Evaluation of the causes for racial disparity in surgical treatment of early stage lung cancer

Variability in the treatment of elderly patients with stage IIIA (N2) non-small-cell lung cancer

INTRODUCTION

: We evaluated treatment patterns of elderly patients with stage IIIA (N2) non-small-cell lung cancer (NSCLC).

METHODS

: The use of surgery, chemotherapy, and radiation for patients with stage IIIA (T1-T3N2M0) NSCLC in the Surveillance, Epidemiology, and End Results-Medicare database from 2004 to 2007 was analyzed. Treatment variability was assessed using a multivariable logistic regression model that included treatment, patient, tumor, and census track variables. Overall survival was analyzed using the Kaplan-Meier approach and Cox proportional hazard models.

RESULTS

: The most common treatments for 2958 patients with stage IIIA (N2) NSCLC were radiation with chemotherapy (n = 1065, 36%), no treatment (n = 534, 18%), and radiation alone (n = 383, 13%). Surgery was performed in 709 patients (24%): 235 patients (8%) had surgery alone, 40 patients (1%) had surgery with radiation, 222 patients had surgery with chemotherapy (8%), and 212 patients (7%) had surgery, chemotherapy, and radiation. Younger age (p < 0.0001), lower T-status (p < 0.0001), female sex (p = 0.04), and living in a census track with a higher median income (p = 0.03) predicted surgery use. Older age (p < 0.0001) was the only factor that predicted that patients did not get any therapy. The 3-year overall survival was 21.8 ± 1.5% for all patients, 42.1 ± 3.8% for patients that had surgery, and 15.4 ± 1.5% for patients that did not have surgery. Increasing age, higher T-stage and Charlson Comorbidity Index, and not having surgery, radiation, or chemotherapy were all risk factors for worse survival (all p values < 0.001).

CONCLUSIONS

: Treatment of elderly patients with stage IIIA (N2) NSCLC is highly variable and varies not only with specific patient and tumor characteristics but also with regional income level.

Racial differences in withdrawal of mechanical ventilation do not alter mortality in neurologically injured patients

PURPOSE

Racial differences in withdrawal of mechanical ventilation (WMV) have been demonstrated among patients with severe neurologic injuries. We ascertained whether such differences might be accounted for by imbalances in socioeconomic status or disease severity, and whether such racial differences impact hospital mortality or result in greater discharge to long-term care facilities.

MATERIALS AND METHODS

We evaluated WMV among 1885 mechanically ventilated patients with severe neurologic injury (defined as Glasgow Coma Scale <9), excluding those progressing to brain death within the first 48 hours.

RESULTS

Withdrawal of mechanical ventilation was less likely in nonwhite patients (22% vs 31%, P < .001). Nonwhites were younger and were more likely to have Medicaid or no insurance, live in ZIP codes with low median household incomes, be unmarried, and have greater illness severity; but after adjustment for these variables, racial difference in WMV persisted (odds ratio, 0.56; 95% confidence interval, 0.42-0.76). Nonwhite patients were more likely to die instead with full support or progress to brain death, resulting in equivalent overall hospital mortality (40% vs 42%, P = .44). Among survivors, nonwhites were more likely to be discharged to long-term care facilities (27% vs 17%, P < .001).

CONCLUSIONS

Surrogates of nonwhite neurologically injured patients chose WMV less often even after correcting for socioeconomic status and other confounders. This difference in end-of-life decision making does not appear to alter hospital mortality but may result in more survivors left in a disabled state.

Racial differences in rates of aortic valve replacement in patients with severe aortic stenosis

Racial disparities exist in the treatment of many cardiovascular diseases. Aortic valve replacement (AVR) is the only treatment for aortic stenosis (AS) that improves patient symptoms and survival. To date, no studies have compared the rate of AVR among different races. The records of patients with an aortic valve area <1 cm(2) by echocardiography diagnosed between January 2004 and May 2010 at Barnes-Jewish Hospital were reviewed retrospectively. Patients were stratified by race. Of the 880 patients analyzed, 10% were African American (AA), and 90% were European American (EA). AA more frequently had hypertension (82% vs 67%, p <0.01), diabetes mellitus (45% vs 32%, p = 0.02), chronic kidney disease (28% vs 17%, p = 0.01), and end stage renal disease (18% vs 2%, p <0.001). AA underwent AVR less frequently than EA (39% vs 53%, p = 0.02) and refused intervention more often (33% vs 20%, p = 0.04). When treated, AA and EA had similar 3-year survival (49% [38 to 60] vs 50% [45 to 54], p = 0.31). Identification of the factors associated with treatment refusal would further our ability to counsel patients on the decision to pursue AVR.

Inpatient bariatric surgery among eligible black and white men and women in the United States, 1999-2010

OBJECTIVES

We examined national trends in bariatric surgery for adults, focusing on differences in utilization by race and access to health care.

METHODS

We analyzed subjects eligible for bariatric surgery in the National Hospital Discharge Survey and the National Health and Nutrition Examination Survey for 1999-2010. Primary outcome measures included population-based estimates and comparison of blacks and whites eligible for surgery with those who actually received it.

RESULTS

A higher percentage of black than white women and of black than white men were eligible for bariatric surgery. But a higher proportion of eligible white women and men than black women and men received bariatric surgery. 69.8% of eligible white women and 72.9% of white women who received bariatric surgery had private health insurance, compared with 49.9% and 71.1% of black women. 71.4% of eligible white men and 75.9% of white men who received bariatric surgery had private health insurance, compared with 52.4% and 74.7% of black men. Among men eligibility and surgery rates were lower than for women of the same race, and significant differences were found by race in the same directions as for women.

CONCLUSIONS

Eligible whites received bariatric surgery at higher levels than eligible blacks, apparently partly because of differences in insurance coverage.

Use of new treatment modalities for non-small cell lung cancer care in the Medicare population

BACKGROUND

Many older patients with early stage non-small cell lung cancer (NSCLC) do not receive curative therapy. New surgical techniques and radiation therapy modalities, such as video-assisted thoracoscopic surgery (VATS), potentially allow more patients to receive treatment. The adoption of these techniques and their impact on access to cancer care among Medicare beneficiaries with stage I NSCLC are unknown.

METHODS

We used the Surveillance, Epidemiology and End Results-Medicare database to identify patients with stage I NSCLC diagnosed between 1998 and 2007. We assessed temporal trends and created hierarchical generalized linear models of the relationship between patient, clinical, and regional factors and type of treatment.

RESULTS

The sample comprised 13,458 patients with a mean age of 75.7 years. The proportion of patients not receiving any local treatment increased from 14.6% in 1998 to 18.3% in 2007. The overall use of surgical resection declined from 75.2% to 67.3% ( P , .001), although the proportion of patients undergoing VATS increased from 11.3% to 32.0%. Similarly, although the use of new radiation modalities increased from 0% to 5.2%, the overall use of radiation remained stable. The oldest patients were less likely to receive surgical vs no treatment (OR, 0.12; 95% CI, 0.09-0.16) and more likely to receive radiation vs surgery (OR, 13.61; 95% CI, 9.75-19.0).

CONCLUSION

From 1998 to 2007, the overall proportion of older patients with stage I NSCLC receiving curative local therapy decreased, despite the dissemination of newer, less-invasive forms of surgery and radiation.

