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Invited Critique
February 1, 2004

Racial Disparities in Rectal Cancer Treatment—Invited Critique

Arch Surg. 2004;139(2):156. doi:10.1001/archsurg.139.2.156

Significant variation in the care of the patient with rectal cancer has been noted by numerous authors.1,2 Variations based on surgical subspecialization, hospital volumes, and surgeon volumes have all been subject to intense scrutiny. Morris and colleagues looked at the treatment of the patient with rectal cancer, using the SEER database, and found significant differences based on the patient's race. Specifically, they found that sphincter salvage procedures were less likely to be applied to African American patients than to white patients. Additionally, the authors found that most white and African American patients did not receive radiation therapy for stage II to III rectal cancer, contrary to the 1990 National Institutes of Health consensus conference, with African Americans again being less likely than whites to receive radiation therapy. I found this article to be interesting and thought provoking. In recent years, the medical literature has been relatively replete with subanalyses of large publicly available databases such as SEER. These large databases have inherent strengths (mainly in their large numbers), and they have inherent weaknesses, some of which are highlighted by this article. To begin with, the authors imply that physicians are consciously or subconsciously treating African American patients differently from white patients (note specifically their concluding sentence). They seem to believe that a physician would treat a patient with an abdominoperineal resection vs a low anterior resection simply because the patient is African American rather than white. On the surface, this is insulting, particularly to a physician who has spent more than a decade of his career treating patients at a large, county-run teaching hospital that focuses on the care of indigent and minority patients. A far more likely explanation is that socioeconomic factors and surgeons' specialization affected the outcomes observed in the SEER database. This difference has been observed by others.1,3,4 Further influencing factors may have been hospital volume and/or the treating surgeons' volume of cases, which have also been shown to influence the rate of sphincter-sparing procedures.2