County-Level Variations in Receipt of Surgery for Early-Stage Non-small Cell Lung Cancer in the United States

Impact of Medicaid expansion under the Patient Protection and Affordable Care Act on lung cancer care in the US

Background

Healthcare disparities significantly affect access to care and outcomes in lung cancer patients. The Patient Protection and Affordable Care Act (ACA) Medicaid expansion (ME) was enacted with the aim of improving access to quality and affordable healthcare. This study aims to determine the impact of ME on access to care and outcomes for patients with lung cancer.

Methods

We conducted a retrospective analysis of adults (ages 40-64 years) diagnosed with non-small cell lung cancer (NSCLC) in the National Cancer Database between 2009-2019. The study population was divided into a pre-expansion era (A: 2009-2013) and a post-expansion era (B: 2015-2019). The exposure of interest was residence in a state that expanded Medicaid in 2014 (ME) vs. non-expansion (NE). Outcomes were insurance coverage, clinical stage at diagnosis, treatment facility, and survival. Propensity score analysis was used to determine the association between ME and survival.

Results

A total of 202,003 patients were included (era B, 51.6%). The median age was 58 years, the majority of patients were male (53.0%), White (79.7%), had no comorbidities (62.0%) and adenocarcinoma (57.4%). From era A to B, insurance coverage increased to 96.7% (+6.6%), stage I disease to 25.3% (+6.5%), and treatment at an academic facility to 43.9% (+3.5%) in the ME group. For the NE group, the increases were up to 88.3% (+4.3%), 21.6% (+4.0%), and 28.6% (+0.2%), respectively. The increase in stage I cancer diagnosis was most noticeable in females. Following risk adjustment, era B was associated with an improvement in survival outcomes irrespective of ME status.

Conclusions

Disparities in lung cancer care seem to have improved after ME. Ongoing monitoring is still necessary to confirm the program's long-term impact on lung cancer survival.

Disparity in Treatment Receipt by Race and Treatment Guideline Revision Years for Stage 1A Non-Small Cell Lung Cancer Patients in the US

INTRODUCTION

Treatment guideline revision introduced by the National Comprehensive Cancer Network (NCCN) is referred to by about 95% of the United States (US) oncologists in treatment decision-making for stage 1A non-small cell lung cancer. It is vital to account for this factor that affects the standard treatment receipt among stage 1A patients, with about a 75% survival rate if treated on time. The first choice for medically fit patients is lobectomy; however, over the decades since the initial guidelines were published, several medical advances have introduced trends in treatment receipt along with other sociodemographic factors that could help identify survival outcomes associated with treatment receipt. Establishing the role of treatment guideline revision years is important to determine a close to true causal relationship in racial treatment disparities.

METHODS

US national cancer registry data for all US counties and historical Area Health Resource Files for the study period 1988-2015 were utilized. Logistic regression analysis was adjusted for clustering of standard errors at the state level and for time-invariant unobserved factors for the year of diagnosis and county. The time-invariant unobservable for each year of diagnosis and county specificity were accounted for by including their dummy variables in the regression model with standard errors clustered at the state level.

RESULTS

Black patients, Medicaid beneficiaries, large fringe metropolitan residents, and those diagnosed post-2007 treatment revisions years are less likely to receive lobectomy, which is the standard treatment guideline for medically fit patients.

CONCLUSION

The study concludes that there exists a difference in treatment type received among stage 1A NSCLC patients in the US by race, socioeconomic status, and treatment guideline revisions.

American Cancer Society's report on the status of cancer disparities in the United States, 2023

