Social Disparities in Lung Cancer Risk and Screening

Implementation of an Electronic Medical Record Alert Significantly Increases Lung Cancer Screening Uptake

INTRODUCTION

Lung cancer survival is significantly improved with early detection. However, lung cancer screening (LCS) uptake remains low despite national recommendations. Our aim was to determine whether implementation of an electronic medical record (EMR) alert and order set would increase LCS uptake.

STUDY DESIGN

A query of current and former smokers identified 62,630 patients aged 50 and above in the primary care setting between January 1, 2021 and May 5, 2022. We randomly reviewed 3704 charts for LCS eligibility and recorded who received LCS in the form of low-dose computed tomography amongst the eligible patients. We collected demographic information including gender, race, primary language, ethnicity, zip code, and insurance. Data analysis was performed utilizing 2-proportional z tests.

RESULTS

We identified 461 patients who were LCS eligible. Our overall LCS uptake was 19.9% (92/461). Three-time frames were analyzed: (1) prior to EMR alert implementation, (2) after implementation of EMR alert (January 7, 2021), and (3) after implementation of EMR alert and order set (March 3, 2021). Screening uptake was significantly improved with initiation of EMR alert (1/46 [2.2%] to 23/109 [21.1%]; P = .003). LCS uptake remained similarly high after subsequent order set implementation (23/109 [21.1%] and 68/306 [22.2%]; P = .72). Amongst the different demographics, age was significantly associated with screening uptake, with age ≥65 demonstrating statistically significant increased rates of screening (15.6% [41/263] for <65 vs 25.8% [51/198] for ≥65; P = .007).

CONCLUSION

Implementation of EMR alerts significantly improves LCS uptake in the primary care setting. Such efforts should be considered in other hospital settings to improve LCS uptake.

Identifying priority populations for lung cancer screening intervention using neighborhood-level factors and cancer registry data

To evaluate the association of neighborhood level economic, environmental, and social indicators with lung cancer (LC) incidence and mortality. Data for adult incident LC cases in Allegheny County, Pennsylvania, diagnosed between 2015-2019 were obtained from Pennsylvania cancer registry. Cases were summarized at census-tract level. Publicly available data on neighborhood deprivation index (NDI), built environment, and racial isolation at census-tracts were linked to cases. Poisson regression was used to compute relative risk (RR) for LC incidence and mortality, adjusting for covariates. A total of 3256 LC cases were included in the analyses. About 68% were ≥65 years, 54% female, 14% Black or African American, and 63% deceased. Results of the multivariable model found that increasing quintiles (Q) of NDI were significantly associated with increasing risk of LC incidence and mortality. The RRs (95% confidence interval) of LC incidence for Q2, Q3, Q4 and Q5 were 1.36 (1.21-1.52), 1.55 (1.40-1.72), 1.68 (1.51-1.87), 2.08 (1.82-2.38), respectively, compared with Q1 (P trend <0.01). The corresponding RRs for LC mortality were 1.46 (1.27-1.68), 1.63 (1.42-1.88), 1.74 (1.51-2.01), 2.04 (2.02-2.88) (P trend <0.01). Targeted interventions for LC prevention and early detection in high NDI neighborhoods may be more effective to reduce LC health disparities.

Lipid polymer hybrid nanoparticles against lung cancer and their application as inhalable formulation

Lung cancer is a leading cause of global cancer mortality, often treated with chemotherapeutic agents. However, conventional approaches such as oral or intravenous administration of drugs yield low bioavailability and adverse effects. Nanotechnology has unlocked new gateways for delivering medicine to their target sites. Lipid-polymer hybrid nanoparticles (LPHNPs) are one of the nano-scaled delivery platforms that have been studied to exploit advantages of liposomes and polymers, enhancing stability, drug loading, biocompatibility and controlled release. Pulmonary administration of drug-loaded LPHNPs enables direct lung deposition, rapid onset of action and heightened efficacy at low doses of drugs. In this manuscript, we will review the potential of LPHNPs in management of lung cancer through pulmonary administration.

Increasing Uptake of Lung Cancer Screening Among Emergency Department Patients: A Pilot Study

BACKGROUND

Lung cancer is the leading cause of cancer death in the United States. Lung cancer screening (LCS) decreases lung cancer mortality. Emergency department (ED) patients are at disproportionately high risk for lung cancer. The ED, therefore, is an optimal environment for interventions to promote LCS.

OBJECTIVES

Demonstrate the operational feasibility of identifying ED patients in need of LCS, referring them to LCS services, deploying a text message intervention to promote LCS, and conducting follow-up to determine LCS uptake.

