Racial differences in the treatment of early-stage lung cancer

Cancer statistics for African Americans, 2013

In this article, the American Cancer Society estimates the number of new cancer cases and deaths for African Americans and compiles the most recent data on cancer incidence, mortality, survival, and screening prevalence based upon incidence data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data from the National Center for Health Statistics. It is estimated that 176,620 new cases of cancer and 64,880 deaths will occur among African Americans in 2013. From 2000 to 2009, the overall cancer death rate among males declined faster among African Americans than whites (2.4% vs 1.7% per year), but among females, the rate of decline was similar (1.5% vs 1.4% per year, respectively). The decrease in cancer death rates among African American males was the largest of any racial or ethnic group. The reduction in overall cancer death rates since 1990 in men and 1991 in women translates to the avoidance of nearly 200,000 deaths from cancer among African Americans. Five-year relative survival is lower for African Americans than whites for most cancers at each stage of diagnosis. The extent to which these disparities reflect unequal access to health care versus other factors remains an active area of research. Overall, progress in reducing cancer death rates has been made, although more can and should be done to accelerate this progress through ensuring equitable access to cancer prevention, early detection, and state-of-the-art treatments.

Developments in early-stage NSCLC: advances in radiotherapy

An increase in the number of predominantly elderly patients with early-stage non-small-cell lung cancer is anticipated in many Western populations. Patients often have major co-morbidities and are at increased risk for surgical morbidity and mortality. In the past decade, the use of stereotactic ablative radiotherapy (SABR) has achieved excellent results, with only mild toxicity in such vulnerable patient groups, leading to SABR becoming accepted as a standard of care for unfit patients in several countries. The planning and delivery of SABR has rapidly improved in recent years, particularly with the use of 'on-board' imaging at treatment units, and shortened treatment delivery times. Increasingly, more central tumors are being treated using lower doses per fraction (so-called risk-adapted schemes). It is also becoming clear that long-term follow-up should take place at specialist centers in order to distinguish the evolving fibrosis that is frequently observed from the relatively infrequent local recurrences. Given the high local control rates and limited toxicity, increasing attention is being paid to the use of SABR in the subgroup of so-called borderline operable patients, and clinical trials comparing surgery and SABR in these patients are ongoing.

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.

African American health disparities in lung cancer

Lung cancer is a leading cause of cancer-related deaths in the United States and globally. African Americans experience significant differences in lung cancer incidence and mortality. Smoking is the single greatest risk for lung cancer, making smoking cessation programs a potentially fruitful approach for reducing the risk of lung cancer. Despite clinical practice guidelines that prompt nurses to advise patients to quit smoking, only a small percentage of nurses do so. Minority patients are less likely than Whites to receive smoking cessation advice. This article discusses recent findings on the pathophysiology and risks for lung cancer. The literature on smoking cessation research is examined to determine the features of successful cessation interventions. Recommendations are offered for enhancing tobacco cessation efforts in nursing practice, education, and research.

Racial differences in antibiotic prescribing by primary care pediatricians

OBJECTIVE

To determine whether racial differences exist in antibiotic prescribing among children treated by the same clinician.

METHODS

Retrospective cohort study of 1,296,517 encounters by 208,015 children to 222 clinicians in 25 practices in 2009. Clinical, antibiotic prescribing, and demographic data were obtained from a shared electronic health record. We estimated within-clinician associations between patient race (black versus nonblack) and (1) antibiotic prescribing or (2) acute respiratory tract infection diagnosis after adjusting for potential patient-level confounders.

RESULTS

Black children were less likely to receive an antibiotic prescription from the same clinician per acute visit (23.5% vs 29.0%, odds ratio [OR] 0.75; 95% confidence interval [CI]: 0.72-0.77) or per population (0.43 vs 0.67 prescriptions/child/year, incidence rate ratio 0.64; 95% CI 0.63-0.66), despite adjustment for age, gender, comorbid conditions, insurance, and stratification by practice. Black children were also less likely to receive diagnoses that justified antibiotic treatment, including acute otitis media (8.7% vs 10.7%, OR 0.79; 95% CI 0.75-0.82), acute sinusitis (3.6% vs 4.4%, OR 0.79; 95% CI 0.73-0.86), and group A streptococcal pharyngitis (2.3% vs 3.7%, OR 0.60; 95% CI 0.55-0.66). When an antibiotic was prescribed, black children were less likely to receive broad-spectrum antibiotics at any visit (34.0% vs 36.9%, OR 0.88; 95% CI 0.82-0.93) and for acute otitis media (31.7% vs 37.8%, OR 0.75; 95% CI 0.68-0.83).

CONCLUSIONS

When treated by the same clinician, black children received fewer antibiotic prescriptions, fewer acute respiratory tract infection diagnoses, and a lower proportion of broad-spectrum antibiotic prescriptions than nonblack children. Reasons for these differences warrant further study.

Factors associated with referral to medical oncology and subsequent use of adjuvant chemotherapy for non-small-cell lung cancer: a population-based study

BACKGROUND

Adjuvant chemotherapy (act) for non-small-cell lung cancer (nsclc) is associated with improved survival in the general population, but may be underutilized. We explored the factors associated with referral to medical oncology and subsequent use of act among all patients with resected nsclc in Ontario, Canada.

METHODS

The Ontario Cancer Registry was used to identify all incident cases of nsclc diagnosed in Ontario during 2004-2006. We linked electronic records of treatment and of physician billing to identify surgery, act, and medical oncology consultation. A multivariate logistic regression model was used to evaluate factors associated with referral to medical oncology and subsequent use of act.

RESULTS

Among 3354 cases of nsclc resected in Ontario during 2004-2006, 1830 (55%) were seen postoperatively by medical oncology, and 1032 (31%) were treated with act. Patients more than 70 years of age were less likely than younger patients to have a consultation [odds ratio (or): 0.4; p < 0.001]. A higher proportion of cases with stage ii or iii nsclc than with stage i disease were referred (ors: 2.7, 2.0 respectively; p < 0.005). We observed substantial geographic variation in the proportion of surgical cases referred (range: 32%-88%) that was not explained by differences in case mix. Among cases referred to medical oncology, older patients (age 60-69 years, or: 0.4; age 70+ years, or: 0.1; p < 0.001) with greater comorbidity (Charlson comorbidity index: 3+; or: 0.5; p < 0.05) and a longer postoperative stay (median length of stay: 7+ days; or: 0.7; p = 0.001) were less likely to receive act. Use of act was greater in patients with stage ii or iii than with stage i disease (ors: 3.0, 2.7 respectively; p < 0.001); use also varied with geographic location (range: 46%-63%).

CONCLUSIONS

The initial decision to refer to medical oncology is associated with age and stage of disease, and those factors have an even greater effect on the decision to offer act. Comorbidity and postoperative length of stay were not associated with initial referral, but were associated with use of act in patients seen by medical oncology.

United states acculturation and cancer patients' end-of-life care

Background

Culture shapes how people understand illness and death, but few studies examine whether acculturation influences patients’ end-of-life treatment preferences and medical care.

Methods and Findings

In this multi-site, prospective, longitudinal cohort study of terminally-ill cancer patients and their caregivers (n = 171 dyads), trained interviewers administered the United States Acculturation Scale (USAS). The USAS is a 19-item scale developed to assess the degree of “Americanization” in first generation or non-US born caregivers of terminally-ill cancer patients. We evaluated the internal consistency, concurrent, criterion, and content validity of the USAS. We also examined whether caregivers’ USAS scores predicted patients’ communication, treatment preferences, and end-of-life medical care in multivariable models that corrected for significant confounding influences (e.g. education, country of origin, English proficiency). The USAS measure was internally consistent (Cronbach α = 0.98); and significantly associated with US birthplace (r = 0.66, P<0.0001). USAS scores were predictive of patients’ preferences for prognostic information (AOR = 1.31, 95% CI:1.00–1.72), but not comfort asking physicians’ questions about care (AOR 1.23, 95% CI:0.87–1.73). They predicted patients’ preferences for feeding tubes (AOR = 0.68, 95% CI:0.49–0.99) and wish to avoid dying in an intensive care unit (AOR = 1.36, 95% CI:1.05–1.76). Scores indicating greater acculturation were also associated with increased odds of patient participation in clinical trials (AOR = 2.20, 95% CI:1.28–3.78), compared with lower USAS scores, and greater odds of patients receiving chemotherapy (AOR = 1.59, 95% CI:1.20–2.12).