Patient preference and contraindications in measuring quality of care: what do administrative data miss?

PURPOSE

Prior studies report that half of patients with lung cancer do not receive guideline-concordant care. With data from a national Veterans Health Administration (VHA) study on quality of care, we sought to determine what proportion of patients refused or had a contraindication to recommended lung cancer therapy.

PATIENTS AND METHODS

Through medical record abstraction, we evaluated adherence to six quality indicators addressing lung cancer-directed therapy for patients diagnosed within the VHA during 2007 and calculated the proportion of patients receiving, refusing, or having contraindications to recommended treatment.

RESULTS

Mean age of the predominantly male population was 67.7 years (standard deviation, 9.4 years), and 15% were black. Adherence to quality indicators ranged from 81% for adjuvant chemotherapy to 98% for curative resection; however, many patients met quality indicator criteria without actually receiving recommended therapy by having a refusal (0% to 14%) or contraindication (1% to 30%) documented. Less than 1% of patients refused palliative chemotherapy. Black patients were more likely to refuse or bear a contraindication to surgery even when controlling for comorbidity; race was not associated with refusals or contraindications to other treatments.

CONCLUSION

Refusals and contraindications are common and may account for previously demonstrated low rates of recommended lung cancer therapy performance at the VHA. Racial disparities in treatment may be explained, in part, by such factors. These results sound a cautionary note for quality measurement that depends on data that do not reflect patient preference or contraindications in conditions where such considerations are important.

Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington State

STUDY DESIGN

Prospective population-based cohort study.

OBJECTIVE

To identify early predictors of lumbar spine surgery within 3 years after occupational back injury.

SUMMARY OF BACKGROUND DATA

Back injuries are the most prevalent occupational injury in the United States. Few prospective studies have examined early predictors of spine surgery after work-related back injury.

METHODS

Using Disability Risk Identification Study Cohort (D-RISC) data, we examined the early predictors of lumbar spine surgery within 3 years among Washington State workers, with new workers compensation temporary total disability claims for back injuries. Baseline measures included worker-reported measures obtained approximately 3 weeks after claim submission. We used medical bill data to determine whether participants underwent surgery, covered by the claim, within 3 years. Baseline predictors (P < 0.10) of surgery in bivariate analyses were included in a multivariate logistic regression model predicting lumbar spine surgery. The area under the receiver operating characteristic curve of the model was used to determine the model's ability to identify correctly workers who underwent surgery.

RESULTS

In the D-RISC sample of 1885 workers, 174 (9.2%) had a lumbar spine surgery within 3 years. Baseline variables associated with surgery (P < 0.05) in the multivariate model included higher Roland-Morris Disability Questionnaire scores, greater injury severity, and surgeon as first provider seen for the injury. Reduced odds of surgery were observed for those younger than 35 years, females, Hispanics, and those whose first provider was a chiropractor. Approximately 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor. The area under the receiver operating characteristic curve of the multivariate model was 0.93 (95% confidence interval, 0.92-0.95), indicating excellent ability to discriminate between workers who would versus would not have surgery.

CONCLUSION

Baseline variables in multiple domains predicted lumbar spine surgery. There was a very strong association between surgery and first provider seen for the injury even after adjustment for other important variables.

Socioeconomic inequalities in lung cancer treatment: systematic review and meta-analysis

BACKGROUND

Intervention-generated inequalities are unintended variations in outcome that result from the organisation and delivery of health interventions. Socioeconomic inequalities in treatment may occur for some common cancers. Although the incidence and outcome of lung cancer varies with socioeconomic position (SEP), it is not known whether socioeconomic inequalities in treatment occur and how these might affect mortality. We conducted a systematic review and meta-analysis of existing research on socioeconomic inequalities in receipt of treatment for lung cancer.

METHODS AND FINDINGS

MEDLINE, EMBASE, and Scopus were searched up to September 2012 for cohort studies of participants with a primary diagnosis of lung cancer (ICD10 C33 or C34), where the outcome was receipt of treatment (rates or odds of receiving treatment) and where the outcome was reported by a measure of SEP. Forty-six papers met the inclusion criteria, and 23 of these papers were included in meta-analysis. Socioeconomic inequalities in receipt of lung cancer treatment were observed. Lower SEP was associated with a reduced likelihood of receiving any treatment (odds ratio [OR] = 0.79 [95% CI 0.73 to 0.86], p<0.001), surgery (OR = 0.68 [CI 0.63 to 0.75], p<0.001) and chemotherapy (OR = 0.82 [95% CI 0.72 to 0.93], p = 0.003), but not radiotherapy (OR = 0.99 [95% CI 0.86 to 1.14], p = 0.89), for lung cancer. The association remained when stage was taken into account for receipt of surgery, and was found in both universal and non-universal health care systems.

CONCLUSIONS

Patients with lung cancer living in more socioeconomically deprived circumstances are less likely to receive any type of treatment, surgery, and chemotherapy. These inequalities cannot be accounted for by socioeconomic differences in stage at presentation or by differences in health care system. Further investigation is required to determine the patient, tumour, clinician, and system factors that may contribute to socioeconomic inequalities in receipt of lung cancer treatment.

Influence of comorbidity on racial differences in receipt of surgery among US veterans with early-stage non-small-cell lung cancer

PURPOSE

It is unclear why racial differences exist in the frequency of surgery for lung cancer treatment. Comorbidity is an important consideration in selection of patients for lung cancer treatment, including surgery. To assess whether comorbidity contributes to the observed racial differences, we evaluated racial differences in the prevalence of comorbidity and their impact on receipt of surgery.

PATIENTS AND METHODS

A total of 1,314 patients (1,135 white, 179 black) in the Veterans Health Administration diagnosed with early-stage non-small-cell lung cancer in 2007 were included. The effect of comorbidity on surgery was determined by using generalized linear models with a logit link accounting for patient clustering within Veterans Administration Medical Centers.

RESULTS

Compared with whites, blacks had greater prevalence of hypertension, liver disease, renal disease, illicit drug abuse, and poor performance status, but lower prevalence of respiratory disease. The impact of most individual comorbidities on receipt of surgery was similar between blacks and whites, and comorbidity did not influence the race-surgery association in a multivariable analysis. The proportion of blacks not receiving surgery as well as refusing surgery was greater than that among whites.

CONCLUSION

Blacks had a greater prevalence of several comorbid conditions and poor performance status; however, the overall comorbidity score did not differ by race. In general, the effect of comorbidity on receipt of surgery was similar in blacks and whites. Racial differences in comorbidity do not fully explain why blacks undergo lung cancer surgery less often than whites.

Racial differences and disparities in cancer care and outcomes: where's the rub?

Despite a profusion of studies over the past several years documenting racial differences in cancer outcomes, there is a paucity of data as to the root causes underlying these observations. This article reviews work to date focusing on black-white differences in cancer outcomes, explores potential mechanisms underlying these differences, and identifies patient, physician, and health care system factors that may account for persistent racial disparities in cancer care. Research strategies to elucidate the relative influence of these various factors and policy recommendations to reduce persistent disparities are also discussed.

