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Liu Q, Medina HN, Rodriguez E, Jacobs KT, Brown C, Koru-Sengul T, Lopes G, Pinheiro PS. Trends and Disparities in Curative-Intent Treatment for Early-Stage Non-Small Cell Lung Cancer: A Population-Based Analysis of Surgery and SBRT. Cancer Epidemiol Biomarkers Prev 2024; 33:489-499. [PMID: 38252069 DOI: 10.1158/1055-9965.epi-23-1182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/01/2023] [Accepted: 01/18/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Despite the increasing adoption of stereotactic body radiotherapy (SBRT) as a recommended alternative for early-stage non-small cell lung cancer (NSCLC), population-based research on racial/ethnic disparities in curative-intent treatment accounting for SBRT remains limited. This study investigated trends and disparities in receiving curative-intent surgery and/or SBRT in a diverse, retrospective cohort. METHODS Early-stage NSCLC cases (2005-2017) from the Florida cancer registry were linked to individual-level statewide discharge data containing comorbidities and specific treatment information. Joinpoint regression assessed trends in treatment receipt. Multivariable logistic regression examined associations between race/ethnicity and treatment type. RESULTS Among 64,999 patients with early-stage NSCLC, 71.6% received curative-intent treatment (surgery and/or SBRT): 73.1%, 72.4%, and 60.3% among Hispanic, White, and Black patients, respectively (P < 0.01). SBRT use increased steeply from 2005 to 2007 and then by 7.9% annually from 2007 to 2017 (P < 0.01); curative-intent surgery remained stable from 2005 to 2014 before declining by 6.2% annually during 2014-2017 (P = 0.04). The Black-White disparity in receipt of curative-intent treatment was significant [ORadj, 0.65; 95% confidence interval (CI), 0.60-0.71]. Patients with Charlson comorbidity index (CCI)≥3 had 36% (ORadj, 0.64; 95% CI, 0.60-0.69) lower odds of receiving curative-intent surgery and no significant difference for SBRT (ORadj, 1.06; 95% CI, 0.93-1.20) compared with CCI = 0. CONCLUSIONS Racial disparities in receiving curative-intent treatment for early-stage NSCLC persist despite the availability of SBRT, suggesting the full potential of curative-intent treatment for early-stage NSCLC remains unachieved. IMPACT Addressing disparities in early-stage NSCLC requires addressing differential treatment patterns and enhancing accessibility to treatments like underutilized SBRT, particularly for high-comorbidity populations such as Black patients.
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Affiliation(s)
- Qinran Liu
- Department of Public Health Sciences, University of Miami School of Medicine, Miami, Florida
| | - Heidy N Medina
- Department of Public Health Sciences, University of Miami School of Medicine, Miami, Florida
| | | | - Kamaria T Jacobs
- Institute of Public Health, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, Florida
| | - Clyde Brown
- Institute of Public Health, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, Florida
| | - Tulay Koru-Sengul
- Department of Public Health Sciences, University of Miami School of Medicine, Miami, Florida
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Gilberto Lopes
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Paulo S Pinheiro
- Department of Public Health Sciences, University of Miami School of Medicine, Miami, Florida
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
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Chen AM, Garcia AD, Alexandrescu M, Healy E. Effect of a same day appointment initiative on racial disparities in access for radiation oncology. J Cancer Policy 2023; 38:100445. [PMID: 37716467 DOI: 10.1016/j.jcpo.2023.100445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 09/04/2023] [Accepted: 09/14/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE We present our single-institution experience with the development of a same day access scheduling initiative for an outpatient radiation oncology unit, focusing on its potential influence on ameliorating racial disparities. METHODS AND MATERIALS From March 2021 to August 2022, a pilot initiative was conducted such that all new patients referred to a tertiary care-based radiation oncology department were offered the ability to be seen as a same day consultation. The timespan of this analysis was categorized into 2 distinct successive periods over 36 months-a 18-month pre-initiative period (September 2019 to February 2021) and another subsequent one (March 2021 to August 2022). Descriptive statistics were used to study the impact of this initiative on access-related benchmarks. RESULTS A total of 2897 patients were referred. Among the 2107 patients scheduled, three hundred and sixteen (15 %) opted for same day appointments. Black, Latino, and Asian patients were significantly more likely to use the same day access initiative versus Caucasian patients (p = 0.01). The same day access initiative increased the proportion of patients seen within 5 days from referral from 8 % to 34 % for Blacks, 12-57 % for Latinos, and 18-67 % for Asians, compared to 39-55 % for Caucasians (p < 0.001). The no-show rate was reduced from 20 % to 7 % and 14-5 %, for Black and Latino patients, respectively (p < 0.001). CONCLUSIONS The implementation of a same day access initiative narrowed disparities with respect to access-related benchmarks.
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Affiliation(s)
- Allen M Chen
- Department of Radiation Oncology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, United States.
| | - Andrew D Garcia
- Department of Radiation Oncology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, United States
| | - Marcela Alexandrescu
- Department of Radiation Oncology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, United States
| | - Erin Healy
- Department of Radiation Oncology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, United States
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Mirsky MM, Mitchell C, Hong A, Cao S, Fu P, Margevicius S, Wu S, Dowlati A, Nelson A, Selfridge JE, Ramaiya N, Hoimes C, Alahmadi A, Bruno DS. Outcomes of Antineoplastic Immunotherapy at a Large Healthcare Organization: Impact of Provider, Race and Socioeconomic Status. Cancer Manag Res 2023; 15:913-927. [PMID: 37674660 PMCID: PMC10478776 DOI: 10.2147/cmar.s403569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/20/2023] [Indexed: 09/08/2023] Open
Abstract
Purpose Disparities in cancer care delivery remain a pressing health-care crisis within the United States (US). The use of immune checkpoint inhibitors (ICIs) and their management may be a disparity generator that impacts survival. This retrospective study assessed disparities in a cohort of patients with a variety of solid tumors treated with ICIs within a single health-care organization focusing on the impact of race, socioeconomic status (SES) and site of care delivery on survival and the development of severe immune-related adverse events (irAEs). Patients and Methods Manual chart review was performed on all patients with solid tumors treated with ICIs within a health-care organization from 2012 to 2018. Care delivery was dichotomized as DOP (disease-oriented provider at academic center) and COP (community oncology provider). Primary and secondary outcomes were overall survival (OS) and rates of grade 3-4 irAEs, respectively. Relationships with covariates of interest, including race, socioeconomic status and type of care delivery, were assessed among both outcomes. Results A total of 1070 eligible patients were identified. Of those, 11.4% were of Black race, 59.7% had either non-small cell lung cancer (NSCLC) or melanoma and 82.8% had stage IV disease. Patients of Black race and lower SES were more likely to be treated by DOPs (p<0.0001). A superior OS was associated with care delivered by DOPs when compared to COPs (HR 0.68; 95% CI 0.56-0.84; p=0.0002), which was durable after accounting for race, SES, histopathologic diagnosis and disease stage. Melanoma patients experienced higher rates of severe irAEs (HR 2.37; 95% CI 1.42-3.97; p=0.001). Race, SES and site of care delivery were not related to rates of severe irAEs. Conclusion In a large health-care organization, patients treated with checkpoint inhibitors by DOPs benefited from a significant OS advantage that was durable after controlling for racial and socioeconomic factors, providing evidence that disease-oriented care has the potential to mitigate racial and socioeconomic disparities.