In 2021, the American Cancer Society published its first biennial report on the status of cancer disparities in the United States. In this second report, the authors provide updated data on racial, ethnic, socioeconomic (educational attainment as a marker), and geographic (metropolitan status) disparities in cancer occurrence and outcomes and contributing factors to these disparities in the country. The authors also review programs that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. There are substantial variations in risk factors, stage at diagnosis, receipt of care, survival, and mortality for many cancers by race/ethnicity, educational attainment, and metropolitan status. During 2016 through 2020, Black and American Indian/Alaska Native people continued to bear a disproportionately higher burden of cancer deaths, both overall and from major cancers. By educational attainment, overall cancer mortality rates were about 1.6-2.8 times higher in individuals with ≤12 years of education than in those with ≥16 years of education among Black and White men and women. These disparities by educational attainment within each race were considerably larger than the Black-White disparities in overall cancer mortality within each educational attainment, ranging from 1.03 to 1.5 times higher among Black people, suggesting a major role for socioeconomic status disparities in racial disparities in cancer mortality given the disproportionally larger representation of Black people in lower socioeconomic status groups. Of note, the largest Black-White disparities in overall cancer mortality were among those who had ≥16 years of education. By area of residence, mortality from all cancer and from leading causes of cancer death were substantially higher in nonmetropolitan areas than in large metropolitan areas. For colorectal cancer, for example, mortality rates in nonmetropolitan areas versus large metropolitan areas were 23% higher among males and 21% higher among females. By age group, the racial and geographic disparities in cancer mortality were greater among individuals younger than 65 years than among those aged 65 years and older. Many of the observed racial, socioeconomic, and geographic disparities in cancer mortality align with disparities in exposure to risk factors and access to cancer prevention, early detection, and treatment, which are largely rooted in fundamental inequities in social determinants of health. Equitable policies at all levels of government, broad interdisciplinary engagement to address these inequities, and equitable implementation of evidence-based interventions, such as increasing health insurance coverage, are needed to reduce cancer disparities.

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use - results of a scoping review

BACKGROUND

Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use.

METHODS

We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the 'Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)' recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered.

RESULTS

Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies.

CONCLUSIONS

Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

The global burden of lung cancer: current status and future trends

Lung cancer is the leading cause of cancer-related death worldwide. However, lung cancer incidence and mortality rates differ substantially across the world, reflecting varying patterns of tobacco smoking, exposure to environmental risk factors and genetics. Tobacco smoking is the leading risk factor for lung cancer. Lung cancer incidence largely reflects trends in smoking patterns, which generally vary by sex and economic development. For this reason, tobacco control campaigns are a central part of global strategies designed to reduce lung cancer mortality. Environmental and occupational lung cancer risk factors, such as unprocessed biomass fuels, asbestos, arsenic and radon, can also contribute to lung cancer incidence in certain parts of the world. Over the past decade, large-cohort clinical studies have established that low-dose CT screening reduces lung cancer mortality, largely owing to increased diagnosis and treatment at earlier disease stages. These data have led to recommendations that individuals with a high risk of lung cancer undergo screening in several economically developed countries and increased implementation of screening worldwide. In this Review, we provide an overview of the global epidemiology of lung cancer. Lung cancer risk factors and global risk reduction efforts are also discussed. Finally, we summarize lung cancer screening policies and their implementation worldwide.

Patient and provider factors predict non-surgical management for complex upper gastrointestinal cancers

BACKGROUND

Surgery is the only potentially curative treatment for non-metastatic upper gastrointestinal cancers. We analyzed patient and provider characteristics associated with non-surgical management.

METHODS

We queried the National Cancer Database for patients with upper gastrointestinal cancers from 2004 to 2018 who underwent surgery, refused surgery, or for whom surgery was contraindicated. Multivariate logistic regression identified factors associated with surgery being refused or contraindicated, and Kaplan-Meier curves assessed survival.

RESULTS

We identified 249,813 patients based on our selection criteria-86.3% had surgery, 2.4% refused, and for 11.3%, surgery was contraindicated. Median overall survival was 48.2 months for patients who underwent surgery versus 16.3 and 9.4 months for the refusal and contraindicated groups. Medical and non-medical factors predicted both surgery refusals and contraindications, such as increasing age (odds ratio = 1.07 and 1.03, respectively, P < .001), Black race (odds ratio = 1.72 and 1.45, P < .001), comorbidities (Charlson-Deyo score 2+, odds ratio = 1.18 and 1.66, P < .001), low socioeconomic status (odds ratio = 1.70 and 1.40, P < .001), no health insurance (odds ratio = 3.26 and 2.34, P < .001), community cancer programs (odds ratio = 1.43 and 1.40, P < .001), low volume facilities (odds ratio = 1.82 and 1.52, P < .001), and stage 3 disease (odds ratio = 1.51 and 6.50, P < .001). On subset analysis (excluding patients age >70, Charlson-Deyo score 2+, and stage 3 cancer), non-medical predictors of both outcomes were similar.