Conclusion

The USAS is a reliable and valid measure of “Americanization” associated with advanced cancer patients’ end-of-life preferences and care. USAS scores indicating greater caregiver acculturation were associated with increased odds of patient participation in cancer treatment (chemotherapy, clinical trials) compared with lower scores. Future studies should examine the effects of acculturation on end-of-life care to identify patient and provider factors that explain these effects and targets for future interventions to improve care (e.g., by designing more culturally-competent health education materials).

Short- and long-term risk of colorectal adenoma recurrence among whites and blacks

BACKGROUND

It is unclear whether the higher burden from colorectal cancer among blacks is due to an increased biological susceptibility.

OBJECTIVE

To determine whether non-Hispanic blacks (blacks) have a higher risk of adenoma recurrence than non-Hispanic whites (whites) after removal of colorectal adenoma.

DESIGN

Secondary analysis of the Polyp Prevention Trial (PPT) data.

SETTING

United States.

PATIENTS

Patients were 1668 self-identified whites and 153 blacks who completed the 4-year trial. Of these, 688 whites and 55 blacks enrolled in a posttrial, passive Polyp Prevention Trial Continued Follow-up Study (PPT-CFS) and underwent another colonoscopy.

MAIN OUTCOME MEASUREMENTS

Recurrence and location of the adenoma and advanced adenoma by race-ethnicity during PPT and cumulative recurrence over a mean follow-up of 8.3 years (range, 4.9-12.4 years) among PPT-CFS enrollees.

RESULTS

Blacks had similar risk of recurrence of adenoma (39.2% vs 39.4%; incidence risk ratio [RR] = .98; 95% CI, .80-1.20) and advanced adenoma (8.5% vs 6.4%; RR = 1.18; 95% CI, .68-2.05) as whites at the end of PPT. Recurrence risk did not differ by colon subsite. Among PPT-CFS enrollees, the cumulative recurrence rate over a maximal follow-up period of 12 years was similar for blacks and whites for adenoma (67.3% vs 67.0%; RR = 1.01; 95% CI, .84-1.21) and advanced adenoma (14.5% vs 16.9%; RR = 1.03; 95% CI, .60-1.79).

LIMITATION

There were few blacks in the long-term follow-up study.

CONCLUSIONS

Adenoma and advanced adenoma recurrence did not differ by race. Our study does not support more frequent surveillance colonoscopies for blacks with a personal history of adenoma as an intervention to reduce colorectal cancer disparity.

Variations in use of PET among Medicare beneficiaries with non-small cell lung cancer, 1998-2007

PURPOSE

To explore demographic and regional factors associated with the use of positron emission tomography (PET) in patients with non-small cell lung cancer (NSCLC) and to determine whether their associations with PET use has changed over time.

MATERIALS AND METHODS

The Office of Human Research Ethics at the University of North Carolina and the institutional review board of the Duke University Health System approved (with waiver of informed consent) this retrospective analysis of Surveillance Epidemiology and End Results Medicare data for Medicare beneficiaries given a diagnosis of NSCLC between 1998 and 2007. The primary outcome was change in the number of PET examinations 2 months before to 4 months after diagnosis, examined according to year and sociodemographic subgroup. PET use was compared between demographic and geographic subgroups and between early (1998-2000) and late (2005-2007) cohorts by using χ(2) tests. Factors associated with use of PET during the study period were further examined by using logit and linear probability multivariable regression analyses.

RESULTS

The final cohort included 46 544 patients with 46 935 cases of NSCLC. By 2005, more than half of patients underwent one or more PET examinations, regardless of demographic subgroup. In multivariable logistic regression analysis, patients who underwent PET were more likely to be married, nonblack, and younger than 80 years and to live in census tracts with higher education levels or in the Northeast (P < .001 for all). Living within 40 miles of a PET facility was initially associated with undergoing PET (P < .001), but this association disappeared by 2007. Imaging rates increased more rapidly in patients who were nonblack (P ≤ .01), patients who were younger than 81 years (P < .001), and patients who lived in the Northeast and South (P < .001).

CONCLUSION

PET imaging among Medicare beneficiaries with NSCLC was initially concentrated among nonblack patients younger than 81 years. Despite widespread adoption among all subgroups, differences within demographic subgroups remained.

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.

Differences in treatments and outcomes for idiopathic scoliosis patients treated in the United States from 1998 to 2007: impact of socioeconomic variables and ethnicity

BACKGROUND CONTEXT

Scoliosis is a significant cause of disability and health-care resource utilization in the United States.

PURPOSE

Our aim was to evaluate potential disparities in the selection of treatments and outcomes for idiopathic scoliosis patients on a national level. To date, only one study has examined inpatient complications, discharge disposition, and mortality with respect to scoliosis treatment on a national scale.

STUDY DESIGN/SETTING

Retrospective review of cases having a primary diagnosis of idiopathic scoliosis using the nationwide inpatient sample (NIS) administrative data from 1998 to 2007.

PATIENT SAMPLE

The NIS data were queried to identify patients with a primary diagnosis of idiopathic scoliosis (International Classification of Diseases, Ninth Revision [ICD-9] diagnosis code: 737.30) admitted routinely. Surgically treated patients were identified as those patients who underwent a spinal fusion (ICD-9-Clinical Modification code: 81.08) as a principal procedure.

OUTCOME MEASURES

Rates of surgical versus nonsurgical treatments were measured as were inhospital complications and mortality rates.

METHODS

No external funding was received for this work. Univariate and multivariate analyses evaluated race, sex, socioeconomic factors, and hospital characteristics as predictors of surgical versus nonsurgical treatments, as well as inhospital complications and mortality rates.

RESULTS

The study analyzed 9,077 surgically and 1,098 nonsurgically treated patients with idiopathic scoliosis. Univariate analysis showed both patient- and hospital-level variables as strongly associated with surgical versus nonsurgical treatments and outcomes. Multivariate analysis revealed that Caucasians and private insurance patients were more likely to undergo surgical treatment (p<.05) even when controlling for comorbidities. Additionally, Caucasians had a reduced risk of nonroutine discharge compared with non-Caucasians (p=.03). Large hospitals had higher surgery rates (p=.08) than small- or medium-sized facilities and a lower risk of mortality (p=.04). Caucasians (65.1%) were more commonly admitted to large teaching hospitals than African American (59.8%) or Hispanic (41.8%) patients.

CONCLUSIONS

Differences were found in the selection of surgical versus nonsurgical treatments, as well as inhospital morbidity for hospitalized idiopathic scoliosis patients based on ethnic and socioeconomic variables. This may in part be because of differences in access to the resources of large teaching hospitals for different ethnic and socioeconomic groups or variability in severity of scoliosis among these groups that was not captured in this database.

Disparities in the treatment and outcomes of lung cancer among HIV-infected individuals

OBJECTIVES

HIV-infected people have elevated risk for lung cancer and higher mortality following cancer diagnosis than HIV-uninfected individuals. It is unclear whether HIV-infected individuals with lung cancer receive similar cancer treatment as HIV-uninfected individuals.

