Increased Public Assistance Tied to Better Cancer Survival in Black Patients

CHICAGO — Overall survival (OS) in Black patients with cancer improved significantly, and racial disparities in cancer survival decreased, with increased state-level spending on public welfare programs, a large retrospective review showed.

Every 10% increase in public welfare spending was associated with an 8.6% improvement in cancer survival among Black patients, almost four times greater than the overall increase in survival when looking at all patients with cancer. At the same time, the longstanding Black/white disparity in cancer survival declined by more than 40% with the additional spending, reported Justin Barnes, MD, of Washington University in St. Louis.

Whether the increased investment in public welfare related specifically to healthcare or to other factors remains unclear, Barnes said during a press briefing that preceded the American Society of Clinical Oncology annual meeting.

“I see these data as a proof-of-concept project,” said Barnes. “Some sort of public welfare investment seems to be helping improve oncologic outcomes for some of our most socioeconomically at-risk patients, but we don’t know the specifics. Future works is needed to determine the specific most influential public welfare expenditures. If we can do this, we can more rigorously evaluate state-level policies and their associations with cancer outcomes.”

“Understanding the specific beneficial policies can lead to future advocacy efforts, then hopefully, ultimately, policy changes that will improve outcomes for all our patients and help close the gap in race-based disparities,” he stated.

The study added to existing evidence that investment in public welfare “can mitigate structural racism and at least partially address social determinants of health, such as financial stability, education, place of residence, and insurance status,” said ASCO chief medical officer Julie Gralow, MD.

“This research found that states that increased public welfare spending have improved the overall survival for Black patients with a variety of solid tumors and also resulted in a decrease in racial disparities between non-Hispanic Black and white patients,” she said. “This important data provides clear support for the benefits of an investment in public welfare spending at the state level, including Medicaid expansion.”

Barnes noted that Black patients with cancer have worse 5-year OS as compared with whites (63% vs 68% as of 2019). Though multifactoral, racial disparities in healthcare are thought to be related in part to reduced access to care and to various social determinants of health and structural racism, such as income, education, and place of residence.

State-level spending on public welfare programs varies and includes multiple assistance programs, such as cash assistance and Medicaid. Overall, states spend about $2,000 per capita on public welfare programs, about 22% of state budgets. However, the actual share of spending devoted to public welfare varies from 9% to 31% across different states.

“Since state public welfare spending directly addresses at least some of the social determinants of health and could impact cancer outcomes, we hypothesized that higher investment in public welfare could be associated with narrower disparities in cancer outcomes,” said Barnes.

To investigate the hypothesis, Barnes and colleagues analyzed data from the NCI Surveillance, Epidemiology, and End Results (SEER) program for adults with newly diagnosed cancer during 2007 to 2016. The SEER database encompasses 13 states that constitute 28% of the U.S. population. Investigators also analyzed U.S. Census Bureau annual spending data for the 13 states, including statistics on public welfare spending.

The analysis included 2.9 million patients, and the primary outcome of the study was 5-year OS.

Overall, the results showed that with every 10% increase in public welfare spending, 5-year OS improved by 2.4% for all patients with all cancers, including a 2.6% improvement for white patients with cancer and an 8.6% improvement for Black patients. A 10% increase in public welfare spending would reduce the current Black/white disparity in cancer survival of 10.8% by about 4.6%, said Barnes.

The association between increased public welfare spending and improved OS for Black patients was consistent across multiple types of cancer, including solid tumors and hematologic malignancies. The improved survival reduced the Black/white disparity by about 40%-50% across different types of cancer.