeutic value not only for patients but for the entire health care system because they can reduce overall cost while improving quality. Indeed, conceptualizing and implementing solutions to address racial disparities as we move toward health equity requires a more integrative approach through the lens of social determinants of health. We cannot fix medical issues such as CRC in the vacuum of surgery and chemotherapy; instead, we must address social risks by providing social support as key adjuvants.

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Article Information

Published: June 9, 2021. doi:10.1001/jamanetworkopen.2021.13651

Correction: This article was corrected on July 6, 2021, to correct the spelling of the first author’s name.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Francois F et al. JAMA Network Open.

Corresponding Author: Fritz Francois, MD, MScI, Division of Gastroenterology and Hepatology, Department of Medicine, NYU Grossman School of Medicine, 530 First Ave, HCC-3F, New York, NY 10016 (

Conflict of Interest Disclosures: Dr Williams reported owning stock in Boston Scientific. No other disclosures were reported.

Sargent  D, Sobrero  A, Grothey  A,  et al.  Evidence for cure by adjuvant therapy in colon cancer: observations based on individual patient data from 20,898 patients on 18 randomized trials.   J Clin Oncol. 2009;27(6):872-877. doi:10.1200/JCO.2008.19.5362PubMedGoogle ScholarCrossref
Simpson  DR, Martínez  ME, Gupta  S,  et al.  Racial disparity in consultation, treatment, and the impact on survival in metastatic colorectal cancer.   J Natl Cancer Inst. 2013;105(23):1814-1820. doi:10.1093/jnci/djt318PubMedGoogle ScholarCrossref
Davis  RE, Trickey  AW, Abrahamse  P, Kato  I, Ward  K, Morris  AM.  Association of cumulative social risk and social support with receipt of chemotherapy among patients with advanced colorectal cancer.   JAMA Netw Open. 2021;4(6):e2113533. doi:10.1001/jamanetworkopen.2021.13533Google Scholar
Nelson  A.  Unequal treatment: confronting racial and ethnic disparities in health care.   J Natl Med Assoc. 2002;94(8):666-668.PubMedGoogle Scholar
World Health Organization. World Conference on Social Determinants of Health: case studies on social determinants. Published 2014. Accessed April 21, 2021.
Gill  AA, Enewold  L, Zahm  SH,  et al.  Colon cancer treatment: are there racial disparities in an equal-access healthcare system?   Dis Colon Rectum. 2014;57(9):1059-1065. doi:10.1097/DCR.0000000000000177PubMedGoogle ScholarCrossref
Thornton  RLJ, Glover  CM, Cené  CW, Glik  DC, Henderson  JA, Williams  DR.  Evaluating strategies for reducing health disparities by addressing the social determinants of health.   Health Aff (Millwood). 2016;35(8):1416-1423. doi:10.1377/hlthaff.2015.1357PubMedGoogle ScholarCrossref
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