DESIGN/METHODS

We studied adults more than 18 years of age with lung cancer reported to the Texas Cancer Registry (N = 156 930) from 1995 to 2009. HIV status was determined by linkage with the Texas enhanced HIV/AIDS Reporting System. For nonsmall cell lung cancer (NSCLC) cases, we identified predictors of cancer treatment using logistic regression. We used Cox regression to evaluate effects of HIV and cancer treatment on mortality.

RESULTS

Compared with HIV-uninfected lung cancer patients (N = 156 593), HIV-infected lung cancer patients (N = 337) were more frequently young, non-Hispanic black, men, and with distant stage disease. HIV-infected NSCLC patients less frequently received cancer treatment than HIV-uninfected patients [60.3 vs. 77.5%; odds ratio 0.39, 95% confidence interval (CI) 0.30-0.52, after adjustment for diagnosis year, age, sex, race, stage, and histologic subtype]. HIV infection was associated with higher lung cancer-specific mortality (hazard ratio 1.34, 95% CI 1.15-1.56, adjusted for demographics and tumor characteristics). Inclusion of cancer treatment in adjusted models slightly attenuated the effect of HIV on lung cancer-specific mortality (hazard ratio 1.25; 95% CI 1.06-1.47). Also, there was a suggestion that HIV was more strongly associated with mortality among untreated than among treated patients (adjusted hazard ratio 1.32 vs. 1.16, P-interaction = 0.34).

CONCLUSION

HIV-infected NSCLC patients were less frequently treated for lung cancer than HIV-uninfected patients, which may have affected survival.

Socioeconomic inequalities in lung cancer treatment: systematic review and meta-analysis

BACKGROUND

Intervention-generated inequalities are unintended variations in outcome that result from the organisation and delivery of health interventions. Socioeconomic inequalities in treatment may occur for some common cancers. Although the incidence and outcome of lung cancer varies with socioeconomic position (SEP), it is not known whether socioeconomic inequalities in treatment occur and how these might affect mortality. We conducted a systematic review and meta-analysis of existing research on socioeconomic inequalities in receipt of treatment for lung cancer.

METHODS AND FINDINGS

MEDLINE, EMBASE, and Scopus were searched up to September 2012 for cohort studies of participants with a primary diagnosis of lung cancer (ICD10 C33 or C34), where the outcome was receipt of treatment (rates or odds of receiving treatment) and where the outcome was reported by a measure of SEP. Forty-six papers met the inclusion criteria, and 23 of these papers were included in meta-analysis. Socioeconomic inequalities in receipt of lung cancer treatment were observed. Lower SEP was associated with a reduced likelihood of receiving any treatment (odds ratio [OR] = 0.79 [95% CI 0.73 to 0.86], p<0.001), surgery (OR = 0.68 [CI 0.63 to 0.75], p<0.001) and chemotherapy (OR = 0.82 [95% CI 0.72 to 0.93], p = 0.003), but not radiotherapy (OR = 0.99 [95% CI 0.86 to 1.14], p = 0.89), for lung cancer. The association remained when stage was taken into account for receipt of surgery, and was found in both universal and non-universal health care systems.

CONCLUSIONS

Patients with lung cancer living in more socioeconomically deprived circumstances are less likely to receive any type of treatment, surgery, and chemotherapy. These inequalities cannot be accounted for by socioeconomic differences in stage at presentation or by differences in health care system. Further investigation is required to determine the patient, tumour, clinician, and system factors that may contribute to socioeconomic inequalities in receipt of lung cancer treatment.

Influence of comorbidity on racial differences in receipt of surgery among US veterans with early-stage non-small-cell lung cancer

PURPOSE

It is unclear why racial differences exist in the frequency of surgery for lung cancer treatment. Comorbidity is an important consideration in selection of patients for lung cancer treatment, including surgery. To assess whether comorbidity contributes to the observed racial differences, we evaluated racial differences in the prevalence of comorbidity and their impact on receipt of surgery.

PATIENTS AND METHODS

A total of 1,314 patients (1,135 white, 179 black) in the Veterans Health Administration diagnosed with early-stage non-small-cell lung cancer in 2007 were included. The effect of comorbidity on surgery was determined by using generalized linear models with a logit link accounting for patient clustering within Veterans Administration Medical Centers.

RESULTS

Compared with whites, blacks had greater prevalence of hypertension, liver disease, renal disease, illicit drug abuse, and poor performance status, but lower prevalence of respiratory disease. The impact of most individual comorbidities on receipt of surgery was similar between blacks and whites, and comorbidity did not influence the race-surgery association in a multivariable analysis. The proportion of blacks not receiving surgery as well as refusing surgery was greater than that among whites.

CONCLUSION

Blacks had a greater prevalence of several comorbid conditions and poor performance status; however, the overall comorbidity score did not differ by race. In general, the effect of comorbidity on receipt of surgery was similar in blacks and whites. Racial differences in comorbidity do not fully explain why blacks undergo lung cancer surgery less often than whites.

Racial disparities in esophageal cancer outcomes

BACKGROUND

Racial disparities in outcomes have been documented among patients with esophageal cancer. The purpose of this study is to identify mechanisms for ethnicity/race-related differences in the use of cancer-directed surgery and mortality.

METHODS

Data from the Surveillance, Epidemiology and End Results (SEER) program were used to evaluate non-Hispanic black, non-Hispanic white and Hispanic patients diagnosed with non-metastatic esophageal cancer (squamous cell carcinoma or adenocarcinoma) from 2003-2008. Age, marital status, stage, histology and location were examined as predictors of receipt of surgery and mortality in multivariate analyses.

RESULTS

A total of 6,737 patient files (84 % white, 10 % black, 6 % Hispanic) were analyzed. Black and Hispanic patients were more likely than whites to have squamous cell carcinoma (86 vs. 41 vs. 26 %, respectively; p < 0.001) and lesions in the midesophagus (58 vs. 38 vs. 26 %, respectively; p < 0.001). Blacks and Hispanics were less likely to undergo esophagectomy (adjusted odds ratio 0.48, 95 % confidence interval (CI) 0.39-0.60 and 0.71, 95 % CI 0.56-0.90]. We noted significant variations in esophagectomy rates among patients with midesophageal cancers; 15 % of blacks underwent esophagectomy compared to 22 % of Hispanics and 29 % of whites (p < 0.001). Black and Hispanic patients had a higher unadjusted risk of mortality (hazard ratio 1.38, 95 % CI 1.25-1.52 and 1.20, 95 % CI 1.05-1.37). However, differences in mortality were no longer significant after adjusting for receipt of surgery.

CONCLUSIONS

Disparities in esophageal cancer outcomes are associated with the lower use of cancer-directed surgery. To decrease disparities in mortality it will be necessary to understand and target underlying causes of lower surgery rates in nonwhite patients and develop interventions, especially for midesophageal cancers.

Racial disparities in surgical resection and survival among elderly patients with poor prognosis cancer

BACKGROUND

Reports indicate that black patients have lower survival after the diagnosis of a poor prognosis cancer, compared with white patients. We explored the extent to which this disparity is attributable to the underuse of surgery.

STUDY DESIGN

Using the Surveillance, Epidemiology, and End Results program and Medicare database, we identified 57,364 patients, ages 65 years and older, with a new diagnosis of nonmetastatic liver, lung, pancreatic, and esophageal cancer, from 2000 to 2005. We evaluated racial differences in resection rates after adjustment for patient, tumor, and hospital characteristics using hierarchical logistic regression. Cox proportional hazards regression was used to assess racial differences in survival after adjusting for patient, tumor, and hospital characteristics, and receipt of surgery.

