From Pulmonology Advisor

This is part 1 of a 3-part series related to the American Lung Association’s 2020 State of Lung Cancer report.

Racial Disparities in Treatment and Survival in Lung Cancer: An Introduction

Racial disparities in treatment and survival between Black and White patients with lung cancer has long been shown through a sizable body of research. Numerous recent studies confirm those persistent gaps while providing additional insights and potential solutions.

In a study published in 2019 in the Journal of Thoracic and Cardiovascular Surgery, researchers examined data pertaining to 22,724 patients (93.4% White and 6.6% Black) who were diagnosed with primary stage I non-small cell lung cancer (NSCLC) between 1992 and 2009. Patient data was obtained from the Surveillance, Epidemiology, and End Results (SEER)-Medicare registry.¹

Using multivariate regression analyses and adjusting for demographic and clinical factors, the authors found that Black patients were less likely to receive any type of treatment compared to White patients (adjusted odds ratio [aOR], 0.62; 95% CI, 0.53-0.73; P <.0001).

Black patients who were treated were less likely to receive surgery only (aOR, 0.70; 95% CI, 0.61-0.79; P <.0001) and more likely to receive radiation therapy only (aOR, 1.47; 95% CI, 1.24-1.74; P <.0001) or chemotherapy only (aOR, 2.46; 95% CI, 1.74-3.49; P <.0001).

Black patients were also offered surgery less often than White patients (aOR, 0.75; 95% CI, 0.65-0.86), and those were offered surgery were more likely to refuse it compared to White patients (aOR, 1.98; 95% CI, 1.40-2.81). 

In general, lung cancer “diagnosis occurs at later stages in minorities, and treatment differs, with Black [patients] receiving less surgical treatment than White [patients],” according to coauthor Emanuela Taioli MD, PhD, director of the Institute for Translational Epidemiology, director of the Center for the Study of Thoracic Diseases Outcomes, and professor of Population Health Science and Policy as well as Thoracic Surgery at the Icahn School of Medicine at Mount Sinai in New York City.

“Our study adds that surgery for stage I lung cancer is significantly less frequent in Black [patients] than White [patients] despite being the gold standard, and mortality is consequentially higher in Black than White [patients],” Dr Taioli said. “However, when the stage-appropriate treatment — in this case, surgery — is performed, survival is the same between groups.”

Although the reasons driving these treatment disparities have not been fully elucidated, there “may be communication barriers or other factors such as insurance copayments that play a role,” Dr Taioli stated. “There are implicit biases in the communication of treatment plans with minority-group patients that need to be addressed by clinicians and surgeons.”

Several other recent studies similarly found lower surgery rates among Black vs White patients with NSCLC, including a 2020 study of 19,624 older adult patients with stage I to stage II disease.² As with the study by Taioli et al, data for this investigation were drawn from the SEER-Medicare registry. Based on hierarchical linear modeling, the results revealed that Black patients were less likely than White patients to undergo resection after consultation with a surgeon (aOR, 0.57; 95% CI, 0.47-0.69).²

Significant heterogeneity in rates was observed between surgeons (P <.001), and further analysis showed “variability beyond chance across surgeons in resection rates of Black vs White patients,” suggesting that physician-related factors contribute to the noted racial disparities. However, specialization in thoracic surgery was found to reduce this contribution.²

Recent Improvements in Racial Disparities in Treatment and Survival of Lung Cancer

In a study published in September 2020 in the Journal of Surgical Oncology, researchers investigated treatment trends among 174,338 patients (90.6% White and 9.4% Black) diagnosed with stage I NSCLC between 2004 and2015, based on records from the National Cancer Data Base.³ While no significant difference was observed in rates of stereotactic ablative radiotherapy (8.8% vs 9.2%; P =.066), Black patients were less likely to undergo surgery compared to White patients (60.3% vs 66.9%; P <.001) and more likely to receive external beam radiation therapy (12.4% vs 10.6%; P <.001) compared to White patients.³

The results also demonstrated an increase in surgery rates for both groups over the 2004 to2015 time period (from 44.4% to 61.8% among Black patients and from 57.6% to 65.6% among White patients). In a model adjusting for definitive treatment, Black patients showed improved survival during this time period (hazard ratio, 0.97; 95% CI, 0.94-0.99).³

“Improvements in the delivery of surgery and equal utilization of definitive radiation therapy are at least partially responsible for closing the survival gap between” Black and White patients with early-stage NSCLC, the study authors concluded.³

To learn more about racial disparities in lung cancer, we interviewed one of the study authors, Olugbenga T. Okusanya, MD, FACS, assistant professor in the Division of Thoracic Surgery at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Parts 2 and 3 of this series will feature interviews with additional experts in this area.

What is known about racial disparities in lung cancer between Black patients and White patients?

Dr Okusanya: It is currently known that lung cancer incidence between Black and White patients is essentially equal, though Black patients are more likely to be diagnosed at an advanced stage. For patients with early-stage disease, Black patients consistently have worse outcomes. This inequity has primarily been attributed to the lower use of surgery in Black patients. Surgery for early-stage lung cancer represents the best chance at a cure and is associated with the best overall survival for all treatment modalities. Radiation therapy is a second-line option and has become more popular as more effective radiation modalities, such as stereotactic ablative radiosurgery, have become more widely available.

What are believed to be the reasons for these racial disparities in treatment adn survival?

Dr Okusanya: The reasons for these disparities are several. There is a complicated interaction of medical mistrust, poor physician-patient relationships, socioeconomic factors, comorbidities, and potentially racism that account for these disparities.

What did your recent findings add to our understanding of this topic?

Our study showed that the gap in the utilization of surgery between Black and White patients has narrowed since 2004. We also showed that the utilization of radiation therapy has been equal between the 2 groups over time. These findings suggest that the overall improvement in outcomes for Black patients with early-stage lung cancer is likely due to improvements in surgical therapy utilization.³

What are the immediate implications for clinicians, and what long-term efforts are needed?

Dr Okusanya: The immediate implications are that all patients, and especially Black patients, should be evaluated and counseled in the most thorough way possible for surgical therapy. Studies have shown that interventions to shepherd patients through their lung cancer surgery evaluation can lead to improved surgery rates for all patients and narrow the gaps between Black and White patients.

Are there any further points you would like to mention about the topic?

We appreciate the opportunity to share our work. We believe that identifying and then eliminating health care inequities is a valuable mission worthy of the time and effort of health care and medical researchers.

References

1. Wolf A, Alpert N, Tran BV, Liu B, Flores R, Taioli E. Persistence of racial disparities in early-stage lung cancer treatment. J Thorac Cardiovasc Surg. 2019;157(4):1670-1679.e4. doi:10.1016/j.jtcvs.2018.11.108

2. Ezer N, Mhango G, Bagiella E, Goodman E, Flores R, Wisnivesky JP. Racial disparities in resection of early stage non-small cell lung cancer: variability among surgeons. Med Care. 2020;58(4):392-398. doi:10.1097/MLR.0000000000001280

3. Lutfi W, Martinez-Meehan D, Sultan I, et al. Racial disparities in local therapy for early stage non-small-cell lung cancer. J Surg Oncol. Published online September 14, 2020. doi:10.1002/jso.26206