Socioeconomic disparities in lung cancer treatment and outcomes persist within a single academic medical center

BACKGROUND

Socioeconomic disparities in treatment and outcomes of non-small-cell lung cancer (NSCLC) are well established. To explore whether these differences are secondary to individual or institutional characteristics, we examined treatment selection and outcome in a diverse population treated at a single medical center.

PATIENTS AND METHODS

We performed a retrospective analysis of consecutive patients diagnosed with NSCLC stages I-III from 2000 to 2005 at the University of Texas Southwestern Medical Center. Treatment selection was dichotomized as 'standard' (surgery for stage I-II; surgery and/or radiation therapy for stage III) or 'other.' Associations between patient characteristics (including socioeconomic status) and treatment selection were examined using logistic regression; associations between characteristics and overall survival were examined using Cox regression models and Kaplan-Meier survival analysis.

RESULTS

A total of 450 patients were included. Twenty-eight percent of patients had private insurance, 43% had Medicare, and 29% had an indigent care plan. The likelihood of receiving 'standard' therapy was significantly associated with insurance type (indigent plan versus private insurance odds ratio [OR] 0.13, 95% confidence interval [CI] 0.04, 0.43 for stage I-II; OR 0.38, 95% CI 0.14, 1.00 for stage III). For patients with stage I-II NSCLC, survival was associated with age, sex, insurance type (indigent plan versus private insurance hazard ratio for death 1.98; 95% CI 1.16, 3.37), stage, and treatment selection. In stage III NSCLC, survival was associated with treatment selection.

CONCLUSION

Within a single academic medical center, socioeconomically disadvantaged patients with stage I-III NSCLC are less likely to receive 'standard' therapy. Socioeconomically disadvantaged patients with stage I-II NSCLC have inferior survival independent of therapy.

Disparities in rates of spine surgery for degenerative spine disease between HIV-infected and uninfected veterans

STUDY DESIGN

Retrospective analysis of nationwide Veterans Health Administration clinical and administrative data.

OBJECTIVE

Examine the association between HIV infection and the rate of spine surgery for degenerative spine disease.

SUMMARY OF BACKGROUND DATA

Combination antiretroviral therapy has prolonged survival in HIV-infected patients, increasing the prevalence of chronic conditions such as degenerative spine disease that may require spine surgery.

METHODS

We studied all HIV-infected patients under care in the Veterans Health Administration from 1996 to 2008 (n = 40,038) and uninfected comparator patients (n = 79,039) matched on age, sex, race, year, and geographic region. The primary outcome was spine surgery for degenerative spine disease, defined by International Classification of Diseases, Ninth Revision procedure and diagnosis codes. We used a multivariate Poisson regression to model spine surgery rates by HIV infection status, adjusting for factors that might affect suitability for surgery (demographics, year, comorbidities, body mass index, combination antiretroviral therapy, and laboratory values).

RESULTS

Two hundred twenty-eight HIV-infected and 784 uninfected patients underwent spine surgery for degenerative spine disease during 700,731 patient-years of follow-up (1.44 surgeries per 1000 patient-years). The most common procedures were spinal decompression (50%) and decompression and fusion (33%); the most common surgical sites were the lumbosacral (50%) and cervical (40%) spine. Adjusted rates of surgery were lower for HIV-infected patients (0.86 per 1000 patient-years of follow-up) than for uninfected patients (1.41 per 1000 patient-years; incidence rate ratio 0.61, 95% confidence interval: 0.51-0.74, P < 0.001). Among HIV-infected patients, there was a trend toward lower rates of spine surgery in patients with detectable viral load levels (incidence rate ratio 0.76, 95% confidence interval: 0.55-1.05, P = 0.099).

CONCLUSION

In the Veterans Health Administration, HIV-infected patients experience significantly reduced rates of surgery for degenerative spine disease. Possible explanations include disease prevalence, emphasis on treatment of nonspine HIV-related symptoms, surgical referral patterns, impact of HIV on surgery risk-benefit ratio, patient preferences, and surgeon bias.

Radiotherapy for hilar or mediastinal lymph node metastases after definitive treatment with stereotactic body radiotherapy or surgery for stage I non-small cell lung cancer

PURPOSE

Management of regional lymph node (LN) recurrence is an important issue in definitive treatment of non-small cell lung cancer (NSCLC). We evaluated clinical outcomes of conventional radiotherapy for hilar or mediastinal LN metastases developing after stereotactic body radiotherapy (SBRT) or surgery for stage I NSCLC.

METHODS AND MATERIALS

Between 2004 and 2008, 26 patients with hilar or mediastinal LN metastases without local recurrence and distant metastasis after SBRT (n = 14) or surgery (n = 12) were treated with conventional radiotherapy. Twelve of the 14 post-SBRT patients (86%) were judged medically inoperable at the time of SBRT. All patients were treated to the hilum and mediastinum with conventional daily fractions of 2.0 Gy (n = 25) or 2.4 Gy (n = 1). The median total dose for treating metastatic LN was 60 Gy (range, 54-66 Gy) for the post-SBRT patients and 65 Gy (range, 60-66 Gy) for the post-surgery patients. Only 1 of the 14 post-SBRT patients and 8 of the 12 post-surgery patients received chemotherapy.

RESULTS

For all 26 patients, the overall and cause-specific survival rates at 3 years from radiation for LN metastases were 36% and 51%, respectively (14% and 39%, respectively, for the 14 post-SBRT patients and both 64% for the 12 post-surgery patients). Three of the SBRT patients were alive at 35 to 43 months with (n = 2) or without (n = 1) further recurrence, and 4 of the post-surgery patients were alive at 36 to 62 months with (n = 2) or without (n = 2) further recurrence. The incidence of ≥grade 2 pulmonary toxicity was 49% at 1 year (53% for post-SBRT patients and 44% for post-surgery patients). A grade 5 pulmonary toxicity was observed in 1 of the post-SBRT patients.

CONCLUSIONS

Conventional radiotherapy could successfully salvage LN relapses after SBRT as well as after surgery in 7 of 26 patients. Radiotherapy in this setting appears reasonably well tolerated.

Reasons for underuse of recommended therapies for colorectal and lung cancer in the Veterans Health Administration

BACKGROUND

Many studies have documented low rates of effective cancer therapies, particularly in older or minority populations. However, little is known about why effective therapies are underused in these populations.

METHODS

The authors examined medical records of 584 patients with cancer diagnosed or treated in Department of Veterans Affairs facilities to assess reasons for lack of 1) surgery for stage I/II nonsmall cell lung cancer, 2) surgery for stage I/II/III rectal cancer, 3) adjuvant radiation therapy for stage II/III rectal cancer, and 4) adjuvant chemotherapy for stage III colon cancer. They also assessed differences in reasons for underuse by patient age and race.

RESULTS

Across the 4 guideline-recommended treatments, 92% to 99% of eligible patients were referred to the appropriate cancer specialist; however, therapy was recommended in only 74% to 92% of eligible cases. Poor health was cited in the medical record as the reason for lack of therapy in 15% to 61% of underuse cases; patient refusal explained 26% to 58% of underuse cases. African American patients were more likely to refuse surgery. Older patients were more likely to refuse treatments.

CONCLUSIONS

Recommendation against therapy was a primary factor in underuse of effective therapies in older and sicker patients. Patients' refusal of therapy contributed to age and racial disparities in care. Improved data on the effectiveness of cancer therapies in community populations and interventions aimed at improved communication of known risks and benefits of therapy to cancer patients could be effective tools to reduce underuse and lingering disparities in care.