METHODS

We conducted a randomized clinical trial to determine the feasibility and provide estimates of the preliminary efficacies of 1) basic referral for LCS and 2) basic referral plus a text messaging intervention, grounded in behavioral change theory, to promote uptake of LCS among ED patients. Participants aged 50 to 80, identified as eligible for LCS, were randomized to study arms and followed up at 150 days to assess interval LCS uptake (primary outcome), barriers to screening, and perceptions of the study interventions.

RESULTS

A total of 303 patients were surveyed, with 198 identified as eligible for LCS and subsequently randomized. Results indicated that 24% of participants with follow-up data received LCS (11% of the total randomized sample). Rates of screening at follow-up were similar across study arms. The intervention significantly improved normative perceptions of LCS (p = 0.015; Cohen's d = 0.45).

CONCLUSION

This pilot study demonstrates the feasibility of ED-based interventions to increase uptake of LCS among ED patients. A scalable ED-based intervention that increases LCS uptake could reduce lung cancer mortality.

Early Detection and Interception of Lung Cancer

Recent advances in lung cancer treatment have led to dramatic improvements in 5-year survival rates. And yet, lung cancer remains the leading cause of cancer-related mortality, in large part, because it is often diagnosed at an advanced stage, when cure is no longer possible. Lung cancer screening (LCS) is essential for intercepting the disease at an earlier stage. Unfortunately, LCS has been poorly adopted in the United States, with less than 5% of eligible patients being screened nationally. This article will describe the data supporting LCS, the obstacles to LCS implementation, and the promising opportunities that lie ahead.

Willingness for Lung Cancer Screening: Disparities Among Informed, Screening-Eligible Individuals

Background

Lung cancer is the leading cause of cancer-related death. Although lung cancer screening has been shown to reduce mortality, only a small fraction of eligible people receive screening. This study briefly educated screening-eligible individuals about lung cancer risk, prevention, and screening recommendations. We then evaluated race and gender as predictors of willingness to be screened once participants were educated.

Methods

An online lung cancer screening learning module was created and distributed to convenience samples of screening-eligible White Americans (n = 173) and Black Americans (n = 52) between November 2022 and February 2023. Participants viewed short modules about lung cancer risks and screening. Thereafter, participants rated their willingness to consider future screening using theory of planned behavior measurement frameworks (attitudes, norms, perceived control, and intentions to screen), with higher scores indicating greater willingness. Participant demographics were recorded.

Results

Black Americans reported higher perceived control over obtaining screening than White Americans (t 223 = -3.10; P < .001; d = 1.28). We observed no other racial differences in willingness as Black Americans and White Americans reported similar attitudes, normative beliefs, and intentions. Women also showed more positive attitudes and greater intention to be screened than men did (t 223 = -2.42; P = .02; d = 1.66).

Conclusions

Once informed about lung cancer risks, prevention, and screening recommendations, Black Americans may be as willing as White Americans to undergo screening, highlighting potential causal factors other than willingness for existing racial disparities in lung cancer screening uptake. Gender differences in willingness highlight a potential need for gender-targeted outreach and communication.

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.

Rural communities experience higher radon exposure versus urban areas, potentially due to drilled groundwater well annuli acting as unintended radon gas migration conduits

Repetitive, long-term inhalation of radioactive radon gas is one of the leading causes of lung cancer, with exposure differences being a function of geographic location, built environment, personal demographics, activity patterns, and decision-making. Here, we examine radon exposure disparities across the urban-to-rural landscape, based on 42,051 Canadian residential properties in 2034 distinct communities. People living in rural, lower population density communities experience as much as 31.2% greater average residential radon levels relative to urban equivalents, equating to an additional 26.7 Bq/m3 excess in geometric mean indoor air radon, and an additional 1 mSv/year in excess alpha radiation exposure dose rate to the lungs for occupants. Pairwise and multivariate analyses indicate that community-based radon exposure disparities are, in part, explained by increased prevalence of larger floorplan bungalows in rural areas, but that a majority of the effect is attributed to proximity to, but not water use from, drilled groundwater wells. We propose that unintended radon gas migration in the annulus of drilled groundwater wells provides radon migration pathways from the deeper subsurface into near-surface materials. Our findings highlight a previously under-appreciated determinant of radon-induced lung cancer risk, and support a need for targeted radon testing and reduction in rural communities.

