Ethnic disparities in the treatment of stage I non-small cell lung cancer

National enrollment of lung cancer clinical trials is disproportionate based on race and health care access

OBJECTIVE

Despite declining lung cancer mortality in the United States, survival differences remain among racial and ethnic minorities in addition to those with limited health care access. Improvements in lung cancer treatment can be obtained through clinical trials, yet there are disparities in clinical trial enrollment of other cancer types. This study aims to evaluate disparities in lung cancer clinical trial enrollment to inform future enrollment initiatives.

METHODS

We analyzed patients with non-small cell lung cancer from the National Cancer Database (2004-2018), categorizing them as enrolled or not enrolled in clinical trials based on "rx_summ_other" data element. Clinical, demographic, and institutional factors associated with trial enrollment were assessed using bivariate and multivariate analysis, adjusting for institutional-level clustering.

RESULTS

A total of 1924 (0.12%) patients with lung cancer were enrolled in clinical trials. Enrolled patients were predominantly non-Hispanic White (82%), with greater socioeconomic status, treated at academic programs (67%), and had private insurance (42%) or Medicare (44%). They also traveled further for treatment compared with unenrolled patients (56 vs 27 miles, P < .001). After adjusting for demographic and clinical factors, lung cancer trial enrollment was significantly less likely among Black (odds ratio, 0.55; 95% confidence interval, 0.5-0.7, P < .001) and Hispanic (0.66; 95% confidence interval, 0.5-0.9, P = .01) patients. Patients with Medicaid or uninsured, in the lowest socioeconomic status group, and those treated at community-based cancer programs were the least likely to enroll.

CONCLUSIONS

Enrollment in lung cancer trials disproportionally excludes minority patients, those in the lowest socioeconomic status, community cancer programs, and the underinsured. These disparities in demographic and access for trial participation show a need for improved enrollment strategies.

Trends in racial and ethnic disparities in health-related quality of life in older adults with lung cancer

INTRODUCTION

We aimed to quantitatively examine differences in health-related quality of life (HRQOL) by race/ethnicity among older adults with lung cancer.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey (SEER-MHOS) data set, we identified two cohorts of patients ≥65 years old with lung cancer diagnosed from 2004 to 2015 who completed the health outcomes survey within 36 months pre- and post-diagnosis. The Physical Component Summary (PCS) and Mental Component Summary (MCS) were used to measure HRQOL. Racial/ethnic groups were White, Black, Asian, and Hispanic. Univariate (UVA) and multivariable (MVA) linear regression analyses with pairwise contrasts assessed disparities among the racial/ethnic groups. MVA models were adjusted for sex, age, marital status, education, income, year diagnosed, comorbidity count, limitations in activities of daily living, national region, histology, and treatment type (post-diagnosis cohort only).

RESULTS

We identified 4025 patients in the pre-diagnosis cohort (White = 75.9 %, Asian = 6.3 %, Black = 8.7 %, and Hispanic = 6.1 %; stages I = 28.8 %, II = 8.9 %, III = 21.7 %, IV = 27.8 %, unknown = 12.7 %) and 2465 patients in the post-diagnosis cohort (White = 74.4 %, Asian = 7.8 %, Black = 8.8 %, and Hispanic = 5.8 %; stages I = 40.2 %, II = 14.1 %, III = 17.5 %, IV = 10.7 %, unknown = 17.5 %; treatment type surgery = 0.9 %, radiation = 46.5 %, radiation and surgery = 26.8 %, no radiation or surgery = 25.9 %). Upon pre-diagnosis cohort UVA, White and Asian patients had higher mean MCS scores than Black and Hispanic patients (51.3 and 52.7 vs 47.4 and 47.4, respectively; p < .001 and p < .001), White patients had higher mean PCS scores than Black patients (38.6 vs 36.0; p < .001), and Asian patients had higher mean PCS scores than White, Black, and Hispanic patients (40.7 vs 38.6, 36.0 and 37.5, respectively; p = .008, p < .001, and p = .005). On pre-diagnosis MVA, White and Asian patients had higher mean MCS scores than Hispanic patients (51.2 and 52.0, respectively, vs 47.2; p < .001). On pre-diagnosis MVA, Asian patients had higher mean PCS scores than White patients (52.0 and 51.2; p = .002).On post-diagnosis UVA, White and Asian patients had higher mean MCS scores than Black patients (48.9 and 48.9, respectively, vs 46.3; p = .006 and p = .042), White patients had higher mean MCS scores than Hispanic patients (48.9 vs 46.1; p = .015), White patients had higher mean PCS scores than Black patients (33.8 vs 31.9; p = .018), and Hispanic patients had higher mean PCS scores than Black patients (34.9 vs. 31.9; p = .019). On post-diagnosis MVA, race/ethnicity was no longer associated with differing MCS or PCS.

DISCUSSION

Among older patients with lung cancer, those identifying as White or Asian had higher pre-diagnosis mental HRQOL than Hispanic patients. However, HRQOL differences before diagnosis among all racial/ethnic groups were no longer significant after cancer diagnosis and treatment. Understanding these patterns of HRQOL can be used for more pointed initiatives to improve therapeutic strategy, compliance, goals of care, and treatment-related morbidity.

Diversity and Disparities in Lung Cancer Outcomes Among Minorities

ABSTRACT

Because of diversities and disparities, lung cancer incidence and mortality rates among minorities are disproportionate compared with non-Hispanic White (NHW) populations. This review focuses on the disparities in lung cancer screening, diagnosis, treatment, and outcomes that minorities, mainly Hispanic and Black, experience compared with NHW populations. Despite efforts such as improving the eligibility criteria for screening to improve lung cancer survival rates, disparities persist, particularly among minority populations. However, the "Hispanic Paradox" describes the lower incidence and better survival rates observed in Hispanics compared with other ethnic groups best explained by possible contributions such as genetics and other factors such as dietary habits. Disparities in screening, particularly among underrepresented populations, are frequently explained by cultural, socioeconomic, and health care access barriers. There are also disparities in receiving appropriate treatment, such as surgical treatment, with fewer Hispanics and Blacks undergoing surgery than NHW individuals, resulting in lower overall survival rates. In addition, the prevalence of biomarker testing varies by racial and ethnic groups, influencing personalized treatment plans and outcomes. Finally, because of genetic and social determinants of health, the clinical outcomes of targeted therapy and immunotherapy may differ among minority populations. Identifying and addressing social determinants of health in real time are a "must" to have a significant impact in reducing lung cancer disparities. A comprehensive and multifaceted strategy is required to rectify disparities in cancer treatment. This strategy includes increasing levels of awareness and education, reducing financial and access barriers, and promoting increased diversity in clinical trial recruitment. By effectively addressing these complex challenges, the objective of providing equitable cancer care to all patients, regardless of race or ethnicity, can be achieved. To identify and address disparities, heightened awareness and education are essential. Access to health care is ensured by reducing financial and access barriers. Finally, increased diversity in clinical trial recruitment advances the generalizability of findings and promotes equitable representation of all racial and ethnic groups, resulting in improved outcomes for all patients.

Factors leading to disparity in lung cancer diagnosis among black/African American communities in the USA: a qualitative study

OBJECTIVE

This study has two objectives: first, to explore the diagnostic experiences of black/African American (BAA) patients with lung cancer to pinpoint pitfalls, suboptimal experiences and instances of discrimination leading to disparities in outcomes compared with patients of other ethnic backgrounds, especially white patients. The second objective is to identify the underlying causes contributing to health disparities in the diagnosis of lung cancer among BAA patients.

METHODS

We employed a phenomenological research approach, guiding in-depth interviews with patients self-identifying as BAA diagnosed with lung cancer, as well as caregivers, healthcare professionals and community advocates knowledgeable about BAA experiences with lung cancer. We performed thematic analysis to identify experiences at patient, primary care and specialist levels. Contributing factors were identified using the National Institute of Minority Health and Health Disparities (NIMHD) health disparity model.