CONCLUSION

Refusal of and medical contraindications for surgery profoundly impact overall survival. The same factors (ie, race, socioeconomic status, hospital volume, and hospital type) predict these outcomes. These findings suggest variation and potential bias that may exist between physicians and patients discussing cancer surgery.

Progress in reducing cancer mortality in the United States by congressional district, 1996-2003 to 2012-2020

BACKGROUND

United States cancer death rates have been steadily declining since the early 1990s, but information on disparities in progress against cancer mortality across congressional districts is lacking. This study examined trends in cancer death rates, overall and for lung, colorectal, female breast, and prostate cancer by congressional district.

METHODS

County level cancer death counts and population data from the National Center for Health Statistics were used to estimate relative change in age-standardized cancer death rates from 1996-2003 to 2012-2020 by sex and congressional district.

RESULTS

From 1996-2003 to 2012-2020, overall cancer death rates declined in every congressional district, with most congressional districts showing a 20%-45% decline among males and a 10%-40% decline among females. In general, the smallest percent of relative declines were found in the Midwest and Appalachia, whereas the largest declines were found in the South along the East Coast and the southern border. As a result, the highest cancer death rates generally shifted from congressional districts across the South in 1996-2003 to districts in the Midwest and central divisions of the South (including Appalachia) in 2012-2020. Death rates for lung, colorectal, female breast, and prostate cancers also declined in almost all congressional districts, although with some variation in relative changes and geographical patterns.

CONCLUSIONS

Progress in reducing cancer death rates during the past 25 years considerably vary by congressional district, underscoring the need for strengthening existing and implementing new public health policies for broad and equitable application of proven interventions such as raising tax on tobacco and Medicaid expansion.

The Persistence of Poverty and its Impact on Cancer Diagnosis, Treatment and Survival

OBJECTIVE

To determine the effect of persistent poverty on the diagnosis, surgical resection and survival of patients with non-small cell lung (NSCLC), breast, and colorectal cancer.

BACKGROUND

Disparities in cancer outcomes exist in counties with high levels of poverty, defined as ≥20% of residents below the federal poverty level. Despite this well-established association, little is known about how the duration of poverty impacts cancer care and outcomes. One measure of poverty duration is that of "persistent poverty," defined as counties in high poverty since 1980.

METHODS

In this retrospective cohort study, patients with NSCLC, breast and colorectal cancer were identified from SEER (2012-2016). County-level poverty was obtained from the American Community Survey (1980-2015). Outcomes included advanced stage at diagnosis (stage III-IV), resection of localized disease (stage I-II) and cancer-specific survival. Hierarchical generalized linear models and accelerated failure time models with Weibull distribution were used, adjusted for patient-level covariates and region.

RESULTS

Overall, 522,514 patients were identified, of which 5.1% were in persistent poverty. Patients in persistent poverty were more likely to present with advanced disease [NSCLC odds ratio (OR): 1.12, 95% confidence interval (CI): 1.06-1.18; breast OR: 1.09, 95% CI: 1.02-1.17; colorectal OR: 1.00, 95% CI: 0.94-1.06], less likely to undergo surgery (NSCLC OR: 0.81, 95% CI: 0.73-0.90; breast OR: 0.82, 95% CI: 0.72-0.94; colorectal OR: 0.84, 95% CI: 0.70-1.00) and had increased cancer-specific mortality (NSCLC HR: 1.09, 95% CI: 1.06-1.13; breast HR: 1.18, 95% CI: 1.05-1.32; colorectal HR: 1.09, 95% CI: 1.03-1.17) as compared with those without poverty. These differences were observed to a lesser magnitude in counties with current, but not persistent, poverty and disappeared in counties no longer in poverty.

CONCLUSIONS

The duration of poverty has a direct impact on cancer-specific outcomes, with the greatest effect seen in persistent poverty and resolution of disparities when a county is no longer in poverty. Policy focused on directing resources to communities in persistent poverty may represent a possible strategy to reduce disparities in cancer care and outcomes.

Barriers and facilitators to early-stage lung cancer care in the USA: a qualitative study

PURPOSE

Improved outcomes in lung cancer treatment are seen in high-volume academic centers, making it important to understand barriers to accessing care at such institutions. Few qualitative studies examine the barriers and facilitators to early-stage lung cancer care at US academic institutions.

