Impact of Race on Treatment and Survival among U.S. Veterans with Early-Stage Lung Cancer

Sublobar Resection vs Lobectomy for Stage IA Non-Small Cell Lung Carcinoma-Takeaways From Modern Randomized Trials

Sublobar resection for early-stage non-small cell lung cancer has been an emerging topic of great interest to thoracic surgeons. However, data regarding the efficacy and safety of sublobar resection vs lobectomy was lacking until now. Recently, 3 published randomized controlled trials (Cancer and Leukemia Group B [CALGB]140503/Alliance, Japan Clinical Oncology Group [JCOG]0802 and Das Deutsche Register Klinischer Studien [DRKS]00004897) confirmed the noninferiority of sublobar resection for early-stage non-small cell lung cancer in carefully selected populations. This review aims to summarize and compare these 3 landmark trials and inform surgeons of new best practices.

Lung Cancer Survival Trends in the Veterans Health Administration

INTRODUCTION

Lung cancer survival is improving in the United States. We investigated whether there was a similar trend within the Veterans Health Administration (VHA), the largest integrated healthcare system in the United States.

MATERIALS AND METHODS

Data from the Veterans Affairs Central Cancer Registry were analyzed for temporal survival trends using Kaplan-Meier estimates and linear regression.

RESULTS

A total number of 54,922 Veterans were identified with lung cancer diagnosed from 2010 to 2017. Histologies were classified as non-small-cell lung cancer (NSCLC) (64.2%), small cell lung cancer (SCLC) (12.9%), and 'other' (22.9%). The proportion with stage I increased from 18.1% to 30.4%, while stage IV decreased from 38.9% to 34.6% (both P < .001). The 3-year overall survival (OS) improved for stage I (58.6% to 68.4%, P < .001), stage II (35.5% to 48.4%, P < .001), stage III (18.7% to 29.4%, P < .001), and stage IV (3.4% to 7.8%, P < .001). For NSCLC, the median OS increased from 12 to 21 months (P < .001), and the 3-year OS increased from 24.1% to 38.3% (P < .001). For SCLC, the median OS remained unchanged (8 to 9 months, P = .10), while the 3-year OS increased from 9.1% to 12.3% (P = .014). Compared to White Veterans, Black Veterans with NSCLC had similar OS (P = .81), and those with SCLC had higher OS (P = .003).

CONCLUSION

Lung cancer survival is improving within the VHA. Compared to White Veterans, Black Veterans had similar or higher survival rates. The observed racial equity in outcomes within a geographically and socioeconomically diverse population warrants further investigation to better understand and replicate this achievement in other healthcare systems.

Trends and Disparities in Curative-Intent Treatment for Early-Stage Non-Small Cell Lung Cancer: A Population-Based Analysis of Surgery and SBRT

BACKGROUND

Despite the increasing adoption of stereotactic body radiotherapy (SBRT) as a recommended alternative for early-stage non-small cell lung cancer (NSCLC), population-based research on racial/ethnic disparities in curative-intent treatment accounting for SBRT remains limited. This study investigated trends and disparities in receiving curative-intent surgery and/or SBRT in a diverse, retrospective cohort.

METHODS

Early-stage NSCLC cases (2005-2017) from the Florida cancer registry were linked to individual-level statewide discharge data containing comorbidities and specific treatment information. Joinpoint regression assessed trends in treatment receipt. Multivariable logistic regression examined associations between race/ethnicity and treatment type.

RESULTS

Among 64,999 patients with early-stage NSCLC, 71.6% received curative-intent treatment (surgery and/or SBRT): 73.1%, 72.4%, and 60.3% among Hispanic, White, and Black patients, respectively (P < 0.01). SBRT use increased steeply from 2005 to 2007 and then by 7.9% annually from 2007 to 2017 (P < 0.01); curative-intent surgery remained stable from 2005 to 2014 before declining by 6.2% annually during 2014-2017 (P = 0.04). The Black-White disparity in receipt of curative-intent treatment was significant [ORadj, 0.65; 95% confidence interval (CI), 0.60-0.71]. Patients with Charlson comorbidity index (CCI)≥3 had 36% (ORadj, 0.64; 95% CI, 0.60-0.69) lower odds of receiving curative-intent surgery and no significant difference for SBRT (ORadj, 1.06; 95% CI, 0.93-1.20) compared with CCI = 0.