RESULTS

From March to November 2021, we conducted individual interviews with 19 participants, including 9 patients/caregivers and 10 providers/advocates. Participants reported recurring and increased pain before seeking treatment, treatment for non-cancer illnesses, delays in diagnostic tests and referrals, poor communication and bias when dealing with specialists and primary care providers. Factors contributing to suboptimal experiences included reluctance by insurers to cover costs, provider unwillingness to conduct comprehensive testing, provider bias in recommending treatment, high healthcare costs, and lack of healthcare facilities and qualified staff to provide necessary support. However, some participants reported positive experiences due to their insurance, availability of services and having an empowered support structure.

CONCLUSIONS

BAA patients and caregivers encountered suboptimal experiences during their care. The NIMHD model is a useful framework to organise factors contributing to these experiences that may be leading to health disparities. Additional research is needed to fully capture the extent of these experiences and identify ways to improve BAA patient experiences in the lung cancer diagnosis pathway.

Surgical Treatment at an Academic Medical Center is Associated with Statistically Insignificant Lung Cancer Survival Outcome Differences Related to ZIP Code

BACKGROUND

Low socioeconomic status is a well-characterized adverse prognostic factor in large lung cancer databases. However, such characterizations may be confounded as patients of lower socioeconomic status are more often treated at low-volume, non-academic centers. We evaluated whether socioeconomic status, as defined by ZIP code median income, was associated with differences in lung cancer resection outcomes within a high-volume academic medical center.

METHODS

Consecutive patients undergoing resection for non-small cell lung cancer were identified from a prospectively maintained database (2011-18). Patients were assigned an income value based on the median income of their ZIP code as determined by census-based geographic data. We stratified the population into income quintiles representative of SES and compared demographics (chi-square), surgical outcomes, and survival (Kaplan-Meier).

RESULTS

We identified 1,693 patients, representing 516 ZIP codes. Income quintiles were Q1: $24,421-53,151; Q2:$53,152-73,982; Q3:$73,983-99,063; Q4:$99,064-123,842; and Q5:$123,843-250,001. Compared to Q5 patients, Q1 patients were younger (median 69 vs. 73, p < 0.001), more likely male (44 vs. 36%, p = 0.035), and more likely Asian, Black, or self-identified as other than white, Asian, or Black. (67 vs. 11%, p =  < 0.001). We found minor differences in surgical outcomes and no significant difference in 5-year survival between Q1 and Q5 patients (5-year: 86 vs. 85%, p = 0.886).

CONCLUSIONS

Surgical care patterns at a high-volume academic medical center are similar among patients from varying ZIP codes. Surgical treatment at such a center is associated with no survival differences based upon socioeconomic status as determined by ZIP code. Centralization of lung cancer surgical care to high-volume centers may reduce socioeconomic outcome disparities.

Efficacy of a Smoking Cessation Intervention for Survivors of Cervical Intraepithelial Neoplasia or Cervical Cancer: A Randomized Controlled Trial

PURPOSE

Women who smoke and have a history of cervical intraepithelial neoplasia (CIN) or cervical cancer represent a vulnerable subgroup at elevated risk for recurrence, poorer cancer treatment outcomes, and decreased quality of life. The purpose of this study was to evaluate the long-term efficacy of Motivation And Problem Solving (MAPS), a novel treatment well-suited to meeting the smoking cessation needs of this population.

METHODS

Women who were with a history of CIN or cervical cancer, age 18 years and older, spoke English or Spanish, and reported current smoking (≥100 lifetime cigarettes plus any smoking in the past 30 days) were eligible. Participants (N = 202) were recruited in clinic in Oklahoma City and online nationally and randomly assigned to (1) standard treatment (ST) or (2) MAPS. ST consisted of repeated referrals to a tobacco cessation quitline, self-help materials, and combination nicotine replacement therapy (patch plus lozenge). MAPS comprised all ST components plus up to six proactive telephone counseling sessions over 12 months. Logistic regression and generalized estimating equations evaluated the intervention. The primary outcome was self-reported 7-day point prevalence abstinence from tobacco at 18 months, with abstinence at 3, 6, and 12 months and biochemically confirmed abstinence as secondary outcomes.

RESULTS

There was no significant effect for MAPS over ST at 18 months (14.2% v 12.9%, P = .79). However, there was a significant condition × assessment interaction (P = .015). Follow-up analyses found that MAPS (v ST) abstinence rates were significantly greater at 12 months (26.4% v 11.9%, P = .017; estimated OR, 2.60; 95% CI, 1.19 to 5.89).

CONCLUSION

MAPS led to a greater than two-fold increase in smoking abstinence among survivors of CIN and cervical cancer at 12 months. At 18 months, abstinence in MAPS declined to match the control condition and the treatment effect was no longer significant.

Research Priorities for Interventions to Address Health Disparities in Lung Nodule Management: An Official American Thoracic Society Research Statement

Background: Lung nodules are common incidental findings, and timely evaluation is critical to ensure diagnosis of localized-stage and potentially curable lung cancers. Rates of guideline-concordant lung nodule evaluation are low, and the risk of delayed evaluation is higher for minoritized groups. Objectives: To summarize the existing evidence, identify knowledge gaps, and prioritize research questions related to interventions to reduce disparities in lung nodule evaluation. Methods: A multidisciplinary committee was convened to review the evidence and identify key knowledge gaps in four domains: 1) research methodology, 2) patient-level interventions, 3) clinician-level interventions, and 4) health system-level interventions. A modified Delphi approach was used to identify research priorities. Results: Key knowledge gaps included 1) a lack of standardized approaches to identify factors associated with lung nodule management disparities, 2) limited data evaluating the role of social determinants of health on disparities in lung nodule management, 3) a lack of certainty regarding the optimal strategy to improve patient-clinician communication and information transmission and/or retention, and 4) a paucity of information on the impact of patient navigators and culturally trained multidisciplinary teams. Conclusions: This statement outlines a research agenda intended to stimulate high-impact studies of interventions to mitigate disparities in lung nodule evaluation. Research questions were prioritized around the following domains: 1) need for methodologic guidelines for conducting research related to disparities in nodule management, 2) evaluating how social determinants of health influence lung nodule evaluation, 3) studying approaches to improve patient-clinician communication, and 4) evaluating the utility of patient navigators and culturally enriched multidisciplinary teams to reduce disparities.

Racial Diversity and Reporting in United States Food and Drug Administration Registration Trials for Thoracic Malignancies from 2006 to 2020

There is significant racial disparity in thoracic malignancies in terms of epidemiology and outcomes. We analyzed race reporting and racial diversity in the registration trials of drugs approved by the FDA for thoracic malignancies from 2006 to 2020. We found a significant under-representation of non-white participants in FDA drug registration trials in thoracic malignancies. Furthermore, though almost all trials report some race information, FDA guidelines are not universally followed. There is a disproportionate disease burden of lung cancer in under-represented race communities, and clinical trials should prioritize racial diversity and inclusion efforts.

Disparities in Supportive Care Needs Over Time Between Racial and Ethnic Minority and Non-Minority Patients With Advanced Lung Cancer

CONTEXT

Little is known about inequities in supportive care needs among diverse patients with advanced lung cancer.

OBJECTIVES

We aimed to examine differences in supportive care needs between racial/ethnic minority and non-minority patients with lung cancer and identify how these needs change over time.

METHODS

We performed a prospective cohort study of patients newly diagnosed with advanced lung cancer (stage III and IV). Patients completed a validated survey at baseline, 4-, 8- and 12-months post-diagnosis, assessing supportive care needs: medical communication/information, psychological/emotional support, daily living, financial concerns, physical symptoms, and spiritual and social needs. Univariable and multivariable regression analyses compared differences in supportive care needs between minority (Black and Latinx) and non-minority patients. A mixed effect model with minority status, follow-up time and the interaction between minority status and time assessed the association between each need and minority status with changes over time.

RESULTS

We enrolled 99 patients; 55 (56%) were minorities and 44 (44%) were non-minorities. At baseline, minorities reported significantly higher needs across each domain except medical communication/information. Over time, these reported differences remained consistent except for medical communication. After adjustment, the needs of both minorities and non-minorities increased significantly in the psychological/emotional, daily living and physical symptom domains.