METHODS

Adult patients with suspected or diagnosed early-stage non-small cell lung cancer presenting to a multidisciplinary lung cancer clinic at a US academic institution over a 6-month period beginning in 2019 were purposively sampled for semi-structured interviews. Semi-structured interviews were conducted and a qualitative content analysis was performed using the framework method. Themes relating to barriers and facilitators to lung cancer care were identified through iterative team-based coding.

RESULTS

The 26 participants had a mean age of 62 years (SD: 8.4 years) and were majority female (62%), white (77%), and urban (85%). We identified 6 major themes: trust with providers and health systems are valued by patients; financial toxicity negatively influenced the diagnostic and treatment experience; social constraints magnified other barriers; patient self-advocacy as a facilitator of care access; provider advocacy could overcome other barriers; care coordination and good communication were important to patients.

CONCLUSIONS

We have identified several barriers and facilitators to lung cancer care at an academic center in the US. These factors need to be addressed to improve quality of care among lung cancer patients. Further work will examine our findings in a community setting to understand if our findings are generalizable to patients who do not access a tertiary cancer care center.

Rural-urban survival disparities for patients with surgically treated lung cancer

BACKGROUND

Nonsmall-cell lung cancer (NSCLC) is a common diagnosis among patients living in rural areas and small towns who face unique challenges accessing care. We examined differences in survival for surgically treated rural and small-town patients compared to those from urban and metropolitan areas.

METHODS

The National Cancer Database was used to identify surgically treated NSCLC patients from 2004 to 2016. Patients from rural/small-town counties were compared to urban/metro counties. Differences in patient clinical, sociodemographic, hospital, and travel characteristics were described. Survival differences were examined with Kaplan-Meier curves and Cox proportional hazards models.

RESULTS

The study included 366 373 surgically treated NSCLC patients with 12.4% (n = 45 304) categorized as rural/small-town. Rural/small-town patients traveled farther for treatment and were from areas characterized by lower income and education(all p < 0.001). Survival probabilities for rural/small-town patients were worse at 1 year (85% vs. 87%), 5 years (48% vs. 54%), and 10 years (26% vs. 31%) (p < 0.001). Travel distance >100 miles (hazard ratio [HR] = 1.11, 95% confidence interval [CI]: 1.07-1.16, vs. <25 miles) and living in a rural/small-town county (HR = 1.04, 95% CI: 1.01-1.07) were associated with increased risk for death.

CONCLUSIONS

Rural and small-town patients with surgically treated NSCLC had worse survival outcomes compared to urban and metropolitan patients.

Facility-level national trends in racial disparities of surgical therapy for early-stage lung cancer

OBJECTIVE

The racial gap in surgical treatment for early-stage non-small cell lung cancer (NSCLC) has been narrowing at the population level, but it is unknown if this trend persists at the facility level.

PATIENTS AND METHODS

We queried the National Cancer Database Participant User File from 2006 to 2016 for patients with stage I NSCLC. Facilities were grouped by type, location, and resection volume. The cumulative surgery rate for Black and White patients in each group was calculated, and an incidence rate difference of receipt of surgery was determined. Logistic regression with estimation of marginal effects was used to assess the probability difference of receiving surgery in Black versus White patients in each year.

RESULTS

In total, 315,474 patients were included; 287,585 (91.2%) were White and 27,889 (8.8%) were Black. The surgery rate was greater for White patients (60.2% vs 55.8%, P < .001). For most groups, the surgery disparity narrowed over the study period. The disparity widened in community cancer programs; facilities in the New England, West North Central, and Pacific regions; and the lowest volume facilities. The probability difference for receiving surgery was significantly smaller in 2016 versus 2006 in the Middle Atlantic region and community cancer programs; the difference was unchanged for all other groupings.

CONCLUSIONS

Trends in disparities in the use of resection for early-stage NSCLC are not universal across facility groupings. As efforts are made toward addressing racial disparities in surgical care for NSCLC, it will be important to remember that population-level analyses may mask lack of progress in certain facility groups.