RESULTS

Compared with white patients, black patients were less likely to undergo surgery for liver (adjusted odds ratio [aOR] = 0.49; 95% CI, 0.29-0.83), lung (aOR = 0.62; 95% CI, 0.56-0.69), pancreas (aOR = 0.53; 95% CI, 0.41-0.70), and esophagus cancers (aOR = 0.64; 95% CI, 0.42-0.99). Hospitals varied in their surgery rates among patients with potentially resectable disease. However, resection rates were consistently lower for black patients, regardless of the resection rate of the treating hospital. Although there were no racial differences in overall survival with liver and esophageal cancer, black patients experienced poorer survival for lung (adjusted hazard ratio = 1.05; 95% CI, 1.00-1.10) and pancreas cancer (adjusted hazard ratio = 1.15; 95% CI, 1.03-1.30). In both instances, there were no residual racial disparities in overall survival after adjusting for use of surgery.

CONCLUSIONS

Black patients are less likely to undergo surgery after diagnosis of a poor prognosis cancer. Our findings suggest that surgery is an important predictor of overall mortality, and that efforts to reduce racial disparities will require stakeholders to gain a better understanding of why elderly black patients are less likely to get to the operating room.

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.

Circles of care: development and initial evaluation of a peer support model for African Americans with advanced cancer

Peer support interventions extend care and health information to underserved populations yet rarely address serious illness. Investigators from a well-defined academic-community partnership developed and evaluated a peer support intervention for African Americans facing advanced cancer. Evaluation methods used the Reach, Efficacy, Adoption, Implementation, Maintenance (RE-AIM) framework. Investigators initially recruited and trained 24 lay health advisors who shared information or support with 210 individuals. However, lay advisors reported barriers of medical privacy and lack of confidence working alone with people with cancer. Training was modified to match the support team model for peer support; training reached 193 volunteers, 104 of whom formed support teams for 47 persons with serious illness. Support teams were adopted by 23 community organizations, including 11 African American churches. Volunteers in teams felt prepared to implement many aspects of supportive care such as practical support (32%) or help with cancer or palliative care resources (43%). People with serious illness requested help with practical, emotional, spiritual, and quality of life needs; however, they rarely wanted advocacy (3%) or cancer or palliative care resources (5%) from support teams. Volunteers had difficulty limiting outreach to people with advanced cancer due to medical privacy concerns and awareness that others could benefit. Support teams are a promising model of peer support for African Americans facing advanced cancer and serious illness, with reach, adoption, and implementation superior to the lay advisor model. This formative initial evaluation provides evidence for feasibility and acceptance. Further research should examine the efficacy and potential for maintenance of this intervention.

Comparative effectiveness research in oncology methodology: observational data

The goal of comparative effectiveness research is to inform clinical decisions between alternate treatment strategies using data that reflect real patient populations and real-world clinical scenarios for the purpose of improving patient outcomes. Observational studies using population-based registry data are increasingly relied on to fill the information gaps created by lack of evidence from randomized controlled trials. Administrative data sets have many advantages, including large sample sizes, long-term follow-up, and inclusion of data on physician and systems characteristics as well as cost. In this review, we describe the characteristics of many of the commonly used population-based data sets and discuss the elements included within these data sets. An overview of common research themes that rely on population-based data and illustrative examples are presented. Finally, an overview of the analytic techniques commonly employed by health services researchers to limit the effects of selection bias and confounding is discussed. The analysis of well-designed studies of comparative effectiveness is complex. However, careful framing, appropriate study design, and application of sophisticated analytic techniques can improve the accuracy of nonrandomized studies. There are multiple areas where the unique characteristics of observational studies can inform medical decision making and health policy, and it is critical to appreciate the opportunities, strengths, and limitations of observational research.

Do patient expectations about arthroplasty at initial presentation for hip or knee pain differ by sex and ethnicity?

BACKGROUND

Many studies show gender and ethnic differences in healthcare utilization and outcomes. Patients' presurgical cognitions regarding surgical outcomes also may vary by gender and ethnicity and play a role in explaining utilization and outcome differences. However, it is unclear whether and to what extent gender and ethnicity play a role in patients' presurgical cognitions.

QUESTIONS/PURPOSES

Do gender and ethnicity influence outcome expectations? Is arthroplasty-related knowledge affected by gender and ethnicity? Do gender and ethnicity influence willingness to pay for surgery?

METHODS

In a prospective, multicenter study we gave 765 patients an anonymous questionnaire on expectations, arthroplasty knowledge, and preferences before their consultation for hip and/or knee pain, from March 2005 to July 2007.

RESULTS

Six hundred seventy-two of the 765 patients (88%) completed questionnaires. Non-Hispanics and men were more likely to indicate they would be able to engage in more activities. Non-Hispanics and men had greater arthroplasty knowledge. Hispanics and women were more likely to report they would not pay for a total joint arthroplasty (TJA) relative to non-Hispanics and men.

CONCLUSIONS

Sex and ethnic differences in patients presenting for their initial visit to the orthopaedists for hip or knee pain influence expectations, knowledge, and preferences concerning TJAs. Longitudinal study of relationships between patients' perceptions and utilization or outcomes regarding TJA is warranted.

Impact of payment reform on chemotherapy at the end of life

PURPOSE

To assess the impact of 2005 and 2006 reductions in chemotherapy reimbursement, mandated in the Medicare Modernization Act, on patterns of chemotherapy receipt in the last 14 days of life.

PATIENTS AND METHODS

Included in the study were Medicare beneficiaries dying with poor-prognosis cancer from 2003 to 2007. We compared pre- and postreform probability and frequency of chemotherapy receipt in the last 14 days of life, a validated quality measure, using linear models. We assessed changes in chemotherapy use in physician offices (where prescribing is often directly linked to physician income) and hospital outpatient departments (where the link is indirect and likely weaker).

RESULTS

Among patients receiving chemotherapy in the 6 months before death in physicians' offices before the policy implementation (2003 to 2004), 18% received chemotherapy in the last 14 days of life. Those dying after implementation (2006 to 2007) were 3.5 percentage points (95% CI, -5.4 to -1.6; P < .001), or 20%, less likely to receive chemotherapy in the 14 days before death than those dying before implementation. By contrast, there was no significant change in the percentage of patients receiving chemotherapy in the last 14 days of life in hospital outpatient departments between 2003 and 2004 and 2006 to 2007.

CONCLUSION

In physician offices, where drugs generate the majority of revenue and prescribing patterns can determine physician income, use of chemotherapy at the end of life fell significantly after reimbursement reductions; no concurrent change occurred in hospital outpatient departments. These results suggest that payment reform may be used to better align appropriate financial incentives with better quality of care.

Lung cancer survival among black and white patients in an equal access health system

BACKGROUND

Racial disparities in lung cancer outcomes have been observed in the general population. However, it is unclear whether survival differences persist when patients have equal access to health care. Our objective was to determine if lung cancer survival differed among black and white patients in the U.S. Military Health System (MHS), an equal access health care system.

METHODS

The study subjects were 10,181 black and white patients identified through the Department of Defense's Automated Central Tumor Registry, who were 20 years old or more and diagnosed with lung cancer between 1990 and 2003. Racial differences in all-cause survival were examined using the Kaplan-Meier method and Cox proportional hazards regression models stratified by histology. For comparison, survival rates in the general population were calculated using Surveillance Epidemiology and End Results-9 data.

RESULTS

Analyses included 9,154 white and 1,027 black patients: 1,834 small cell lung cancers, 3,876 adenocarcinomas, 2,741 squamous cell carcinomas, and 1,730 large cell carcinomas. Although more favorable crude survival was observed among black patients than white patients with small cell lung cancer (P = 0.04), survival was similar between the two groups after covariate adjustment. Racial differences in survival were nonsignificant for adenocarcinomas, squamous cell carcinomas, and large cell carcinomas. Survival rates appeared to be better in the MHS than in the general population.