CONCLUSION

Minority patients with advanced lung cancer are more likely to have higher baseline and persistent supportive care needs relatives to non-minority patients. Clinicians caring for minority patients with lung cancer should provide targeted supportive care evaluation and treatment to ensure health equity.

Disparities in clinical and demographic characteristics among Asian/Pacific Islander and Non-Hispanic White newly diagnosed lung cancer patients

PURPOSE

Racial disparities persist among lung cancer patients but have not been adequately studied among Asian/Pacific Islander (API) subgroups, which are heterogeneous. This study compared clinical and demographic characteristics at diagnosis of API subgroups and NHW patients.

METHODS

NHW and API adults diagnosed with lung cancer were identified from the Surveillance, Epidemiology, and End Results database (1990-2015). API was divided into eight subgroups: Chinese, Japanese, Filipino, Hawaiian/Pacific Islander, Korean, Vietnamese, Asian Indian/Pakistani, and Other. Multivariable multinomial logistic regression models were used to assess adjusted associations of clinical and demographic factors with API/subgroups.

RESULTS

There were 522,702 (92.6%) NHW and 41,479 (7.4%) API lung cancer patients. API were less likely to be diagnosed at the age of ≥ 80 years (OR_adj 0.53, 95% CI 0.48-0.58 for ≥ 80 vs. ≤ 39 years) than NHW. However, Japanese patients were more often diagnosed at ≥ 80 years compared to other ethnic subgroups. API were less often female (OR_adj 0.85, 95% CI 0.83-0.86), and unmarried (OR_adj 0.71, 95% CI 0.68-0.74); however, among API, Japanese, Hawaiian/Pacific Islander, Korean, and Vietnamese were more often unmarried, compared to Chinese patients. API were more frequently diagnosed at stage IV, compared to stage I (OR_adj 1.31, 95% CI 1.27-1.35). API had significantly less squamous cell carcinoma (OR_adj 0.54, 95% CI 0.52-0.56, compared to adenocarcinoma); among API, Japanese, Filipino, Hawaiian/Pacific Islander, Korean, Asian Indian/Pakistani, and Other were more likely than Chinese patients to present with squamous cell histology (range: OR_adj[Other] 1.24, 95% CI 1.09-1.41; OR_adj[Hawaiian/Pacific Islander] 2.47, 95% CI 2.22-2.75).

CONCLUSION

At diagnosis, there are significant differences in demographic and clinical characteristics between NHW, API, and API subgroups. Treating API patients as a single population may overlook biological, environmental, and behavioral differences that might be beneficial in designing prevention strategies and treatment.

Evaluation of the Efficacy of a Smoking Cessation Intervention for Cervical Cancer Survivors and Women With High-Grade Cervical Dysplasia: Protocol for a Randomized Controlled Trial

BACKGROUND

The prevalence of smoking among cervical cancer survivors is strikingly high, yet no smoking cessation interventions to date have specifically targeted this population. This paper describes the study design, methods, and data analysis plans for a randomized clinical trial designed to evaluate the efficacy of a theoretically and empirically based Motivation And Problem Solving (MAPS) approach for promoting and facilitating smoking cessation among cervical cancer survivors. MAPS is a comprehensive, dynamic, and holistic intervention that incorporates empirically supported cognitive behavioral and social cognitive theory-based treatment strategies within an overarching motivational framework. MAPS is designed to be appropriate for all smokers regardless of their motivation to change and views motivation as dynamically fluctuating from moment to moment throughout the behavior change process.

OBJECTIVE

This 2-group randomized controlled trial compares the efficacy of standard treatment to MAPS in facilitating smoking cessation among women with a history of high-grade cervical dysplasia or cervical cancer.

METHODS

Participants (N=202) are current smokers with a history of high-grade cervical dysplasia or cervical cancer recruited nationally and randomly assigned to one of two treatment conditions: (1) standard treatment (ST) or (2) MAPS. ST consists of repeated letters referring participants to their state's tobacco cessation quitline, standard self-help materials, and free nicotine replacement therapy when ready to quit. MAPS has all ST components along with 6 proactive telephone counseling sessions delivered over 12 months. The primary outcome is abstinence from tobacco at 18 months. Secondary outcomes include abstinence over time across all assessment points, abstinence at other individual assessment time points, quit attempts, cigarettes per day, and use of state quitlines. Hypothesized treatment mechanisms and cost-effectiveness will also be evaluated.

RESULTS

This study was approved by the institutional review boards at the University of Texas MD Anderson Cancer Center, the University of Oklahoma Health Sciences Center, and Moffitt Cancer Center. Participant enrollment concluded at Moffitt Cancer Center in January 2020, and follow-up data collection was completed in July 2021. Data analysis is ongoing.

CONCLUSIONS

This study will yield crucial information regarding the efficacy and cost-effectiveness of a MAPS approach for smoking cessation tailored to the specific needs of women with a history of high-grade cervical dysplasia or cervical cancer. Findings indicating that MAPS has substantially greater efficacy than existing evidence-based tobacco cessation treatments would have tremendous public health significance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02157610; https://clinicaltrials.gov/ct2/show/NCT02157610.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34502.

Ethnic Differences in Survival Among Lung Cancer Patients: A Systematic Review

Background

Despite a substantially worse risk factor profile, Hispanics in the United States experience lower incidence of many diseases and longer survival than non-Hispanic Whites (NHWs), an epidemiological phenomenon known as the Hispanic Health Paradox (HHP). This systematic review evaluated the published longitudinal literature to address whether this pattern extends to lung cancer survival.

Methods

Searches of Medline, PubMed, Embase, Web of Science, and the Cochrane Library were conducted for publications dated from January 1, 2000, to July 18, 2018. Records were restricted to articles written in English, employing a longitudinal design, and reporting a direct survival comparison (overall survival [OS], cancer-specific survival [CSS]) between NHW and Hispanic lung cancer patients.

Results

A final sample of 29 full-text articles were included, with 28 fully adjusted models of OS and 21 of CSS included. Overall, 26 (92.9%) OS models and 20 (95.2%) CSS models documented either no difference (OS = 16, CSS = 11) or a Hispanic survival advantage (OS = 10, CSS = 9). Both larger studies and those including foreign-born Hispanics were more likely to show a Hispanic survival advantage, and 2 studies of exclusively no-smokers showed a survival disadvantage. A number of reporting gaps were identified including Hispanic background and sociodemographic characteristics.

Conclusions

Hispanics exhibit similar or better survival in the context of lung cancer relative to NHWs despite a considerably worse risk factor profile. These findings support the HHP in the context of lung cancer. Further research is needed to understand the potential mechanisms of the HHP as it relates to lung cancer.

Perceptions and Patterns of Cigarette and E-Cigarette Use among Hispanics: A Heterogeneity Analysis of the 2017-2019 Health Information National Trends Survey

There are documented disparities in smoking behaviors among Hispanic adults in the U.S., but little is known about patterns of e-cigarette use. Using data from the HINTS 5 cycle 1-3, we examined cigarette and e-cigarette history and current use, as well as perceptions of the dangers of e-cigarette use relative to cigarette use. Primary predictors were Hispanic ethnic group, gender, age, education, income, and English language proficiency. Binary outcomes were modeled using the logit link, and multinomial outcome variables were modeled using generalized logit model. Fifty-three percent of participants were Mexican, 8% Puerto Rican, 4% were Cuban, and 35% identified as other Hispanics. Of the 1618 respondents, 23% were former cigarette smokers and 10% were current cigarette smokers. Twenty percent reported history of electronic cigarettes and 4% reported current use. In multivariable models, Hispanic women were significantly less likely to report ever being smokers compared to Hispanic men (aOR = 0.61, 95% CI = 0.42, 0.88). Puerto Ricans were 2.4 times as likely to report being current smokers (95% CI = 1.11, 5.11) compared to Mexicans. Among Hispanics, significant differences in e-cigarette and cigarette use behaviors emerged by gender, age, ethnicity, and cancer history, with implications for tailoring smoking prevention and cessation messages.

