Current evidence shows that African-Americans (AAs) with gastrointestinal (GI) cancers (colorectal, pancreatic and esophageal cancer) are less likely to undergo surgery, and suggests that those who undergo surgery may be less likely to receive best-evidence surgical care that is timely and minimizes adverse surgical outcomes. An effort to eliminate these racial/ethnic disparities is warranted especially in Alabama (AL) and Mississippi (MS). These two states of the US Deep South have high GI cancer incidence and mortality, and high mortality for AAs in particular, large AA populations, and challenges for access to quality care such as limited affordability and availability. Neither surgical care disparities nor their driving mechanisms have been examined in these states. In addition, lay navigation and Enhanced Recovery After Surgery (ERAS) are effective models on which to build a plan to eliminate surgical disparities. At our institution, the implementation of ERAS processes has led to the elimination of surgical disparities in length of stay without compromising surgical outcomes. Our long term objective is to ultimately eliminate disparities in GI cancer surgery care and outcomes by improving access to timely surgery and facilitating the adoption of ERAS in AL and MS. Our aims are to: 1) Identify gaps in surgical care for GI cancers in AL and MS. With a survey of 450 AA and 550 white GI cancer patients, and medical chart abstraction, we will assess differences for AAs and whites in i) receipt of surgery, ii) time from diagnosis to surgery, and iii) exposure to 17 ERAS processes; 2) Examine potential mechanisms of surgical disparities. Combining survey results with those of individual interviews with 48 AA and white patients and with 48 GI cancer care providers in a mixed methods integrated analysis, we will provide a comprehensive assessment of patient, provider, and system level factors that affect access to care mechanisms, i.e., whether surgery care and ERAS processes are acceptable, affordable, available, accessible and accommodating; 3) Assess the feasibility of a combined surgery-focused lay navigation and ERAS intervention in GI cancer. Results from Aims 1 an 2 will guide the development of a surgery-focused navigator program to facilitate access to timely surgery and support patients in the peri- to post- surgery phases. By accomplishing Aims 1-3, we will define: i) future intervention targets for GI cancer patients in AL and MS, i.e., populations and surgery processes; ii) mechanisms to address in order to achieve effective surgical care; and iii) a surgery focused navigation program to optimize the uptake of surgery and implementation of ERAS for AAs. Thus, the expected outcome of this project is a concrete and detailed actionable plan to eliminate surgical disparities in AL and MS. Without this significant new knowledge, progress toward the elimination of disparities in GI cancer surgery is hindered. With this plan, we will be well prepared to achieve our objective and have a high impact on the goals of the National Institute on Minority Health and Health Disparities (NIMHD) and the National Cancer Institute (NCI) to advance scientific knowledge that will help all people live longer, healthier lives, and eliminate health disparities.

This project is relevant to public health because, while surgery is one crucial step to achieve curative intent for patients with gastrointestinal cancers, disparities in access and quality of surgery care exist for African American patients. To address these disparities in two states of the Deep South, we propose to identify gaps in surgical care, examine potential mechanisms that contribute to these gaps, and develop a surgery-focused lay navigation model in combination with Enhanced Recovery After Surgery (ERAS) processes to support African American GI cancer patients from the pre to post surgery. The product of this project, i.e., a plan to eliminate surgical disparities in this region, is relevant to the National Institute on Minority Health and Health Disparities (NIMHD) and the National Cancer Institute (NCI) as reported in PAR- 18-288 on Surgical Disparities Research.