The Impact of Race and Socioeconomic Status on Management of Potentially Resectable Pancreatic Cancer: Analysis From a Metropolitan Area in the Southeast United States

Abstract

Background

Social determinants of health are associated with differences in care and outcomes for pancreatic ductal adenocarcinoma (PDAC) patients. This study evaluates the impact of race and socioeconomic status (SES) on the presentation, management, and survival of patients with potentially resectable PDAC within a metropolitan hospital system in the Southeast United States.

Methods

A retrospective analysis of PDAC patients (2014-2020) across a multi-hospital system was performed. Associations between race as well as socioeconomic and clinicopathologic data with presentation, treatment, and survival were analyzed.

Results

Among 222 patients, 104 (46.9%) were Black and 118 (53.1%) were White. Black patients presented at a significantly younger age (61 vs 66, P = 0.007) and resided within the lowest 2 quintiles for median income (68.2% vs 42.4%, P < 0.0001). Compared with White patients, Black patients were more likely to have Medicaid/no insurance (22.1% vs 11.9%, P = 0.040). Receipt of multimodal therapy and curative intent resection was not significantly different between Black and White patients (80% vs 84.3%, P = 0.372; 46% vs 54.6%, P = 0.275), ≤50th percentile vs > 50th percentile income (79.5% vs 85.1%, P = 0.358; 47.6% vs 53.8%, P = 0.428), or Medicare/private vs Medicaid/no insurance (84.4% vs 71.4% P = 0.120; 50% vs 53.8%, P = 0.719). On survival analysis, outcomes were determined by receipt of multimodal treatment and histopathological factors but did not differ based on race or SES.

Discussion

This analysis demonstrates that patients with PDAC can receive similar treatment despite differences in race and SES. Interestingly, Black patients presented at a significantly younger age, warranting further evaluation of risk factors and tumor biology.

Keywords

pancreas socioeconomic surgical oncology

Key Takeaways

• Treatment of patients with pancreatic ductal adenocarcinoma can be equivalent despite differences in race and socioeconomic status

• Black patients present at a significantly younger age which could be due to race specific risk factors and/or tumor biology

• Future investigation of the impact of social determinants of health on the outcomes of cancer patients should be performed at the local level to gain actionable insights into these patterns

Introduction

Although there is a rising incidence of pancreatic ductal adenocarcinoma (PDAC), survival rates remain poor. As seen in other malignancies, there is population-based data demonstrating an association between social determinants of health and differences in the presentation of PDAC patients and inequalities in the delivery of optimal cancer therapy. At a national level, Black patients are reported to have a 40%-90% higher incidence of being diagnosed with PDAC, often at a younger age and with more advanced disease when compared to other racial groups.^1-3 Studies using large administrative databases have shown lower rates of multimodal therapy and curative intent surgery among Black patients, those without insurance, and patients considered to have lower socioeconomic status (SES).^1-7

While these studies demonstrate overarching trends in PDAC disparities at a national level, the observed outcomes stem from multiple factors and are expected to differ among institutions, communities, and regions. Without investigation at a more granular, local level, these disparities cannot be fully understood or effectively addressed. The current study examines the presentation, management, and survival of patients with potentially resectable PDAC in a hospital system that services a community with a large, socioeconomically disparate, Black population in the Southeast United States. We hypothesized that Black patients would present with more advanced disease, be less likely to receive optimal oncologic management, and have inferior outcomes compared to White patients. This evaluation was intended to identify differences in disease presentation and delivery of therapy to better understand how potential disparities might be addressed at the local level.

Methods

A retrospective analysis of patients diagnosed with PDAC from 2014-2020 across a multi-hospital system affiliated with the University of Tennessee Heath Science Center (UTHSC) in Memphis, TN, was performed. Institutional Review Board review at UTHSC was performed and approval was granted. Cases were identified based on an institutional tumor registry utilizing ICD-10 codes for PDAC. Patients were excluded if race was other than Black or White (these patients made up a small portion of the database: 1.2% Hispanic). The patient cohort was divided into 2 racial groups: Black and White. Patient demographics including age, gender, race, income status (based on median income by zip code), insurance status, and Charlson comorbidity index (CCI) were collected. Patients were stratified into income quintiles based on reported state percentiles from the 2022 United States Census Bureau⁸ with the fifth quintile indicating the highest median income. Clinical, operative, and pathologic features were captured including tumor location, resectability status at presentation, type of resection performed, pathologic stage based on the American Joint Committee on Cancer (AJCC) eighth edition schema, and histologic features including lymphovasular invasion (LVI), perineural invasion (PNI), tumor grade, and resection margin. Patients were deemed resectable, borderline resectable, or locally advanced based on anatomic criteria as defined by the National Comprehensive Cancer Network.⁹ Patients were also classified as borderline resectable based on poor performance status at the time of diagnosis. Disease specific survival (DSS) was calculated in months and analyzed.