Sociodemographic disparities in the management of advanced lung cancer: a narrative review

Treatment of advanced non-small cell lung cancer (NSCLC) has markedly changed in the past decade with the integration of biomarker testing, targeted therapies, immunotherapy, and palliative care. These advancements have led to significant improvements in quality of life and overall survival. Despite these improvements, racial and socioeconomic disparities in lung cancer mortality persist. This narrative review aims to assess and synthesize the literature on sociodemographic disparities in the management of advanced NSCLC. A narrative overview of the literature was conducted using PubMed and Scopus and was narrowed to articles published from January 1, 2010, until July 22, 2020. Articles relevant to sociodemographic variation in (I) chemoradiation for stage III NSCLC, (II) molecular biomarker testing, (III) systemic treatment, including chemotherapy, targeted therapy, and immunotherapy, and (IV) palliative and end of life care were included in this review. Twenty-two studies were included. Sociodemographic disparities in the management of advanced NSCLC varied, but recurring findings emerged. Across most treatment domains, Black patients, the uninsured, and patients with Medicaid were less likely to receive recommended lung cancer care. However, some of the literature was limited due to incomplete data to adequately assess appropriateness of care, and several studies were out of date with current practice guidelines. Sociodemographic disparities in the management of advanced lung cancer are evident. Given the rapidly evolving treatment paradigm for advanced NSCLC, updated research is needed. Research on interventions to address disparities in advanced NSCLC is also needed.

Evaluation of Revised US Preventive Services Task Force Lung Cancer Screening Guideline Among Women and Racial/Ethnic Minority Populations

Importance

Lung cancer incidence and mortality disproportionately affect women and racial/ethnic minority populations, yet screening guidelines for the past several years were derived from clinical trials of predominantly White men. To reflect current evidence, the US Preventive Services Task Force (USPSTF) has revised the eligibility criteria, which may help to ameliorate sex- and race/ethnicity-related disparities in lung cancer screening.

Objective

To determine the changes associated with the revised USPSTF guideline for lung cancer screening eligibility among female, Black, and Hispanic populations using a large nationwide survey.

Design, Setting, and Participants

This cross-sectional study included respondents to the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System who were 50 to 80 years of age with a smoking history in 19 states that used the optional lung cancer screening module. The change in eligibility among female, male, Black, Hispanic, and White participants was examined. Eligibility by sex and race/ethnicity was compared with a reference population. Data were collected from January 1, 2017, to December 31, 2018, and analyzed from May 8 to June 11, 2020.

Exposures

Self-reported sex, race/ethnicity, age, and smoking history.

Main Outcomes and Measures

Lung cancer screening eligibility using the revised USPSTF criteria. The previous criteria included current or past smokers (within 15 years) who were 55 to 80 years of age and had a smoking history of more than 30 pack-years. In the revised criteria, age was modified to 50 to 80 years; smoking history, to 20 pack-years.

Results

Among 40 869 respondents aged 50 to 80 years with a smoking history, 21 265 (52.0%) were women, 3430 (8.4%) were Black, and 1226 (30.0%) were Hispanic (mean [SD] age, 65.6 [7.9] years). The revised criteria increased eligibility for the following populations: men (29.4% to 38.3% [8.9% difference]; P < .001), women (25.9% to 36.4% [10.5% difference]; P < .001), White individuals (31.1% to 40.9% [9.8% difference]; P < .001), Black individuals (16.3% to 28.8% [12.5% difference]; P < .001), and Hispanic individuals (10.5% to 18.7% [8.2% difference]; P < .001). The odds of eligibility were lower for women compared with men (adjusted odds ratio [AOR], 0.88; 95% CI, 0.79-0.99; P = .04) and for Black (AOR, 0.43; 95% CI, 0.33-0.56; P < .001) and Hispanic populations (AOR, 0.70; 95% CI, 0.62-0.80; P < .001) compared with the White population.

Conclusions and Relevance

The revised USPSTF guideline may likely increase lung cancer screening rates for female, Black, and Hispanic populations. However, despite these potential improvements, lung cancer screening inequities may persist without tailored eligibility criteria.

Socioeconomic Factors Associated with Lack of Treatment in Early Stage Non-Small Cell Lung Cancer

With modern radiotherapy, stage I non-small cell lung cancer (S1NSCLC) cure is extended to nonsurgical candidates. Despite this, some S1NSCLC remains untreated. We aim to identify factors associated with no treatment. 62,213 S1NSCLC cases were identified (SEER: 2004-2012). Demographics were compared using Chi-squared. Multivariate analysis was performed using COX proportional HR. 11.9% of the 7373 patients lacked treatment. No insurance, Medicaid-dependence, unmarried status, advancing age, lower income, African American and Asian/Pacific Islander race, and male sex are associated with no treatment (p < .0001). No treatment portends a worse cancer-specific survival (21% vs 66% at 5Y, p < .0001) and OS (10% vs 50% at 5Y, p < .0001).

Disparities in the surgical management of early stage non-small cell lung cancer: how far have we come?

It is currently estimated that nearly one-third of patients with newly diagnosed non-small cell lung cancer (NSCLC) have stage I-II disease on clinical evaluation. Curative-intent surgical resection has been a cornerstone of the therapeutic management of such patients, offering the best clinical and oncologic outcomes in the long-term. In 1999, Peter Bach and colleagues brought attention to racial disparities in the receipt of curative-intent surgery in the NSCLC population. In the time since this seminal study, there is accumulating evidence to suggest that disparities in the receipt of definitive surgery continue to persist for patients with early stage NSCLC. In this review, we sought to provide an up-to-date assessment of 20 years of surgical disparities literature in the NSCLC population. We summarized common and unrecognized disparities in the receipt of surgical resection for early stage NSCLC and demonstrated that demographic and socioeconomic factors such as race/ethnicity, special patient groups, income and insurance continue to impact the receipt of definitive resection. Additionally, we found that discrepancies in patient and provider perceptions of and attitudes toward surgery, access to invasive staging, distance to treatment centers and negative stigmas about lung cancer that patients experience may act to perpetuate disparities in surgical treatment of early stage lung cancer.

Global Epidemiology of Lung Cancer

While lung cancer has been the leading cause of cancer-related deaths for many years in the United States, incidence and mortality statistics - among other measures - vary widely worldwide. The aim of this study was to review the evidence on lung cancer epidemiology, including data of international scope with comparisons of economically, socially, and biologically different patient groups. In industrialized nations, evolving social and cultural smoking patterns have led to rising or plateauing rates of lung cancer in women, lagging the long-declining smoking and cancer incidence rates in men. In contrast, emerging economies vary widely in smoking practices and cancer incidence but commonly also harbor risks from environmental exposures, particularly widespread air pollution. Recent research has also revealed clinical, radiologic, and pathologic correlates, leading to greater knowledge in molecular profiling and targeted therapeutics, as well as an emphasis on the rising incidence of adenocarcinoma histology. Furthermore, emergent evidence about the benefits of lung cancer screening has led to efforts to identify high-risk smokers and development of prediction tools. This review also includes a discussion on the epidemiologic characteristics of special groups including women and nonsmokers. Varying trends in smoking largely dictate international patterns in lung cancer incidence and mortality. With declining smoking rates in developed countries and knowledge gains made through molecular profiling of tumors, the emergence of new risk factors and disease features will lead to changes in the landscape of lung cancer epidemiology.

Factors contributing to disparities in mortality among patients with non-small-cell lung cancer

Historically, non-small-cell lung cancer (NSCLC) patients who are non-white, have low incomes, low educational attainment, and non-private insurance have worse survival. We assessed whether differences in survival were attributable to sociodemographic factors, clinical characteristics at diagnosis, or treatments received. We surveyed a multiregional cohort of patients diagnosed with NSCLC from 2003 to 2005 and followed through 2012. We used Cox proportional hazard analyses to estimate the risk of death associated with race/ethnicity, annual income, educational attainment, and insurance status, unadjusted and sequentially adjusting for sociodemographic factors, clinical characteristics, and receipt of surgery, chemotherapy, and radiotherapy. Of 3250 patients, 64% were white, 16% black, 7% Hispanic, and 7% Asian; 36% of patients had incomes <$20 000/y; 23% had not completed high school; and 74% had non-private insurance. In unadjusted analyses, black race, Hispanic ethnicity, income <$60 000/y, not attending college, and not having private insurance were all associated with an increased risk of mortality. Black-white differences were not statistically significant after adjustment for sociodemographic factors, although patients with patients without a high school diploma and patients with incomes <$40 000/y continued to have an increased risk of mortality. Differences by educational attainment were not statistically significant after adjustment for clinical characteristics. Differences by income were not statistically significant after adjustment for clinical characteristics and treatments. Clinical characteristics and treatments received primarily contributed to mortality disparities by race/ethnicity and socioeconomic status in patients with NSCLC. Additional efforts are needed to assure timely diagnosis and use of effective treatment to lessen these disparities.