CONCLUSIONS AND IMPACT

All-cause survival was similar among black and white lung cancer patients in the MHS. Providing equal access to health care may eliminate racial disparities in lung cancer survival while improving the outcome of all cases.

Characteristics associated with the use of nonanatomic resections among Medicare patients undergoing resections of early-stage lung cancer

BACKGROUND

Racial disparities in access to surgical resection for treatment of early-stage non-small-cell lung cancer (NSCLC) are well documented. However it is unclear how race, clinical, and hospital characteristics affect the surgical approach among patients undergoing resection.

METHODS

Using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)/Medicare linked database, we identified patients 67 years of age or older diagnosed with stage I NSCLC who underwent surgical resection from 2000 to 2007. Surgical approach was categorized as lobectomy or segmentectomy (anatomic) versus wedge resection (nonanatomic). We used logistic regression to identify the association between demographic, clinical, and hospital factors and the use of nonanatomic resections.

RESULTS

There were 8,986 patients in the sample (mean age, 75 years; 53% women); 12.8% underwent nonanatomic resection. The use of nonanatomic resection increased significantly, from 11.0% in 2000 to 15.9% in 2007 (p=0.008). In multivariable analysis, race was not associated with the receipt of nonanatomic resection. Factors associated with the use of nonanatomic resections included age greater than 80 years (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.15-1.98), T1a primary tumor status, chronic obstructive pulmonary disease (COPD) (OR, 1.81; 95% CI, 1.55-2.12), and volume of hospital lung resections performed (highest versus lowest hospital volume, OR, 1.58; 95% CI, 1.23-2.04). More nonanatomic resections were performed in 2007 than in 2000 (OR, 1.73; 95% CI, 1.27-2.37). After stratifying by tumor size, the temporal trend in the use of nonanatomic resection remained significant only among patients with tumors greater than 3 cm.

CONCLUSIONS

Since 2000, the use of nonanatomic resections in stage I NSCLC has increased, most significantly among patients with larger tumors. After adjusting for clinical factors, there was no relation between race and type of surgical resection.

Racial disparities in medical expenditures within body weight categories

BACKGROUND

Despite federal guidelines calling for the reduction of obesity and elimination of health disparities, black-white differences in obesity prevalence and in medical expenditures and utilization of health care services persist.

OBJECTIVES

To examine black-white differences in medical expenditures and utilization of health care services (office-based visits, hospital outpatient visits, ER visits, inpatient stays and prescription medication) within body weight categories.

STUDY DESIGN

This study used data from the 2006 Medical Expenditures Panel Survey (MEPS) and included 15,164 non-Hispanic white and non-Hispanic black adults. We used a standard two-part econometric model to examine black-white differences in how expenditures (total annual medical expenditures and expenditures for each type of service) vary within body weight categories.

KEY RESULTS

Blacks in each weight category were less likely to use any medical care than their white counterparts, even after controlling for socio-demographic characteristics, perceived health status, health conditions and health beliefs. Among those who received medical care, there is no significant difference in the total amount spent on care between blacks and whites. Compared to whites, blacks in each body weight category were significantly less likely to use office-based visits, hospital outpatient visits, and medications. Among those who used medications, blacks had significantly lower expenditures than whites. Blacks in obese class II/III were significantly less likely to have any medical expenditures on inpatient care than their white counterparts.

CONCLUSIONS

Black-white racial differences in total medical expenditures were observed in each body weight category and were significantly different in the obese I class, overweight, and healthy weight categories. Obese blacks also spent a smaller amount than obese whites--the insignificance might be due to the smaller sample size. These differences cannot be fully explained by socio-demographics, health conditions, or health beliefs. Black-white differences in medical expenditures may be largely due to relatively inexpensive types of care (office-based visits, outpatient care, medication) rather than more costly ones (inpatient care, ER).

Racial differences and disparities in cancer care and outcomes: where's the rub?

Despite a profusion of studies over the past several years documenting racial differences in cancer outcomes, there is a paucity of data as to the root causes underlying these observations. This article reviews work to date focusing on black-white differences in cancer outcomes, explores potential mechanisms underlying these differences, and identifies patient, physician, and health care system factors that may account for persistent racial disparities in cancer care. Research strategies to elucidate the relative influence of these various factors and policy recommendations to reduce persistent disparities are also discussed.

Patient factors, health care factors and survival from lung cancer according to ethnic group in the south of London, UK

International and UK data suggest that there are ethnic differences in survival for some malignancies. The aim of the present study was to identify any health inequalities related to lung cancer and ethnicity. Data on 423 patients with a diagnosis of lung cancer treated at a large specialist cancer hospital in London UK were analysed. Data on stage of disease at diagnosis, co-morbidities, socio-economic status, treatments received and survival were collected and examined for differences by ethnic group. There was a significant difference between black and minority ethnic (BME) patients and White-European patients in socio-economic status (Chi-square test P-value < 0.001). BME patients were over-represented in the most deprived socio-economic groups and under-represented in the most affluent. There were no significant differences in histology, stage of disease, co-morbidities and performance status or treatments received between the different ethnic groups. Ethnicity was not associated with survival. Significant prognostic factors for overall survival were performance status (P < 0.001), stage of disease (P = 0.001) and gender (P = 0.003). Our findings suggest that patients from BME groups are over-represented in more deprived socio-economic groups; however, this did not impact on significant prognostic factors or the treatments that they received. Importantly ethnicity did not influence survival.

Homicide as a medical outcome: racial disparity in deaths from assault in US Level I and II trauma centers

BACKGROUND

Since 1900, thousands of medical journal articles have been published on the topic of racial disparities in health and medical outcomes in the United States, including overlapping disparities based on health insurance status. But research on the question of such disparities in the medical treatment of injury from assault-matters of public safety, considerable public expense, and policy debate-is lacking.

METHODS

To determine differences by race and insurance status on death from intentional injury by others on and after trauma center arrival, propensity score matching is used to estimate adjusted mortality risk ratios by race and medical insurance controlling for facility, case, and injury characteristics. Analysis is based on a nationally representative sample of 100 Level I and II US trauma centers (National Trauma Data Bank 2005-2008) and includes 137,618 black and white assault cases aged 15 years and older: 35% white, and 65% black, with 46% of the whites and 60% of the blacks coded as uninsured.

RESULTS

Black patients showed higher overall raw mortality rates from assault than whites (8.9% vs. 5.1%), but after propensity score matching, the black to white adjusted risk ratio for death from assault (homicide) dropped significantly across firearm, cutting/piercing, and blunt injuries. After adjustment, estimated black deaths were 29% in excess of white deaths for firearm injuries, 36% in excess for cutting/piercing injuries, and 61% in excess for blunt injuries. Uninsured blacks comprised 76% of all excess trauma center deaths from assault.

CONCLUSIONS

Along with insurance status, and after excluding on-scene deaths, among patients brought to the Level I and II trauma centers, race is a substantial independent predictor of who dies from assault. Blacks, especially the uninsured, have significantly worse outcomes overall, but there is some evidence that this pattern is minimized at higher levels of injury severity.

LEVEL OF EVIDENCE

I, prognostic study.

Life-Threatening Disparities: The Treatment of Black and White Cancer Patients

Cancer mortality and survival rates are much poorer for Black patients than for White patients. We argue that Black-White treatment disparities are a major reason for these disparities. We examine three specific kinds of Black-White treatment disparities: disparities in information exchange in oncology interactions, disparities in the treatment of breast cancer, and disparities in the treatment of clinically localized prostate cancer. In the final section, we discuss possible causes of these disparities, with a primary focus on communication within medical interactions and the role that race-related attitudes and beliefs may play in the quality of communication in these interactions.