Descriptive statistics (reported as medians with interquartile range) were used to characterize the patient population where applicable. χ² analysis was performed for categorical variables while continuous variables were analyzed using Student’s t-test or the Wilcoxon rank sum test where appropriate. Primary outcomes were evaluated using survival analysis. Patients without the primary outcome of death or loss to follow‐up were considered censored. Kaplan-Meier curves and median survival were calculated for both groups and compared in a univariable manner using the log‐rank test. Variables exhibiting significance less than 0.2 were considered for inclusion in the full multiple regression model. Multivariable regression analysis was performed to determine significant predictors for DSS using a Cox‐Proportional Hazards model. All clinically relevant interaction terms were examined. Statistical significance was set at P < 0.05 and derived from two-tailed tests. The 95% confidence intervals were provided where applicable. All analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC).

Results

Over the study period, 222 patients were identified with PDAC; 104 (46.9%) were Black and 118 (53.1%) were White. Median age at diagnosis was significantly lower for Black compared to White patients (61 vs 66, P < 0.007). Approximately 55% of the entire cohort was female. Among Black patients, the majority was female (66.4%); among White patients, the majority was male (56.8%). Black patients were more likely to reside within the lowest 2 quintiles for median income (68.2% vs 42.4%, P < 0.0001). Between both racial groups, the majority had private insurance or Medicare; however, compared to White patients, Black patients were more likely to have Medicaid/no insurance (22.1% vs 11.9%, P = 0.04). Tumor location and clinical stage at presentation were not significantly different between the cohorts (Table 1).

Table 1.

Comparison of Demographics and Presenting Characteristics Between African American and White Patients With Pancreatic Cancer (N = 222)

Characteristic	Black (N = 104) (46.9%)	White (N = 118) (53.1%)	P-value
Median age (IQR)	61 (56-69)	66 (60-73)	0.0007
Gender			0.0006
Male	35 (33.6)	67 (56.8)
Female	69 (66.4)	51 (43.2)
Median BMI (IQR)	26.6 (23-31.3)	26.1 (22.4-30.1)	0.187
Diabetes mellitus			0.656
Present	34 (30.8)	34 (28.8)
Absent	70 (67.3)	84 (71.2)
Smoking history			0.358
Present	54 (51.9)	66 (55.9)
Absent	50 (48.1)	52 (44.1)
Income			< 0.0001
1^st quintile	12 (11.5)	1 (0.9)
2^nd quintile	59 (56.7)	49 (41.5)
3^rd quintile	26 (25)	31 (26.3)
4^th quintile	7 (6.8)	30 (25.4)
5^th quintile	0 (0)	7 (5.9)
Income			0.0001
≤50^th percentile	71 (68.3)	50 (42.4)
>50^th percentile	33 (31.7)	68 (57.6)
Health insurance			0.04
State-sponsored/none	23 (22.1)	14 (11.9)
Private/Medicare	81 (77.9)	104 (88.1)
Tumor location			0.151
Head/Uncinate	80 (76.9)	76 (64.4)
Neck	11 (10.6)	25 (21.2)
Body	11 (10.6)	15 (12.7)
Tail	2 (1.9)	2 (1.7)
Clinical stage at presentation			0.283
Resectable	26 (25)	40 (33.9)
Borderline resectable	29 (27.8)	33 (27.9)
Locally advanced/Metastatic	49 (47.2)	45 (38.1)

Abbreviations: IQR, interquartile range.

Bold text denotes statistical significance (P-value<0.05).

After excluding patients with locally advanced/unresectable or metastatic disease, 22 patients were too frail/elderly to pursue any aggressive cancer directed therapy, and 15 patients were lost to follow up. The final study cohort included 91 patients considered to have potentially resectable disease. As shown in Table 2, Black patients remained significantly younger and more likely to reside in the lowest income quintiles. Although Black patients in this potentially resectable cohort were more likely to have Medicaid/no insurance compared to White patients, this was not statistically significant (23.7% vs 11.3%, P = 0.117). Of these 91 patients, 9 (9.9%) had aborted resection for occult metastases or more locally advanced disease at exploration; 82 (90.1%) completed curative intent pancreatectomy. There were no differences in tumor‐specific histopathologic features including T or N class, margin status, presence of LVI or PNI, and tumor grade between Black and White patients (Table 3). As shown in Table 4, race, income, and insurance status did not influence completion of curative intent surgery.