CONCLUSIONS

Racial disparities in receiving curative-intent treatment for early-stage NSCLC persist despite the availability of SBRT, suggesting the full potential of curative-intent treatment for early-stage NSCLC remains unachieved.

IMPACT

Addressing disparities in early-stage NSCLC requires addressing differential treatment patterns and enhancing accessibility to treatments like underutilized SBRT, particularly for high-comorbidity populations such as Black patients.

What health inequalities exist in access to, outcomes from and experience of treatment for lung cancer? A scoping review

OBJECTIVES

Lung cancer (LC) continues to be the leading cause of cancer-related deaths and while there have been significant improvements in overall survival, this gain is not equally distributed. To address health inequalities (HIs), it is vital to identify whether and where they exist. This paper reviews existing literature on what HIs impact LC care and where these manifest on the care pathway.

DESIGN

A systematic scoping review based on Arksey and O'Malley's five-stage framework.

DATA SOURCES

Multiple databases (EMBASE, HMIC, Medline, PsycINFO, PubMed) were used to retrieve articles.

ELIGIBILITY CRITERIA

Search limits were set to retrieve articles published between January 2012 and April 2022. Papers examining LC along with domains of HI were included. Two authors screened papers and independently assessed full texts.

DATA EXTRACTION AND SYNTHESIS

HIs were categorised according to: (a) HI domains: Protected Characteristics (PC); Socioeconomic and Deprivation Factors (SDF); Geographical Region (GR); Vulnerable or Socially Excluded Groups (VSG); and (b) where on the LC pathway (access to, outcomes from, experience of care) inequalities manifest. Data were extracted by two authors and collated in a spreadsheet for structured analysis and interpretation.

RESULTS

41 papers were included. The most studied domain was PC (32/41), followed by SDF (19/41), GR (18/41) and VSG (13/41). Most studies investigated differences in access (31/41) or outcomes (27/41), with few (4/41) exploring experience inequalities. Evidence showed race, rural residence and being part of a VSG impacted the access to LC diagnosis, treatment and supportive care. Additionally, rural residence, older age or male sex negatively impacted survival and mortality. The relationship between outcomes and other factors (eg, race, deprivation) showed mixed results.

CONCLUSIONS

Findings offer an opportunity to reflect on the understanding of HIs in LC care and provide a platform to consider targeted efforts to improve equity of access, outcomes and experience for patients.

Factors leading to disparity in lung cancer diagnosis among black/African American communities in the USA: a qualitative study

OBJECTIVE

This study has two objectives: first, to explore the diagnostic experiences of black/African American (BAA) patients with lung cancer to pinpoint pitfalls, suboptimal experiences and instances of discrimination leading to disparities in outcomes compared with patients of other ethnic backgrounds, especially white patients. The second objective is to identify the underlying causes contributing to health disparities in the diagnosis of lung cancer among BAA patients.

METHODS

We employed a phenomenological research approach, guiding in-depth interviews with patients self-identifying as BAA diagnosed with lung cancer, as well as caregivers, healthcare professionals and community advocates knowledgeable about BAA experiences with lung cancer. We performed thematic analysis to identify experiences at patient, primary care and specialist levels. Contributing factors were identified using the National Institute of Minority Health and Health Disparities (NIMHD) health disparity model.

RESULTS

From March to November 2021, we conducted individual interviews with 19 participants, including 9 patients/caregivers and 10 providers/advocates. Participants reported recurring and increased pain before seeking treatment, treatment for non-cancer illnesses, delays in diagnostic tests and referrals, poor communication and bias when dealing with specialists and primary care providers. Factors contributing to suboptimal experiences included reluctance by insurers to cover costs, provider unwillingness to conduct comprehensive testing, provider bias in recommending treatment, high healthcare costs, and lack of healthcare facilities and qualified staff to provide necessary support. However, some participants reported positive experiences due to their insurance, availability of services and having an empowered support structure.

CONCLUSIONS

BAA patients and caregivers encountered suboptimal experiences during their care. The NIMHD model is a useful framework to organise factors contributing to these experiences that may be leading to health disparities. Additional research is needed to fully capture the extent of these experiences and identify ways to improve BAA patient experiences in the lung cancer diagnosis pathway.