Rural-Urban Disparities in Cancer Outcomes: Opportunities for Future Research

Cancer care disparities among rural populations are increasingly documented and may be worsening, likely because of the impact of rurality on access to state-of-the-art cancer prevention, diagnosis, and treatment services, as well as higher rates of risk factors such as smoking and obesity. In 2018, the American Society of Clinical Oncology undertook an initiative to understand and address factors contributing to rural cancer care disparities. A key pillar of this initiative was to identify knowledge gaps and promote the research needed to understand the magnitude of difference in outcomes in rural vs nonrural settings, the drivers of those differences, and interventions to address them. The purpose of this review is to describe continued knowledge gaps and areas of priority research to address them. We conducted a comprehensive literature review by searching the PubMed (Medline), Embase, Web of Science, and Cochrane Library databases for studies published in English between 1971 and 2021 and restricted to primary reports from populations in the United States and abstracted data to synthesize current evidence and identify continued gaps in knowledge. Our review identified continuing gaps in the literature regarding the underlying causes of rural-urban disparities in cancer outcomes. Rapid advances in cancer care will worsen existing disparities in outcomes for rural patients without directed effort to understand and address barriers to high-quality care in these areas. Research should be prioritized to address ongoing knowledge gaps about the drivers of rurality-based disparities and preventative and corrective interventions.

American Cancer Society's report on the status of cancer disparities in the United States, 2021

In this report, the authors provide comprehensive and up-to-date US data on disparities in cancer occurrence, major risk factors, and access to and utilization of preventive measures and screening by sociodemographic characteristics. They also review programs and resources that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. The overall cancer death rate is 19% higher among Black males than among White males. Black females also have a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. There are also substantial variations in death rates for specific cancer types and in stage at diagnosis, survival, exposure to risk factors, and receipt of preventive measures and screening by race/ethnicity, socioeconomic status, and geographic location. For example, kidney cancer death rates by sex among American Indian/Alaska Native people are ≥64% higher than the corresponding rates in each of the other racial/ethnic groups, and the 5-year relative survival for all cancers combined is 14% lower among residents of poorer counties than among residents of more affluent counties. Broad and equitable implementation of evidence-based interventions, such as increasing health insurance coverage through Medicaid expansion or other initiatives, could substantially reduce cancer disparities. However, progress will require not only equitable local, state, and federal policies but also broad interdisciplinary engagement to elevate and address fundamental social inequities and longstanding systemic racism.

Geographic differences in therapy for stage I non-small-cell lung cancer in older adults

BACKGROUND

Geographic and socioeconomic factors impact patient treatment choices for certain cancers. Whether they impact treatment in older adults with lung cancer is unknown. We investigated geographic differences in treatment for stage I non-small-cell lung cancer (NSCLC) in older adults in the United States.

METHODS

Using the Surveillance, Epidemiology and End Results Database 18th submission, a cohort of stage I NSCLC patients ≥60-years-old was created. Treatment differences (surgery or radiation alone) by geographic location and socioeconomic factors were analyzed.

RESULTS

Forty-three thousand three hundred and eighty-seven stage I NSCLC patients were analyzed. Demographics and socioeconomic factors varied across all 13 states (p < 0.001). Surgery was the most common treatment in all states (range 58.6% in AK to 86.5% in CT) (all p < 0.001). Our multivariable analysis found older individuals had higher odds of getting radiation as compared to surgery (odds ratio [OR]: 1.22 for 65-69 years-old to OR: 8.95 for 85+ years-old; p < 0.001). Multiple states (LA, HI, IA, MI, WA, NM) were associated with increased odds of radiation use (vs. surgery alone) (all p < 0.05). People with lower education level (OR: 0.98) and median income (OR: 0.99) and non-Black race (OR: 0.52 for "other" to OR: 0.68 for "White" race with respect to Black race) were associated with lower odds of radiation (p < 0.05).

CONCLUSIONS

Our study identified treatment differences for stage I NSCLC patients in the United States related to demographics, socioeconomic factors, and geographic location.

Surgery without preoperative histological confirmation of lung cancer: what is the current clinical practice?

BACKGROUND

There are discordances in the guidelines regarding the need to acquire histological diagnosis before surgical treatment of (presumed) lung cancer. Preoperative histological confirmation is always encouraged in this setting to prevent unnecessary surgery or when sublobar resection for small-sized tumors is considered. The aim of this retrospective cohort study was to assess the proportion of patients undergoing lung cancer resection in the Netherlands without preoperative pathological confirmation, based on the intraoperative pathological diagnosis (IOD) rate, and to determine characteristics that may influence IOD frequency.