Table 2.

Comparison of Demographics and Presenting Characteristics Between African American and White Patients With Potentially Resectable Pancreatic Cancer Undergoing Surgery (N = 91)

Characteristic	Black (N = 38) (42%)	White (N = 53) (58%)	P-value
Median age (IQR)	61.5 (57-69)	65 (59-72)	0.032
Gender			0.001
Male	12 (31.6)	35 (66)
Female	26 (68.4)	18 (34)
Median BMI (IQR)	27.2 (23.4-32.9)	26.5 (21.6-30.8)	0.123
Diabetes mellitus			0.588
Present	7 (18.4)	11 (20.7)
Absent	31 (83.8)	42 (79.3)
Smoking history			0.042
Present	14 (36.8)	22 (41.5)
Absent	24 (41.5)	31 (58.5)
Income			0.025
1^st quintile	5 (13.2)	1 (1.9)
2^nd quintile	18 (47.4)	20 (37.7)
3^rd quintile	12 (31.6)	15 (28.3)
4^th quintile	3 (7.9)	13 (24.5)
5^th quintile	0 (0)	4 (7.6)
Income			0.05
≤50^th percentile	23 (60.5)	21 (39.6)
>50^th percentile	15 (39.5)	32 (60.4)
Health insurance			0.117
State-sponsored/none	9 (23.7)	6 (11.3)
Private/Medicare	29 (76.3)	47 (88.7)
Tumor location			0.289
Head/Uncinate	33 (86.8)	38 (71.7)
Neck	3 (7.9)	11 (20.8)
Body	2 (5.3)	3 (5.7)
Tail	0 (0)	1 (1.9)
Clinical stage at presentation			0.477
Resectable	20 (52.6)	35 (66)
Borderline resectable	18 (48.4)	18 (34)

Abbreviations: IQR, interquartile range.

Bold text denotes statistical significance (P-value<0.05).

Table 3.

Comparison of Treatment and Clinicopathologic Characteristics Between Black and White Patients Completing Curative Intent Surgery (N = 82)

Characteristic	Black (N = 35)	White (N = 47)	P-value
Curative intent surgery	35 (42.7)	47 (57.3)	0.275
Median age (IQR)	61 (54-68)	65 (59-72)	0.033
Median charlson comorbidity index (total, 10-year survival)	4 (3-5)	4 (4-6)	0.059
AJCC tumor classification			0.379
Tx	0 (0)	1 (2.1)
T0	2 (5.7)	1 (2.1)
Tis	2 (5.7)	0 (0)
T1	10 (28.6)	9 (19.2)
T2	16 (45.7)	25 (53.2)
T3	5 (14.3)	10 (21.3)
T4	0 (0)	1 (2.1)
AJCC node classification			0.174
N0	16 (45.7)	26 (55.3)
N1	12 (34.3)	18 (38.3)
N2	7 (20)	3 (6.4)
Median no. Of lymph nodes evaluated (IQR)	18 (10-23)	15 (10-24)	0.409
Mean lymph node positive	1 (0-3)	0 (0-2)	0.097
Grade
Well differentiated	8 (22.8)	14 (29.8)	0.583
Moderately differentiated	24 (68.6)	27 (57.4)
Poorly differentiated	3 (8.6)	6 (12.8)
Margin status
R0	28 (80)	35 (74.5)	0.557
R1	7 (20)	12 (25.5)	0.557
Lymphovascular invasion
No	26 (72.3)	32 (68.1)	0.542
Yes	9 (25.7)	15 (31.9)	0.542
Perineural invasion
No	14 (40)	15 (31.9)	0.449
Yes	21 (60)	32 (68.1)	0.449
Median time of follow up	22.1 (6.1-39.3)	16.3 (3.9-26.5)	0.171

Abbreviations: IQR, interquartile range.

Table 4.