Examining the role of access to care: Racial/ethnic differences in receipt of resection for early-stage non-small cell lung cancer among integrated system members and non-members

OBJECTIVES

To examine the role of uniform access to care in reducing racial/ethnic disparities in receipt of resection for early stage non-small cell lung cancer (NSCLC) by comparing integrated health system member patients to demographically similar non-member patients.

MATERIALS AND METHODS

Using data from the California Cancer Registry, we conducted a retrospective cohort study of patients from four racial/ethnic groups (White, Black, Hispanic, Asian/Pacific Islander), aged 21-80, with a first primary diagnosis of stage I or II NSCLC between 2004 and 2011, in counties served by Kaiser Permanente Northern California (KPNC) at diagnosis. Our cohort included 1565 KPNC member and 4221 non-member patients. To examine the relationship between race/ethnicity and receipt of surgery stratified by KPNC membership, we used modified Poisson regression to calculate risk ratios (RR) adjusted for patient demographic and tumor characteristics.

RESULTS

Black patients were least likely to receive surgery regardless of access to integrated care (64-65% in both groups). The magnitude of the black-white difference in the likelihood of surgery receipt was similar for members (RR: 0.82, 95% CI: 0.73-0.93) and non-members (RR: 0.86, 95% CI: 0.80-0.94). Among members, roughly equal proportions of Hispanic and White patients received surgery; however, among non-members, Hispanic patients were less likely to receive surgery (non-members, RR: 0.93, 95% CI: 0.86-1.00; members, RR: 0.98, 95% CI: 0.89-1.08).

CONCLUSION

Disparities in surgical treatment for NSCLC were not reduced through integrated health system membership, suggesting that factors other than access to care (e.g., patient-provider communication) may underlie disparities. Future research should focus on identifying such modifiable factors.

Sociodemographics, but not Acculturation Proxies, Account for Differences in Lifetime Cessation between White and Hispanic Smokers

Objective

Prominent addiction theories predict that Hispanic smokers should have more success at quitting than White smokers due to less physical dependence on average, but extant findings are mixed. This might be due in part to a lack of attention to confounding demographic and acculturation-related variables. Our study compared likelihood of lifetime cessation between White and Hispanic men and women of different language proficiency, nativity and residency status, controlling for age, education, and poverty level.

Method

Data from 123,574 White and Hispanic participants in the 2011-2015 National Health Interview Surveys were used. Logistic regression analyses examined ethnic differences in odds of being a former smoker. Predicted probabilities of being a former smoker were calculated from these models.

Results

In unadjusted analyses, White men demonstrated higher odds of being a former smoker compared with Hispanic men, Hispanic women, and White women. In adjusted analyses, Hispanics demonstrated higher odds of being a former smoker compared with Whites, and differences by acculturation proxies emerged.

Conclusions

Not accounting for demographics may suppress ethnic differences in likelihood of smoking cessation. Among Hispanics, demographics may be more important determinants of lifetime quitting than acculturation-related characteristics.

The influence of insurance type on stage at presentation, treatment, and survival between Asian American and non-Hispanic White lung cancer patients

The effect of insurance type on lung cancer diagnosis, treatment, and survival in Asian patients living in the United States is still under debate. We have analyzed this issue using the Surveillance, Epidemiology, and End Results database. There were 102,733 lung cancer patients age 18–64 years diagnosed between 2007 and 2013. Multilevel regression analysis was performed to identify the association between insurance types, stage at diagnosis, treatment modalities, and overall mortality in Asian and non‐Hispanic White (NHW) patients. Clinical characteristics were significantly different between Asian and NHW patients, except for gender. Asian patients were more likely to present with advanced disease than NHW patients (OR_adj = 1.12, 95% CI = 1.06–1.19). Asian patients with non‐Medicaid insurance underwent lobectomy more than NHW patients with Medicaid or uninsured; were more likely to undergo mediastinal lymph node evaluation (MLNE) (OR_adj = 1.98, 95% CI = 1.72–2.28) and cancer‐directed surgery and/or radiation therapy (OR_adj = 1.41, 95% CI = 1.20–1.65). Asian patients with non‐Medicaid insurance had the best overall survival. Uninsured or Medicaid‐covered Asian patients were more likely to be diagnosed with advanced disease, less likely to undergo MLNE and cancer‐directed treatments, and had shorter overall survival than their NHW counterpart.

Future cancer research priorities in the USA: a Lancet Oncology Commission

We are in the midst of a technological revolution that is providing new insights into human biology and cancer. In this era of big data, we are amassing large amounts of information that is transforming how we approach cancer treatment and prevention. Enactment of the Cancer Moonshot within the 21st Century Cures Act in the USA arrived at a propitious moment in the advancement of knowledge, providing nearly US$2 billion of funding for cancer research and precision medicine. In 2016, the Blue Ribbon Panel (BRP) set out a roadmap of recommendations designed to exploit new advances in cancer diagnosis, prevention, and treatment. Those recommendations provided a high-level view of how to accelerate the conversion of new scientific discoveries into effective treatments and prevention for cancer. The US National Cancer Institute is already implementing some of those recommendations. As experts in the priority areas identified by the BRP, we bolster those recommendations to implement this important scientific roadmap. In this Commission, we examine the BRP recommendations in greater detail and expand the discussion to include additional priority areas, including surgical oncology, radiation oncology, imaging, health systems and health disparities, regulation and financing, population science, and oncopolicy. We prioritise areas of research in the USA that we believe would accelerate efforts to benefit patients with cancer. Finally, we hope the recommendations in this report will facilitate new international collaborations to further enhance global efforts in cancer control.

Racial and Ethnic Disparities in Early-Stage Lung Cancer Survival

BACKGROUND

Black patients with lung cancer diagnosed at early stages-for which surgical resection offers a potential cure-experience worse overall survival than do their white counterparts. We undertook a population-based study to estimate the racial and ethnic disparity in death from competing causes and assessed its contribution to the gap in overall survival among patients with early-stage lung cancer.

METHODS

We collected survival time data for 105,121 Hispanic, non-Hispanic Asian, non-Hispanic black, and non-Hispanic white patients with early-stage (IA, IB, IIA, and IIB) lung cancer diagnosed between 2004 and 2013 from the Surveillance, Epidemiology, and End-Results registries. We modeled survival time using competing risk regression and included as covariates sex, age at diagnosis, race/ethnicity, stage at diagnosis, histologic type, type of surgical resection, and radiation sequence.

RESULTS

Adjusting for demographic, clinical, and treatment characteristics, non-Hispanic blacks experienced worse overall survival compared with non-Hispanic whites (adjusted hazard ratio [aHR], 1.05; 95% CI, 1.02-1.08), whereas Hispanics and non-Hispanic Asians experienced better overall survival (aHR, 0.93; 95% CI, 0.89-0.98; and aHR, 0.82; 95% CI, 0.79-0.86, respectively). Worse survival from competing causes of death, such as cardiovascular disease and other cancers-rather than from lung cancer itself-led to the disparity in overall survival among non-Hispanic blacks (adjusted relative risk, 1.07; 95% CI, 1.02-1.12).

CONCLUSIONS

Narrowing racial and ethnic disparities in survival among patients with early-stage lung cancer will rely on more than just equalizing access to surgical resection and will need to include better management and treatment of smoking-related comorbidities and diseases.

Survival among Never-Smokers with Lung Cancer in the Cancer Care Outcomes Research and Surveillance Study

RATIONALE

Differences in patient characteristics and outcomes have been observed among current, former, and never-smokers with lung cancer, but most prior studies included few never-smokers and were not prospective.