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Affiliation(s)
- Matthew M Mirsky
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Carley Mitchell
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Augustine Hong
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Shufen Cao
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Pingfu Fu
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Seunghee Margevicius
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Sulin Wu
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Afshin Dowlati
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ariel Nelson
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - J Eva Selfridge
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Nikhil Ramaiya
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Christopher Hoimes
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Asrar Alahmadi
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Debora S Bruno
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Huang CY, Mack S, Grenda TR, Barta JA, Till BM, Evans NR, Okusanya O. Race is a Risk Factor for the Deferral of Resection and Radiation for Early-Stage Lung Cancer. Clin Lung Cancer 2022; 23:e460-e472. [PMID: 35989162 DOI: 10.1016/j.cllc.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/05/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE There remain profound race-related disparities in the treatment of non-small cell lung cancer (NSCLC). Deferral of operative management for early-stage disease is recognized as driver of this disparity. Black race has been associated with higher rates of surgical deferral. It remains unclear how race impacts likelihood of receiving radiation therapy after declining surgical management of NSCLC. PATIENTS AND METHODS A retrospective cohort analysis was completed using data from the National Cancer Database (NCBD) for patients 18 and over with stage I NSCLC offered surgical resection from 2004 to 2015 (N = 89,462). Multivariable logistic regression identified predictors of surgical deferral and predictors for deferral of radiation after deferral of surgery. Kaplan-Meier survival analysis with log-rank tests and multivariable Cox proportional hazards regressions were performed. RESULTS 87,293 (97.6%) patients underwent surgery, 2169 (2.4%) deferred. Patients who deferred had 2.1 times higher hazard ratio for mortality, (HR = 2.08, [1.97, 2.29], P < .001). Of those that deferred, 1250 (57.6%) received postdeferral radiation. Compared to White patients, Black patients had OR of 1.82 for deferring both surgery and radiation (aOR: 1.82, [1.31, 2.53], P < .001) and Asian and Pacific Island (API) patients had an OR of 2.67 (aOR: 2.67, [1.27, 4.64], P = .008). Other predictors of deferral of therapy included: Medicare or lack of insurance, and treatment at nonacademic medical centers. CONCLUSION Insurance status and Black race, and API race are associated with deferring surgical therapy and radiation therapy for NSCLC. These findings are consistent with the large body of work showing worse outcomes for treatment of NSCLC in minority patients.
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Affiliation(s)
- Charles Y Huang
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Shale Mack
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Tyler R Grenda
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Julie A Barta
- Division of Pulmonary Medicine and Critical Care, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Brian M Till
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Nathaniel R Evans
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA; Division of Thoracic and Esophageal Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Olugbenga Okusanya
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.
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Racial and ethnic differences in patient ratings of colorectal and non-small-cell lung cancer care: A SEER-CAHPS study. Cancer Causes Control 2022; 33:1125-1133. [PMID: 35864368 DOI: 10.1007/s10552-022-01606-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 06/27/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Although significant racial and ethnic disparities exist in colorectal and lung cancer treatment and survival, racial differences in patient-reported experience of care are not well understood. The purpose of this study was to examine differences in patient-reported ratings of colorectal and non-small-cell lung cancer care by race/ethnicity. METHODS Medicare beneficiaries with AJCC stage I-IV colorectal and non-small-cell lung cancer (2003-2013) who completed a Medicare Consumer Assessment of Healthcare Providers (CAHPS) survey within 5 years of cancer diagnosis were identified in the linked SEER-CAHPS dataset. Scores were compared by race/ethnicity, defined as White, Black, or any other race/ethnicity. RESULTS Of the 2,621 identified patients, 161 (6.1%) were Black, 2,279 (87.0%) White, and 181 (6.9%) any other race/ethnicity. Compared to White patients, Black patients were younger, had lower educational level, and had higher census tract poverty indicator (p < 0.001). Black patients rated their ability to get care quickly significantly lower than White patients (63.5 (SE 3.38) vs. 71.4 (SE 2.12), p < 0.01), as did patients of any other race/ethnicity (LS mean 66.2 (SE 2.89), p = 0.02). Patients of any other race/ethnicity reported their ability to get needed care significantly lower than White patients (LS mean 81.9 (SE 2.46) vs. 86.7 (SE 1.75), p = 0.02); however, there was no difference in ability to get needed care between Black and White patients. CONCLUSION Patient ratings for getting care quickly were lower in non-White patients, indicating racial disparities in perceived timeliness of care.
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Snyder RA, Hu CY, DiBrito SR, Chang GJ. Association of Medicaid Expansion with Racial Disparities in Cancer Stage at Presentation. Cancer 2022; 128:3340-3351. [PMID: 35818763 DOI: 10.1002/cncr.34347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study evaluates the independent association of Medicaid expansion on stage of presentation among patients of Black and White race with colorectal (CRC), breast, or non-small cell lung cancer (NSCLC). METHODS A cohort study of patients with CRC, breast cancer, or NSCLC (2009-2017) in the National Cancer Database was performed. Difference-in-differences (DID) analysis was used to compare changes in tumor stage at diagnosis between Medicaid expansion (MES) and non-expansion states (non-MES) before and after expansion. Predictive margins were calculated by race, year, and insurance status to account for effect heterogeneity. Stage migration was determined by measuring the combined proportional increase in stage I and decrease in stage IV disease at diagnosis. RESULTS Black patients gained less Medicaid coverage than White patients (6.0% vs 13.1%, p < 0.001) after expansion. Among Black and White patients, there was a shift towards increased early-stage diagnosis (DID 3.5% and 3.5%, respectively; p < 0.001) and decreased late-stage diagnosis (DID White: -3.5%; Black -2.5%; p < 0.001) in MES compared to non-MES following expansion. Overall stage migration was greater for White compared to Black patients with CRC (10.3% vs. 5.1%) and NSCLC (8.1% vs. 6.7%) after expansion. Stage migration effects in patients with breast cancer were similar by race (White 4.8% vs. Black 4.5%). CONCLUSION An increased proportion of Black and White patients residing in Medicaid expansion states presented with earlier stage cancer following Medicaid expansion. However, because the proportion of Black patients is higher in non-expansion states, national racial disparities in cancer stage at presentation appear worse following Medicaid expansion.
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Affiliation(s)
- Rebecca A Snyder
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA.,Department of Public Health, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Chung-Yuan Hu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sandra R DiBrito
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Ghandourh W, Holloway L, Batumalai V, Chlap P, Field M, Jacob S. Optimal and actual rates of Stereotactic Ablative Body Radiotherapy (SABR) utilisation for primary lung cancer in Australia. Clin Transl Radiat Oncol 2022; 34:7-14. [PMID: 35282142 PMCID: PMC8907547 DOI: 10.1016/j.ctro.2022.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/01/2022] [Indexed: 12/02/2022] Open
Abstract
Stereotactic Ablative Body Radiotherapy (SABR) plays a major role in the management of early-stage non-small cell lung cancer (NSCLC). An evidence-based model is developed to estimate optimal rates of lung SABR utilisation within the Australian population. Optimal utilisation rates are compared against actual utilisation rates to evaluate service provision.