Evaluation and treatment of high-risk patients with early-stage lung cancer

Standard therapy for early-stage non-small cell lung cancer is lobectomy for patients who are able to tolerate such surgery. However, the risk of postoperative morbidity is not trivial, with a 30% to 40% incidence of postoperative complications and a 1% to 5% incidence of operative mortality. Some patients, though technically resectable, refuse surgery or are considered medically inoperable because of insufficient respiratory reserve, cardiovascular disease, or general frailty. This group is considered either "high risk" or "medically inoperable."

"Cutting" on cancer: attitudes about cancer spread and surgery among primary care patients in the U.S.A

Many underserved groups in the United States experience disparities in cancer survival. Part of the disparity may be due to differences in treatment or treatment uptake. Previous studies uncovered patient beliefs that surgery could cause cancer to spread and have suggested that this belief may affect uptake of cancer treatment. We explored patients' explanations about surgical treatment of cancer and cancer spread, as well as the perceived impact on decision-making among primary care patients from an underserved area. Focus groups and interviews were conducted with patients (n = 42) at a primary care federally qualified health center in 2006 and 2007. Focus groups/interviews were semi-structured and were audio-taped and transcribed. An inductive text analysis with multiple coders was used to analyze the data and extract themes. We found that nearly all respondents had heard that surgery ("cutting") and exposing cancer to the air would hasten cancer spread and result in worse outcomes. Most participants expressed agreement with this belief. Many participants said this concern would influence their decision about whether to have surgery and/or reported that a family member had refused surgery for this reason. A smaller group of respondents disagreed with this belief and offered experiential evidence to the contrary or hypotheses about its origination. The idea that "cutting" and "air" during surgery can cause cancer to spread may be more prevalent among patients than suspected, based on this sample of predominantly African American patients. While we were unable to disentangle the ideas about "cutting" from those about "exposure to air", this set of beliefs, when held strongly, can negatively influence patients' or family members' decisions to seek surgical care and, if it is more prevalent in underserved groups, may contribute to cancer disparities.

Disparities between blacks and whites in tobacco and lung cancer treatment

Racial disparities exist in lung cancer incidence, morbidity, and mortality. Smoking is responsible for the majority of lung cancers, and racial disparities also exist in smoking outcomes. Black smokers are less likely than white smokers to engage in evidence-based tobacco treatment, and black smokers are less likely than white smokers to stop smoking. Continued smoking following a lung cancer diagnosis is a potential indicator of poor lung cancer treatment outcomes, yet lung cancer patients who smoke are unlikely to receive evidence-based tobacco treatment. The risks from continued smoking after diagnosis deserve attention as a modifiable factor toward lessening racial disparities in lung cancer outcomes.

Racial disparities in the use of revascularization before leg amputation in Medicare patients

OBJECTIVE

Black patients with peripheral arterial disease undergo amputation at two to four times the rate of white patients. In order to determine whether differences in attempts at limb salvage might contribute to this disparity, we studied the limb care received prior to amputation by black patients compared with whites.

METHODS

Using inpatient Medicare data for the years 2003 through 2006, we identified a retrospective sample of all beneficiaries who underwent major lower extremity amputation. "Limb salvage care" was defined as limb-related admissions and procedures that occurred during the 2 years prior to amputation. We used multiple logistic regression to compare rates of revascularization and other limb care received by black versus white amputees, adjusting for individual patient characteristics. We then controlled for hospital referral region in order to assess whether differences in care might be attributable to the geographic regions in which black and white patients received care. Finally, we examined the timing of revascularization relative to amputation for both races.

RESULTS

Our sample included 24,600 black and 65,881 white amputees. Compared with whites, black amputees were more likely to be female and had lower socioeconomic status. Average age, rates of diabetes, and levels of comorbidity were similar between races. Black amputees were significantly less likely than whites to have undergone revascularization (23.6% vs 31.6%; P < .0001), any limb-related admission (39.6% vs 44.7%; P < .0001), toe amputation (12.9% vs 13.8%; P < .0005), or wound debridement (11.6% vs 14.2%; P < .0001) prior to amputation. After adjusting for differences in individual patient characteristics, black amputees remained significantly less likely than whites to undergo revascularization (odds ratios [OR], 0.72 [95% confidence interval, .68-.76]), limb-related admission (OR, 0.81 [0.78-0.84]), or wound debridement prior to amputation (OR, 0.80 [0.75-0.85]). Timing of revascularization relative to amputation was similar between races. Observed differences in care were shown to exist within hospital referral regions and were not accounted for by regional differences in where black and white patients received care.

CONCLUSION

Black patients are much less likely than whites to undergo attempts at limb salvage prior to amputation. Further studies should explore whether this disparity might be attributable to race-related differences in severity of arterial disease, patient preferences, or physician decision making.

Racial disparities on the use of invasive and noninvasive staging in patients with non-small cell lung cancer

INTRODUCTION

Racial disparities have been reported in non-small cell lung cancer (NSCLC) staging and therapeutic outcomes. We investigated whether such disparities exist in the era of modern noninvasive staging modalities, including positron emission tomography scan use.

METHODS

NSCLC patients from the California Cancer Registry diagnosed between January 1, 1994, and December 31, 2004, were included. The likelihood of obtaining invasive (thoracoscopy, bronchoscopy, and mediastinoscopy) and noninvasive staging procedures (computed tomography, magnetic resonance imaging, and positron emission tomography scans), along with surgical resection, were analyzed using logistic regression adjusted for known confounders.

RESULTS

Of 13,762 NSCLC patients, 12,395 with adequate staging information were included. 10,217 patients (82%) were classified as white, 2178 patients (18%) were non-white, and 738 were black patients (6%). No association was seen between race and the use of either noninvasive (odds ratio [OR] = 1.02; p = 0.76) or invasive staging procedures (OR = 0.96; p = 0.44). However, compared with white patients, black patients had a lower likelihood of undergoing surgery, regardless of noninvasive (OR = 0.6; p <0.001) or invasive staging use (OR = 0.63; p = 0.02). There was no survival difference for those who underwent surgery between white and non-white patients, regardless of noninvasive (hazard ratio = 0.95; p = 0.45) or invasive staging (hazard ratio = 1.03; p = 0.79).

CONCLUSIONS

In contrast to prior published work, we found no difference in rates of both invasive and noninvasive staging between white and non-white patients. However, non-white patients-particularly blacks-were less likely to receive surgery. The reason for the apparent difference in surgical rates could not be explained by the variables we evaluated. Thus, other factors such as personal preference or access to care require further investigation.

Dose-volume comparison of proton radiotherapy and stereotactic body radiotherapy for non-small-cell lung cancer

PURPOSE

This study designed photon and proton treatment plans for patients treated with hypofractionated proton radiotherapy (PT) at the Southern Tohoku Proton Therapy Center (STPTC). We then calculated dosimetric parameters and compared results with simulated treatment plans for stereotactic body radiotherapy (SBRT), using dose--volume histograms to clearly explain differences in dose distributions between PT and SBRT.