Comparison of the Impact of Demographic and Socioeconomic Factors on Receipt of Curative Intent Surgery

Characteristic	Curative surgery N = 82 (%)	P-value
Race		0.275
Black	35 (46)
White	47 (54.6)
Income		0.428
≤50^th percentile	40 (47.6)
>50^th percentile	42 (53.8)
Insurance		0.719
State-sponsored/none	14 (53.8)
Private/Medicare	68 (50)

Among the 91 potentially resectable patients, 75 (82%) received multimodal therapy. As shown in Table 5, race, income, and insurance status did not significantly impact this treatment. In line with national guidelines, all patients with borderline resectable PDAC received neoadjuvant chemotherapy +/− chemoradiation. Among 40 patients with anatomically resectable disease that underwent upfront surgery, 24 (60%) received adjuvant chemotherapy (Table 6). While there were similar rates of adjuvant therapy regardless of race and income, only 2 of 6 (33%) patients with Medicaid/no insurance received adjuvant therapy compared to 22 of 34 (64.7%) with private insurance/Medicare (P = 0.018).

Table 5.

Comparison of the Impact of Demographic and Socioeconomic Factors on Receipt of Any Multimodality Treatment on Patients Undergoing Surgery

Characteristic	Multimodality treatment N = 75 (82%)	P-value
Race (N)		0.372
Black (40)	32 (80)
White (51)	43 (84.3)
Income		0.358
≤50^th percentile (44)	35 (79.5)
>50^th percentile (47)	40 (85.1)
Insurance		0.120
State-sponsored/none (14)	10 (71.4)
Private/Medicare (77)	65 (84.4)

Table 6.

Comparison of the Impact of Demographic and Socioeconomic Factors on Patients Undergoing Upfront Resection Receiving Adjuvant Treatment

Characteristic	Adjuvant treatment N = 24 (60%)	P-value
Race (N)		0.356
Black (16)	11 (68.8)
White (24)	13 (54.2)
Income		0.301
≤50^th percentile (21)	12 (57.1)
>50^th percentile (19)	12 (63.1)
Insurance		0.018
State-sponsored/none (6)	2 (33)
Private/Medicare (34)	22 (64.7)

Bold text denotes statistical significance (P-value<0.05).

For patients completing curative‐intent resection, median follow up was 22.1 months for Black patients and 16.3 months for White patients. Univariable log rank analysis for predictors of DSS is shown in Table 7. Median DSS was 21 months for Black and 16.2 months for White patients (P = 0.145). Patients in the ≤50^th percentile income did have a lower median DSS than those in the >50 percentile; however, this did not reach significance (11.3 vs 18.8 months, P = 0.066). DSS was similar between patients with Medicaid/no insurance and those with private insurance/Medicare (17.5 vs 18.8 months, P = 0.482). Factors found to result in significant differences in survival included surgery alone vs multimodal therapy, lymph node status, PNI, tumor grade, and resection margin status. On multivariable Cox regression analysis including factors that approached significance on univariable analysis, only margin status (HR 2.372, 95% CI 1.012-5.289, P = 0.0392) was an independent predictor of DSS (Table 8).

Table 7.

Univariable Analysis of Predictors of Disease Specific Survival for Patients Undergoing Curative Intent Surgery

Characteristic (N = 82)	Median OS in months (IQR)	P-value
Age		0.903
<65 (46)	16.1 (5.7-38.7)
>65 (36)	17.1 (5-30.5)
Gender		0.107
Female (38)	20.3 (6.3-39.4)
Male (44)	13 (2.8-47.9)
Race		0.145
Black (35)	21 (6.5-39.4)
White (47)	16.2 (4.6-27.6)
Income		0.102
≤50^th percentile (40)	11.3 (2.4-30.6)
>50^th percentile (42)	18.8 (7.5-33.1)
Insurance		0.482
State-sponsored/none (14)	17.5 (1.5-26)
Private/Medicare (68)	16.3 (5.8-32.5)
Initial status		0.066
Resectable (47)	20.7 (13.1-45.2)
Borderline resectable (35)	18.8 (11.4-43.4)
Treatment		0.027
Surgery only (15)	12.4 (2.1-28)
Multimodal therapy (67)	19.2 (6.4-33.1)
AJCC tumor classification		0.062
T0 (3)	58.6 (39.7-68.9)
Tis (2)	27.4 (16.1-38.7)
T1 (19)	17.4 (7.5-27.4)
T2 (41)	11.3 (2.5-31.9)
T3 (15)	17.8 (9.1-28)
T4 (1)	53.4
Lymph node status		0.003
Negative (44)	24.6 (9.4-41.5)
Positive (38)	9.4 (2-23)
Lymphovascular invasion		0.057
Negative (58)	19.9 (6.3-38.7)
Positive (24)	10.2 (2.3-26.8)
Perineural invasion		0.011
Negative (29)	24.6 (13.7-39.7)
Positive (53)	11.4 (2.5-27.6)
Grade		0.012
Well differentiated (22)	21 (6.1-39)
Moderately differentiated (51)	12.1 (2-25.9)
Poorly/Undifferentiated (9)	47.9 (18.8-53.5)
Resection margin		0.003
R0 (68)	21.5 (6.9-38.7)
R1 (14)	5.3 (2-13)