Background and purpose Radiotherapy utilisation rates considerably vary across different countries and service providers, highlighting the need to establish reliable benchmarks against which utilisation rates can be assessed. Here, optimal utilisation rates of Stereotactic Ablative Body Radiotherapy (SABR) for lung cancer are estimated and compared against actual utilisation rates to identify potential shortfalls in service provision. Materials and Methods An evidence-based optimal utilisation model was constructed after reviewing practice guidelines and identifying indications for lung SABR based on the best available evidence. The proportions of patients likely to develop each indication were obtained, whenever possible, from Australian population-based studies. Sensitivity analysis was performed to account for variations in epidemiological data. Practice pattern studies were reviewed to obtain actual utilisation rates. Results A total of 6% of all lung cancer patients were estimated to optimally require SABR at least once during the course of their illness (95% CI: 4–6%). Optimal utilisation rates were estimated to be 32% for stage I and 10% for stage II NSCLC. Actual utilisation rates for stage I NSCLC varied between 6 and 20%. For patients with inoperable stage I, 27–74% received SABR compared to the estimated optimal rate of 82%. Conclusion The estimated optimal SABR utilisation rates for lung cancer can serve as useful benchmarks to highlight gaps in service delivery and help plan for more adequate and efficient provision of care. The model can be easily modified to determine optimal utilisation rates in other populations or updated to reflect any changes in practice guidelines or epidemiological data.
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Abstract
Social disparities in lung cancer diagnosis, treatment, and survival have been studied using national databases, statewide registries, and institution-level data. Some disparities emerge consistently, such as lower adherence to treatment guidelines and worse survival by race and socioeconomic status, whereas other disparities are less well studied. A critical appraisal of current data is essential to increasing equity in lung cancer care.
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Affiliation(s)
- Irmina Elliott
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr Falk Cardiovascular Research Building, Stanford, CA 94305-5407, USA
| | - Cayo Gonzalez
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr Falk Cardiovascular Research Building, Stanford, CA 94305-5407, USA
| | - Leah Backhus
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr Falk Cardiovascular Research Building, Stanford, CA 94305-5407, USA
| | - Natalie Lui
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr Falk Cardiovascular Research Building, Stanford, CA 94305-5407, USA.
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Sosa E, D’Souza G, Akhtar A, Sur M, Love K, Duffels J, Raz DJ, Kim JY, Sun V, Erhunmwunsee L. Racial and socioeconomic disparities in lung cancer screening in the United States: A systematic review. CA Cancer J Clin 2021; 71:299-314. [PMID: 34015860 PMCID: PMC8266751 DOI: 10.3322/caac.21671] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 12/14/2022] Open
Abstract
Nonsmall cell lung cancer (NSCLC) is the leading cause of cancer deaths. Lung cancer screening (LCS) reduces NSCLC mortality; however, a lack of diversity in LCS studies may limit the generalizability of the results to marginalized groups who face higher risk for and worse outcomes from NSCLC. Identifying sources of inequity in the LCS pipeline is essential to reduce disparities in NSCLC outcomes. The authors searched 3 major databases for studies published from January 1, 2010 to February 27, 2020 that met the following criteria: 1) included screenees between ages 45 and 80 years who were current or former smokers, 2) written in English, 3) conducted in the United States, and 4) discussed socioeconomic and race-based LCS outcomes. Eligible studies were assessed for risk of bias. Of 3721 studies screened, 21 were eligible. Eligible studies were evaluated, and their findings were categorized into 3 themes related to LCS disparities faced by Black and socioeconomically disadvantaged individuals: 1) eligibility; 2) utilization, perception, and utility; and 3) postscreening behavior and care. Disparities in LCS exist along racial and socioeconomic lines. There are several steps along the LCS pipeline in which Black and socioeconomically disadvantaged individuals miss the potential benefits of LCS, resulting in increased mortality. This study identified potential sources of inequity that require further investigation. The authors recommend the implementation of prospective trials that evaluate eligibility criteria for underserved groups and the creation of interventions focused on improving utilization and follow-up care to decrease LCS disparities.
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Affiliation(s)
- Ernesto Sosa
- Department of Populations Sciences, City of Hope National Medical Center
| | - Gail D’Souza
- Department of Surgery, City of Hope Comprehensive Cancer Center
| | - Aamna Akhtar
- Department of Surgery, City of Hope Comprehensive Cancer Center
| | - Melissa Sur
- Department of Populations Sciences, City of Hope National Medical Center
| | - Kyra Love
- Division of Library Services, City of Hope National Medical Center
| | - Jeanette Duffels
- Division of Library Services, City of Hope National Medical Center
| | - Dan J Raz
- Department of Surgery, City of Hope Comprehensive Cancer Center
| | - Jae Y Kim
- Department of Surgery, City of Hope Comprehensive Cancer Center
| | - Virginia Sun
- Department of Populations Sciences, City of Hope National Medical Center
- Department of Surgery, City of Hope Comprehensive Cancer Center
| | - Loretta Erhunmwunsee
- Department of Populations Sciences, City of Hope National Medical Center
- Department of Surgery, City of Hope Comprehensive Cancer Center
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Meghani SH, Levoy K, Magan KC, Starr LT, Yocavitch L, Barg FK. "I'm Dealing With That": Illness Concerns of African American and White Cancer Patients While Undergoing Active Cancer Treatments. Am J Hosp Palliat Care 2021; 38:830-841. [PMID: 33107324 PMCID: PMC8424597 DOI: 10.1177/1049909120969121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND National oncology guidelines recommend early integration of palliative care for patients with cancer. However, drivers for this integration remain understudied. Understanding illness concerns at the time of cancer treatment may help facilitate integration earlier in the cancer illness trajectory. OBJECTIVE To describe cancer patients' concerns while undergoing cancer treatment, and determine if concerns differ among African Americans and Whites. METHODS A 1-time, semi-structured qualitative interview was conducted with a purposive subsample of cancer patients participating in a larger study of illness concerns. Eligible patients were undergoing cancer treatments and had self-reported moderate-to-severe pain in the last week. Analysis encompassed a qualitative descriptive approach with inductive thematic analysis. RESULTS Participants (16 African American, 16 White) had a median age of 53 and were predominantly females (72%) with stage III/IV cancer (53%). Illness concerns were largely consistent across participants and converged on 3 themes: symptom experience (pain, options to manage pain), cancer care delivery (communication, care coordination and care transitions), and practical concerns (access to community and health system resources, financial toxicity). CONCLUSIONS The findings extend the scope of factors that could be utilized to integrate palliative care earlier in the cancer illness trajectory, moving beyond the symptoms- and prognosis-based triggers that typify current referrals to also consider diverse logistical concerns. Using this larger set of concerns aids anticipatory risk mitigation and planning (e.g. care transitions, financial toxicity), helps patients receive a larger complement of support services, and builds cancer patients' capacity toward a more patient-centered treatment and care experience.