OBJECTIVES

We used data from a large, prospective study of lung cancer care and outcomes in the United States to compare characteristics of never-smokers and smokers with lung cancer and to examine survival among the never-smokers.

METHODS

Smoking status at diagnosis was determined by self-report and survival was determined from medical records and cancer registries, with follow-up through June 2010 or later. Cox regression was used to examine the association between smoking and survival, and to identify predictors of survival among never-smokers.

MEASUREMENTS AND MAIN RESULTS

Among 3,410 patients with lung cancer diagnosed between September 1, 2003 and October 14, 2005 who completed a baseline patient survey, there were 274 never-smokers (8%), 1,612 former smokers (47%), 1,496 current smokers or smokers who quit recently (44%), and 28 with missing information about smoking status (<1%). Never-smokers appeared more likely than former and current/recent smokers to be female and of Asian or Hispanic race/ethnicity, and to have adenocarcinoma histology, fewer comorbidities, private insurance, and higher income and education. Compared with never-smokers, the adjusted hazard of death from any cause was 29% higher among former smokers (hazard ratio, 1.29; 95% confidence interval, 1.08-1.55), and 39% higher among current/recent smokers (hazard ratio, 1.39; 95% confidence interval, 1.16-1.67). Factors predicting worse overall survival among never-smokers included Hispanic ethnicity, severe comorbidity, undifferentiated histology, and regional or distant stage. Never-smoking Hispanics appeared more likely to have regional or advanced disease at diagnosis and less likely to undergo surgical resection, although these differences were not statistically significant.

CONCLUSIONS

Never-smokers with lung cancer are more likely than ever-smokers to be female, Asian or Hispanic, and more advantaged socioeconomically, suggesting possible etiologic differences in lung cancer by smoking status. Among never-smokers, Hispanics with lung cancer had worse survival than non-Hispanic whites.

Comparative Analysis of Clinicopathologic Features of, Treatment in, and Survival of Americans with Lung or Bronchial Cancer

Ethnic disparities in lung and bronchial cancer diagnoses and disease-specific survival (DSS) rates in the United States are well known. However, few studies have specifically assessed these differences in Asian subgroups. The primary objectives of the retrospective analysis described herein were to identify any significant differences in clinicopathologic features, treatment, and survival rate between Asian lung cancer patients and lung cancer patients in other broad ethnic groups in the United States and to determine the reasons for these differences among subgroups of Asian patients with lung or bronchial cancer. We searched the Surveillance, Epidemiology, and End Results Program database to identify patients diagnosed with lung or bronchial cancer from 1990 to 2012. Differences in clinicopathologic features, treatment, and DSS rate in four broad ethnic groups and eight Asian subgroups were compared. The study population consisted of 849,088 patients, 5.2% of whom were of Asian descent. Female Asian patients had the lowest lung and bronchial cancer incidence rates, whereas male black patients had the highest rates. Asian patients had the best 5-year DSS rate. In our Asian subgroup analysis, Indian/Pakistani patients had the best 5-year DSS rate, whereas Hawaiian/Pacific Islander patients had the worst 5-year DSS rates. We found the differences in DSS rate among the four broad ethnic groups and eight Asian subgroups when we grouped patients by age and disease stage, as well. Asian patients had better DSS rates than those in the other three broad ethnic groups in almost every age and disease-stage group, especially in older patients and those with advanced-stage disease. In conclusion, we found that clinicopathologic features and treatment of lung and bronchial cancer differ by ethnicity in the United States, and the differences impact survival in each ethnic group.

Non-Small-Cell Lung Cancer Clinicopathologic Features and Survival Outcomes in Asian Pacific Islanders Residing in the United States: A SEER Analysis

Background. The objective of our study was to ascertain racial/ethnic disparities in Asian/Pacific Islanders (API) for non-small-cell lung cancer (NSCLC) clinicopathologic features and survival outcomes based on various tumor characteristics and treatment modalities. Method. SEER database identified invasive NSCLC cases from 2004 to 2010. Variables included American Joint Committee on Cancer (AJCC) stage 7, tumor grade, tumor size, histology, age, marital status, radiation, surgery, and reason for no surgery. The Kruskall-Wallis test and the Z test were used to examine differences between races/ethnicities and the referent, non-Hispanic white (NHW). Multivariate Cox proportional analyses were used to establish the weight of the prognostic significance contributing to disease-specific survival (DSS) in each AJCC stage. Result. Improved DSS was seen in API across stage I (HR: 0.78), stage II (HR: 0.79), and stage IV (HR: 0.86), respectively, compared to the referent NHW (P < 0.01). Prognosis was improved by being married, being female gender, AIS histology, and birth outside the US (P < 0.01). Conclusion. We have demonstrated improved survival among API in early stage and stage IV NSCLC. Further research is necessary to clarify the role of lifestyle and tumor biology for these differences.

Cultural factors associated with racial disparities in lung cancer care

RATIONALE

Minority patients with lung cancer are less likely to receive stage-appropriate treatment. Along with access to care and provider-related factors, cultural factors such as patients' lung cancer beliefs, fatalism, and medical mistrust may help explain this disparity.

OBJECTIVES

To determine cultural factors associated with disparities in lung cancer treatment.

METHODS

Patients with newly diagnosed lung cancer were recruited from four medical centers in New York City from 2008 to 2011. Using validated tools, we surveyed participants about their beliefs regarding lung cancer, fatalism, and medical mistrust. We compared rates of stage-appropriate treatment among blacks, Hispanics, and nonminority patients. Multiple regression analyses and structural equation modeling were used to assess whether cultural factors are associated with and/or mediate disparities in care.

MEASUREMENTS AND MAIN RESULTS

Of the 352 patients with lung cancer in the study, 21% were black and 20% were Hispanic. Blacks were less likely to receive stage-appropriate treatment (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.27-0.93) compared with whites, even after adjusting for age, sex, marital status, insurance, income, comorbidities, and performance status. No differences in treatment rates were observed among Hispanics (OR, 1.05; 95% CI, 0.53-2.07). Structural equation modeling showed that cultural factors (negative surgical beliefs, fatalism, and medical mistrust) partially mediated the relationship between black race and lower rates of stage-appropriate treatment (total effect: -0.43, indirect effect: -0.13; 30% of total effect explained by cultural factors).

CONCLUSIONS

Negative surgical beliefs, fatalism, and mistrust are more prevalent among minorities and appear to explain almost one-third of the observed disparities in lung cancer treatment among black patients. Interventions targeting cultural factors may help reduce undertreatment of minorities.

Comparing teaching versus nonteaching hospitals: the association of patient characteristics with teaching intensity for three common medical conditions

PURPOSE

To quantify the role of teaching hospitals in direct patient care, the authors compared characteristics of patients served by hospitals of varying teaching intensity.

METHOD

The authors studied Medicare beneficiaries ≥ 66 years old, hospitalized in 2009-2010 for acute myocardial infarction, heart failure, or pneumonia. They categorized hospitals as nonteaching, teaching, or Council of Teaching Hospitals and Health Systems (COTH) members and performed secondary analyses using intern and resident-to-bed ratios. The authors used descriptive statistics, adjusted odds ratios, and linear propensity scores to compare patient characteristics among teaching intensity levels. They supplemented Medicare mortality model variables with race, transfer status, and distance traveled.

RESULTS

Adjusted for comorbidities, black patients had 2.44 (95% confidence interval [CI] 2.36-2.52), 2.56 (95% CI 2.51-2.60), and 2.58 (95% CI 2.51-2.65) times the odds of COTH hospital admission compared with white patients for acute myocardial infarction, heart failure, and pneumonia, respectively. For patients transferred from another hospital's inpatient setting, the corresponding adjusted odds ratios of COTH hospital admission were 3.99 (95% CI 3.85-4.13), 4.60 (95% CI 4.34-4.88), and 4.62 (95% CI 4.16-5.12). Using national data, distributions of propensity scores (probability of admission to a COTH hospital) varied markedly among teaching intensity levels. Data from Massachusetts and California illustrated between-state heterogeneity in COTH utilization.