Bold text denotes statistical significance (P-value<0.05).

Table 8.

Multivariable Analysis of Predictors of Disease-specific Survival for Patients Who Completed Curative Intent Surgery

Variable	Univariable			Multivariable
Variable	HR	95% CI	P-value	HR	95% CI	P-value
Age ≥65	1.026	0.550 to 1.907	0.9354
Male gender	1.867	0.954 to 3.755	0.0716
Black	0.596	0.297 to 1.146	0.1299
≤50^th percentile income	1.687	0.720 to 3.498	0.1887
Borderline resectable	0.562	0.290 to 1.051	0.0770
Surgery only	2.200	1.048 to 4.291	0.0267	2.218	0.884 to 5.353	0.0805
Lymph node positive	2.101	1.132 to 3.937	0.0187	1.861	0.881 to 4.011	0.1066
Lymphovascular invasion	1.963	0.977 to 3.749	0.0473	0.607	0.264 to 1.352	0.2270
Perineural invasion	3.036	1.532 to 6.565	0.0025	2.470	0.972 to 6.730	0.0648
R1 margin	2.618	1.273 to 5.068	0.0058	2.372	1.012 to 5.289	0.0392

Abbreviations: HR, Hazard Ratio; CI, confidence interval.

Bold text denotes statistical significance (P-value<0.05).

Discussion

The current study evaluates the presentation, treatment, and DSS of PDAC patients within a hospital system in Memphis, TN, that services a predominantly Black population with socioeconomic disparities. The analysis found that Black patients were more likely to present at younger age but had similar clinical stage at presentation and histopathological features compared to White patients. Importantly, despite socioeconomic disparities between Black and White patients in this study, there was no significant difference in the completion of curative intent surgery, receipt of multimodal therapy, or DSS.

Previous studies have reported a higher incidence of PDAC among Black patients compared to other racial groups.^3,5,10,11 However, the demographic pattern within these studies mirrors that of the national population with Black patients representing a minority (<15%). In contrast, Black patients account for 65% of the population in Memphis, TN.⁸ The distribution of cases in this analysis suggests that within this community the incidence of PDAC cases is not higher among Black patients. Notably, the median age at diagnosis among Black patients was 61, which is significantly lower than White patients within the community and much lower than the national average of 70.¹² Although prior studies have also identified a younger age at diagnosis among Black patients with PDAC,¹³ the median age of 61 in the current study is much lower than Black patients within national cohorts. When examining known modifiable risk factors for PDAC such as smoking, obesity, and diabetes as potential explanations for this age discrepancy, we did not identify a difference between Black and White patients. However, the true impact of these risk factors accounting for racial disparities in PDAC is unclear.¹⁴ Moreover, these observed differences are likely related to the interaction between known risk factors as well as diet,¹⁵ genetics,¹⁶ and the intestinal/pancreatic microbiome.^17,18 Ultimately, understanding differences in the incidence and age at diagnosis between racial and socioeconomic groups will require deeper translational investigation.

Although survival rates remain low for all stages of PDAC, resection offers the only opportunity for cure and can significantly prolong life in appropriately selected patients. Several studies have demonstrated that curative intent resection is performed less often in Black compared to White patients.^11,19-23 Some of these studies have reported that Black patients were less likely to be offered resection,^6,20,24 while others demonstrated equal rates of being offered resection between racial groups with Black patients less likely to undergo pancreatectomy.^11,21 In addition to Black race, lower rates of resection have been reported among patients with lower SES assessed by insurance, income, and education.^3,5,25