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Affiliation(s)
- Salimah H. Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing; Philadelphia, Pennsylvania
| | - Kristin Levoy
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing; Philadelphia, Pennsylvania
| | | | - Lauren T. Starr
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing; Philadelphia, Pennsylvania
| | | | - Frances K. Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania
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Lin Y, Mak KS. Racial and socioeconomic disparities in the use of stereotactic body radiotherapy for treating non-small cell lung cancer: a narrative review. J Thorac Dis 2021; 13:3764-3771. [PMID: 34277068 PMCID: PMC8264671 DOI: 10.21037/jtd-20-3199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 03/04/2021] [Indexed: 12/25/2022]
Abstract
In the past two decades, there has been a steady increase in the use of stereotactic body radiotherapy (SBRT) as an alternative to surgical intervention for early-stage non-small cell lung cancer (NSCLC) patients; however, not much is known about the impact of race and socioeconomic status (SES) on the delivery of SBRT. Here, we conduct a narrative review to examine potential disparities in the use of SBRT. Keyword searches of MEDLINE/PubMed, Web of Science, Embase, and Google Scholar databases were performed for studies focused on race, SES, and the use of SBRT published between 2000 and 2020. Six studies were identified, and showed that minority patients, especially Blacks, were less likely to receive SBRT and had a significantly longer median time between diagnosis to SBRT treatment. Patients with lower income or lower education, as well as those from lower socioeconomic regions were less likely to receive SBRT; they were more likely to receive conventionally fractionated external beam radiation (CFRT) or no treatment. These racial and socioeconomic factors were associated with worse survival in other general early-stage NSCLC studies. In conclusion, the limited number of published studies suggest significant disparities in the treatment of early-stage NSCLC with SBRT. These factors potentially lead to worse survival outcomes among vulnerable patient populations. Equal access to SBRT should be a focus of healthcare delivery systems, to ensure optimal clinical outcomes for patients with early-stage NSCLC.
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Affiliation(s)
- Yue Lin
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, USA
| | - Kimberley S Mak
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, USA
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Zhao X, Zhu X, Zhuang H, Guo X, Song Y, Ju X, Wang P, Yuan Z, Zhang H. Clinical efficacy of Stereotactic Body Radiation Therapy (SBRT) for adrenal gland metastases: A multi-center retrospective study from China. Sci Rep 2020; 10:7836. [PMID: 32398700 PMCID: PMC7217854 DOI: 10.1038/s41598-020-64770-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 01/24/2020] [Indexed: 11/23/2022] Open
Abstract
To evaluate the efficacy and safety of CyberKnife Stereotactic Body Radiation Therapy (SBRT) in the treatment of adrenal gland metastases (AGM), we designed a large-scale multicenter retrospective study to report the safety and efficacy of SBRT for inoperable AGM. In this study, 75 (61 males, 14 females) patients with 84 AGM and Karnofsky performance score ≥70 were treated by SBRT from October 2006 to January 2017. Of these, the purpose of treatment were controlling all known metastatic sites for 21 patients while 54 for palliation of bulky adrenal metastases. The efficacy and safety of SBRT were evaluated during follow-up. Potential factors predictive of local control (LC) and overall survival (OS) were identified by univariate and multivariate analysis. Median follow-up time was 12.7 months (range 1.8–96.4). The complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD) rates were 23.8%, 23.8%, 31.0% and 21.4%, respectively. The 0.5, 1, and 2-year LC rates were 93.6%, 83.8%, and 62.1%, respectively; OS rates on the same follow-up intervals were 93.7%, 62.5%, and 49.6%, respectively, and the corresponding PFS rates were 48.5%, 33.9%, and 16.0%, respectively. The treatment was well tolerated with 2 patients reporting grade-3 diarrhea and fatigue, respectively. Multivariate analysis showed that simultaneous treatment of SBRT for other metastatic lesions, the number of AGM, initiation of systemic therapy, and the maximum diameter of AGM were predictive of LC rates. Moreover, patients with AGM < 5 cm had a superior OS compared with those with AGM ≥ 5 cm (28.0 months vs. 17.6 months, P = 0.032). SBRT is an effective therapeutic option for treatment of AGM with high LC rates with minimal toxicity.
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Affiliation(s)
- Xianzhi Zhao
- Department of Radiation Oncology, Shanghai Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Xiaofei Zhu
- Department of Radiation Oncology, Shanghai Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Hongqing Zhuang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, 100191, China
| | - Xueling Guo
- Department of Radiation Oncology, Shanghai Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Yongchun Song
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, 300060, China
| | - Xiaoping Ju
- Department of Radiation Oncology, Shanghai Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Ping Wang
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, 300060, China
| | - Zhiyong Yuan
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, 300060, China.
| | - Huojun Zhang
- Department of Radiation Oncology, Shanghai Changhai Hospital, Naval Medical University, Shanghai, 200433, China.
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Khorfan R, Kruser TJ, Coughlin JM, Bharat A, Bilimoria KY, Odell DD. Survival of Primary Stereotactic Body Radiation Therapy Compared With Surgery for Operable Stage I/II Non-small Cell Lung Cancer. Ann Thorac Surg 2020; 110:228-234. [PMID: 32147416 DOI: 10.1016/j.athoracsur.2020.01.073] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/14/2020] [Accepted: 01/30/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Stereotactic body radiation therapy (SBRT) is an accepted primary treatment option for inoperable early-stage non-small cell lung cancer (NSCLC). The role of SBRT in the treatment of operable disease remains unclear. We retrospectively evaluated patients with operable early-stage NSCLC who elected to receive primary SBRT, examined factors associated with SBRT, and compared overall survival after surgical resection and SBRT. METHODS The National Cancer Database was queried for patients with stage I/II, N0 NSCLC from 2004 to 2016. The proportion of patients who refused recommended surgery and were treated with SBRT was calculated. A propensity score predicting the probability of refusing surgery and receiving SBRT was generated and used to match SBRT and resected patients. Long-term overall survival was compared in the matched cohort using the Kaplan-Meier method and Cox regression. RESULTS We identified 1359 patients (0.98%) who refused recommended surgery and elected SBRT. This proportion increased annually, from 0.1% in 2004 to 1.7% in 2016. Factors associated with SBRT were older age, black race, Medicaid coverage, lower T stage, and more recent diagnosis year. Propensity matching resulted in 1315 well-balanced pairs. Surgery was associated with higher median survival (74 vs 47 months, P < .01) in the matched cohort. Survival benefit persisted after adjusting for covariates on Cox regression (hazard ratio, 1.69; P < .01). CONCLUSIONS Median survival was significantly higher after surgery compared with SBRT in a risk-adjusted matched cohort of patients judged to be surgical candidates. Operable patients considering primary SBRT should be educated regarding this difference in survival.
