Lung Cancer Experts Encourage Use of System-Based Interventions to Address Racial Disparities

Experts at the CHEST 2024 annual meeting in Boston, Massachusetts, highlighted significant racial and ethnic disparities in lung cancer and recommended using system-based interventions that leverage transparency, accountability, and enhanced communication to mitigate these differences.

During the session “Addressing Disparities in Lung Cancer Care,” Neelima Naluvuri, MD, assistant professor of medicine at the Duke University School of Medicine, began by stating that lung cancer screening rates are unacceptably low, with the average rate being 5.8% among eligible patients in 2022.

Even with this small percentage, racial disparities still exist among those who receive lung cancer screenings. In 2018, Naluvuri reported that lung cancer screening rates were significantly lower in Black patients than in non-Black patients despite the lung cancer risk among Black or Hispanic patients being equivalent to or greater than White patients with histories of tobacco use.

These differences in screening rates directly correlate to disparities in the rates of lung cancer incidence, morbidity, and survival among patients of color, as discussed by Francesca Duncan, MD, MS, assistant professor of medicine at the Indiana University School of Medicine.

She noted that Black males have the highest incidence rate of lung cancer, while American Indian and Alaskan Native females have the highest mortality rate. Also, Black patients are less likely to be diagnosed with early-stage disease and, therefore, have worse survival than White patients.

These statistics were further demonstrated by Duncan’s study, “Racial Disparities in Staging, Treatment, and Mortality in Non-Small Cell Lung Cancer (NSCLC).”¹ It found that a greater percentage of Black patients were diagnosed with lung cancer between the ages of 50 and 64; in comparison, White patients were more likely to be diagnosed at 65 or older. Also, a larger percentage of Black patients were diagnosed at an advanced disease stage than White patients.

Factors associated with advanced-stage diagnosis included being male, uninsured, and of Black race. Similarly, the study found worse overall survival rates among Black patients, male patients, uninsured patients, and single patients compared to their counterparts. Based on these findings, Duncan tasked attendees to ensure their organizations prioritize understanding and addressing lung cancer disparities.

“While I’m very happy to be here, my hope is that in 40 to 50 years we’re not sitting here in these same seats having the same conversation about lung cancer disparities,” she said.

Similar trends were reported by Stella Ogake, MD, FCCP, assistant professor of medicine at The Ohio State University College of Medicine, who presented on lung cancer treatment disparities.

She first highlighted that the standard of care for patients with early-stage NSCLC is anatomic lung resection with a multistation lymph node dissection. Post-resection survival can be over 85% at 5 years among patients with early-stage NSCLC. However, Ogake noted that patients of color are significantly less likely to undergo surgery, and, in some cases, they receive no treatment at all.

She highlighted a study that reported that Black patients were least likely to receive surgery, regardless of whether it was an integrated or non-integrated care setting.² Conversely, Asian and White patients were equally likely to receive surgery in either setting. In terms of care setting, another study found that Black patients were more likely to undergo surgery at an academic facility than a community facility (OR, 1.12; 95% CI, 1.01-1.24; P = .04).³ Consequently, Black patients treated at academic facilities had significantly higher overall survival.

Lastly, she highlighted a study that examined the level of adherence to predefined, stage-specific, guideline-concordant treatment among US patients with lung cancer of different age and racial groups.⁴ It determined that non-Hispanic Black patients were less likely to receive guideline-concordant treatment (OR, 0.82; 95% CI, 0.81-0.84); this association persisted after adjusting for covariates (adjusted odds ratio [aOR], 0.78; 95% CI, 0.76-0.08).

Ogake said that these treatment disparities are driven by SDOH factors, like care access, education level, and insurance status. Other factors impacting care disparities include guideline-concordant treatment differences, being treated at an academic institution vs a community institution, and implicit bias.

Consequently, Samuel Cykert, MD, professor of medicine at the University of North Carolina (UNC) at Chapel Hill School of Medicine, emphasized the need for system-level interventions with real-time transparency, accountability, and enhanced communication to mitigate these lung cancer disparities.

Therefore, he shared the example of the racial equity analysis and solution used by the Greensboro Health Disparities Collaborative (GHDC) through UNC’s Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) project; this helped to improve care for Black patients by reducing racial disparities.

Using electronic medical records (EMRs), Cykert explained that a warning system was created to alert providers when patients missed appointments or care milestones, especially patients of color. Also, regular audits identified care disparities, and ACCURE navigators helped patients overcome barriers like transportation, finances, and mistrust in the health care system.

He noted that the intervention’s impact was analyzed among patients with early-stage lung cancer in 5 cancer centers.⁵ At baseline, the crude treatment rates were 78% for White patients vs 69% for Black patients (P < .001); these were confirmed after adjusting for comorbidities (OR, 0.66; 95% CI, 0.51-0.85; P = .001).

After implementing their solution, the crude treatment rate was 96.5% for Black patients vs 95% for White patients (P = .56), which was confirmed in the adjusted analysis (OR, 2.1; 95% CI, 0.41-10.4; P = .39). Therefore, this method helped to mitigate disparities and improve care for all patients, not just one group. Because of these positive findings, Cykert encouraged other cancer centers to adopt similar interventions to help mitigate care disparities.

“If we work with affected communities to determine appropriate outcome measures, and if we apply the interventions in real time using transparency, accountability, and excellent communication, system-based interventions cause inequities to be mitigated and care is improved for everyone,” he concluded.

References

1. Duncan FC, Al Nasrallah N, Nephew L, et al. Racial disparities in staging, treatment, and mortality in non-small cell lung cancer. Transl Lung Cancer Res. 2024;13(1):76-94. doi:10.21037/tlcr-23-407
2. Check DK, Albers KB, Uppal KM, et al. 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. Lung Cancer. 2018;125:51-56. doi:10.1016/j.lungcan.2018.09.006
3. Merritt RE, Abdel-Rasoul M, D'Souza DM, Kneuetz PJ. Racial disparities in overall survival and surgical treatment for early stage lung cancer by facility type. Clin Lung Cancer. 2021;22(5):e691-e698. doi:10.1016/j.cllc.2021.01.007
4. Blom EF, Ten Haaf K, Arenberg DA, de Koning HJ. Disparities in receiving guideline-concordant treatment for lung cancer in the United States. Ann Am Thorac Soc. 2020;17(2):186-194. doi:10.1513/AnnalsATS.201901-094OC
5. Cykert S, Eng E, Walker P, et al. A system-based intervention to reduce Black-White disparities in the treatment of early stage lung cancer: A pragmatic trial at five cancer centers. Cancer Med. 2019;8(3):1095-1102. doi:10.1002/cam4.2005