Racial disparities in receipt and comparative effectiveness of oxaliplatin for stage III colon cancer in older adults

BACKGROUND

African Americans in the United States have higher rates of colon cancer mortality than other races. This study examines the use of oxaliplatin, a novel chemotherapeutic agent approved in 2004, among African American and Caucasian American patients with stage III colon cancer to determine whether differential receipt or differential effectiveness of the drug may explain the racial disparity in colon cancer mortality.

METHODS

The authors conducted a population-based retrospective cohort study of stage III colon cancer patients aged 65 years and older treated from 2004 through 2006 who initiated chemotherapy within 90 days of surgical resection (N = 1162) using Surveillance, Epidemiology and End Results-Medicare data. Patients receiving oxaliplatin (n = 477) were compared with those receiving 5-fluorouracil without oxaliplatin (n = 685). The authors estimated prevalence ratios and hazard ratios (HRs) using multivariate binomial regression and Cox models to evaluate racial differences in oxaliplatin receipt and survival.

RESULTS

African Americans were as likely as Caucasian Americans to receive oxaliplatin (40.5 vs 41.1%; prevalence ratio, 0.90; 95% confidence interval [CI], 0.71-1.13). Oxaliplatin was associated with lower mortality compared with 5-fluorouracil (HR, 0.76; 95% CI, 0.58-1.00). This benefit appeared stronger among African Americans (HR, 0.31; 95% CI, 0.09-1.05) than Caucasian Americans (HR, 0.80; 95% CI, 0.60-1.06).

CONCLUSIONS

In Medicare-insured patients receiving chemotherapy, the authors observed no meaningful racial disparities in receipt of oxaliplatin and, among those receiving it, potentially better survival among African Americans. Differential receipt and effectiveness of oxaliplatin-containing regimens does not appear to contribute to the previously documented racial disparities in colon cancer survival. Understanding reasons for potentially enhanced effectiveness among African Americans may inform efforts to resolve racial disparities in colon cancer outcomes.

Positron emission tomography for assessing local failure after stereotactic body radiotherapy for non-small-cell lung cancer

PURPOSE

We analyzed whether positron emission tomography (PET)/computed tomography standardized uptake values (SUVs) after stereotactic body radiotherapy (SBRT) could predict local recurrence (LR) in non-small-cell lung cancer (NSCLC).

METHODS AND MATERIALS

This study comprised 128 patients with Stage I (n = 68) or isolated recurrent/secondary parenchymal (n = 60) NSCLC treated with image-guided SBRT to 50 Gy over 4 consecutive days; prior radiotherapy was allowed. PET/computed tomography scans were obtained before therapy and at 1 to 6 months after therapy, as well as subsequently as clinically indicated. Continuous variables were analyzed with Kruskal-Wallis tests and categorical variables with Pearson chi-square or Fisher exact tests. Actuarial local failure rates were calculated with the Kaplan-Meier method.

RESULTS

At a median follow-up of 31 months (range, 6-71 months), the actuarial 1-, 2-, and 3-year local control rates were 100%, 98.5%, and 98.5%, respectively, in the Stage I group and 95.8%, 87.6%, and 85.8%, respectively, in the recurrent group. The cumulative rates of regional nodal recurrence and distant metastasis were 8.8% (6 of 68) and 14.7% (10 of 68), respectively, for the Stage I group and 11.7% (7 of 60) and 16.7% (10 of 60), respectively, for the recurrent group. Univariate analysis showed that SUVs obtained 12.1 to 24 months after treatment for the Stage I group (p = 0.007) and 6.1 to 12 months and 12.1 to 24 months after treatment for the recurrent group were associated with LR (p < 0.001 for both). Of the 128 patients, 17 (13.3%) had ipsilateral consolidation after SBRT but no elevated metabolic activity on PET; none had LR. The cutoff maximum SUV of 5 was found to have 100% sensitivity, 91% specificity, a 50% positive predictive value, and a 100% negative predictive value for predicting LR.

CONCLUSIONS

PET was helpful for distinguishing SBRT-induced consolidation from LR. SUVs obtained more than 6 months after SBRT for NSCLC were associated with local failure. A maximum SUV greater than 5, especially at more than 6 months after SBRT, should prompt biopsy to rule out LR.

Race, socioeconomic status, and the use of bariatric surgery in Michigan

Studies examining the characteristics of patients undergoing bariatric surgery in the USA have concluded that the procedure is not being used equitably. We used population-based data from Michigan to explore disparities in the use of bariatric surgery by gender, race, and socioeconomic status. We constructed a summary measure of socioeconomic status (SES) for Michigan postal ZIP codes using data from the 2000 census and divided the population into quintiles according to SES. We then used data from the state drivers' license list and 2004-2005 state inpatient and ambulatory surgery databases to examine population-based rates of morbid obesity and bariatric surgery in adults according to gender, race, and socioeconomic status. There is an inverse linear relationship between SES and morbid obesity. In the lowest SES quintile, 13% of females and 7% of males have a body mass index >40 compared to 4% of females and males in the highest SES quintile. Overall rates of bariatric surgery were highest for black females (29.4/10,000), followed by white (21.3/10,000), and other racial minority (8.6/10,000) females. Rates of bariatric surgery were low (<6/10,000) for males of all racial groups. An inverse linear relationship was observed between SES and rates of bariatric surgery among whites. However, for racial minorities, rates of surgery are lower in the lowest SES quintiles with the highest rates of bariatric surgery in the medium or highest SES quintiles. In contrast with prior studies, we do not find evidence of wide disparities in the use of bariatric surgery.

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.

Racial and regional disparities in lung cancer incidence

BACKGROUND

Lung cancer is the second most commonly diagnosed cancer and the leading cause of cancer-related death in the United States (US). We examined data from 2004 to 2006 for lung cancer incidence rates by demographics, including race and geographic region, to identify potential health disparities.

METHODS

Data from cancer registries affiliated with the Centers for Disease Control and Prevention's (CDC) National Program of Cancer Registries (NPCR), and the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results Program (SEER) were used for this study; representing 100% of the US population. Age-adjusted incidence rates and 95% confidence intervals for demographic (age, sex, race, ethnicity, and US Census region), and tumor (stage, grade, and histology) characteristics were calculated.

RESULTS

During 2004 to 2006, 623,388 people (overall rate of 68.9 per 100,000) were diagnosed with lung cancer in the US. Lung cancer incidence rates were highest among men (86.2), Blacks (73.0), persons aged 70 to 79 years (431.1), and those living in the South (74.7). Among Whites, the highest lung cancer incidence rate was in the South (75.6); the highest rates among Blacks (88.9) and American Indians/Alaska Natives (65.4) in the Midwest, Asians/Pacific Islanders in the West (40.0), and Hispanics in the Northeast (40.3).

CONCLUSIONS

Our findings of racial, ethnic, and regional disparities in lung cancer incidence suggest a need for the development and implementation of more effective culturally specific preventive and treatment strategies that will ultimately reduce the disproportionate burden of lung cancer in the US.

Underuse of curative surgery for early stage upper gastrointestinal cancers in the United States

BACKGROUND

Surgery is the cornerstone of potentially curative therapy for upper gastrointestinal cancer. We analyzed the patterns of treatment regarding the use of surgery for early-stage upper gastrointestinal cancer in the United States.

METHODS

The Surveillance, Epidemiology, and End Research database was used to identify patients with cancer of the esophagus, stomach, pancreas, liver, gallbladder, biliary tract, or duodenum (2004-2007). Only patients with potentially resectable stage I and II disease were selected. The primary outcome measure was the use of curative intent surgery. The secondary outcomes were the predictors of surgery.