METHODS

Data on 10,226 patients, who underwent surgical treatment for lung cancer from 2010 to 2015, were retrieved from the Netherlands National Cancer Registry. We registered an IOD when the date of diagnosis equaled the date of the first surgical intervention. Tabulations and multivariable logistic regression were used to identify predictive parameters for IOD.

RESULTS

36% of surgical procedures were classified as IOD, and decreased with increasing tumor size and extent of surgery (57% for segmentectomy, 39% for lobectomy and 11% for pneumonectomy). IOD was more frequently observed in adenocarcinoma (41%), varied between hospitals from 13% to 66% and was less common when patients were referred from a hospital where thoracic surgery was not performed. Previous history of cancer did not affect IOD.

CONCLUSIONS

More than one-third of patients with suspected lung cancer in the Netherlands was operated without preoperative histological confirmation. There was significant variation in IOD rates between different hospitals, which deserves further detailed analysis when striving for uniform surgical quality of care for patients with lung cancer.

County-Level Variation in Utilization of Surgical Resection for Early-Stage Hepatopancreatic Cancer Among Medicare Beneficiaries in the USA

INTRODUCTION

Geographic variations in access to care exist in the USA. We sought to characterize county-level disparities relative to access to surgery among patients with early-stage hepatopancreatic (HP) cancer.

METHODS

Data were extracted from the Surveillance, Epidemiology, and End Results (SEER)-Medicare Linked database from 2004 to 2015 to identify patients undergoing surgery for early-stage HP cancer . County-level information was acquired from the Area Health Resources Files (AHRF). Multivariable logistic regression analysis was performed to assess factors associated with utilization of HP surgery on the county level.

RESULTS

Among 13,639 patients who met inclusion criteria, 66.9% (n = 9125) were diagnosed with pancreatic cancer and 33.1% (n = 4514) of patients had liver cancer. Among patients diagnosed with early-stage liver and pancreas malignancy, two-thirds (n = 8878, 65%) underwent surgery. Marked county-level variation in the utilization of surgery was noted among patients with early-stage HP cancer ranging from 57.1% to more than 83.3% depending on which county a patient resided. After controlling for patient and tumor-related characteristics, counties with the highest quartile of patients living below the poverty level had 35% lower odds of receiving surgery for early stage HP cancer compared patients who lived in a county with the lowest proportion of patients below the poverty line (OR 0.65, 95% CI 0.55-0.77). In addition, patients residing in counties with the highest surgeon-to-population ratio (OR 2.01, 95% CI 1.52-2.65), as well as the highest hospital bed-to-population ratio (OR 1.29, 95% CI 1.07-1.54), were more likely to undergo surgical treatment for an early-stage HP malignancy.

CONCLUSION

Area-level variations among patients undergoing surgery for early-stage HP cancer were mainly due to differences in structural measures and county-level factors. Policies targeting high-poverty counties and improvement in structural measures may reduce variations in utilization of surgery among patients diagnosed with early-stage HP cancer.

Cancer Outcomes Among Medicare Beneficiaries And Their Younger Uninsured Counterparts

Proposals for expanding Medicare insurance coverage to uninsured Americans approaching the Medicare eligibility age of sixty-five has been the subject of intense debate. We undertook this study to assess cancer survival differences between uninsured patients younger than age sixty-five and older Medicare beneficiaries by using data from the National Cancer Database from the period 2004-16. The main outcomes were survival at one, two, and five years for sixteen cancer types in 1,206,821 patients. We found that uninsured patients ages 60-64 were nearly twice as likely to present with late-stage disease and were significantly less likely to receive surgery, chemotherapy, or radiotherapy than Medicare beneficiaries ages 66-69, despite lower comorbidity among younger patients. Compared with older Medicare patients, younger uninsured patients had strikingly lower five-year survival across cancer types. For instance, five-year survival in younger uninsured patients with late-stage breast or prostate cancer was 5-17 percent lower than that among older Medicare patients. We conclude that survival after a diagnosis of cancer is considerably lower in younger uninsured patients than in older Medicare patients. Expanding comprehensive health insurance coverage to people approaching Medicare age eligibility may improve cancer outcomes in the US.

Narrative review of socioeconomic and racial disparities in the treatment of early stage lung cancer

Background

To review and discuss the current literature regarding socio-economic and racial disparities in the treatment of early-stage non-small cell lung cancer (NSCLC).

