In the past decade, cancer therapy for patients with metastatic cancer has been significantly transformed by immune, targeted, and hormonal systemic therapies. But disturbing disparities remain even in effective, lower-cost treatments.

Black patients are significantly more likely not to receive any cancer treatment at all, according to a new study by LDI Fellows Jalpa Doshi and Carmen Guerra, and former LDI Fellow John K. Lin, Assistant Professor at MD Anderson Cancer Center.

The team explored whether racial and ethnic disparities exist along the “care cascade,” the distinct steps in the pathway from diagnosis through treatment. They analyzed data from more than 18,000 older adults with newly diagnosed metastatic breast, colorectal, lung, and prostate cancers.

In the largest study of its kind, the researchers found that while most patients were diagnosed without consistent disparities, Black and Hispanic patients were less likely to receive treatment after diagnosis compared with white patients. Overall survival was also lower for Black patients across all four cancers.

The team also found that low-income and dually eligible patients make up a large, untreated group that was less likely to be prescribed affordable and effective cancer drugs.

The authors described these findings as “critical” and noted the need for more intervention studies to identify barriers and propose solutions.   

What made you focus on the cancer care process and where racial and ethnic disparities emerge?

Lin: Among health services researchers, descriptive studies like this have become a bit unfashionable. We are rightly trying to move away from documenting disparities and toward developing interventions to fix them. But I think there is still a need for certain descriptive studies. The guiding principle of our study was that cancer care is so complex that when you zoom in, you see disparities in every possible facet of cancer care – there are disparities in seeing an oncologist in a timely manner, receiving any treatment for your cancer, receiving the right treatment, being able to afford expensive treatments, and getting the treatment in a timely manner. When designing interventions to address disparities, which should we prioritize?

Guerra: Smaller studies had indicated that there might be racial disparities in the receipt of these new therapies among racial and ethnic minorities. We wanted to understand where in the care cascade these disparities were emerging.

What is your most important finding about cancer care disparities and why?

Lin: We found that Black people with metastatic cancer are more likely to die than white people because they are more likely to never receive treatment for their cancer. A shockingly high number of Black Medicare patients never receive any treatment for their cancer: 41% with breast cancer, 77% with colorectal cancer, 74% with lung cancer, and 44% with prostate cancer. We have known for some time that many Medicare patients don’t receive treatment for colorectal and lung cancer because chemotherapies can be tough for older patients. So part of the high rates of patients not being treated is because they may be frail or simply do not want to undergo treatment. But these rates are honestly very surprising for breast and prostate cancer. The treatments are older hormonal treatments that are inexpensive and can be safely given even to people with a lot of comorbidities. We also found that if you look at Black patients and white patients who did receive any type of treatment, there are no longer any differences in mortality.

Doshi: That last point is critical: the survival gap essentially vanishes when treatment is initiated. That tells us that this isn’t a question of biology, but one of access. This is a solvable problem if we focus on getting existing therapies to the patients who need them.

Can you explain what systemic therapy is, how decision-making happens, and what was previously known about its impact on cancer outcomes?

Lin: Systemic therapies include chemotherapy, hormonal therapy, immunotherapy, and targeted drugs–basically, treatments that address cancer anywhere in the body. We knew that these treatments were effective. Much of our focus on cancer health equity has been on the high-cost drugs that have come out which are difficult to afford. There have been major concerns about how the high out-of-pocket costs of these expensive drugs may be contributing to disparities. I don’t want to downplay the importance of access to these novel drugs. However, our study is important because we demonstrated that a much more fundamental disparity matters significantly more. Black patients are simply less likely to receive even the more affordable drugs.

You found that people who receive a Low-Income Subsidy (LIS) from Medicare to help pay for drugs and people who are dually eligible for both Medicare and Medicaid had some of the worst care disparities. Why is that?

Lin: This is a really critical point: we find that a large part of the racial and ethnic disparity in treatment stems from the fact that patients who have full or partial Low-Income Subsidy (LIS) status or dual eligibility are particularly unlikely to get treated. This is important because individuals with LIS or dual eligibility have very little or no out-of-pocket costs for their medications. In fact, when you look at patients who were prescribed a drug, you find that those who with full LIS status are more likely to fill those prescriptions. Our findings strongly suggest that full LIS and dually eligible patients are simply less likely to ever be prescribed these drugs–even after seeing an oncologist. We don’t know why this might be happening, and I think qualitative research will help uncover whether this is due to socioeconomic barriers, physician bias, or another factor we haven’t considered.

Doshi: These findings underscore that insurance coverage alone doesn’t guarantee equitable care. Even without the major cost barriers associated with cancer treatment–such as high out-of-pocket costs at the pharmacy–structural and logistical barriers can still prevent patients from receiving treatment.

What policy implications do you see for addressing metastatic cancer disparities?

Lin: We need intervention studies to focus on targeting the dually eligible population and getting more of them treated for cancer. This one step could help us take huge strides toward reducing disparities in mortality. It is super important for those working with patients to know that Medicaid has transportation benefits and Medicare has care navigation benefits that are reimbursable for patients with cancer. Because there is a reimbursable avenue to intervene on this population, I am hopeful our research can lead to large-scale efforts to reduce disparities.

Guerra: Our findings suggest that interventions aimed at improving outcomes among Black older adults with metastatic cancer should focus on reducing disparities in the uptake, timeliness, and quality of first-line systemic therapies.

Doshi: One clear message for policymakers is that the intersection between Medicare and Medicaid is where disparities are most acutely amplified. We need better coordination between the two programs to ensure that dually eligible patients don’t fall through the cracks simply because their coverage is fragmented.

What limitations should readers be aware of when interpreting these findings?

Lin: We looked only at the fee-for-service Medicare population. However, the Medicare population likely has the fewest disparities out of any other group in the U.S. because Medicare provides relatively good insurance. To reduce cancer disparities in the U.S. as a whole, we need to address the much larger population that is uninsured or underinsured.

Where are you going next with your research on cancer disparities?

Lin: We are developing a qualitative study to understand why patients are not receiving treatment. We hope this work will help us further explore potential solutions.

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The study, “Racial and Ethnic Disparities Along the Treatment Cascade Among Medicare Fee-for-Service Beneficiaries With Metastatic Breast, Colorectal, Lung, and Prostate Cancers,” was published August 27, 2025 in the Journal of Clinical Oncology. Authors include John K. Lin, Jiangong Niu, Sharon H. Giordano, Pengxiang Li, Rebecca A. Snyder, Kaiping Liao, Meng Li, Ana Aparicio, William Chapin, Jianjun Zhang, Jenny Xiang, Nirosha Perera, Debanjan Pain, Carmen E. Guerra, and Jalpa A. Doshi.

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