RESULTS

We identified 29,249 patients with a median age of 69 years. Only 54% of the patients underwent cancer-directed surgical resection, ranging from 28% for liver cancer to 89% for gallbladder cancer. The remaining patients underwent either local excision (8%) or no surgery (38%). Among the no surgery group, most patients (79%) were documented as "not being recommended for resection." The independent variables on multivariate analysis predictive of a nonoperative approach included black race, age older than 75 years, tumor size greater than 5 cm, and high poverty level (P < 0.001). Patients who did not undergo surgery had worse median and overall survival at 3 years than patients undergoing surgery (11 months versus 36 months and 14% versus 43%, respectively; P < 0.001).

CONCLUSIONS

Almost one half of patients with early-stage upper gastrointestinal cancer did not receive potentially curative surgery, with an adverse effect on overall survival. A combination of demographic, tumor, and socioeconomic factors were predictive of a lack of surgical resection.

Integrating multiple social statuses in health disparities research: the case of lung cancer

OBJECTIVE

To illustrate the complex patterns that emerge when race/ethnicity, socioeconomic status (SES), and gender are considered simultaneously in health care disparities research and to outline the needed research to understand them by using disparities in lung cancer risks, treatment, and outcomes as an example.

PRINCIPAL FINDINGS

SES, gender, and race/ethnicity are social categories that are robust predictors of variations in health and health services utilization. These are usually considered separately, but intersectionality theory indicates that the impact of each depends on the others. Each reflects historically and culturally contingent variations in social, economic, and political status. Distinct patterns of risk and resilience emerge at the intersections of multiple social categories and shape the experience of health, health care access, utilization, quality, and outcomes where these categories intersect. Intersectional approaches call for greater attention to understand social processes at multiple levels of society and require the collection of relevant data and utilization of appropriate analytic approaches to understand how multiple risk factors and resources combine to affect the distribution of disease and its management.

CONCLUSIONS

Understanding how race/ethnicity, gender, and SES are interactive, interdependent, and social identities can provide new knowledge to enhance our efforts to effectively address health disparities.

Image-guided thermal ablation of lung malignancies

Primary and secondary lung malignancies are often treated with surgery. Many patients are poor surgical candidates owing to advanced age or medical comorbidities. Alternatives to surgery for localized disease include radiation therapy and the newer treatments known as image-guided thermal ablation. Image-guided thermal ablation involves the use of needlelike applicators that are placed directly into tumors by using imaging guidance. Tumors are destroyed by the application of either intense heat or cold. The specific ablative modalities of radiofrequency ablation, microwave ablation, laser ablation, and cryoablation are reviewed with respect to the various clinical indications for treatment of both primary and secondary lung malignancies.

Racial disparities in being recommended to surgery for oral and oropharyngeal cancer in the United States

OBJECTIVES

To investigate the impact of race on the likelihood of patients being recommended for surgery after a diagnosis of oral and oropharyngeal cancer.

METHODS

A total of 68,445 cases of oral and oropharyngeal cancer were extracted from the 1988 to 2005 Surveillance, Epidemiology, and End Results (SEER) database. County-level rurality data and income data were merged using the US Department of Agriculture Rural-Urban Continuum Codes dataset and US Census Bureau Small Area Income & Poverty Estimates dataset. We used logistic regression analyses to investigate the impact of race on being recommended to surgery for oral and oropharyngeal cancer, adjusting for demographic, socioeconomic, and clinical factors. Stratified analyses were further conducted by tumor site and rural/urban status.

RESULTS

Recommendation to surgery varied significantly by race, with black patients less likely than white patients to be recommended to surgery for their oral and oropharyngeal cancer. The racial difference in recommendation to surgery varied significantly by age, geography, and tumor subsite. Racial disparities are most evident in lip and buccal cancer from rural areas (OR, 4.4; 95% CI, 2.6-7.5); and least evident in oropharyngeal cancer from urban areas (OR, 1.2; 95% CI, 1.1-1.3). The magnitude of the racial disparity is attenuated with increasing age.

CONCLUSIONS

We observed substantial racial disparities in surgery recommendation for oral and oropharyngeal cancer in the United States. Our results suggest the need to improve accessibility to better health care in racial minority groups, particularly in rural areas, and call for individual and institutional efforts to avoid physician bias related to the patient's sociodemographic characteristics in healthcare service.

Factors associated with adherence to chemotherapy guidelines in patients with non-small cell lung cancer

BACKGROUND

Evidence-based guidelines recommend chemotherapy for medically fit patients with stages II-IV non-small cell lung cancer (NSCLC). Adherence to chemotherapy guidelines has rarely been studied among large populations, mainly because performance status (PS), a key component in assessing chemotherapy appropriateness, is missing from claims-based datasets. Among a large cohort of patients with known PS, we describe first line chemotherapy use relative to guideline recommendations and identify patient factors associated with guideline concordant use.

PATIENTS AND METHODS

Insured patients, ages 50+, with stages II-IV NSCLC between 2000 and 2007 were identified via tumor registry (n=406). Chart abstracted PS, automated medical claims, Census tract information, and travel distance were linked to tumor registry data. Chemotherapy was considered appropriate for patients with PS 0-2. Multivariate logit models were fit to evaluate patient characteristics associated with chemotherapy over- and under-use per guideline recommendations. Tests of statistical significance were two sided.

RESULTS

Overall compliance with first line chemotherapy guidelines was 71%. Significant (p<0.05) predictors of chemotherapy underuse (19%) included increasing age (odds ratio [OR], 1.09), higher income (OR, 1.02), diagnosed before 2003 (OR, 2.05), and vehicle access (OR, 6.96) in the patient's neighborhood. Significant predictors of chemotherapy overuse (10%) included decreasing age (OR, 0.92), diagnosed after 2003 (OR, 3.24), and higher income (OR, 1.05) in the patient's neighborhood. Among NSCLC patients 29% do not receive guideline recommended chemotherapy treatment missing opportunities for cure or beneficial palliation, or receiving chemotherapy with more risk of harm than benefit. Care concordant with guidelines is influenced by age, economic considerations such as income and transportation barriers.

Comparison of demographic characteristics, surgical resection patterns, and survival outcomes for veterans and nonveterans with non-small cell lung cancer in the Pacific Northwest

INTRODUCTION

Lung cancer is a leading cause of death in the United States and among veterans. This study compares patterns of diagnosis, treatment, and survival for veterans diagnosed with non-small cell lung cancer (NSCLC) using a recently established cancer registry for the Veterans Affairs Pacific Northwest Network with the Puget Sound Surveillance, Epidemiology, and End Results cancer registry.

METHODS

A cohort of 1715 veterans with NSCLC were diagnosed between 2000 and 2006, and 7864 men were diagnosed in Washington State during the same period. Demographics, tumor characteristics, initial surgical patterns, and survival across the two registries were evaluated.

RESULTS

Veterans were more likely to be diagnosed with stage I or II disease (32.8%) compared with the surrounding community (21.5%, p = 0.001). Surgical resection rates were similar for veterans (70.2%) and nonveterans (71.2%) older than 65 years with early-stage disease (p = 0.298). However, veterans younger than 65 years with early-stage disease were less likely to undergo surgical resection (83.3% versus 91.5%, p = 0.003). Because there were fewer late-stage patients among veterans, overall survival was better, although within each stage group veterans experienced worse survival compared with community patients. The largest differences were among early-stage patients with 44.6% 5-year survival for veterans compared with 57.4% for nonveterans (p = 0.004).

CONCLUSIONS

The use of surgical resection among younger veterans with NSCLC may be lower compared with the surrounding community and may be contributing to poorer survival. Cancer quality of care studies have primarily focused on patients older than 65 years using Medicare claims; however, efforts to examine care for younger patients within and outside the Department of Veterans Affairs are needed.