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Affiliation(s)
- Rhami Khorfan
- Surgical Outcomes and Quality Improvement Center (SOQIC), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Timothy J Kruser
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julia M Coughlin
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Ankit Bharat
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center (SOQIC), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David D Odell
- Surgical Outcomes and Quality Improvement Center (SOQIC), Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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14
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Yap ML, O'Connell DL, Goldsbury D, Weber M, Barton M. Factors Associated With Radiotherapy Utilisation In New South Wales, Australia: Results From The 45 and Up Study. Clin Oncol (R Coll Radiol) 2020; 32:282-291. [PMID: 32007353 DOI: 10.1016/j.clon.2020.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/03/2019] [Accepted: 12/09/2019] [Indexed: 12/28/2022]
Abstract
AIMS Actual radiotherapy utilisation rates tend to be lower than the estimated optimal rates. Little is known about the factors contributing to this difference. Our aim was to identify factors associated with radiotherapy receipt for a cohort of cancer patients in New South Wales (NSW), Australia. MATERIALS AND METHODS In total, 267 153 participants in the NSW 45 and Up Study completed a questionnaire during 2006-2009 providing detailed health and socio-demographic information and consented to record linkage with administrative health datasets. Single primary cancers diagnosed after study enrolment were identified through linkage with the NSW Cancer Registry to December 2013. Radiotherapy receipt was determined from claims to the Medicare Benefits Schedule and/or records in the NSW Admitted Patient Data Collection (2006 to June 2016). Competing risks regression was used to examine associations between health and socio-demographic characteristics and radiotherapy treatment. RESULTS Of 17 873 patients with an incident cancer, 5414 (30.3%) received radiotherapy during follow-up (median 5.3 years). Patients less likely to receive radiotherapy were aged <60 or 80+ years, female, had a Charlson co-morbidity index of 1+, needed help with daily tasks or lived ≥100 km from the nearest radiotherapy centre. CONCLUSION Distinct subgroups of patients are less likely to receive radiotherapy. Advocacy and/or policy changes are needed to improve access.
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Affiliation(s)
- M L Yap
- Collaboration for Cancer Outcomes, Research and Evaluation (CCORE), Ingham Institute for Applied Medical Research, UNSW Sydney, Liverpool, NSW, Australia; Liverpool and Macarthur Cancer Therapy Centres, Liverpool, NSW, Australia; School of Medicine, Western Sydney University, Campbelltown, NSW, Australia; Cancer Research Division, Cancer Council NSW, Kings Cross, NSW, Australia; Sydney Medical School - Public Health, University of Sydney, Sydney, NSW, Australia.
| | - D L O'Connell
- Cancer Research Division, Cancer Council NSW, Kings Cross, NSW, Australia; Sydney Medical School - Public Health, University of Sydney, Sydney, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - D Goldsbury
- Cancer Research Division, Cancer Council NSW, Kings Cross, NSW, Australia
| | - M Weber
- Cancer Research Division, Cancer Council NSW, Kings Cross, NSW, Australia; Sydney Medical School - Public Health, University of Sydney, Sydney, NSW, Australia
| | - M Barton
- Collaboration for Cancer Outcomes, Research and Evaluation (CCORE), Ingham Institute for Applied Medical Research, UNSW Sydney, Liverpool, NSW, Australia; Liverpool and Macarthur Cancer Therapy Centres, Liverpool, NSW, Australia
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Williams CD, Alpert N, Redding TS, Bullard AJ, Flores RM, Kelley MJ, Taioli E. Racial Differences in Treatment and Survival among Veterans and Non-Veterans with Stage I NSCLC: An Evaluation of Veterans Affairs and SEER-Medicare Populations. Cancer Epidemiol Biomarkers Prev 2020; 29:112-118. [PMID: 31624076 DOI: 10.1158/1055-9965.epi-19-0245] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/28/2019] [Accepted: 10/07/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Surgery is the preferred treatment for stage I non-small cell lung cancer (NSCLC), with radiation reserved for those not receiving surgery. Previous studies have shown lower rates of surgery among Blacks with stage I NSCLC than among Whites. METHODS Black and White men ages ≥65 years with stage I NSCLC diagnosed between 2001 and 2009 were identified in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database and Veterans Affairs (VA) cancer registry. Logistic regression and Cox proportional hazards models were used to examine associations between race, treatment, and survival. RESULTS Among the patients in the VA (n = 7,895) and SEER (n = 8,744), the proportion of Blacks was 13% and 7%, respectively. Overall, 16.2% of SEER patients (15.4% of Whites, 26.0% of Blacks) and 24.5% of VA patients received no treatment (23.4% of Whites, 31.4% of Blacks). In both cohorts, Blacks were less likely to receive any treatment compared with Whites [ORadj = 0.57; 95% confidence interval (CI), 0.47-0.69 for SEER-Medicare; ORadj = 0.68; 95% CI, 0.58-0.79 for VA]. Among treated patients, Blacks were less likely than Whites to receive surgery only (ORadj = 0.57; 95% CI, 0.47-0.70 for SEER-Medicare; ORadj = 0.73; 95% CI, 0.62-0.86 for VA), but more likely to receive chemotherapy only and radiation only. There were no racial differences in survival. CONCLUSIONS Among VA and SEER-Medicare patients, Blacks were less likely to get surgical treatment. Blacks and Whites had similar survival outcomes when accounting for treatment. IMPACT This supports the hypothesis that equal treatment correlates with equal outcomes and emphasizes the need to understand multilevel predictors of lung cancer treatment disparities.
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Affiliation(s)
- Christina D Williams
- Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Health Care System, Durham, North Carolina.
- Division of Medical Oncology, Department of Medicine, Duke University, Durham, North Carolina
| | - Naomi Alpert
- Department of Population Health Science and Policy, Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Thomas S Redding
- Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - A Jasmine Bullard
- Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Raja M Flores
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael J Kelley
- Division of Medical Oncology, Department of Medicine, Duke University, Durham, North Carolina
- Division of Hematology-Oncology, Medical Service, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Emanuela Taioli
- Department of Population Health Science and Policy, Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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16
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Liu W, Liu A, Chan J, Boldt RG, Munoz-Schuffenegger P, Louie AV. What is the optimal radiotherapy utilization rate for lung cancer?-a systematic review. Transl Lung Cancer Res 2019; 8:S163-S171. [PMID: 31673521 DOI: 10.21037/tlcr.2019.08.12] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Lung cancer is a major cause of morbidity and mortality globally. Although radiotherapy (RT) may be beneficial in the radical and/or palliative management of many lung cancer patients, it is underutilized worldwide. Population-level development of RT resources requires estimates of optimal radiotherapy utilization rates (ORUR) and actual radiotherapy utilization rate (ARUR). A systematic review of PubMed database for English-language articles from January 2009 to January 2019 was performed. Keywords included utilization, underutilization, demand, epidemiologic, benchmark, RT and cancer. Data abstracted included: study population, diagnosis, stage, year of diagnosis, timing of RT, intent of RT, ARUR, and ORUR. Eligible studies provided ARUR or ORUR for lung cancer, small cell lung cancer (SCLC), or non-small cell lung cancer (NSCLC). Included ARUR were based on at least 1,000 patients who were diagnosed or treated in 2009 or later. Included ORUR were based on evidence review or ARUR in 2009 or later. The initial search strategy yielded 1,627 unique abstracts. After review, 105 articles were determined appropriate for full-text review. From these, a final set of 21 articles met all inclusion criteria. In eight papers, ORUR was estimated. Estimated lifetime ORUR ranged from 61% to 82%. Methods for estimation included the evidence-based guideline model, Malthus model, and criterion-based benchmarking (CBB) model. The majority of estimates (6/8) used the evidence-based guideline model. Fifteen papers provided ARUR on lung cancer, inclusive of SCLC and NSCLC. ARUR within 9 months to 1 year of diagnosis ranged from 39% to 46%. Lifetime ARUR was an estimated 52% in Ontario, Canada. Palliative intent ARUR ranged from 12% in Central Poland to 46% in Ontario, Canada. RT is underutilized for lung cancer globally, and there is wide geographical variation in the level of underutilization.