METHODS AND MATERIALS

Twenty-one patients with stage I non-small-cell lung cancer (stage IA, n = 15 patients; stage IB, n = 6 patients) were studied. All tumors were located in the peripheral lung, and total dose was 66 Gray equivalents (GyE) (6.6 GyE/fraction). For treatment planning, beam incidence for proton beam technique was restricted to two to three directions for PT, and seven or eight noncoplanar beams were manually selected for SBRT to achieve optimal planning target volume (PTV) coverage and minimal dose to organs at risk.

RESULTS

Regarding lung tissues, mean dose, V5, V10, V13, V15, and V20 values were 4.6 Gy, 13.2%, 11.4%, 10.6%, 10.1%, and 9.1%, respectively, for PT, whereas those values were 7.8 Gy, 32.0%, 21.8%, 17.4%, 15.3%, and 11.4%, respectively, for SBRT with a prescribed dose of 66 Gy. Pearson product moment correlation coefficients between PTV and dose--volume parameters of V5, V10, V15, and V20 were 0.45, 0.52, 0.58, and 0.63, respectively, for PT, compared to 0.52, 0.45, 0.71, and 0.74, respectively, for SBRT.

CONCLUSIONS

Correlations between dose--volume parameters of the lung and PTV were observed and may indicate that PT is more advantageous than SBRT when treating a tumor with a relatively large PTV or several tumors.

Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer

CONTEXT

Lung cancer is the leading cause of cancer death in the United States. Surgical resection for stage I or II non-small cell cancer remains the only reliable treatment for cure. Patients who do not undergo surgery have a median survival of less than 1 year. Despite the survival disadvantage, many patients with early-stage disease do not receive surgical care and rates are even lower for black patients.

OBJECTIVES

To identify potentially modifiable factors regarding surgery in patients newly diagnosed with early-stage lung cancer and to explore why blacks undergo surgery less often than whites.

DESIGN, SETTING, AND PATIENTS

Prospective cohort study with patients identified by pulmonary, oncology, thoracic surgery, and generalist practices in 5 communities through study referral or computerized tomography review protocol. A total of 437 patients with biopsy-proven or probable early-stage lung cancer were enrolled between December 2005 and December 2008. Before establishment of treatment plans, patients were administered a survey including questions about trust, patient-physician communication, attitudes toward cancer, and functional status. Information about comorbid illnesses was obtained through chart audits.

MAIN OUTCOME MEASURE

Lung cancer surgery within 4 months of diagnosis.

RESULTS

A total of 386 patients met full eligibility criteria for lung resection surgery. The median age was 66 years (range, 26-90 years) and 29% of patients were black. The surgical rate was 66% for white patients (n = 179/273) compared with 55% for black patients (n = 62/113; P = .05). Negative perceptions of patient-physician communication manifested by a 5-point decrement on a 25-point communication scale (odds ratio [OR], 0.42; 95% confidence interval [CI], 0.32-0.74) and negative perception of 1-year prognosis postsurgery (OR, 0.27; 95% CI, 0.14-0.50; absolute risk, 34%) were associated with decisions against surgery. Surgical rates for blacks were particularly low when they had 2 or more comorbid illnesses (13% vs 62% for <2 comorbidities; OR, 0.04 [95% CI, 0.01-0.25]; absolute risk, 49%) and when blacks lacked a regular source of care (42% with no regular care vs 57% with regular care; OR, 0.20 [95% CI, 0.10-0.43]; absolute risk, 15%).

CONCLUSIONS

A decision not to undergo surgery by patients with newly diagnosed lung cancer was independently associated with perceptions of communication and prognosis, older age, multiple comorbidities, and black race. Interventions to optimize surgery should consider these factors.

Do racial or socioeconomic disparities exist in lung cancer treatment?

BACKGROUND

Determine the effects of race, socioeconomic status, and treatment on outcomes for patients diagnosed with lung cancer.

METHODS

The Florida cancer registry and inpatient and ambulatory data were queried for patients diagnosed from 1998-2002.

RESULTS

A total 76,086 of lung cancer patients were identified. Overall, 55.6% were male and 44.4% were female. The demographic distribution of patients was 92.7% Caucasian, 6.7% African American, and 5.7% Hispanic. The mean age of diagnosis was 70 years old. African American patients presented at a younger age, with more advanced disease, and were less likely to undergo surgical therapy than their Caucasian counterparts. Median survival time (MST) for the entire cohort was 8.7 months, while MST for African American patients was 7.5 months. Patients who received surgery, chemotherapy, or radiation therapy demonstrated significantly improved outcomes. Stepwise multivariate analysis revealed that African American race was no longer a statistically significant predictor of worse outcomes once corrections were made for demographics and comorbid conditions, suggesting that the originally reported disparities in lung cancer outcomes and race may be in part because of poor pretreatment performance status. In contrast, patients of the lowest socioeconomic status continue to have a slightly worse overall prognosis than their affluent counterparts (hazard ratio = 1.05, P = .001).

CONCLUSIONS

Lung cancer continues to carry a poor prognosis for all patients. Once comorbidities are corrected for, African American patients carry equivalently poor outcomes. Nonetheless, emphasis must be placed on improving pretreatment performance status among African American patients and efforts for earlier diagnosis among the impoverished patients must be made.

Dissecting racial disparities in the treatment of patients with locoregional pancreatic cancer: a 2-step process

BACKGROUND

Previous studies have demonstrated that black patients with pancreatic cancer are less likely to undergo resection and have worse overall survival compared with white patients. The objective of this study was to determine whether these disparities occur at the point of surgical evaluation or after evaluation has taken place.

METHODS

The authors used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data (1992-2002) to compare black patients and white patients with locoregional pancreatic cancer in univariate models. Logistic regression was used to determine the effect of race on surgical evaluation and on surgical resection after evaluation. Cox proportional hazards models were used to identify which factors influenced 2-year survival.

RESULTS

Nine percent of 3777 patients were black. Blacks were substantially less likely than whites to undergo evaluation by a surgeon (odds ratio, 0.57; 95% confidence interval, 0.42-0.77) when the model was adjusted for demographics, tumor characteristics, surgical evaluation, socioeconomic status, and year of diagnosis. Patients who were younger and who had fewer comorbidities, abdominal imaging, and a primary care physician were more likely to undergo surgical evaluation. Once they were seen by a surgeon, blacks still were less likely than whites to undergo resection (odds ratio, 0.64; 95% confidence interval, 0.49-0.84). Although black patients had decreased survival in an unadjusted model, race no longer was significant after accounting for resection.

CONCLUSIONS

Twenty-nine percent of black patients with potentially resectable pancreatic cancers never received surgical evaluation. Without surgical evaluation, patients cannot make an informed decision and will not be offered resection. Attaining higher rates of surgical evaluation in black patients would be the first step to eliminating the observed disparity in the resection rate.

Disparities in cancer care: an operative perspective

BACKGROUND

Health disparities in cancer care have been described and stem from a complex interplay of patient, provider, and instutional factors.

METHODS

A review of the literature describing disparities in aspects of cancer care was performed.

RESULTS

Disparities in outcomes including overall survival for minority populations have been demonstrated to exist for race, age, and socioeconomic status.

CONCLUSION

Disparities in cancer care and outcomes clearly exist for many poorly understood reasons. After a diagnosis of cancer, barriers to care may develop at multiple points along the course of the patient's disease.