Radiotherapy and chemotherapy for elderly patients with stage I-II unresected lung cancer

Radiotherapy (RT) is the standard therapy for unresected stage I-II nonsmall cell lung cancer (NSCLC). Using population-based data, we compared survival and toxicity among unresected elderly patients treated with combined chemoradiotherapy (CRT) or RT alone. Using the Surveillance, Epidemiology and End Results (SEER) registry (National Cancer Institute, Bethesda, MD, USA) we identified 3,006 cases of unresected stage I-II NSCLC. We used propensity score methods to compare survival and rates of toxicity of patients treated with RT versus CRT. Overall, 844 (28%) patients received CRT. Adjusted analyses showed that CRT was associated with improved survival (hazard ratio 0.85, 95% CI 0.78-0.94). Combination therapy was also associated with better survival among stage I patients treated with intermediate complexity RT (HR 0.80, 95% CI 0.70-0.90); however, no difference in survival was observed among patients treated with complex RT. In stage II patients, CRT was associated with improved survival regardless of the RT technique (HR 0.61-0.72). CRT was associated with increased odds of toxicity. Despite increased toxicity, CRT may improve survival of elderly unresected patients with stage II disease as well as stage I NSCLC treated with intermediate RT complexity. Randomised trials are needed to clarify the balance of benefits and risk of CRT in unresected patients.

Discrimination makes me sick! An examination of the discrimination-health relationship

The attitudes of the general British population towards Muslims changed post 2001, and this change led to a significant increase in Anti-Muslim discrimination. We use this exogenous attitude change to estimate the causal impact of increased discrimination on a range of objective and subjective health outcomes. The difference-in-differences estimates indicate that discrimination worsens blood pressure, cholesterol, BMI and self-assessed general health. Thus, discrimination is a potentially important determinant of the large racial and ethnic health gaps observed in many countries. We also investigate the pathways through which discrimination impacts upon health, and find that discrimination has a negative effect on employment, perceived social support, and health-producing behaviours. Crucially, our results hold for different control groups and model specifications.

Radiotherapy for hilar or mediastinal lymph node metastases after definitive treatment with stereotactic body radiotherapy or surgery for stage I non-small cell lung cancer

PURPOSE

Management of regional lymph node (LN) recurrence is an important issue in definitive treatment of non-small cell lung cancer (NSCLC). We evaluated clinical outcomes of conventional radiotherapy for hilar or mediastinal LN metastases developing after stereotactic body radiotherapy (SBRT) or surgery for stage I NSCLC.

METHODS AND MATERIALS

Between 2004 and 2008, 26 patients with hilar or mediastinal LN metastases without local recurrence and distant metastasis after SBRT (n = 14) or surgery (n = 12) were treated with conventional radiotherapy. Twelve of the 14 post-SBRT patients (86%) were judged medically inoperable at the time of SBRT. All patients were treated to the hilum and mediastinum with conventional daily fractions of 2.0 Gy (n = 25) or 2.4 Gy (n = 1). The median total dose for treating metastatic LN was 60 Gy (range, 54-66 Gy) for the post-SBRT patients and 65 Gy (range, 60-66 Gy) for the post-surgery patients. Only 1 of the 14 post-SBRT patients and 8 of the 12 post-surgery patients received chemotherapy.

RESULTS

For all 26 patients, the overall and cause-specific survival rates at 3 years from radiation for LN metastases were 36% and 51%, respectively (14% and 39%, respectively, for the 14 post-SBRT patients and both 64% for the 12 post-surgery patients). Three of the SBRT patients were alive at 35 to 43 months with (n = 2) or without (n = 1) further recurrence, and 4 of the post-surgery patients were alive at 36 to 62 months with (n = 2) or without (n = 2) further recurrence. The incidence of ≥grade 2 pulmonary toxicity was 49% at 1 year (53% for post-SBRT patients and 44% for post-surgery patients). A grade 5 pulmonary toxicity was observed in 1 of the post-SBRT patients.

CONCLUSIONS

Conventional radiotherapy could successfully salvage LN relapses after SBRT as well as after surgery in 7 of 26 patients. Radiotherapy in this setting appears reasonably well tolerated.

Racial disparities in stage-specific colorectal cancer mortality rates from 1985 to 2008

PURPOSE

Since the early 1980s, colorectal cancer (CRC) mortality rates for whites and blacks in the United States have been diverging as a result of earlier and larger reductions in death rates for whites. We examined whether this mortality pattern varies by stage at diagnosis.

METHODS

The Incidence-Based Mortality database of the Surveillance, Epidemiology, and End Results (SEER) Program was used to examine data from the nine original SEER regions. Our main outcome measures were changes in stage-specific mortality rates by race.

RESULTS

From 1985 to 1987 to 2006 to 2008, CRC mortality rates decreased for each stage in both blacks and whites, but for every stage, the decreases were smaller for blacks, particularly for distant-stage disease. For localized stage, mortality rates decreased 30.3% in whites compared with 13.2% in blacks; for regional stage, declines were 48.5% in whites compared with 34.0% in blacks; and for distant stage, declines were 32.6% in whites compared with 4.6% in blacks. As a result, the black-white rate ratios increased from 1.17 (95% CI, 0.98 to 1.39) to 1.41 (95% CI, 1.21 to 1.63) for localized disease, from 1.03 (95% CI, 0.93 to 1.14) to 1.30 (95% CI, 1.17 to 1.44) for regional disease, and from 1.21 (95% CI, 1.10 to 1.34) to 1.72 (95% CI, 1.58 to 1.86) for distant-stage disease. In absolute terms, the disparity in distant-stage mortality rates accounted for approximately 60% of the overall black-white mortality disparity.

CONCLUSION

The black-white disparities in CRC mortality increased for each stage of the disease, but the overall disparity in overall mortality was largely driven by trends for late-stage disease. Concerted efforts to prevent or detect CRC at earlier stages in blacks could improve the worsening black- white disparities.

The role of unconscious bias in surgical safety and outcomes

Racial, ethnic, and gender disparities in health outcomes are a major challenge for the US health care system. Although the causes of these disparities are multifactorial, unconscious bias on the part of health care providers plays a role. Unconscious bias occurs when subconscious prejudicial beliefs about stereotypical individual attributes result in an automatic and unconscious reaction and/or behavior based on those beliefs. This article reviews the evidence in support of unconscious bias and resultant disparate health outcomes. Although unconscious bias cannot be entirely eliminated, acknowledging it, encouraging empathy, and understanding patients' sociocultural context promotes just, equitable, and compassionate care to all patients.

Reasons for underuse of recommended therapies for colorectal and lung cancer in the Veterans Health Administration

BACKGROUND

Many studies have documented low rates of effective cancer therapies, particularly in older or minority populations. However, little is known about why effective therapies are underused in these populations.

METHODS

The authors examined medical records of 584 patients with cancer diagnosed or treated in Department of Veterans Affairs facilities to assess reasons for lack of 1) surgery for stage I/II nonsmall cell lung cancer, 2) surgery for stage I/II/III rectal cancer, 3) adjuvant radiation therapy for stage II/III rectal cancer, and 4) adjuvant chemotherapy for stage III colon cancer. They also assessed differences in reasons for underuse by patient age and race.

RESULTS

Across the 4 guideline-recommended treatments, 92% to 99% of eligible patients were referred to the appropriate cancer specialist; however, therapy was recommended in only 74% to 92% of eligible cases. Poor health was cited in the medical record as the reason for lack of therapy in 15% to 61% of underuse cases; patient refusal explained 26% to 58% of underuse cases. African American patients were more likely to refuse surgery. Older patients were more likely to refuse treatments.

CONCLUSIONS

Recommendation against therapy was a primary factor in underuse of effective therapies in older and sicker patients. Patients' refusal of therapy contributed to age and racial disparities in care. Improved data on the effectiveness of cancer therapies in community populations and interventions aimed at improved communication of known risks and benefits of therapy to cancer patients could be effective tools to reduce underuse and lingering disparities in care.