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Affiliation(s)
- Wei Liu
- Division of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Alissa Liu
- McMaster University, Hamilton, Ontario, Canada
| | - Jessica Chan
- Division of Radiation Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada
| | - R Gabriel Boldt
- Division of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Pablo Munoz-Schuffenegger
- Departamento de Hematologia-Oncologia, Pontificia Universidad Catolica de Chile, Santiago, Región Metropolitana, Chile
| | - Alexander V Louie
- Division of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada.,Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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17
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Jairam V, Park HS. Strengths and limitations of large databases in lung cancer radiation oncology research. Transl Lung Cancer Res 2019; 8:S172-S183. [PMID: 31673522 DOI: 10.21037/tlcr.2019.05.06] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
There has been a substantial rise in the utilization of large databases in radiation oncology research. The advantages of these datasets include a large sample size and inclusion of a diverse population of patients in a real-world setting. Such observational studies hold promise in enhancing our understanding of questions for which evidence is conflicting or absent in lung cancer radiotherapy. However, it is critical that investigators understand the strengths and limitations of large databases in order to avoid the common pitfalls that beset observational analyses. This review begins by outlining the data variables available in major registries that are used most often in observational analyses. This is followed by a discussion of the type of radiotherapy-related questions that can be addressed using such datasets, accompanied by examples from the lung cancer literature. Finally, we describe some limitations of observational research and techniques to mitigate bias and confounding. We hope that clinicians and researchers find this review helpful for designing new research studies and interpreting published analyses in the literature.
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Affiliation(s)
- Vikram Jairam
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Henry S Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT, USA
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18
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Cykert S, Eng E, Manning MA, Robertson LB, Heron DE, Jones NS, Schaal JC, Lightfoot A, Zhou H, Yongue C, Gizlice Z. A Multi-faceted Intervention Aimed at Black-White Disparities in the Treatment of Early Stage Cancers: The ACCURE Pragmatic Quality Improvement trial. J Natl Med Assoc 2019; 112:468-477. [PMID: 30928088 DOI: 10.1016/j.jnma.2019.03.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Reports continue to show that Blacks with curable lung or breast cancer complete treatment less often than similar Whites contributing to worse survival. ACCURE is an intervention trial designed to address this problem. PATIENTS AND METHODS A pragmatic, quality improvement trial comparing an intervention group to retrospective and concurrent controls. Patients with early stage breast or lung cancer aged 18 to 85 were enrolled (N = 302) at 2 cancer centers between April 2013 and March 2015 for the intervention component. Data from patients seen between January 2007 and December 2012 with these diagnoses were obtained to establish control completion rates. Concurrent data for non-study patients were used to identify secular trends. The intervention included: a real time registry derived from electronic health records of participants to signal missed appointments or unmet care milestones, a navigator, and clinical feedback. The primary outcome was "Treatment Complete", a composite variable representing completion of surgery, recommended radiation and chemotherapy for each patient. RESULTS The mean age in the intervention group was 63.1 years; 37.1% of patients were Black. Treatment completion in retrospective and concurrent controls showed significant Black-White differences (Blacks (B) 79.8% vs. Whites (W) 87.3%, p < 0.001; 83.1% B vs. 90.1% W, p < 0.001, respectively). The disparity lessened within the intervention (B 88.4% and W 89.5%, p = 0.77). Multivariate analyses confirmed disparities reduction. OR for Black-White disparity within the intervention was 0.98 (95% CI 0.46-2.1); Black completion in the intervention compared favorably to Whites in retrospective (OR 1.6; 95% CI 0.90-2.9) and concurrent (OR 1.1; 95% CI 0.59-2.0) controls. CONCLUSION A real time registry combined with feedback and navigation improved completion of treatment for all breast and lung cancer patients and narrowed disparities. Similar multi-faceted interventions could mitigate disparities in the treatment of other cancers and chronic conditions.
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Affiliation(s)
- Samuel Cykert
- The University of North Carolina School of Medicine, 145 N Medical Drive CB# 7165, Chapel Hill, NC 27599, USA.
| | - Eugenia Eng
- Department of Health Behavior, The Gilling's School of Global Public Health, 360 Rosenau Hall, CB# 7440, Chapel Hill, NC 27599, USA
| | - Matthew A Manning
- Cone Health Cancer Center, 501 N Elam Ave, Greensboro, NC 27403, USA
| | - Linda B Robertson
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine 5150 Centre Avenue POB2 Cancer Pavilion, Room 438 Pittsburgh, PA 15232, USA
| | - Dwight E Heron
- Department of Radiation Oncology UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine5230 Centre Ave. Pittsburgh, PA 15232, USA
| | - Nora S Jones
- The Partnership Project, 301 S. Elm Street, Suite 414 Greensboro, NC 27401, USA
| | - Jennifer C Schaal
- The Partnership Project, 301 S. Elm Street, Suite 414 Greensboro, NC 27401, USA
| | - Alexandra Lightfoot
- Department of Health Behavior, The Gilling's School of Global Public Health 1700 Martin Luther King, Jr. Boulevard CB #7426, Chapel Hill, NC 27599, USA
| | - Haibo Zhou
- Department of Biostatistics, The Gilling's School of Global Public Health, The University of North Carolina at Chapel Hill, 3104C McGavran-Greenberg Hall, CB #7420, Chapel Hill, NC 27599, USA
| | - Christina Yongue
- Department of Public Health Education, University of North Carolina at Greensboro, P.O. Box 26170, Greensboro, NC 27402-6170, USA
| | - Ziya Gizlice
- Biostatistical Support Unit, The Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB# 7426, Chapel Hill NC 27599, USA
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19
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Cykert S, Eng E, Walker P, Manning MA, Robertson LB, Arya R, Jones NS, Heron DE. A system-based intervention to reduce Black-White disparities in the treatment of early stage lung cancer: A pragmatic trial at five cancer centers. Cancer Med 2019; 8:1095-1102. [PMID: 30714689 PMCID: PMC6434214 DOI: 10.1002/cam4.2005] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 12/19/2018] [Accepted: 01/11/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Advances in early diagnosis and curative treatment have reduced high mortality rates associated with non-small cell lung cancer. However, racial disparity in survival persists partly because Black patients receive less curative treatment than White patients. METHODS We performed a 5-year pragmatic, trial at five cancer centers using a system-based intervention. Patients diagnosed with early stage lung cancer, aged 18-85 were eligible. Intervention components included: (1) a real-time warning system derived from electronic health records, (2) race-specific feedback to clinical teams on treatment completion rates, and (3) a nurse navigator. Consented patients were compared to retrospective and concurrent controls. The primary outcome was receipt of curative treatment. RESULTS There were 2841 early stage lung cancer patients (16% Black) in the retrospective group and 360 (32% Black) in the intervention group. For the retrospective baseline, crude treatment rates were 78% for White patients vs 69% for Black patients (P < 0.001); difference by race was confirmed by a model adjusted for age, treatment site, cancer stage, gender, comorbid illness, and income-odds ratio (OR) 0.66 for Black patients (95% CI 0.51-0.85, P = 0.001). Within the intervention cohort, the crude rate was 96.5% for Black vs 95% for White patients (P = 0.56). Odds ratio for the adjusted analysis was 2.1 (95% CI 0.41-10.4, P = 0.39) for Black vs White patients. Between group analyses confirmed treatment parity for the intervention. CONCLUSION A system-based intervention tested in five cancer centers reduced racial gaps and improved care for all.