CONCLUSIONS

Major teaching hospitals are significantly more likely to provide care for minorities and patients requiring transfer from other institutions for advanced care.Both are essential to an equitable and high-quality regional health care system.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Disparities in lung transplantation before and after introduction of the lung allocation score

BACKGROUND

In May 2005, the Lung Allocation Score (LAS) became the primary method for determining allocation of lungs for organ transplantation for those at least 12 years of age in the United States. During the pre-LAS period, black patients were more likely than white patients to become too sick or die while awaiting transplant. The association between gender and lung transplant outcomes has not been widely studied.

METHODS

Black and white patients aged ≥ 18 years registered on the United Network for Organ Sharing (UNOS) lung transplantation waiting list from January 1, 2000, to May 3, 2005 (pre-LAS, n = 8,765), and from May 4, 2005, to September 4, 2010 (LAS, n = 8,806), were included. Logistic regression analyses were based on smaller cohorts derived from patients listed in the first 2 years of each era (2,350 pre-LAS, and 2,446 LAS) to allow for follow-up time. Lung transplantation was the primary outcome measure. Multivariable analyses were performed within each interval to determine the odds that a patient would die or receive a lung transplant within 3 years of listing.

RESULTS

In the pre-LAS era, black patients were more likely than white patients to become too sick for transplantation or die within 3 years of waiting list registration (43.8% vs 30.8%; odds ratio [OR], 1.84; p < 0.001). Race was not associated with death or becoming too sick while listed for transplantation in the LAS era (14.0% vs 13.3%; OR, 0.93; p = 0.74). Black patients were less likely to undergo transplantation in the pre-LAS era (56.3% vs 69.2%; OR, 0.54; p < 0.001) but not in the LAS era (86.0% vs 86.7%; OR, 1.07; p = 0.74). Women were more likely than men to die or become too sick for transplantation within 3 years of listing in the LAS era (16.1% vs 11.3%; OR, 1.58; p < 0.001) compared with the pre-LAS era (33.4% vs 30.7%; OR, 1.19; p = 0.08).

CONCLUSION

Racial disparities in lung transplantation have decreased with the implementation of LAS as the method of organ allocation; however, gender disparities may have actually increased in the LAS era.

Effect of insurance status on the surgical treatment of early-stage non-small cell lung cancer

BACKGROUND

Social disparities permeate non-small cell lung cancer (NSCLC) treatment, yet little is known about the effect of insurance status on the delivery of guideline surgical treatment for early-stage (I or II) NSCLC.

METHODS

We used the California Cancer Registry (1996 through 2008) to identify patients 50 to 94 years old with early-stage NSCLC. We used logistic regression models to assess whether or not insurance status (private insurance, Medicare, Medicaid, no insurance, and unknown) had an effect on whether or not a lobectomy (or bilobectomy) is performed.

RESULTS

A total of 10,854 patients met our inclusion criteria. Compared with patients with private insurance, we found that patients with Medicare (adjusted odds ratio [aOR] 0.87; 95% confidence interval [CI]: 0.79 to 0.95), Medicaid (aOR 0.45; 95% CI: 0.36 to 0.57), or no insurance (aOR 0.45; 95% CI: 0.29 to 0.70) were significantly less likely to undergo lobectomy, even after adjusting for patient factors (age, race, and gender) and tumor characteristics (histology and tumor size). Increasing age, African American race, squamous cell carcinoma, and increasing tumor size were significant independent negative predictors of whether or not a lobectomy was performed.

CONCLUSIONS

Patients without private insurance were significantly less likely than patients with private insurance to undergo a lobectomy for early-stage NSCLC. The variables(s) contributing to this disparity have yet to be elucidated.

Racial and ethnic differences in beliefs about lung cancer care

BACKGROUND

Disparities in lung cancer treatment and palliative care are well documented. However,the mechanisms underlying these disparities are not fully understood. In this study, we evaluated racial and ethnic differences in beliefs and attitudes about lung cancer treatment and palliative care among patients receiving a new diagnosis of lung cancer.

METHODS

Patients were recruited from four medical centers in New York City and surveyed about their beliefs regarding lung cancer care, including disease-directed treatments, palliative and end-of-life care, and fatalistic and spiritual beliefs. We used univariate and multiple regression analyses to compare the distribution of beliefs among minority (black and Hispanic) and nonminority patients.

RESULTS

Of the 335 patients, 21% were black, 20% were Hispanic, and 59% were nonminority. Beliefs about chemotherapy and radiotherapy were similar across the three groups ( P > .05),whereas black patients were more likely to believe that surgery might cause lung cancer to spread( P =.008). Fatalistic beliefs potentially affecting cancer treatment were more common among both minority groups ( P ≤ .02). No signifi cant differences were found in attitudes toward clinician communication about cancer prognosis ( P > .05). However, both blacks and Hispanics were more likely to have misconceptions about advance directives and hospice care ( P ≤ .02).

CONCLUSIONS

Similarities and differences in beliefs about disease-directed treatment were observed between minority and nonminority patients with lung cancer. Minority patients hold more fatalistic views about the disease and misperceptions about advance care planning and hospice care. Further research is needed to assess the impact of these beliefs on decisions about lung cancer care and patient outcomes.

Beliefs and attitudes about lung cancer screening among smokers

The National Lung Screening Trial (NLST) recently reported that annual computed tomography (CT) screening is associated with decreased lung cancer mortality in high-risk smokers. Beliefs about lung cancer and screening, particularly across race and ethnicity, and their influence on CT screening utilization are largely unexamined. Our study recruited asymptomatic, high-risk smokers, 55-74 years of age from primary care clinics in an academic urban hospital. Guided by the self-regulation theory, we evaluated cognitive and affective beliefs about lung cancer. Intention to screen for lung cancer with a CT scan was assessed by self-report. We used univariate and logistic regression analyses to compare beliefs about screening and intention to screen among minority (Blacks and Hispanics) and non-minority participants. Overall, we enrolled 108 participants, of which 40% were Black and 34% were Hispanic; the mean age was 62.3 years, and median pack-years of smoking was 26. We found that intention to screen was similar among minorities and non-minorities (p=0.19); however, Hispanics were less likely to report intention to screen if they had to pay for the test (p=0.02). Fatalistic beliefs, fear of radiation exposure, and anxiety related to CT scans were significantly associated with decreased intention to screen (p<0.05). Several differences were observed in minority versus non-minority participants' beliefs toward lung cancer and screening. In conclusion, we found that concerns about cost, which were particularly prominent among Hispanics, as well as fatalism and radiation exposure fears may constitute barriers to lung cancer screening. Lung cancer screening programs should address these factors to ensure broad participation, particularly among minorities.

The influence of Hispanic ethnicity on nonsmall cell lung cancer histology and patient survival: an analysis of the Survival, Epidemiology, and End Results database

BACKGROUND

Most studies exploring ethnic/racial disparities in nonsmall cell lung cancer (NSCLC) compare black patients with whites. Currently, the effect of Hispanic ethnicity on the overall survival of NSCLC is poorly understood. Therefore, the authors carried out a large-scale, population-based analysis using the Surveillance, Epidemiology, and End Results (SEER) data base to determine the impact of Hispanic ethnicity the survival of patients with NSCLC.

METHODS

The authors identified 172,398 adult patients with pathologically confirmed NSCLC from the SEER data base who were diagnosed between 1988 and 2007. A multivariate Cox proportional hazards regression analysis was used to determine the impact of race/ethnicity on overall survival. Pair-wise comparisons were used to determine whether Hispanic ethnicity influenced NSCLC histology or stage at diagnosis.

RESULTS

Compared with non-Hispanic white patients, Hispanic white patients had a statistically significant better overall survival (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.83-0.87), and black patients had worse survival (HR, 1.091; 95% CI, 1.072-1.109). Within the bronchioalveolar carcinoma (BAC) subtype, Hispanic-white patients tend to be over represented (8.1% Hispanic whites vs 5.5% non-Hispanic whites vs 3.7% blacks; P < .001).

