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African Americans have a higher incidence of pancreatic adenocarcinoma compared with non-Hispanic whites.1, 2 In their study, Chang et al. attributed this higher incidence to two established risk factors: a history of diabetes and smoking.2 These findings have been confirmed in more than 30 epidemiologic studies reported in the literature to date.1 The authors should have more accurately stated that the remainder of the risk factors (i.e., increased alcohol consumption, increased body mass index, and low socioeconomic status) are merely speculative and not established and in addition have been disproved in several well designed studies in the literature.1, 3

The authors also failed to highlight the economic disparities between the two demographic groups. They stated that there is equal access to medical insurance when this very disparity has been discussed in several similar previous studies that have consistently demonstrated that approximately 70% of black controls had an annual income of less than U.S.$25,000 compared with 40% of non-Hispanic whites.1 This inequality is reflected further in the contrasting consumer purchasing power and therefore in the consequent accessibility to medical insurance or a lack thereof. Previous studies have gone even further to adjust for potential confounding variables such as family members being supported by that income.1 This finding was not taken into consideration in the study by Chang et al. and was likely a source of bias in their determination of accessibility to medical insurance.

From a technical aspect, Chang et al. reported that African Americans are less likely to undergo surgery because of the higher incidence of cancer occurring in the tail of the pancreas.2 They describe this form of the disease as being less favorable than that diagnosed in the head of the pancreas. Many experienced pancreatic surgeons would differ and instead would agree that distal pancreatectomy (to resect a tumor at the tail) is technically less challenging and is associated with a shorter surgical time (mean of 4.7 hrs vs. 7 hrs) and a shorter hospital stay (15 days vs. 16 days) compared with pancreaticoduodenectomies for patients with ampullary tumors.4 Indeed, the findings of reports from high-volume cancer centers have demonstrated that distal pancreatectomy is a safer procedure than pancreaticoduodenectomy, with a mortality rate of less than 2%.5 To our knowledge, there are few data in the literature to support the suggestion that African Americans tend to have distal pancreatic tumors and therefore are less likely to undergo surgery. This might erroneously suggest that the surgeons to whom these patients are referred are denying them surgery contrary to evidence in the literature. However, we believe the facts are undeniable. Pancreatic adenocarcinoma occurs more commonly in African Americans, but these patients are less likely to either be offered or choose to undergo surgery. These issues raise questions that need to be addressed urgently.

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Awori J. Hayanga M.D.*, * Department of General Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland.