Assessment of social determinants of health (SDOH) in patients with non-metastatic cancer: Real-world evidence from a large geographically representative community oncology network.
Authors: Osterland Andrew Joseph , Wang Yunfei , Wilson Thomas W. , Paulus Jessica K. , Patton Gregory , Firozvi Kashif Alam , Desai Kaushal 
Published: September 2024

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Background:
Understanding the impact of SDOH is essential for addressing health disparities in early detection and cancer care. This study evaluated race and socioeconomic status (SES) as social determinants of early-stage diagnosis and time to metastasis or death (TTMd) among patients diagnosed with non-metastatic cancers.
Methods:
This was a retrospective observational cohort study of patients diagnosed with non-metastatic head & neck squamous cell carcinoma (HNSCC); non-small cell lung cancer (NSCLC); triple-negative or hormone receptor-positive breast cancer (BC); gastric, bladder or kidney cancer; or melanoma. Patients were indexed at earliest diagnosis in The US Oncology Network between 1/1/17 and 6/30/22 andfollowed through 6/30/23. SES was measured using the state area deprivation index (ADI). Disease stage was assessed within 90 days of initial diagnosis. Kaplan-Meier analyses of TTMd were conducted by tumor type. A Cox proportional hazards model was used to evaluate associations between SDOH and TTMd across tumors.
Results:
The cohort included 109,935 patients (54% BC, 20% NSCLC, 6% bladder, 6% HNSCC, 14% other). Of patients with available data, mean (SD) age was 64.8 (13.0) years, 84% were White, 5% were Hispanic, 6% had Medicaid, and 25% resided in the least deprived ADI quintile (Q1). Disease stage (% of N available) and median (95% CI) TTMd in months for tumors with observed variations by SDOH are presented overall, by race and by ADI (Table). Increased risk of TTMd was observed among higher (more deprived) ADI (Q5 vs. Q1: adjusted hazard ratio, aHR 1.16, 95% CI 1.11-1.21, P<0.01; Q4 vs. Q1: aHR 1.15, 95% CI 1.10-1.20, P<0.01) and Black race (vs. White: aHR 1.09, 95% CI 1.04-1.14, P<0.01).
Conclusions:
In this analysis of SDOH in 109,935 US patients with non-metastatic cancer, Black race and lower SES were associated with more advanced disease at first visit and higher risk of metastasis or death. While the magnitude of observed disparities was relatively small, the breadth across tumor types could contribute to significant societal burden in outcomes.

Variable
Overall
White
Black
ADI, Q1 (1-2)
ADI, Q5 (8-10)

HNSCC, N
6,211
4,422
388
1,003
758

TTMd, Median (95% CI)
46.8 (43.7,49.2)
47.7 (45.0,50.7)
43.1 (29.3,47.5)
52.5 (48.1,66.1)
36.1 (27.0,42.8)

NSCLC, N
22,132
15,594
1,714
3,473
2,808

TTMd, Median (95% CI)
22.0 (21.3,22.7)
23.2 (22.3,24.2)
20.5 (18.3,22.8)
27.2 (25.3,30.2)
18.6 (17.1,20.3)

Bladder, N
6,313
4,548
366
1,081
700

TTMd, Median (95% CI)
27.8 (26.0,30.0)
29.4 (26.9,32.8)
21.6 (17.6,28.8)
26.5 (21.5,30.9)
26.8 (22.5,33.4)

Stage, N available
58,140
41,244
4,021
13,326
5,318

I, %
33,220 (57)
23,957 (58)
1,923 (48)
8,633 (65)
2,639 (50)

II, %
13,879 (24)
9,659 (23)
1,155 (29)
2,860 (21)
1,392 (26)

III, %
11,041 (19)
7,628 (18)
943 (23)
1,833 (14)
1,287 (24)

Note: median TTMd was not reached in the BC cohort.