Racial disparities in lung cancer mortality in U.S. congressional districts, 1990-2001

The objective of this study was to detect statistically significant racial disparities in lung cancer mortality at the U.S. congressional district level. We applied absolute disparity statistics to mortality data from the National Center for Health Statistics (NCHS) for 1990-2001, mapped significant lung cancer mortality disparities by race and gender within U.S. congressional districts, and uncovered previously unreported disparities. The disparity statistics comparing black and white females revealed higher mortality rates for black females in the Midwestern U.S., and higher mortality rates for white females in the South-eastern U.S. Our methodology provides a spatial tool for guiding public health cancer control practices to monitor, target and reduce disparities.

Insurance status, geography, race, and ethnicity as predictors of anterior cervical spine surgery rates and in-hospital mortality: an examination of United States trends from 1992 to 2005

STUDY DESIGN

Retrospective cross-sectional study.

OBJECTIVE

To determine the role of race, insurance status, and geographic location on US anterior cervical spine surgery rates and in-hospital mortality between 1992 and 2005.

SUMMARY OF BACKGROUND DATA

Previous investigation indicates that anterior cervical spine surgery has been increasingly used in the management of degenerative cervical spine disease throughout the 1990s. Significant predictors of health outcomes, including race, ethnicity, geography, and insurance coverage have yet to be investigated in detail for these procedures.

METHODS

Cases of anterior cervical spine surgery were identified from the Nationwide Inpatient Sample. The US population counts were taken from the Current Population Survey. Multivariate regression models were employed to describe national rates of anterior cervical spine surgery and model the odds of death among admissions for anterior cervical spine surgery. All models incorporated adjustment for hospital sample clustering, age, and comorbidity status.

RESULTS

Based on an analysis of a total 100,286,482 hospital discharge records, an estimated 965,600 anterior cervical spine procedures were performed between 1992 and 2005 in the United States. During this period, rates of surgery increased by 289%. Though adjusted rates of surgery were lowest among minority populations, disparities decreased with time. The mean age of patients, as well as the average preoperative comorbidity status, increased with time. The odds of mortality did not significantly increase between 1992 and 2005. Odds of in-hospital death were greatest in among black patients (P < 0.001) and lowest in Southern states (P < 0.001) and patients with private insurance (P < 0.001).

CONCLUSION

With the recent rise of anterior cervical spine procedures in the United States, substantial variation in the delivery of surgical care exists along a number of demographic factors. A detailed investigation of variation in surgical decision-making algorithms among spine specialists, as well as a determination of differences among patient populations in attitudes toward surgery, may help elucidate the trends observed in this study.

Racial differences in cancer specialist consultation, treatment, and outcomes for locoregional pancreatic adenocarcinoma

BACKGROUND

Blacks have a higher incidence of pancreatic adenocarcinoma and worse outcomes compared to whites. Identifying barriers in pancreatic cancer care may explain survival differences and provide areas for intervention.

METHODS

Pancreatic adenocarcinoma patients were identified in the Surveillance, Epidemiology, and End Results Registry (1991-2002). Treatment and outcome data were obtained from the linked Surveillance, Epidemiology, and End Results Registry-Medicare databases. Logistic regression was used to assess race as a predictor of specialist consultation/receipt of therapy. Kaplan-Meier survival curves were compared. Cox proportional hazard analyses were performed to estimate survival after adjustment for patient and treatment characteristics.

RESULTS

A total of 13,230 white patients (90%) and 1478 black patients (10%) were identified. Clinical/pathologic factors were compared by race. When we compared whites and blacks by univariate analyses, blacks had lower rates of specialist consultation (P<.01), chemotherapy (P<.01), and resection (P<.01). On multivariate analyses predicting consultation with a cancer specialist, black race negatively predicted consultation with a medical oncologist (adjusted odds ratio [AOR] .74, P<.01), radiation oncologist (AOR .75, P<.01), and surgeon (AOR .71, P<.01). For predicting receipt of therapy after consultation, blacks were less likely to undergo chemotherapy (AOR .59, P<.01) and resection (AOR .79, P=.05). Blacks had worse overall survival on Kaplan-Meier survival curves (log rank, P<.0001). On Cox proportional hazard modeling evaluating survival, black race was no longer independently associated with worse survival after adjustment for resection and adjuvant therapy (hazard ratio, 1.08; 95% confidence interval, .99-1.19).

CONCLUSIONS

Racial disparities exist in pancreatic cancer specialist consultation and subsequent therapy use. Because receipt of care is fundamental to reducing outcome discrepancies, these barriers serve as discrete intervention points to ensure all locoregional pancreatic adenocarcinoma patients receive appropriate specialist referral and subsequent therapy.

Race and sex differences in the receipt of timely and appropriate lung cancer treatment

BACKGROUND

Previous research suggests that disparities in non-small-cell lung cancer (NSCLC) survival can be explained in part by disparities in the receipt of cancer treatment. Few studies, however, have considered race and sex disparities in the timing and appropriateness of treatment across stages of diagnosis.

OBJECTIVE

To evaluate the relationship of sex and race with the receipt of timely and clinically appropriate NSCLC treatment for each stage of diagnosis.

METHOD

Surveillance Epidemiology and End Result data linked to Medicare claims for beneficiaries diagnosed with NSCLC between 1995 and 1999 were used to evaluate the relationship between race and sex with timely and appropriate NSCLC treatment while controlling for other demographic characteristics, comorbidities, socioeconomic status, and provider supply (N = 22,145).

RESULTS

Overall adjusted rates of timely and appropriate treatment are 37.2%, 58.1%, and 29.2% for Medicare beneficiaries diagnosed with stage I or II, III, and IV NSCLC, respectively. Among stage I or II patients, women were 25% less likely to receive timely surgical resection relative to men, and blacks were 66% less likely to receive timely and appropriate treatment than whites. Black men were least likely to receive resection (22.2% compared with 43.7% for white men). Blacks were 34% less likely to receive timely surgery, chemotherapy, or radiation for stage III disease and were 51% less likely to receive chemotherapy in a timely fashion for stage IV disease relative to whites.

CONCLUSION

Significant variations in appropriate timely treatment were found within and across stages of diagnosis, confirming that sex and race differences in NSCLC treatment exist.

Racial disparities and treatment trends in a large cohort of elderly black and white patients with nonsmall cell lung cancer

BACKGROUND

This study investigated whether there was a significant gap in receipt of treatment for nonsmall cell lung cancer (NSCLC) between blacks and whites, and whether the gap or disparity changed during the past 12 years from 1991 to 2002.

METHODS

The study population consisted of 83,101 patients including 75,141 (90.4%) whites and 7960 (9.6%) blacks aged > or =65 years who were diagnosed with American Joint Committee on Cancer (AJCC) stages I-IV NSCLC identified from the Surveillance, Epidemiology, and End Results (SEER) program's Medicare database. Age-adjusted and sex-adjusted rates and crude and adjusted odds ratios for receiving appropriate stage-specific treatment of NSCLC were reported.