Structural Racism and Lung Cancer Risk: A Scoping Review

Importance

Structural racism is associated with persistent inequities in health and health outcomes in the US for racial and ethnic minority groups. This review summarizes how structural racism contributes to differential population-level exposure to lung cancer risk factors and thus disparate lung cancer risk across different racial and ethnic groups.

Observations

A scoping review was conducted focusing on structural racism and lung cancer risk for racial and ethnic minority groups. The domains of structural racism evaluated included housing and built environment, occupation and employment, health care, economic and educational opportunity, private industry, perceived stress and discrimination, and criminal justice involvement. The PubMed, Embase, and MedNar databases were searched for English-language studies in the US from January 1, 2010, through June 30, 2022. The review demonstrated that racial and ethnic minority groups are more likely to have environmental exposures to air pollution and known carcinogens due to segregation of neighborhoods and poor housing quality. In addition, racial and ethnic minority groups were more likely to have exposures to pesticides, silica, and asbestos secondary to higher employment in manual labor occupations. Furthermore, targeted marketing and advertisement of tobacco products by private industry were more likely to occur in neighborhoods with more racial and ethnic minority groups. In addition, poor access to primary care services and inequities in insurance status were associated with elevated lung cancer risk among racial and ethnic minority groups. Lastly, inequities in tobacco use and cessation services among individuals with criminal justice involvement had important implications for tobacco use among Black and Hispanic populations.

Conclusions and Relevance

The findings suggest that structural racism must be considered as a fundamental contributor to the unequal distribution of lung cancer risk factors and thus disparate lung cancer risk across different racial and ethnic groups. Additional research is needed to better identify mechanisms contributing to inequitable lung cancer risk and tailor preventive interventions.

Disparities in lung cancer short- and long-term outcomes after surgery: Analysis from the national cancer database

INTRODUCTION

Social determinants of health are particularly important in lung cancer epidemiology. Previous studies have primarily associated social determinants with long-term outcomes, such as survival, but fail to include short-term outcomes after surgery. The National Cancer Database (NCDB) was used to draw associations between social factors of patients with lung cancer and short-term post-surgical outcomes, while comparing them to prognostic factors, including stage at diagnosis and survival.

METHODS

The 2004-17 NCDB was queried for patients with primary epithelial tumor, squamous cell carcinoma, or adenocarcinoma of the lung treated with curative intent. Linear, binary logistic, Kaplan-Meier, and Cox proportional hazards regression models were utilized.

RESULTS

On logistic regression modeling, male gender, low income, lacking insurance, and facility in the central United States were associated with poor short-term outcomes (<0.05). Increased age, White race, and Black race were associated with increased length of hospital stay and mortality, but negatively correlated with readmission rates (<0.05). Medicare and Medicaid were associated with increased length of stay and mortality, respectively (<0.05). Similar patterns were observed for higher stage at diagnosis (<0.05). Hazard ratios were elevated with increased age, male gender, White race, lacking insurance, Medicaid, and facility in the central United States (<0.05).

CONCLUSION

Many social factors previously associated with poor prognosis after lung cancer diagnosis are also associated with poor short-term outcomes after surgery. This study implies that healthcare providers treating lung cancer should proceed with care while aware that patients with the discussed social factors are predisposed to complicated recoveries.

Disparities in lung cancer

Lung cancer is the second most common cancer and the leading cause of cancer death among men and women in the United States. Despite a substantial decline in lung cancer incidence and mortality across all races in the last few decades, medically underserved racial and ethnic minority populations continue to carry the greatest burden of disease throughout the lung cancer continuum. Black individuals experience a higher incidence of lung cancer due to lower rates of low-dose computed tomography screening, which translate into advanced disease stage at diagnosis and poorer survival outcomes compared with White individuals. With respect to treatment, Black patients are less likely to receive gold standard surgery, have access to biomarker testing or high-quality treatment compared with White patients. The reasons for those disparities are multifactorial and include socioeconomic (eg, poverty, lack of health insurance, and inadequate education), and geographic inequalities. The objective of this article is to review the sources of racial and ethnic disparities in lung cancer, and to propose recommendations to help address them.