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Affiliation(s)
- Samuel Cykert
- Division of General Medicine and Clinical EpidemiologyThe Center for Health Promotion and Disease PreventionThe Lineberger Cancer CenterThe University of North Carolina School of MedicineThe University of North Carolina at Chapel HillChapel HillNorth Carolina
| | - Eugenia Eng
- Department of Health BehaviorThe Gilling's School of Global Public HealthChapel HillNorth Carolina
| | - Paul Walker
- Leo Jenkins Cancer CenterBrody School of Medicine ‐ East Carolina UniversityGreenvilleNorth Carolina
| | | | | | - Rohan Arya
- Palmetto Health and the University of South Carolina School of MedicineColumbiaSouth Carolina
| | | | - Dwight E. Heron
- Department of Radiation OncologyUPMC Hillman Cancer CenterPittsburghPennsylvania
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20
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Haque W, Verma V, Butler E, Teh BS. Utilization of Stereotactic Radiosurgery for Renal Cell Carcinoma Brain Metastases. Clin Genitourin Cancer 2018; 16:e935-e943. [DOI: 10.1016/j.clgc.2018.03.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 03/23/2018] [Indexed: 11/16/2022]
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21
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Deek MP, Kim S, Beck R, Yegya-Raman N, Langenfeld J, Malhotra J, Mahmoud O, Aisner J, Jabbour SK. Variations in Initiation Dates of Chemotherapy and Radiation Therapy for Definitive Management of Inoperable Non-Small Cell Lung Cancer Are Associated With Decreases in Overall Survival. Clin Lung Cancer 2018; 19:e381-e390. [PMID: 29752011 PMCID: PMC10868642 DOI: 10.1016/j.cllc.2018.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 02/10/2018] [Accepted: 03/10/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND We evaluated trends in administration of concurrent chemoradiation therapy (CRT) and how variations in start dates of chemotherapy and radiotherapy affected overall survival (OS) in patients with non-small cell lung cancer (NSCLC) undergoing a course of definitive CRT. MATERIALS AND METHODS Cases of NSCLC treated with definitive CRT were obtained from the National Cancer Database. A survival analysis was performed with Kaplan-Meier curves and Cox proportional hazards models. Propensity score matching was conducted. RESULTS On a national level, only 48.6% of patients began concurrent CRT on the same day. In a propensity-matched population, starting CRT within 6 days was associated with improved OS (17.9 months) compared with starting 7 to 13 days apart (16.5 months; P = .04). Starting dual therapy within 6 days of each other was associated with a 7% reduction in the risk of death (hazard ratio, 0.93; P = .05). Furthermore, in a propensity-matched cohort, starting CRT within 3 days was associated with longer survival (18.7 months) compared with 4 to 6 days apart (17.5 months; P = .02). Starting treatment 4 to 6 days apart was associated with an 8% increased risk of death (hazard ratio, 1.08; P = .04). CONCLUSION A large proportion (48.6%) of patients with unresectable NSCLC do not initiate CRT on the same day as is considered standard by national guidelines. In this population, nonsimultaneous initiation of CRT was associated with differences in OS. Further efforts to understand the mitigating factors and barriers that interfere with timely delivery of concurrent CRT are needed.
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Affiliation(s)
- Matthew P Deek
- Department of Radiation Oncology and Molecular Sciences, Johns Hopkins Hospital, Baltimore, MD; Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Sinae Kim
- Department of Biostatistics, School of Public Health, Rutgers University, Piscataway, NJ; Biometrics Division, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Robert Beck
- Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Nikhil Yegya-Raman
- Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - John Langenfeld
- Rutgers Cancer Institute of New Jersey, Division of Thoracic Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Joyti Malhotra
- Rutgers Cancer Institute of New Jersey, Division of Medical Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Omar Mahmoud
- Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Joseph Aisner
- Rutgers Cancer Institute of New Jersey, Division of Medical Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Salma K Jabbour
- Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ.
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22
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Racial disparities in guideline-concordant cancer care and mortality in the United States. Adv Radiat Oncol 2018; 3:221-229. [PMID: 30202793 PMCID: PMC6128037 DOI: 10.1016/j.adro.2018.04.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/20/2018] [Accepted: 04/29/2018] [Indexed: 01/05/2023] Open
Abstract
Purpose We identified the frequency of racial disparities in guideline-concordant cancer care for select common disease sites in the United States and the impact of guideline concordance on mortality disparities. Methods and materials Using Surveillance, Epidemiology, and End Results Medicare data, we evaluated patients age >65 years of black or non-Hispanic white race who were diagnosed with stage III breast (n = 3607), stage I (n = 14,605) or III (n = 15,609) non-small cell lung, or stage III prostate (n = 3548) cancer between 2006 and 2011. Chemotherapy, surgery, and radiation therapy (RT) treatments were identified using claims data. Pearson χ2 was used to test the associations between race and guideline concordance on the basis of National Comprehensive Cancer Network curative treatment guidelines. Mortality risks were modeled using Cox proportional hazards. Results Black patients were less likely to receive guideline-concordant curative treatment than non-Hispanic white patients for stage III breast cancer postmastectomy RT (53% black, 61% white; P = .0014), stage I non-small cell lung cancer stereotactic radiation or surgery (61% black, 75% white; P < .0001), stage III non-small cell lung cancer chemotherapy in addition to RT or surgery (36% black, 41% white; P = .0001), and stage III prostate cancer RT or prostatectomy (82% black, 95% white; P < .0001). Disparities in guideline concordance impacted racial mortality disparities. Specifically, hazard ratios that demonstrated elevated all-cause mortality risks in black patients were lowered (and more closely approached hazard ratio of 1.00) after adjusting for guideline concordance. A similar impact for cause-specific mortality was observed. Conclusions Racial disparities in the receipt of curative cancer therapy impacted racial mortality disparities across multiple cancer sites. Benchmarking adherence to guideline-concordant care could represent an opportunity to stimulate improvements in disparities in cancer treatment and survival.
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Holmes JA, Chen RC. Racial Disparities in Time From Diagnosis to Treatment for Stage I Non-Small Cell Lung Cancer. JNCI Cancer Spectr 2018; 2:pky007. [PMID: 31360839 PMCID: PMC6649763 DOI: 10.1093/jncics/pky007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 02/06/2018] [Accepted: 03/01/2018] [Indexed: 12/16/2022] Open
Abstract
Background Delay in lung cancer treatment is associated with worse survival outcomes. We examined whether there are racial disparities in time from diagnosis to treatment initiation for stage I non-small cell lung cancer (NSCLC) using data from the National Cancer Data Base, which includes approximately 70% of incident cancer patients across the United States. Methods We analyzed 119 184 patients diagnosed with stage I NSCLC from 2008 to 2013. Median times (in days) from diagnosis to treatment initiation for external beam radiation (EBRT), stereotactic body radiotherapy (SBRT), and surgery (inclusive of wedge resection, lobectomy, and pneumonectomy) were calculated separately and compared among white vs African American (AA) patients using the Wilcoxon rank-sum test. Multivariable linear regression assessed racial differences in days to treatment while adjusting for sex, age, insurance status, regional income, Charlson-Deyo comorbidity score, region, facility type, and treatment. Statistical tests were two-sided. Results AA patients had a statistically significantly longer median time to treatment for all three treatment modalities: EBRT 54 days (AA) vs 48 days (white, P < .001); SBRT 66 days vs 55 days (P < .001); surgery 31 vs 26 days (P < .001). In addition, 34% AA vs 24% white patients (P ≤ .001) had treatment initiation eight or more weeks after diagnosis. In multivariable analysis, AA patients experienced an average 8.2-day delay compared with white patients (P < .001). Conclusions These results shed light on one possible mechanism of the observed racial disparity in mortality outcomes in NSCLC. Future studies are needed to determine if interventions to reduce treatment delays can reduce racial disparities in this disease.