Methods

Narrative review of peer reviewed literature synthesizing findings retrieved from searches of computerized databases, primary article reference lists, authoritative texts and expert options.

Results

The current incidence of lung cancer appears to be similar between White and Black patients. However, Black patients are substantially less likely to receive curative intent surgery. Mitigation strategies do exist to narrow this inequity. Lower socioeconomic status (SES) is associated with a higher incidence of lung cancer, lower utilization of surgery and poorer outcomes after surgery.

Conclusions

Race and SES remain closely linked to outcomes in lung cancer. Outcomes are still worse when controlling for stage and specifically, in early-stage disease, surgical therapy is consistently underused in Black patients and patients of low SES.

Regional Variation in Treatment for Highest-Risk Patients with Non-Small Cell Lung Cancer Patients

BACKGROUND

Non-small cell lung cancer (NSCLC) patients with multiple high-risk socioeconomic factors experience treatment and survival disparities. We aim to assess whether disparities in treatment and survival vary by region for patients with three or more high-risk socioeconomic factors.

METHODS

The National Cancer Database was queried for patients with clinical stage I-IIA NSCLC diagnosed between 2010-2015. Patients were categorized into three groups: standard treatment, non-standard treatment, and no curative treatment. Multivariable logistic regression was used to evaluate regional differences in treatment. Cox proportional hazards regression and the Kaplan-Meier method were used for survival analysis. All statistical tests were two-sided.

RESULTS

93,211 patients met inclusion criteria. For patients with three or more high-risk socioeconomic factors, the odds of non-standard treatment were significantly greater in six regions compared to New England, greatest in West North Central (odds ratio [OR] = 2.09, P<0.001). The odds of no curative treatment were significantly greater in seven regions compared to New England, greatest in West South Central (OR = 3.56, P<0.001). West North Central was associated with the highest risk of all-cause mortality compared to New England (hazard ratio [HR] = 1.10, P<0.001), and Middle Atlantic was associated with the lowest (HR = 0.86, P<0.001). 5-year overall survival was longest in Middle Atlantic (60.8%) and shortest in Mountain (36.8%).

CONCLUSIONS

Patients with three or more high-risk socioeconomic factors experience treatment and survival disparities across the United States, though disparities are more pronounced in certain regions. Regional interventions may help mitigate disparities among highest risk NSCLC patients.

Socioeconomic Inequalities in Premature Cancer Mortality Among U.S. Counties During 1999 to 2018

BACKGROUND

This study investigated socioeconomic inequalities in premature cancer mortality by cancer types, and evaluated the associations between socioeconomic status (SES) and premature cancer mortality by cancer types.

METHODS

Using multiple databases, cancer mortality was linked to SES and other county characteristics. The outcome measure was cancer mortality among adults ages 25-64 years in 3,028 U.S. counties, from 1999 to 2018. Socioeconomic inequalities in mortality were calculated as a concentration index (CI) by income (annual median household income), educational attainment (% with bachelor's degree or higher), and unemployment rate. A hierarchical linear mixed model and dominance analyses were used to investigate SES associated with county-level mortality. The analyses were also conducted by cancer types.

RESULTS

CIs of SES factors varied by cancer types. Low-SES counties showed increasing trends in mortality, while high-SES counties showed decreasing trends. Socioeconomic inequalities in mortality among high-SES counties were larger than those among low-SES counties. SES explained 25.73% of the mortality. County-level cancer mortality was associated with income, educational attainment, and unemployment rate, at -0.24 [95% (CI): -0.36 to -0.12], -0.68 (95% CI: -0.87 to -0.50), and 1.50 (95% CI: 0.92-2.07) deaths per 100,000 population with one-unit SES factors increase, respectively, after controlling for health care environment and population health.

CONCLUSIONS

SES acts as a key driver of premature cancer mortality, and socioeconomic inequalities differ by cancer types.

IMPACT

Focused efforts that target socioeconomic drivers of mortalities and inequalities are warranted for designing cancer-prevention implementation strategies and control programs and policies for socioeconomically underprivileged groups.

Institutional-Level Differences in Quality and Outcomes of Lung Cancer Resections in the United States

BACKGROUND

Institutional-level disparities in non-small cell lung cancer (NSCLC) survival may be driven by reversible differences in care-delivery processes. We quantified the impact of differences in readily identifiable quality metrics on long-term survival disparities in resected NSCLC.