While resection is critical to potential cure and improving outcomes, multimodal therapy undoubtedly enhances these goals for patients with PDAC. Specifically, systemic chemotherapy is known to increase overall survival.^1,26-28 Unfortunately, similar to lower rates of resection, Black patients and those with lower SES have repeatedly been found less likely to receive multimodal care.^{1,6,13,18,26,27,29} A study using the Surveillance, Epidemiology, and End Results Registry and Medicare databases reported that Black patients were significantly less likely to have consultations with cancer specialists including medical oncology, radiation oncology, and surgery.²² Black patients in that study were more likely to reside in lower income areas.²² On multivariable analysis of patients with locoregional disease, even after seeing a specialist, Black patients remained significantly less likely to receive chemotherapy and resection compared to White patients.²² A similar study using a Florida cancer registry and inpatient hospital data found that patients of low SES were less likely to receive surgery, chemotherapy, or radiation and had significantly higher morbidity and mortality rates.²⁹ Factors such as inability to pay or having non-private insurance, lack of transportation, and limited social support are inherent obstacles to access and delivery of cancer directed therapy.

Given the above findings from national studies, we were encouraged by the results of the current analysis, as this work was initiated to identify potential gaps in care within the system and community that could be targeted for improvement. There are several factors that influenced the observed findings. First, many patients likely entered the system via emergency department admissions with provisions made by the hospital system and affiliated providers to deliver subsequent care regardless of insurance status. Second, although the patient cohort is from a community hospital system, it is affiliated with an academic medical center, and the surgeons involved in this study are academic surgical oncologists with expertise in pancreatic cancer care. Third, over the last decade, there has been an increased effort to review patients who are potential surgical candidates in a non-hospital based, community-wide, multidisciplinary hepato-pancreato-biliary tumor board led by academic surgeons with participation from both academic and non-academic medical oncology, radiation oncology, genetics, gastroenterology, radiology, and advanced-practice providers. This community-inclusive approach has greatly facilitated treatment planning and coordination of care between physicians working in different specialty groups. Finally, there are multiple sites for chemotherapy infusion and radiation therapy within the community, which may have limited the need to travel distances that might otherwise preclude these treatments in patients with low SES. While these factors likely helped achieve similar care between the 2 groups in this analysis, it is appreciated that this does not apply to every community or health care system.

That equivalent care and outcomes can be delivered to Black and socioeconomically disparate populations with PDAC has been demonstrated previously. A National Cancer Database analysis by Dhar et al³⁰ found that patients treated in “safety net hospitals,” defined as those having the highest quartile of Medicaid and uninsured patients, achieved similar rates of resection, chemotherapy, chemoradiation, and overall survival. However, the authors of that study highlight the potential negative impact of federal programs, such as the Hospital Readmissions Reduction Program and Hospital Acquired Condition Reduction Program, resulting in financial penalties for these safety net hospitals. While these policies seem well intended, safety net hospitals are inherently at higher risk of patients having longer hospital stays and unplanned readmissions given the patient populations they serve. It would seem appropriate that in the future policymakers consider metrics such as providing equal cancer care to disparate populations when designing federal reimbursement incentives for hospitals and health care systems.

Limitations of the current study include its retrospective nature and relatively small sample size. The patients studied were identified through the tumor registry of 1 of 4 major hospital systems in the community; therefore, it is possible that the findings might vary if patients from the other hospitals were included. However, the makeup of patients within the study likely reflects the overall population within the region secondary to location and referral patterns. Some patients were lost to follow-up following initial resection and thus were unable to contribute to survival data, leading to a possibility for loss to follow-up bias. In addition, the current study does not address other important factors that should be considered in PDAC patients, such as quality-of-life assessments and palliative care and hospice transitions when necessary. In future evaluations, it will be important to assess the impact of timing between diagnosis and specialty referral and initiation of treatment.

In conclusion, the current study demonstrates that equal care can be provided to Black and White patients with PDAC despite socioeconomic disparities. Notably, the median age at diagnosis among Black patients was much lower than the national average as well as Black cohorts in prior studies. Efforts into better understanding the potential interplay between race, modifiable habits, diet, and socioeconomic factors with molecular drivers of disease are needed to better understand this finding. While previous studies have relied on large national databases to analyze the effects of race and SES among PDAC patients, we encourage other groups to examine these factors within their own hospital system and community to identify ways to close local gaps in cancer care disparities.

Footnotes

Author Note

DP, SB, AF, EG, GA, PD: conceptualization, methodology, investigation, data curation, writing and editing of the final manuscript.

ORCID iDs

Andrew M. Fleming

Gabriela L. Aitken

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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