Social Disparities in Lung Cancer

Geographical Disparities in Lung Cancer in Canada: A Review

PURPOSE OF REVIEW

The eastern provinces of Canada exhibit a heightened prevalence and mortality rate of lung cancer compared to their western counterparts. While established risk factors for lung cancer exist in Canada, there remains ambiguity regarding the underlying provincial and territorial trends. This review aims to identify and analyze potential contributors to healthcare inequality, guiding policymakers towards a strategic and sustainable approach at the provincial level.

RECENT FINDINGS

Existing studies emphasize the significant roles played by socio-economic and environmental factors in influencing lung cancer disparities across Canadian provinces. However, a noticeable research gap persists, particularly in systematically examining the factors that amplify geographical disparities in lung cancer incidence and mortality rates within Canada. This review underscores the disparities in lung cancer prevalence and mortality rates between eastern and western Canadian provinces. While socio-economic and environmental factors have been identified as influential, there is an evident need for further research to comprehensively understand and address the underlying contributors to these geographical discrepancies.

The Effect of Social Vulnerability on Initial Stage and Treatment for Non-Small Cell Lung Cancer

OBJECTIVE

The Social Vulnerability Index (SVI) is a composite metric for social determinants of health. The objective of this study was to determine if SVI influences stage at presentation for non-small cell lung cancer (NSCLC) patients and subsequent therapies.

MATERIALS AND METHODS

NSCLC patients from our local contribution to the National Cancer Database (2011-2021) were grouped into low SVI (<75 %ile) and high SVI (>75 %ile) cohorts. Demographics, cancer-related variables, and treatment modalities were compared. Multivariable logistic regression was performed to control for the impact of demographics on cancer presentation and for the impact of oncologic variables on treatment outcomes.

RESULTS

Of 1,662 NSCLC patients, 435 (26 %) were defined as high SVI. Compared to the 1,227 (74 %) low SVI patients, highly vulnerable patients were more likely to be male (53.3 % vs 46.0 %, p = 0.009), non-White (17.2 % vs 9.7 %, p < 0.0001), have comorbidities (29.4 % vs 23.1 %, p = 0.009) and present at a higher AJCC clinical T, M and overall stage (all p < 0.05). These findings persisted on multivariable analysis, with highly vulnerable patients having 1.5x the odds (95 %CI: 1.23-1.86, p < 0.001) of presenting at more advanced stage. Patients with high SVI were less likely to be recommended for and receive surgery (40.9 % vs 53.2 %, p < 0.001), and this finding persisted after controlling for stage at presentation (OR 1.37, 95 %CI 1.04-1.80).

CONCLUSIONS

Highly vulnerable patients present at a more advanced clinical stage and are less likely to be recommended and receive surgery, even after controlling for stage at presentation. Further investigation into these findings is warranted to achieve more equitable oncologic care.

Who are the vulnerable lung cancer patients at risk for not receiving first-line curative or palliative treatment?

BACKGROUND

To identify non-small-cell lung cancer (NSCLC) patients in need of comprehensive support, we examined the association between patient and disease-related factors of vulnerability related to not receiving guideline-recommended treatment.

MATERIAL AND METHODS

We identified 14,597 non-small-cell lung cancer (NSCLC) patients with performance status <3 during 2013-2018 in the Danish Lung Cancer Registry. Multivariate logistic regression models were used to estimate Odds Ratios (ORs) and 95% confidence intervals (CIs) for receiving guideline-recommended treatment according to stage, comorbidities, age, performance status, long distance to hospital, cohabitation status, education and alcohol abuse.

RESULTS

21% of stage I-IIIA NSCLC patients did not receive curative treatment while 10% with stage IIIB-IV did not receive any oncological therapy. Factors associated with reduced likelihood of receiving curative treatment included: advanced stage (OR = 0.45; 95% CI = 0.42-0.49), somatic comorbidity (OR = 0.72; 95% CI = 0.63-0.83), age ≥ 80 years (OR = 0.59; 95% CI = 0.55-0.64), performance status = 2 (OR = 0.33; 95% CI = 0.28-0.39) and living alone (OR = 0.79; 95% CI = 0.69-0.90). Results were similar for stage IIIB-IV NSCLC patients, although a statistically significant association was also seen for long distances to the hospital (OR = 0.71; 95% CI = 0.58-0.86).

CONCLUSIONS

Several factors are associated with not receiving guideline-recommended NSCLC treatment with age, performance status, comorbidity and stage being most predictive of no treatment receipt. Efforts should be made to develop support for vulnerable lung cancer patients to improve adherence to optimal first-line therapy.

Rurality as a Risk Factor for Pulmonary Health Disparities

Rural populations experience significant pulmonary health disparities compared with urban populations. Patients in rural communities experience health determinants including high smoking prevalence, worse nutrition, lower educational attainment, specific occupational exposures, decreased health-care access, as well as unique cultural and political drivers of health. This article describes social determinants of pulmonary health relevant in rural communities, describes examples of existing pulmonary disparities in rural populations, and highlights health policies with potential to mitigate disparities.

Examining ACCURE's Nurse Navigation Through an Antiracist Lens: Transparency and Accountability in Cancer Care

There are persistent disparities in the delivery of cancer treatment, with Black patients receiving fewer of the recommended cancer treatment cycles than their White counterparts on average. To enhance racial equity in cancer care, innovative methods that apply antiracist principles to health promotion interventions are needed. The parent study for the current analysis, the Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) intervention, was a system-change intervention that successfully eliminated the Black-White disparity in cancer treatment completion among patients with early-stage breast and lung cancer. The intervention included specially trained nurse navigators who leveraged real-time data to follow-up with patients during their treatment journeys. Community and academic research partners conducted thematic analysis on all clinical notes (n = 3,251) written by ACCURE navigators after each contact with patients in the specialized navigation arm (n = 162). Analysis was informed by transparency and accountability, principles adapted from the antiracist resource Undoing Racism and determined as barriers to treatment completion through prior research that informed ACCURE. We identified six themes in the navigator notes that demonstrated enhanced accountability of the care system to patient needs. Underlying these themes was a process of enhanced data transparency that allowed navigators to provide tailored patient support. Themes include (1) patient-centered advocacy, (2) addressing system barriers to care, (3) connection to resources, (4) re-engaging patients after lapsed treatment, (5) addressing symptoms and side effects, and (6) emotional support. Future interventions should incorporate transparency and accountability mechanisms and examine the impact on racial equity in cancer care.

Disparities in thoracic surgical oncology

Disparities in access and outcomes of thoracic surgical oncology are long standing. This article examines the patient, population, and systems-level factors that contribute to these disparities and inequities. The need for research and policy to identify and solve these problems is apparent. As leaders in the field of thoracic oncology, surgeons will be instrumental in narrowing these gaps and moving the discipline forward.