Race, Ancestry, and Social Determinants of Health in Surgery

Overview

Health inequities related to racial/ethnic identity are associated with a substantial economic burden in the United States. A recent analysis of data from the Medical Expenditure Panel Survey, the Behavioral Risk Factor Surveillance System, the National Vital Statistics System, and the American Community Survey estimated these costs at $421–451 billion. Most of this economic burden was attributable to the poorer health of the Black population, but the burden attributable to the Hispanic/Latino, American Indian, Alaska Native, and Native Hawaiian communities was also disproportionately high.

Surgeons are arguably most intensely aware of the complex relationship between social determinants of health (SDOH) and the ancestral components of race with regard to a cancer diagnosis. Well-documented variation exists in the burden of cancer between different population subsets defined by race–ethnicity, and the majority of solid organ malignancies continue to require operative intervention as a component of multidisciplinary care. This chapter will therefore focus on race, ancestry, and SDOH in surgical oncology.

In the United States, the most commonly used race/ethnicities categorize individuals as belonging to broad, heterogenous, and inconsistently labeled groups such as those with White/European ancestry (hereafter White); Black/African ancestry (hereafter Black); Hispanic/Latino (hereafter Hispanic); American Indian/Alaska Native (AI/AN); Asian; American Indian or Alaska Native (hereafter AI/AN); Asian/Pacific Islander (hereafter API); or Asian American and Native Hawaiian/Other Pacific Islander (hereafter AA/NHOPI) backgrounds. Much more research is necessary in defining the details of cancer burden related to the disaggregated subsets of these populations, but existing patterns of progress versus persistent challenges in understanding and managing these differences are documented in the American Association of Cancer Research “AACR Cancer Disparities Progress Report 2022” and the American Cancer Society's “Cancer Statistics for African American/Black People 2022” ; a few of these cancer variations are summarized in the following in comparison with White Americans:

• Overall cancer incidence is 6% higher and mortality is 19% higher in Black compared with White men.

• Overall cancer incidence is 8% lower yet mortality is 12% higher in Black compared with White women.

• Endometrial cancer mortality rates are twice as high in Black compared with White women.

• Breast cancer mortality rates are 41% higher in Black compared with White women.

• Breast cancer incidence rates are approximately 50% higher in Black men compared with White men.

• Gastric cancer incidence rates are approximately twofold higher, and mortality rates are more than twofold higher in Blacks compared with Whites.

• Asians have the lowest overall cancer incidence rates compared to other race/ethnic groups, but a disproportionately higher burden of cancers caused by infectious agents, such as liver cancer secondary to chronic hepatitis B virus.

  • Compared with Whites, mortality from nasopharyngeal cancer is nearly 10 times higher in individuals with Chinese background, nearly 4 times higher in those with Filipino background, and more than 5 times higher in those with AA/NHOPI background.

  • Compared with Whites, incidence of liver cancer is more than twofold higher in AI/AN and API individuals.

  • Compared with Whites, mortality from liver cancer is more than twofold higher in AI/AN and API individuals.

  • Compared with Whites, incidence of gastric cancer is nearly twofold higher in API individuals.

  • Compared with Whites, mortality from gastric cancer is more than twofold higher in API individuals.

  • Compared with Whites, mortality from gastric cancer is 2–4 times higher in Korean, Japanese, and NHOPI individuals.

  • Compared with White women who have never smoked, incidence of lung cancer is more than twofold higher in Chinese American women that have never smoked.

  • Compared with White men, mortality rates from gastric cancer are more than twofold higher in Chinese American men, but less than half for South Asian men.

• Compared with Whites, incidence of liver cancer is more than twofold higher in Hispanic individuals.

• Compared with Whites, mortality from liver cancer is more than twofold higher in Hispanic individuals.

• Compared with Whites, incidence of gastric cancer is nearly twofold higher in Hispanic individuals.

• Compared with Whites, mortality from gastric cancer is nearly twofold higher in Hispanic individuals.

The aforementioned patterns summarize cancer disparities relevant to surgeons with regard to multiple different population subsets. However, the unique and horrific experience of slavery in the history of individuals with African ancestry in America has resulted in the long-lasting legacy of systemic racism that exerts a particularly strong adverse effect on the health of Blacks in the United States today. Contemporary manifestations of systemic racism include residential racial segregation, disproportionately high rates of poverty, unemployment, and uninsurance in the Black community, all of which undoubtedly contribute to healthcare access barriers. The disproportionately greater severity of various comorbidities (e.g., hypertension, cardiovascular disease, asthma, and most recently COVID-19) as well as cancer mortality that is documented in Black compared with White Americans is clearly related to the impact of SDOH. African ancestry is also associated with germline genetic factors that can affect cancer burden, and advances in technologies that can quantify geographically defined ancestry have accelerated the pace of research regarding the genetics of cancer disparities. This chapter will therefore also feature an emphasis on the influence of genetic African ancestry on cancer risk. Breast cancer will dominate in the review of correlations between the ancestral germline genetic aspects of race and SDOH because the large-magnitude disparity in breast cancer burden between populations with African ancestry compared with those with European ancestry has generated the most extensive research.