RESULTS

For stages I-II NSCLC combined, blacks were 37% less likely (OR, 0.63; 95% confidence interval [CI], 0.55-0.73) to receive surgery, 42% less likely (OR, 0.58; 95% CI, 0.36-0.92) to receive chemotherapy, and for stages III-IV combined, 57% less likely (OR, 0.43; 95% CI, 0.30-0.61) to receive chemotherapy compared with whites. Older patients, women, and those in lower socioeconomic quartiles had greater disparities in receipt of treatment compared with the highest income quartile. Disparity trends were not significantly narrowed during the past 12 years between blacks and whites for receipt of the above treatments.

CONCLUSIONS

There have been substantial disparities in receiving recommended treatments between blacks and whites, and these disparities have been relatively stable without a significant trend of narrowing during the past 12 years. Efforts should focus on providing appropriate quality treatment and educating blacks on the value of having these treatments to reduce these disparities in receipt of treatment for NSCLC.

Patterns of care in elderly glioblastoma patients

OBJECTIVE

To evaluate the patterns of care in elderly glioblastoma (GBM) patients from a large population-based registry.

METHODS

We identified a cohort of GBM patients 65 years or older from Surveillance, Epidemiology, and End Results cancer registry data linked with Medicare claims between 1994 and 2002. We assessed the impact of demographic characteristics and comorbidities on the probability of undergoing surgical resection, radiotherapy (RT), and chemotherapy within 3 months of diagnosis using multivariate logistic regression.

RESULTS

A total of 4,137 patients with GBM were included, with a median overall survival of 4 months. Sixty-one percent of patients underwent resection at diagnosis; 65% received RT and 10% received chemotherapy within 3 months of diagnosis. In a multivariate regression analysis, age was the most significant predictor of resection, RT, or chemotherapy. Black race (odds ratio [OR], 0.64; p = 0.008) was associated with lower rates of surgical resection. Factors associated with decreased likelihood of receiving RT included unmarried marital status (OR, 0.64; p < 0.0001) and more comorbidities (OR, 0.55; p < 0.0001). Factors associated with decreased likelihood of receiving chemotherapy included unmarried marital status (OR, 0.59; p = 0.0002) and more comorbidities (OR, 0.56; p = 0.02).

INTERPRETATION

Survival of elderly GBM patients was poor in this population-based study. Age, marital status, and comorbidities influenced the probability of receiving RT or chemotherapy in this cohort.

Racial disparities among patients with lung cancer who were recommended operative therapy

HYPOTHESIS

Health care system and provider biases and differences in patient characteristics are thought to be prevailing factors underlying racial disparities. The influence of these factors on the receipt of care would likely be mitigated among patients who are recommended optimal therapy. We hypothesized that there would be no significant evidence of racial disparities among patients with early-stage lung cancer who are recommended surgical therapy.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort study of patients in the Surveillance, Epidemiology, and End Results-Medicare database who were diagnosed with stage I or II lung cancer between January 1, 1992, and December 31, 2002 (follow-up through December 31, 2005).

MAIN OUTCOME MEASURES

Receipt of lung resection and overall survival.

RESULTS

Among 17,739 patients who were recommended surgical therapy (mean [SD] age, 75 [5] years; 89% white, 6% black), black patients less frequently underwent resection compared with white patients (69% vs 83%, respectively; P < .001). After adjustment, black race was associated with lower odds of receiving surgical therapy (odds ratio = 0.43; 99% confidence interval, 0.36-0.52). Unadjusted 5-year survival rates were lower for black patients compared with white patients (36% vs 42%, respectively; P < .001). After adjustment, there was no significant association between race and death (hazard ratio = 1.03; 99% confidence interval, 0.92-1.14) despite a 14% difference in receipt of optimal therapy.

CONCLUSIONS

Even among patients who were recommended surgical therapy, black patients underwent lung resection less often than white patients. Unexpectedly, racial differences in the receipt of optimal therapy did not appear to affect outcomes. These findings suggest that distrust, beliefs and perceptions about lung cancer and its treatment, and limited access to care (despite insurance) might have a more dominant role in perpetuating racial disparities than previously recognized.

Underuse of surgical resection for localized, non-small cell lung cancer among whites and African Americans in South Carolina

BACKGROUND

Early studies using Medicare data reported racial disparities in surgical treatment of localized, non-small cell lung cancer. We analyzed the independent effect of race on use of surgical resection in a recent, population-based sample of patients with localized non-small cell lung cancer, controlling for comorbidity and socioeconomic status.

METHODS

All cases of localized non-small cell lung cancer reported to our state Cancer Registry between 1996 and 2002 were identified and linked to the Inpatient/Outpatient Surgery Files and 2000 Census. Comorbidity (Romano-Charlson index) was calculated using administrative data codes. Educational level and income were estimated using census data. Characteristics of white and African American patients were compared using chi(2) tests. Odds ratios of resection and 95% confidence intervals were calculated using logistic regression.

RESULTS

We identified 2,506 white and 550 African American patients. African Americans were more likely to be younger, male, not married, less educated, poor, and uninsured or covered by Medicaid (all p < 0.0001), and to reside in rural communities (p = 0.0005). Use of surgical resection across races was lower than previously reported, and African Americans were significantly less likely to undergo surgery compared with whites (44.7% versus 63.4%; p < 0.0001). Even after controlling for sociodemographics, comorbidity, and tumor factors, the adjusted odds ratio for resection for African Americans was 0.43 (95% confidence interval, 0.34 to 0.55).

CONCLUSIONS

Underuse of surgical resection for localized, non-small cell lung cancer is a persistent problem, particularly among African Americans. Further studies are urgently needed to identify the patient-, physician-, and health system-related factors underlying these observations and optimize resection rates for non-small cell lung cancer.

Disparities in treatment and outcome for renal cell cancer among older black and white patients

PURPOSE

Black patients with renal cell cancer have shorter survival compared with their white counterparts, but the causes for this disparity are unclear. To elucidate reasons for this inequality, we examined differences in treatment and survival between black and white patients.

PATIENTS AND METHODS

A retrospective cohort study was conducted using data from the linked Surveillance, Epidemiology and End Results (SEER) cancer registry and Medicare databases. Participants included 964 black and 10,482 white patients age >or= 65 years who were enrolled into Medicare and diagnosed with renal cell cancer between 1986 and 1999. Information on surgical treatment was ascertained from both databases, whereas data regarding coexisting illness and survival was obtained from the Medicare database.

RESULTS

The percentage of black patients receiving nephrectomy treatment was significantly lower compared with whites (61.2% v 70.4%; P < .0001). After adjustment for age, sex, median income, cancer stage, tumor size, and comorbidity index, blacks were less likely to undergo nephrectomy treatment compared with whites (risk ratio = 0.93; 95% CI, 0.90 to 0.96). Overall survival was worse for blacks than whites even after adjustment for demographic and cancer prognostic factors (hazard ratio [HR] = 1.16; 95% CI, 1.07 to 1.25); however, additional adjustment for comorbidity index and nephrectomy treatment reduced the disparity substantially (HR = 1.00; 95% CI, 0.93 to 1.09).

CONCLUSION

This study indicates that the lower survival rate among blacks compared with whites with renal cell cancer can be explained largely by the increased number of comorbid health conditions and the lower rate of surgical treatment among black patients.

Ethnic/Racial Disparities in Hospital Procedure Volume for Lung Resection for Lung Cancer

BACKGROUND

Ethnic/racial minorities experience poorer outcomes from lung cancer than non-Hispanic whites. Higher hospital procedure volume is associated with better survival from lung resection for lung cancer.

