In their report in JAMA Network Open, Bakkila et al1 analyzed the data of 565 124 individuals registered in the National Cancer Database from 2004 to 2017 and documented large, systemic, and unexplainable racial and ethnic differences in the rates of standard treatments such as adjunct chemotherapy and radiotherapy for gastrointestinal (GI) tract cancer in the US. Their work documented racial and ethnic inequalities in several quality indicators including but not limited to the rate of cancer-free resection margins.

Almost 2 decades after the Institute of Medicine’s Unequal Treatment report,2 the US health care system continues to treat Black and White patients differently for GI tract cancers; this treatment gap persists across treatment settings and modalities. The study by Bakkila et al¹ also shows that these large inequalities remain significant after controlling for patient and tumor characteristics, payer and facility type, and comorbidities. These findings reinforce the notion that the US health care system is a major contributor to systemic and wide racial inequalities in treatment and outcomes of GI tract cancer surgery.

This study is possibly the largest and most comprehensive to date focused on racial and ethnic inequalities in GI tract cancer surgery in the US. Although smaller-scale studies3 have reported similar results, no previous study has included more than 500 000 patients, and they have rarely investigated such a broad spectrum of cancer sites and treatment modalities. The large sample size and wide range of outcomes in their study increases the external validity of this stark racial and ethnic injustice. The observation that the reported inequalities hold for almost all modalities and cancer sites suggests their systemic nature.¹

If this was not bad enough, these inequalities may be an underestimation of the true disparities, given that Black patients are less likely to receive any diagnosis or treatment. Thus, according to Bakkila et al,1 even when Black patients overcome barriers to their diagnosis and treatment (eg, mistrust in the health care system)⁴ and accept adjunct therapies such as chemotherapy, they still may receive substandard treatment.

Although this report is specific to patients with GI tract cancer who undergo surgery, the unequal treatment of equal conditions across race and ethnicity by the US health care system is not limited to GI tract conditions, surgery, or cancer. Regardless of the nature of the condition, the quality of health care is usually worse for Black, Latinx, and Native American patients compared with White patients, a pattern that can be traced to their systemic disinvestments and exclusions.3 Although we have long looked to the health care system as a solution to health inequalities, as Bakkila et al¹ show, the US health care system in many cases is a source rather than a remedy of health inequalities.

Because Bakkila et al1 use a national treatment database, their study leaves questions about the systemic mechanisms driving inequalities unanswered. Investigating such questions would require other types of data. For example, how do geographic location and levels of clinical training and equipment available at treatment centers influence care given that Black patients disproportionately live in segregated neighborhoods served by underresourced health centers? In addition, Bakkila et al¹ note that some cancer treatments are not offered to patients with comorbid conditions, and that these comorbidities are also unequally distributed by race and ethnicity. However, comorbidities become uneven by race and ethnicity through racially segregated neighborhoods and workplaces that expose residents to a wide range of risk factors, which supports the need for systems-level interventions to reduce exposures rather than merely medical treatments.

Conceptual frameworks that analyze systemic causes of inequalities can help us to move upstream and intervene on systemic factors rather than individual-level risk factors. Fundamental Cause Theory, for example, tracks health inequalities to their origins in social inequalities such as racial hierarchies in the US.5 It posits that unless we address the root causes and underlying social inequalities, merely improving treatment and medical technologies will paradoxically and unintentionally widen the existing health inequalities.⁵ This is because people with flexible resources, such as housing in neighborhoods that are more proximal to clinical centers of excellence, private health insurance, high levels of education, and/or social connections with medical professionals—who are also disproportionately White—will have better access to high-quality treatments and technologies.

The question then becomes: What can or should be done at the system level to address the pervasive inequalities such as those related to cancer treatment? Of course, the ultimate solution is a more even distribution of resources through racial desegregation of US housing, employment, and education systems. In the meantime, our middle-range interventions should engage health system administrators and community leaders of underrepresented racial and ethnic groups in quality improvement campaigns to improve care. One such intervention addressed racial disparities in breast cancer mortality in Chicago, where Black women were more likely to be diagnosed in safety net health centers that lacked certified cancer specialists and diagnostic equipment and were 40% less likely to ever receive care in a prestigious breast imaging center.6 A task force of health system administrators and community leaders of underrepresented racial and ethnic groups was formed to make several systemic interventions, including enhanced training of clinicians and enhanced quality of care measures at safety net clinics while engaging peer navigators to guide newly diagnosed women from safety net clinics to centers of excellence in cancer care. These combined interventions were followed by a 20% decrease in racial and ethnic disparities in breast cancer mortality in Chicago, whereas no such decrease was observed in other US cities with large Black populations.⁶

The time has come to address the root causes of inequalities in the US health care system and society at large that act at a systemic level. Successful case studies3 that have shown efficacy of system-level interventions point us toward approaches that include community-level investments in equitable education, housing, employment, and preventive and primary care. These approaches are best accomplished through community partnerships that address social needs while building political support for such investments.³ Clinical training and practice approaches such as structural competency can also help to reorient clinicians and health systems to collaborate with community organizations and non–health sector agencies such as housing, schools, education, legal aid, urban planning, and policy makers to eliminate health inequalities.⁷ It is only through such concerted movement toward systemic change that we can eliminate racial and ethnic inequalities in health and health care.

Published: April 4, 2022. doi:10.1001/jamanetworkopen.2022.5676

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Assari S et al. JAMA Network Open.

Corresponding Author: Shervin Assari, MD, MPH, Department of Family Medicine, Charles R. Drew University of Medicine and Science, 1731 E 120th St, Los Angeles, CA 90059 (shervinassari@cdrewu.edu).

Conflict of Interest Disclosures: None reported.