In this Hope With Answers podcast, hear from doctors in the field and researchers on the front lines discuss the disparities in lung cancer clinical trials. Disparities in access to healthcare opportunities occur when there is an absence of health equity. These health differences are closely linked with social, economic, and/or environmental disadvantage.
Listen to these lung cancer experts address disparity in all aspects. This includes eligibility, referral programs, healthcare access, and appropriate follow-up for lung cancer screening. They propose strategies to address each of these areas so that we can bridge this disparity, equity and inclusion gap.
Missing Out on Treatments: Disparities in Lung Cancer Clinical Trials
Advances in lung cancer treatments over the last few years have made it possible to live with lung cancer for years after diagnosis. But minority and ethnic populations represent less than 5% of those getting the latest treatments in clinical trials.
Dr. Raymond Osarogiagbon of Baptist Cancer Center in Memphis, Tennessee
Vincent K. Lam, M.D., an Assistant Professor of Oncology at Johns Hopkins, is a clinical/translational investigator with a special interest in lung cancer and an LCFA Young Investigator grantee.
Dr. Triparna Sen, is an Assistant Attending, Department of Medicine, Memorial Sloan Kettering Cancer Center; Assistant Professor, Weil Cornell School of Medicine and an LCFA Young Investigator grantee
There are now very well-documented and significant disparities in lung cancer outcomes for communities of color. And that includes black African-American, Latino, Hispanic, and also native American communities.
“And if I had to define a healthcare disparity in lung cancer, I would say when two people who are at equal risk of having lung cancer, equal harm to benefit ratio from a treatment and equal stage of the disease, are not getting equal treatment.” – Dr. Triparna Sen
Disparities in Lung Cancer Screening
According to the American Thoracic Society Assembly on Thoracic Oncology, the existing lung cancer screening guidelines do not consider racial, ethnic, socioeconomic, and sex-based differences in smoking behaviors or lung cancer risk. Multiple barriers, including access to screening and cost, further contribute to the inequities in implementation and dissemination of lung cancer screening.
“So for example, lung cancer screening. It’s a big deal. We actually have an intervention that can try to catch these cancers early and thus potentially catch them at a stage where they’re curable. And we know that lung cancer screening uptake in minority populations is much lower than non-minority populations.” – Dr. Vincent Lam
A promising way to reduce disparities in lung cancer outcomes is to improve prevention and early detection.
The Effect of the Stigma of Lung Cancer Screening with Minorities
Lung cancer screening has been underused nationally, with recent evidence indicating that few eligible individuals who smoke are being screened and indicating marked variations in rates of Lung Cancer Screening based on race, income, and geographic location.
This is something Dr. Sen has seen is in terms of mindset. There’s often a preconceived notion in the populations from the minority communities. They have the sense of guilt that “I have smoked.” And hence, since they have a smoking history, they think that they are less eligible for either screening or treatment. And that is simply not true. But this is a notion or a stigma that Dr Sen has seen repeatedly come up in communities from these ethnic minority groups.
The NLST (National Lung Screening Trial) demonstrated that Lung Cancer Screening (LCS) with an annual low-dose computed tomography (LDCT) examination resulted in a 20% relative reduction in lung cancer mortality in high-risk individuals who smoke. NLST data show that African American individuals are more likely to benefit from LCS in terms of mortality reduction (hazard ratio, 0.61 in African American individuals vs. 0.86 in white individuals). In addition, the reduction in lung cancer mortality after LCS appears more favorable in women than in men.
How does the health care system contribute to disparities in healthcare?
Doctor Osarogiagbon lists the various levels of disparities in healthcare to question as:
- The patient level – How do biases affect how minorities search for treatment?
- The provider/physician level – What are doctors doing that contributes to the existence of avoidable differences between person and person?
- The healthcare system/institutions – What are these systems doing that allow disparities to happen?
- The social/government policies – Is there enough encouragement and dissemination of clinical trials access?
In working on solutions, there is a paradox that seems to appear. The more targets for interventions, the less effective your interventions will be.
“So for example, there are way more people at risk for disparities than there are providers who give care to them. There are way more providers than there are institutions within which the providers work. And, of course, there are fewer social policies that guide how institutions and providers work. So if we really want to intervene and make the disparities go away, what we have to recognize is that social policies are way more effective than nagging individual people, do this, or do that. Interventions that work at the organizational level are going to be more effective than interventions at the single provider level.” – Dr. Osarogiagbon
Decreasing Disparities in Lung Cancer Clinical Trials: Encouraging Minority Participation
“We are in about the most exciting age in lung cancer. It’s an age of rapid fire discovery. Every six months there is a new drug, just about. A new biomarker or a new drug. The best treatment is a clinical trial. What’s the purpose of research? I say, it’s the opportunity to give tomorrow’s treatment today. Especially when you’re in an age of rapid fire discovery.” – Dr. Osarogiagbon
However, in the US Food and Drug Administration 2018 drug trial snapshots, it showed that although black and African-Americans make up 13.4% of the US population, only 5% are trial participants. And for Hispanic and Latinos, who account for 18% of the US population, less than 1% are trial participants.
Minorities often don’t participate in trials due to logistical challenges, financial burdens and lingering distrust from past victimization in medical experiments. Organizational and systemic changes need to be made to find solutions to these problems. Making changes such as allowing remote consents for clinical trials and decentralizing clinical trial procedures and assessments are a hopeful change to correct the disparities in lung cancer clinical trial programs.
Equitable Access To High Quality Care and Ending Disparities in Lung Cancer Clinical Trials
Dr. Osarogiagbon emphasized that immunotherapy is a big game changer – it’s transforming all of oncology, not just lung cancer. Although clinical trials showed only about 1% of participating people were black, the large data sets are finding that black lung cancer patients actually derive a greater benefit from immunotherapy than other racial groups.
“There’s a lot more funding and grants now dedicated towards research in health disparity. And I think that’s a very important step in the right direction, because earlier, people used to not have so much research capital to be dedicated into analyzing these political sample data. Like the data indicating that black people are responding well to clinical trials.” – Dr. Triparna Sen
Patients have the power to make a difference in health disparities in lung cancer clinical trials by:
- educating themselves on the steps to take
- asking their doctors questions
- looking for information on websites like lcfamerica.org or social media oncogene groups.