OBJECTIVES

We examined whether (1) ethnic/racial minorities are more likely to obtain lung resections at lower volume hospitals, (2) ethnicity/race is associated with inpatient mortality, (3) hospital volume mediates this association, and (4) hospital selection is mediated by racial/ethnic segregation, differences in insurance coverage, or limited hospital choice.

METHODS

Six years of data from the Nationwide Inpatient Sample (NIS 1998-2003, unweighted n = 50,245, weighted n = 129,506) were used in multivariate models controlling for sociodemographic factors, case complexity, and hospital characteristics. Additional analyses were conducted using the Area Resource File, which provided data on ethnic density and number of surgical hospitals in the hospital region.

RESULTS

Blacks/African Americans (odds ratio [OR] = 0.45; 0.34-0.58) and Latinos (OR = 0.44; 0.32-0.63) had lower odds of obtaining lung resection at a high-volume hospital than non-Hispanic whites. Blacks/African Americans (OR = 1.30; 1.01-1.67), Latinos (OR = 1.41; 1.02-1.94), and other racial/ethnic minorities (OR = 1.46; 1.04-2.06) also had higher odds of dying in hospital, but this association was statistically nonsignificant after controlling for hospital volume. Hospital location was not associated with lung resection procedure volume, nor did location mediate the association between ethnicity/race and hospital volume.

CONCLUSIONS

Ethnic/racial minorities are obtaining lung resection in lower volume hospitals and are more likely to die in hospital. Hospital volume is associated with higher mortality, but health insurance, segregation, and number of surgical hospitals within a county do not account for observed disparities.

Racial Differences in Stage and Survival in Head and Neck Squamous Cell Carcinoma

OBJECTIVES

The goal of this study was to characterize differences in survival between black patients and white patients with squamous cell carcinoma of the head and neck (HNSCCA).

DESIGN

Cases of oral tongue and glottic SCCA in black patients or white patients were extracted from the Surveillance, Epidemiology, and End Results (SEER) database (years 1988-2002). For each primary site, TNM staging was imputed, and staging distributions were compared between races. For each black patient, a randomly selected white control was matched for age at diagnosis, sex, stage, surgical treatment, and radiation. Kaplan-Meier survival comparisons for both overall and disease-specific survival were then conducted for the matched pairs.

RESULTS

From 1,919 cases of carcinoma of the oral tongue, those of 151 black and 1,768 white patients were extracted. Black patients had a significantly elevated T stage (P = .001) and N stage (P = .002) at primary presentation. Of glottic carcinoma, 4,578 cases (625 black and 3,953 white patients) were extracted. Black patients again presented with significantly elevated T stage (P < .001) and N stage (P < .001) compared with white patients. For 43 matched pairs with tongue carcinoma, mean overall survival for black patients was 66.1 months versus 74.8 months for matched white controls (P = .502, log-rank test). Disease-specific survival was 91.1 months for black patients versus 109.6 months for white patients (P = .168). For 401 matched pairs with glottic carcinoma, mean overall survival for black patients was 96.6 months versus 114.5 months for white controls (P < .001). Similarly, the mean disease-specific survival was 149.4 months for black patients versus 167.1 months for white patients (P < .001)

CONCLUSION

Controlling for stage and treatment, black patients demonstrate poorer overall and disease-specific survival with SCCA, implying other intrinsic or extrinsic factors influencing survival.

Hypofractionated high-dose proton beam therapy for stage I non-small-cell lung cancer: preliminary results of a phase I/II clinical study

PURPOSE

To present treatment outcomes of hypofractionated high-dose proton beam therapy for Stage I non-small-cell lung cancer (NSCLC).

METHODS AND MATERIALS

Twenty-one patients with Stage I NSCLC (11 with Stage IA and 10 with Stage IB) underwent hypofractionated high-dose proton beam therapy. At the time of irradiation, patient age ranged from 51 to 85 years (median, 74 years). Nine patients were medically inoperable because of comorbidities, and 12 patients refused surgical resection. Histology was squamous cell carcinoma in 6 patients, adenocarcinoma in 14, and large cell carcinoma in 1. Tumor size ranged from 10 to 42 mm (median, 25 mm) in maximum diameter. Three and 18 patients received proton beam irradiation with total doses of 50 Gy and 60 Gy in 10 fractions, respectively, to primary tumor sites.

RESULTS

Of 21 patients, 2 died of cancer and 2 died of pneumonia at a median follow-up period of 25 months. The 2-year overall and cause-specific survival rates were 74% and 86%, respectively. All but one of the irradiated tumors were controlled during the follow-up period. Five patients showed recurrences 6-29 months after treatment, including local progression and new lung lesions outside of the irradiated volume in 1 and 4 patients, respectively. The local progression-free and disease-free rates were 95% and 79% at 2 years, respectively. No therapy-related toxicity of Grade > or =3 was observed.

CONCLUSIONS

Hypofractionated high-dose proton beam therapy seems feasible and effective for Stage I NSCLC. Proton beams may contribute to enhanced efficacy and lower toxicity in the treatment of patients with Stage I NSCLC.

Lung carcinoma in African Americans

Lung carcinoma is the most commonly diagnosed cancer and the leading cause of cancer deaths in the US. It accounts for 12% of all cancers diagnosed worldwide, making it the most common malignancy, other than nonmelanoma skin cancer. A new focus has emerged involving the role of race and ethnicity in lung carcinoma. Current health statistics data demonstrate striking disparities, which are most evident between African American patients and their white counterparts. This disparity is greatest among male patients, where statistically significant differences are seen not only in lung cancer incidence and risk, but also in survival and treatment outcomes. Several hypotheses that attempt to explain this disparity include genetic, cultural and socioeconomic differences, in addition to differences in tobacco use and exposure. Current evidence does not clearly identify the reasons for this observed disparity, or the role the aforementioned factors play in the development and overall outcomes of people with lung cancer in these populations. This disease continues to pose a considerable public health burden and more research is needed to improve understanding of the disparity of lung carcinoma statistics among African Americans. This review summarizes the existing body of knowledge regarding lung carcinoma in African Americans and attempts to identify promising areas for future investigation and intervention.

Lung cancer disparities in African Americans: health versus health care

African Americans with lung cancer have disproportionately worse outcomes than other ethnic groups. The incidence of lung cancer in blacks has remained well above the rates seen for the general population and the 5-year and overall survival rates for blacks with lung cancer are among the lowest of all racial groups. Many studies have focused on socioeconomic status of African Americans as the sole cause of these disparities. Other stu-dies, however, have identified additional factors related to risks for poor outcomes in blacks with lung cancer. This article reviews data on these risks and their relationships to the health and health care of African Americans with lung cancer.

COPD: racial disparities in susceptibility, treatment, and outcomes

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and mortality continues to increase particularly among African Americans. Although this increase may be caused by changing smoking habits, some studies suggest that African Americans may be more susceptible to tobacco smoke than whites. Unlike other respiratory diseases for which there are significant published data on racial and ethnic disparities in disease outcomes, such information is notably lacking in the COPD literature. This article examines the available data concerning racial disparities in COPD susceptibility and care.