Equity and Cancer Survival Among Veterans Health Administration Patients: A Systematic Review and Meta-Analysis

In the US, Black patients with cancer consistently experience worse survival compared to White patients, even after adjusting for age, sex, and disease stage. Whether these disparities exist among patients receiving care in the Veterans Health Administration (VHA), an integrated health system designed to provide near-equal access to care, remains uncertain.

To evaluate whether overall survival (OS) and cancer-specific survival (CSS) differ between Black veterans and those with other race receiving cancer care through VHA.

PubMed was searched from January 2015 through April 2022. Reference lists from identified studies were also reviewed.

Studies of US veterans receiving cancer care through the VHA were included if they reported OS or CSS by race and provided hazard ratios (HRs). Dual independent rating of titles and abstracts was conducted for inclusion.

A random-effects model was used to pool effect sizes, the Paule-Mandel estimator was used to calculate the heterogeneity variance τ2, and Knapp-Hartung adjustments were used to calculate the confidence interval of the pooled effect. Review and meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline.

OS and CSS were compared between Black veterans and those who were not Black using pooled HRs.

Of 101 studies identified, 39 met inclusion criteria and 29 provided sufficient data for meta-analysis. The reported outcomes represented 603 256 veterans with cancer treated between 1983 and 2017, with a mean 29.0% (range, 8.9%-55.0%) of patients categorized as Black. All studies compared race by Black compared with White, except for 7 of 20 prostate cancer studies, which compared race by Black compared with non-Black. Black veterans were found to have better OS (HR, 0.93; 95% CI, 0.89-0.97) and CSS (HR, 0.94; 95% CI, 0.90-0.98). Survival advantages for Black veterans were observed across several cancer types, including bladder, laryngeal, lung, oropharyngeal, prostate, and plasma cell cancers. Between-study heterogeneity was low to moderate.

In this systematic review and meta-analysis of peer-reviewed publications reporting the outcomes of veterans receiving cancer care through VHA, survival outcomes were generally similar or better for Black compared with White or non-Black veterans. These findings suggest that integrated health care systems providing near-equitable access to comprehensive cancer care can substantially reduce or eliminate disparities in cancer outcomes.