CONCLUSIONS

The current study demonstrated that Hispanic-white patients with NSCLC had a decreased risk for overall mortality compared with non-Hispanic whites and blacks. Moreover, Hispanic patients were over represented within the BAC histologic subtype. Thus, the overall survival advantage of Hispanic NSCLC patients may be because of their predilection toward developing certain histologic subtypes of NSCLC. Further studies are warranted to determine the etiologies of such predilections and may reveal certain genetic, environmental, and/or epigenetic factors associated with Hispanic ethnicity.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Disparities in lung cancer staging with positron emission tomography in the Cancer Care Outcomes Research and Surveillance (CanCORS) study

INTRODUCTION

Disparities in treatment exist for nonwhite and Hispanic patients with non-small cell lung cancer, but little is known about disparities in the use of staging tests or their underlying causes.

METHODS

Prospective, observational cohort study of 3638 patients with newly diagnosed non-small cell lung cancer from 4 large, geographically defined regions, 5 integrated health care systems, and 13 VA health care facilities.

RESULTS

Median age was 69 years, 62% were men, 26% were Hispanic or nonwhite, 68% graduated high school, 50% had private insurance, and 41% received care in the VA or another integrated health care system. After adjustment, positron emission tomography (PET) use was 13% lower among nonwhites and Hispanics than non-Hispanic whites (risk ratio [RR] 0.87, 95% confidence interval [CI] 0.77-0.97), 13% lower among those with Medicare than those with private insurance (RR 0.87, 95% CI 0.76-0.99), and 24% lower among those with an elementary school education than those with a graduate degree (RR 0.76, 95% CI 0.57-0.98). Disparate use of PET was not observed among patients who received care in an integrated health care setting, but the association between race/ethnicity and PET use was similar in magnitude across all other subgroups. Further analysis showed that income, education, insurance, and health care setting do not explain the association between race/ethnicity and PET use.

CONCLUSIONS

Hispanics and nonwhites with non-small cell lung cancer are less likely to receive PET imaging. This finding is consistent across subgroups and not explained by differences in income, education, or insurance coverage.

Disparities in lung cancer stage, treatment and survival among American Indians and Alaskan Natives

BACKGROUND

Disparities in lung cancer care and outcomes have been documented for blacks and Hispanics. Less is known about the care received by the American Indian and Alaskan Native population (AI/AN). We sought to evaluate lung cancer outcomes in this population and to asses if potential disparities in survival are explained by differences in stage of disease at diagnosis and type of treatment received.

METHODS

We identified patients with potentially resectable (stages I-IIIA) non-small cell lung cancer (NSCLC) from the Surveillance, Epidemiology and End Results registry between 1988 and 2006. Kaplan-Meier curves were used to compare survival of AI/AN patients to those of other racial groups. Cox regression analysis was used to identify potential mediators of the association between AI/AN origin and worse survival.

RESULTS

Five-year lung cancer survival was 47% for AI/AN, 56% for whites, 51% for blacks, 55% for Hispanics and 59% for individuals of other race (p<0.0001). AI/AN were more likely to be diagnosed with stage IIIA (p<0.0001) and less likely to undergo resection (p<0.0001) than whites. In multivariable regression analyses, controlling for patient characteristics and histology, AI/AN race was associated with worse survival than white patients. When stage, treatment and surgery were added to the model, AI/AN origin was no longer significantly associated with worse outcomes.

CONCLUSIONS

AI/AN with potentially resectable NSCLC have survival rates comparable to other minority groups and worse than whites. These survival differences are partly explained by advanced stage at diagnosis, and lower rates of treatment.

Patients rate physician communication about lung cancer

BACKGROUND

High-quality lung cancer care includes physician-patient communication about the disease and treatment, patient needs/preferences, and care goals. In this study, the authors evaluated communication with patients at all stages across multiple topics.

METHODS

A standardized questionnaire asked patients with lung cancer to rate (on 5-point, verbal descriptor scale) the extent of communication with physicians on symptoms, spiritual concerns, practical needs, proxy appointment, living will preparation, prognosis, care goals, potential complications of therapy, life support preferences, and hospice. Communication was defined as inadequate if the patient reported discussing ≥5 of 11 questionnaire topics "not at all" or "a little bit." Multivariate logistic regression was used to evaluate the factors associated with inadequate communication.

RESULTS

In total, 276 of 348 (79%) eligible patients were enrolled (mean age [±standard deviation], 65 ± 10 years; 55% white, 21% black, and 19% Hispanic; all disease stages). For most topics, the majority of respondents reported that physicians communicated "not at all" or "a little bit." Low ratings were frequent for discussion of emotional symptoms (56%; 95% confidence interval [CI], 49%-62%), practical needs (71%; 95% CI, 65%-76%), spiritual concerns (80%; 95% CI, 75%-85%), proxy appointment (63%; 95% CI, 57%-69%), living will preparation (90%; 95% CI, 85%-93%), life support preferences (80%; 95% CI, 75%-84%), and hospice (88%; 95% CI, 86%-94%). Communication was inadequate for patients of different ages, stages, and races, although Hispanics were less likely than non-Hispanic whites and blacks to report inadequate communication (odds ratio, 0.31; 95% CI, 0.15-0.65).

CONCLUSIONS

Across all stages, patients with lung cancer reported low rates of physician-patient communication on key topics, which may increase patient distress, impair decision-making, and compromise clinical outcomes and use patterns.

Effect of radiotherapy planning complexity on survival of elderly patients with unresected localized lung cancer

PURPOSE

To evaluate whether complex radiotherapy (RT) planning was associated with improved outcomes in a cohort of elderly patients with unresected Stage I-II non-small-cell lung cancer (NSCLC).

METHODS AND MATERIALS

Using the Surveillance, Epidemiology, and End Results registry linked to Medicare claims, we identified 1998 patients aged >65 years with histologically confirmed, unresected stage I-II NSCLC. Patients were classified into an intermediate or complex RT planning group using Medicare physician codes. To address potential selection bias, we used propensity score modeling. Survival of patients who received intermediate and complex simulation was compared using Cox regression models adjusting for propensity scores and in a stratified and matched analysis according to propensity scores.

RESULTS

Overall, 25% of patients received complex RT planning. Complex RT planning was associated with better overall (hazard ratio 0.84; 95% confidence interval, 0.75-0.95) and lung cancer-specific (hazard ratio 0.81; 95% confidence interval, 0.71-0.93) survival after controlling for propensity scores. Similarly, stratified and matched analyses showed better overall and lung cancer-specific survival of patients treated with complex RT planning.

CONCLUSIONS

The use of complex RT planning is associated with improved survival among elderly patients with unresected Stage I-II NSCLC. These findings should be validated in prospective randomized controlled trials.

Assessing environmental and occupational risk factors for lung cancer in Mexican-Americans

BACKGROUND

We investigated environmental and occupational exposures and smoking history (while controlling for demographics) in a population of Mexican-American lung cancer cases and controls from the Houston metropolitan area.

METHODS

Data were collected between 1991 and 2005 as part of an on-going multi-racial/ethnic, lung cancer case-control study. Cases included 212 Mexican-American lung cancer cases from UT MD Anderson Cancer Center. Controls (n = 328) were recruited from Houston's largest multispecialty group practice and frequency matched to the cases by age (± 5 years), sex, and ethnicity. Environmental and occupational factors were analyzed and odds ratios and 95% confidence intervals were calculated using logistic regression.

RESULTS

We detected elevated risks of lung cancer associated with pesticide exposure and found conventional and antimicrobial (e.g., sterilizers, disinfectants, antiseptics) pesticides were associated with an increased risk of lung cancer in Mexican-Americans (conventional pesticides and antimicrobial pesticides combined: OR = 1.80, 95% CI 1.13-2.86; conventional pesticides: OR = 2.05, 95% CI 1.23-2.39; antimicrobial pesticides: OR = 2.48, 95% CI 1.46-4.21).

CONCLUSIONS

Although we found over a two-fold increased risk of lung cancer among Mexican-Americans for pesticides, we could not identify individual pesticides. Our findings are an important preliminary step in identifying factors that are specifically associated with lung cancer risk among Mexican Americans.