Consequences of changing Canadian activity patterns since the COVID-19 pandemic include increased residential radon gas exposure for younger people

The COVID-19 pandemic has produced widespread behaviour changes that shifted how people split their time between different environments, altering health risks. Here, we report an update of North American activity patterns before and after pandemic onset, and implications to radioactive radon gas exposure, a leading cause of lung cancer. We surveyed 4009 Canadian households home to people of varied age, gender, employment, community, and income. Whilst overall time spent indoors remained unchanged, time in primary residence increased from 66.4 to 77% of life (+ 1062 h/y) after pandemic onset, increasing annual radiation doses from residential radon by 19.2% (0.97 mSv/y). Disproportionately greater changes were experienced by younger people in newer urban or suburban properties with more occupants, and/or those employed in managerial, administrative, or professional roles excluding medicine. Microinfluencer-based public health messaging stimulated health-seeking behaviour amongst highly impacted, younger groups by > 50%. This work supports re-evaluating environmental health risks modified by still-changing activity patterns.

Gentrification and Air Quality in a Large Urban County in the United States

Introduction: Increases in industrialization and manufacturing have led to worsening pollution in some components of air quality. In addition, gentrification is occurring in large cities throughout the world. As these socioeconomic and demographic changes occur, there have been no studies examining the association of gentrification with air quality. To investigate this association, we studied the trends of gentrification, changes in racial distribution and changes in air quality in each zip code of a large urban county over a 40-year period. Methods: We conducted a retrospective longitudinal study over 40 years in Wayne County, Michigan using socioeconomic and demographic data from the National Historical Geographic Information System (NHGIS) and air quality data from the United States Environmental Protection Agency (EPA). To assess gentrification, longitudinal analyses were performed to examine median household income, percentage with a college education, median housing value, median gross rent and employment level. The racial distribution was evaluated in each zip code during the time period. Gentrification was studied in relation to air quality using nonparametric 2-sample Wilcon-Mann-Whitney tests and Binomial Generalized Linear Regression models. Results: Although air quality improved overall over the 40-year period, there was a lesser rate of improvement in gentrified areas. Furthermore, gentrification was strongly associated with racial distribution. The most substantial gentrification occurred from 2010 to 2020, in which a specific cluster of adjacent zip codes in downtown Detroit experienced intense gentrification and a drop in the percentage of African-American residents. Conclusions: Gentrified areas seem to have a less pronounced improvement in air quality over time. This reduction in air quality improvement is likely associated with demolitions and the construction of new buildings, such as sporting arenas and accompanying traffic density. Gentrification is also strongly associated with an increase in non-minority residents in an area. Although previous definitions of gentrification in the literature have not included racial distribution, we suggest that future definitions should include this metric given the strong association. Minority residents who are displaced as a result of gentrification do not experience the improvements in housing quality, accessibility to healthy foods and other associations of gentrification.

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.

Feasibility of Single - Encounter Telemedicine Lung Cancer Screening: A Retrospective Cohort Study in an Underserved Population

BACKGROUND

COVID-19 forced a delay of non-essential health services, including lung cancer screening. Our institution developed a single-encounter, telemedicine (SET) lung cancer screening whereby patients receive low-dose CT in-person, but counseling regarding results, coordination of follow-up care and smoking cessation is delivered using telemedicine. This study compares outcomes of SET lung cancer screening to our pre-COVID, single-visit, in-person (SIP) lung cancer screening.

METHODS

A retrospective cohort study was performed we recorded independent variables of gender, race/ethnicity, age, educational attainment, smoking status and dependent variables including cancer diagnosis, stage and treatment between March 2019 to July 2021. Using retrospective analysis, we compared outcomes of SIP lung cancer screening before COVID-19 and SET lung cancer screening amid COVID-19.

RESULTS

There was a significant difference in number of patients screened pre- and amid COVID-19.673 people were screened via SIP, while only 440 were screened via SET. SIP screening consisted of 52.5% Black/African American patients, which decreased to 37% with SET lung cancer screening. There was no significant difference in gender, age, or educational attainment. There was also no significant difference in Lung-RADS score between the 2 methods of screening or diagnostic procedures performed. Ultimately telemedicine based screening diagnosed fewer cancers, 1.6% diagnosed via telemedicine vs 3.3% screened by in person.

CONCLUSION

We implemented SET lung cancer screening to continue lung cancer screening during a global pandemic. Our study established feasibility of telemedicine-based lung cancer screening among our predominantly African American/Black population, though fewer patients were screened. We found no difference in distribution between age, or educational attainment suggesting other factors discouraging lung cancer screening amid COVID-19.

