Addressing Disparities in Uptake, Screening, and Research for Lung Cancer Care

In the management of lung cancer care, including screening, diagnosis, and treatment, there underlie significant disparities in access to care and quality of care when considering factors such as race, gender, and socioeconomic status.

Beginning a discussion at the CHEST Annual Meeting 2021 titled, “Disparities in the Management of Lung Cancer,” panelist Horiana Grosu, MD, associate professor, Department of Pulmonary Medicine, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, addressed some of the most important predictors of survival in lung cancer, particularly stage at diagnosis and how inequalities in care impact patient outcomes.

“Looking at the data, it seems that [inequality] in lung cancer survival is in 3 main categories,” said Grosu. “One is in the category of health itself. So, what does that mean? It means how far advanced was your lung cancer when you present. How bad is that emphysema? Are you currently smoking, and do you have comorbidities?"

She went on to also note the importance of care access and proper treatment, which may depend on geographic area; not having access lowers long-term survival, as does access to health insurance and financial resources.

Rural areas have several factors that increase the risk of lung cancer: populations of lower socioeconomic status, more cigarette smoking, and radon exposure. In rural counties, there is higher incidence of adolescent smoking at an earlier age and an estimated 20% increased incidence of lung cancer, as well as limited access to high-quality treatment.

In managing these increased risks, the US Preventive Services Task Force (USPSTF) recently revised its recommendations for lung cancer screening to lower the starting age of low-dose computed tomography (LDCT) eligibility to 50 instead of 55 and they decreased the number of smoking pack-years from 30 to 20 for eligible patients.

However, as residents of rural areas and those of lower socioeconomic status are more likely to be uninsured or covered by Medicaid—populations whose factors are associated with poorer outcomes in lung cancer survival compared with those with private insurance—changes in eligibility may not reach these at-risk populations whose benefits are determined by the state in which they reside.

In fact, findings of a recent study published in Clinical Lung Cancer indicated that patients with stage 3 non-small cell lung cancer who were uninsured or on governmental insurance were less likely to receive guideline concordant care (eg, radiation or chemotherapy followed by surgery) than those on private insurance, noted Grosu.

As over 50% of USPSTF-eligible patients are identified to be under Medicaid or underinsured, the gap in equitable care may further widen as these populations are not given access to appropriate treatment.

Delving further into the disparities present in lung cancer care, Nichole Tanner, MD, MS, FCCP, specialist in Lung and Thoracic Cancer at Medical University of South Carolina, noted the racial/ethnic differences in patient outcomes.

For Black individuals, who are more likely to develop lung cancer at a younger age, despite having smoked less than White men, screening and clinical trial inclusion has historically excluded these populations.

Nonetheless, findings of studies such as the National Lung Screening Trial showed that Black people, representing only 4.4% of the study cohort, were most likely to benefit from screening than all other racial groups overall in regards to reducing risk of lung cancer mortality (HR, 0.61 vs 0.86).

Discussing a different study in JAMA that included a diverse screening population with greater percentages of Black representation (69%), Tanner noted that findings represented markedly higher prevalence and detection of lung cancer for Black individuals in this study compared with the National Lung Screening Trial (2.6% vs 1.1%).

“Clearly, these data really indicate that patients that are Black have a higher benefit from lung screening and it's important to try to capture this population and include race in the calculations as we think about eligibility for lung screening,” said Tanner.

Ultimately, improved eligibility for screening and greater minority representation in clinical trials will prove futile if uptake among at-risk populations is not improved. In rural communities, Grosu mentioned that several stigmas, including greater beliefs of fatalism, nihilism, and hesitancy in seeking medical intervention, serve as distinct patient-level barriers.

With overall uptake of lung cancer screening across the United States currently standing at less than 10%, and even lower for those living in rural areas, overcoming long-standing barriers of mistrust in the health care system and issues regarding access to care could help to improve patient outcomes.

“While early detection with lung cancer screening has the potential to improve outcomes for lung cancer in general, disparities present in ineligibility and access to Centers of Excellence have the potential to worsen this divide,” said Tanner.

“Lower socioeconomic status with higher incidence of lung cancers–those folks that stand to benefit the most are not being screened….the change in eligibility criteria will lessen that divide but access, knowledge, and uptake is something that is lacking, and something that we really need to do to bring more folks in.”