RESEARCH QUESTION

How do reversible differences in oncologic quality of care contribute to institutional-level disparities in early-stage NSCLC survival?

STUDY DESIGN AND METHODS

We retrospectively analyzed patients in the National Cancer Data Base who underwent NSCLC resection from 2004 through 2015 within institutions categorized as Community, Comprehensive Community, Integrated Network, Academic, and National Cancer Institute (NCI)-Designated Cancer Programs. We estimated percentages and adjusted ORs for six potentially avoidable poor-quality markers: incomplete resection, nonexamination of lymph nodes, nonanatomic resection, non-evidence-based use of adjuvant chemotherapy, non-evidence-based use of adjuvant radiation therapy, and 60-day postoperative mortality. By sequentially eliminating patients with poor-quality markers and calculating adjusted hazard ratios, we quantified their overall survival impact.

RESULTS

Of 169,775 patients, 7%, 46%, 10%, 24%, and 12% underwent surgery at Community, Comprehensive Community, Integrated Network, Academic, and NCI-Designated Cancer Programs, with 5-year overall survival rates of 52%, 56%, 58%, 60% and 66%, respectively. After the sequential elimination process, using NCI-Designated Cancer Centers as a reference, the adjusted hazard ratio for 5-year overall survival changed from 1.47 (95% CI, 1.41-1.53), 1.29 (95% CI, 1.25-1.33), 1.18 (95% CI, 1.14-1.23), and 1.20 (95% CI, 1.16-1.24) for Community, Comprehensive Community, Integrated Networks, and Academic Cancer Programs to 1.35 (95% CI, 1.28-1.42), 1.22 (95% CI, 1.17-1.26), 1.16 (95% CI, 1.11-1.22), and 1.17 (95% CI, 1.12-1.21), respectively (P < .001 for all comparisons with NCI-designated programs). Differences in quality of surgical resection and postoperative care accounted for 11% to 26% of the interinstitutional survival disparities.

INTERPRETATION

Targeting six readily identified poor-quality markers narrowed, but did not eliminate, institutional survival disparities. The greatest impact was in community programs. Residual factors driving persistent institution-level long-term NSCLC survival disparities must be characterized to eliminate them.

Rurality, Stage-Stratified Use of Treatment Modalities, and Survival of Non-small Cell Lung Cancer

BACKGROUND

To eliminate them, non-small cell lung cancer (NSCLC) care and outcome disparities need to be better understood.

RESEARCH QUESTION

How does rurality interact with NSCLC care and outcome disparities?

STUDY DESIGN AND METHODS

We examined guideline-concordant use of active treatment for NSCLC across five institutions in one community-based health care system spanning 44% of the Delta Regional Authority catchment area from 2011 to 2017. Institution- and patient-level rurality were based on Rural-Urban Commuting Area codes. Chi-squared, F-tests, and logistic regressions were used to analyze differences across institutions and rurality; survival was examined using log-rank tests and Cox regression.

RESULTS

Of 6,259 patients, 47% resided in rural areas; two of five institutions were rurally located and provided care for 20% of patients. Compared with rural residents at rural institutions, urban and rural residents attending urban institutions were more likely to receive stage-preferred treatment: OR 1.68 (95%CI, 1.44-1.96), and 1.33 (1.11-1.61), respectively, after adjusting for insurance, age, and clinical stage. Urban and rural residents attending urban institutions had a lower hazard of death compared with rural residents attending rural institutions: hazard ratio (HR) 0.69 (0.64-0.75) and 0.61 (0.55-0.67), respectively. Among recipients of stage-preferred treatment, care at urban institutions remained less hazardous: HR 0.7 (0.63-0.79). When further stratified by stage, care for late-stage patients at urban institutions remained less hazardous: HR 0.8 (0.71-0.91).

INTERPRETATION

Rurality-associated treatment and survival disparities were present at the patient and institution levels, but the institution-level disparity was greater. Rural residents receiving care at urban institutions had similar outcomes to urban residents receiving care at urban hospitals. To overcome rurality-associated NSCLC survival disparity, interventions should preferentially target the institution level, including expanding access to higher-quality guideline-concordant care.