Nanoparticles advanced from preclinical studies to clinical trials for lung cancer therapy

Lung cancer is the leading cause of cancer mortality. As a heterogeneous disease, it has different subtypes and various treatment modalities. In addition to conventional surgery, radiotherapy and chemotherapy, targeted therapy and immunotherapy have also been applied in the clinics. However, drug resistance and systemic toxicity still cannot be avoided. Based on the unique properties of nanoparticles, it provides a new idea for lung cancer therapy, especially for targeted immunotherapy. When nanoparticles are used as carriers of drugs with special physical properties, the nanodrug delivery system ensures the accuracy of targeting and the stability of drugs while increasing the permeability and the aggregation of drugs in tumor tissues, showing good anti-tumor effects. This review introduces the properties of various nanoparticles including polymer nanoparticles, liposome nanoparticles, quantum dots, dendrimers, and gold nanoparticles and their applications in tumor tissues. In addition, the specific application of nanoparticle-based drug delivery for lung cancer therapy in preclinical studies and clinical trials is discussed.

Social factors and behavioural reactions to radon test outcomes underlie differences in radiation exposure dose, independent of household radon level

Radioactive radon gas inhalation causes lung cancer, and public health strategies have responded by promoting testing and exposure reduction by individuals. However, a better understanding of how radon exposure disparities are driven by psychological and social variables is required. Here, we explored how behavioural factors modified residential radon-related radiation doses incurred by 2390 people who performed a radon test. The average time from first awareness to receiving a radon test outcome was 6.8–25.5 months, depending on behaviour and attitudes. 20.5% displayed radon test urgency that reduced irradiation between awareness and outcome to 1.8 mSv from a typical 3.5 mSv, while 14.8% (more likely to be men) displayed delaying behaviours that increased exposure to 8.0 mSv. Of those with low radon, 45.9% indicated no future testing intention, underscoring the importance of original tests to reliably establish risk. Among people finding high radon, 38% mitigated quickly, 29% reported economic impediments, and 33% displayed delaying behaviours. Economic barriers and delaying behaviours resulted in 8.4 mSv/year or 10.3 mSv/year long term excess exposure, respectively, increasing lifetime risk of lung cancer by ~ 30–40%. Excess radiation doses incurred from behaviour were independent of household radon level, highlighting the strong influence of psychological and socioeconomic factors on radon exposure and lung cancer risks.

Current treatments for non-small cell lung cancer

Despite improved methods of diagnosis and the development of different treatments, mortality from lung cancer remains surprisingly high. Non-small cell lung cancer (NSCLC) accounts for the large majority of lung cancer cases. Therefore, it is important to review current methods of diagnosis and treatments of NSCLC in the clinic and preclinic. In this review, we describe, as a guide for clinicians, current diagnostic methods and therapies (such as chemotherapy, chemoradiotherapy, targeted therapy, antiangiogenic therapy, immunotherapy, and combination therapy) for NSCLC.

ER Stress–Related Genes EIF2AK3, HSPA5, and DDIT3 Polymorphisms are Associated With Risk of Lung Cancer

Objective: This study aimed to evaluate the associations between endoplasmic reticulum (ER) stress–related genes EIF2AK3/PERK, HSPA5/GRP78, and DDIT3/CHOP polymorphisms and the risk of lung cancer.

Methods: Six single-nucleotide polymorphisms (SNPs) of EIF2AK3, HSPA5, and DDIT3 were genotyped in 620 cases and 620 controls using a MassARRAY platform.

Results: The minor allele A of rs6750998 was a protective allele against the risk of lung cancer (p < 0.001), while the minor alleles of rs867529, rs391957, and rs697221 were all risk alleles that may lead to multiplied risk of the disease (rp_rs867529 = 0.002; p_rs391957 = 0.015; p_rs697221 < 0.001). Moreover, the rs6750998-TA/AA genotypes were protective genotypes against the risk of lung cancer (p = 0.005); however, the rs867529-GC/CC, rs391957-CC, and rs697221-GA/AA genotypes were associated with elevated lung cancer risk (p_rs867529 = 0.003, p_rs391957 = 0.028, and p_rs697221 = 0.0001). In addition, EIF2AK3-rs6750998 was associated with a decreased risk of lung cancer under dominant, recessive, and log-additive models (p < 0.05). By contrast, the EIF2AK3-rs867529 was correlated with an increased risk of the disease under dominant and log-additive models (p = 0.001). Moreover, HSPA5-rs391957 was related to an elevated risk of the disease under recessive and log-additive models (p < 0.02). DDIT3-rs697221 was identified to have a significant association with the risk of lung cancer under all three genetic models (p < 0.01).

Conclusion: Our results provide new insights on the role of the ER stress–related genes EIF2AK3, HSPA5, and DDIT3 polymorphisms for lung cancer risk.