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Affiliation(s)
- Jordan A Holmes
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Ronald C Chen
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC.,University of North Carolina-Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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Trifiletti DM, Sheehan JP, Grover S, Dutta SW, Rusthoven CG, Kavanagh BD, Sahgal A, Showalter TN. National trends in radiotherapy for brain metastases at time of diagnosis of non-small cell lung cancer. J Clin Neurosci 2017; 45:48-53. [PMID: 28866073 DOI: 10.1016/j.jocn.2017.08.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/10/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND To analyze the national trends of patients treated radiotherapy for brain metastases from non-small cell lung cancer (NSCLC) that were found at diagnosis. METHODS The National Cancer Database was queried for patients with NSCLC diagnosed from 2004 to 2013 that received brain irradiation for metastases and patients grouped into having had received fractionated brain radiotherapy (5-15 fractions with or without radiosurgery) or intracranial radiosurgery alone (1-5 fractions). Univariable and multivariable (MVA) analyses were performed to investigate factors associated with the receipt of SRS alone, and temporal/regional trends. RESULTS 47,746 patients met inclusion criteria, of which 42,148 received fractionated brain irradiation (88%) and 5,598 received radiosurgery (12%). 345 patients received fractioned brain irradiation with a radiosurgical boost (0.8%). The utilization of radiosurgery-alone increased over time owing to increases in each radiosurgery modality. On MVA, several factors were associated with increased odds of receiving intracranial radiosurgery-alone over fractionated brain radiotherapy including more recent year of diagnosis, increased median income, eastern U.S. regions, further distance to the hospital, and the receipt of chemotherapy (each p<0.001). Patients of Asian descent were less likely to receive radiosurgery alone (p=0.044). CONCLUSIONS In the management of brain metastases from NSCLC, overall utilization of an intracranial radiosurgery alone treatment strategy has increased over the past decade. Despite this, there appear to be significant geographic variations and disparities remain based on patient income level and race. Further study is needed to define the reasons for these disparities and appropriate actions to mitigate them.
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Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA.
| | - Jason P Sheehan
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA; Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Surbhi Grover
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sunil W Dutta
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Denver, CO, USA
| | - Brian D Kavanagh
- Department of Radiation Oncology, University of Colorado, Denver, CO, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
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Hawley ST, Morris AM. Cultural challenges to engaging patients in shared decision making. PATIENT EDUCATION AND COUNSELING 2017; 100:18-24. [PMID: 27461943 PMCID: PMC5164843 DOI: 10.1016/j.pec.2016.07.008] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 07/02/2016] [Indexed: 05/08/2023]
Abstract
OBJECTIVE Engaging patients in their health care through shared decision-making is a priority embraced by several national and international groups. Missing from these initiatives is an understanding of the challenges involved in engaging patients from diverse backgrounds in shared decision-making. In this commentary, we summarize some of the challenges and pose points for consideration regarding how to move toward more culturally appropriate shared decision-making. DISCUSSION The past decade has seen repeated calls for health policies, research projects and interventions that more actively include patients in decision making. Yet research has shown that patients from different racial/ethnic and cultural backgrounds appraise their decision making process less positively than do white, U.S.-born patients who are the current demographic majority. CONCLUSION While preliminary conceptual frameworks have been proposed for considering the role of race/ethnicity and culture in healthcare utilization, we maintain that more foundational and empirical work is necessary. We offer recommendations for how to best involve patients early in treatment and how to maximize decision making in the way most meaningful to patients. Innovative and sustained efforts are needed to educate and train providers to communicate effectively in engaging patients in informed, shared decision-making and to provide culturally competent health care.
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Affiliation(s)
- Sarah T Hawley
- Professor of Medicine and Health Management and Policy, University of Michigan & Research Investigator, Ann Arbor VA Center for Clinical Management Research, 2800 Plymouth Road, 4th Floor, Ann Arbor, MI 48109, United States.
| | - Arden M Morris
- Associate Professor of Surgery and Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, United States
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Williams CD, Salama JK, Moghanaki D, Karas TZ, Kelley MJ. Impact of Race on Treatment and Survival among U.S. Veterans with Early-Stage Lung Cancer. J Thorac Oncol 2016; 11:1672-81. [DOI: 10.1016/j.jtho.2016.05.030] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/20/2016] [Accepted: 05/29/2016] [Indexed: 01/09/2023]
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Lobectomy versus stereotactic body radiotherapy in healthy patients with stage I lung cancer. J Thorac Cardiovasc Surg 2016; 152:44-54.e9. [PMID: 27131846 DOI: 10.1016/j.jtcvs.2016.03.060] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 03/04/2016] [Accepted: 03/13/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Stereotactic body radiotherapy is an effective treatment for patients with early-stage non-small cell lung cancer who are not healthy enough to undergo surgery; however, the relative efficacy versus surgery in healthy patients is unknown. The National Cancer Database contains information on patient health and eligibility for surgery, allowing the long-term survival associated with lobectomy and stereotactic body radiotherapy to be compared in healthy patients with clinical stage I disease. METHODS The National Cancer Database was queried for patients who underwent lobectomy or stereotactic body radiotherapy for clinical stage I lung cancer between 2008 and 2012. Healthy patients were selected by excluding patients not offered surgery because of health-related reasons and only including patients documented to be free of comorbidities. RESULTS A total of 13,562 comorbidity-free patients with clinical stage I lung cancer treated with lobectomy were compared with 1781 patients treated with stereotactic body radiotherapy. Time-stratified Cox proportional hazards models found lobectomy to be associated with a significantly better outcome than stereotactic body radiotherapy for both T1N0M0 tumors (hazard ratio, 0.38; 95% confidence interval, 0.33-0.43; P < .001) and T2N0M0 tumors 5 cm or less (hazard ratio, 0.38; confidence interval, 0.31-0.46; P < .001). In a propensity-matched analysis of 1781 pairs, lobectomy remained superior to stereotactic body radiotherapy (5-year survival 59% vs 29%, P < .001). Furthermore, when the subset of stereotactic patients who had refused a recommended surgery (n = 229) were propensity matched to lobectomy patients, lobectomy was associated with improved survival (5-year survival 58% vs 40%, P = .010). CONCLUSIONS Among healthy patients with clinical stage I non-small cell lung cancer in the National Cancer Database, lobectomy is associated with a significantly better outcome than stereotactic body radiotherapy. Further study is warranted to clarify the comparative effectiveness of surgery and stereotactic body radiotherapy across various strata of patient health.
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