Health Equity in Patients Receiving Durvalumab for Unresectable Stage III Non-Small Cell Lung Cancer in the US Veterans Health Administration

BACKGROUND

Real-world evidence is limited regarding the relationship between race and use of durvalumab, an immunotherapy approved for use in adults with unresectable stage III non-small cell lung cancer (NSCLC) post-chemoradiotherapy (CRT). This study aimed to evaluate if durvalumab treatment patterns differed by race in patients with unresectable stage III NSCLC in a Veterans Health Administration (VHA) population.

MATERIALS AND METHODS

This was a retrospective analysis of White and Black adults with unresectable stage III NSCLC treated with durvalumab presenting to any VHA facility in the US from January 1, 2017, to June 30, 2020. Data captured included baseline characteristics and durvalumab treatment patterns, including treatment initiation delay (TID), interruption (TI), and discontinuation (TD); defined as CRT completion to durvalumab initiation greater than 42 days, greater than 28 days between durvalumab infusions, and more than 28 days from the last durvalumab dose with no new durvalumab restarts, respectively. The number of doses, duration of therapy, and adverse events were also collected.

RESULTS

A total of 924 patients were included in this study (White = 726; Black = 198). Race was not a significant factor in a multivariate logistic regression model for TID (OR, 1.39; 95% CI, 0.81-2.37), TI (OR, 1.58; 95% CI, 0.90-2.76), or TD (OR, 0.84; 95% CI, 0.50-1.38). There were also no significant differences in median (interquartile range [IQR]) number of doses (White: 15 [7-24], Black: 18 [7-25]; P = .25) or median (IQR) duration of therapy (White: 8.7 months [2.9-11.8], Black: 9.8 months [3.6-12.0]; P = .08), although Black patients were less likely to experience an immune-related adverse event (28% vs. 36%, P = .03) and less likely to experience pneumonitis (7% vs. 14%, P < .01).

CONCLUSION

Race was not found to be linked with TID, TI, or TD in this real-world study of patients with unresectable stage III NSCLC treated with durvalumab at the VHA.

Cancer-related Fatigue in Lung Cancer: A Research Agenda: An Official American Thoracic Society Research Statement

Background: Fatigue is the most common symptom among cancer survivors. Cancer-related fatigue (CRF) may occur at any point in the cancer care continuum. Multiple factors contribute to CRF development and severity, including cancer type, treatments, presence of other symptoms, comorbidities, and medication side effects. Clinically, increasing physical activity, enhancing sleep quality, and recognizing sleep disorders are integral to managing CRF. Unfortunately, CRF is infrequently recognized, evaluated, or treated in lung cancer survivors despite more frequent and severe symptoms than in other cancers. Therefore, increased awareness and understanding of CRF are needed to improve health-related quality of life in lung cancer survivors. Objectives: 1) To identify and prioritize knowledge and research gaps and 2) to develop and prioritize research questions to evaluate mechanistic, diagnostic, and therapeutic approaches to CRF among lung cancer survivors. Methods: We convened a multidisciplinary panel to review the available literature on CRF, focusing on the impacts of physical activity, rehabilitation, and sleep disturbances in lung cancer. We used a three-round modified Delphi process to prioritize research questions. Results: This statement identifies knowledge gaps in the 1) detection and diagnostic evaluation of CRF in lung cancer survivors; 2) timing, goals, and implementation of physical activity and rehabilitation; and 3) evaluation and treatment of sleep disturbances and disorders to reduce CRF. Finally, we present the panel's initial 32 research questions and seven final prioritized questions. Conclusions: This statement offers a prioritized research agenda to 1) advance clinical and research efforts and 2) increase awareness of CRF in lung cancer survivors.

Racial and ethnic variation in referral times for thoracic oncologic surgery in a major metropolitan area

OBJECTIVE

The study objective was to understand the impact of race/ethnicity on access to thoracic surgical care for patients undergoing lung resection for cancer.

METHODS

We performed a retrospective analysis on 206 consecutive patients who underwent lung resection for cancer (120 female, 86 male; median age 66 years), with respect to how race and ethnicity impact time to referral for thoracic surgery to a major healthcare center. Time between initial radiographic appearance of a lung nodule/mass 1 cm or greater to surgical referral and time from surgical referral to operation were evaluated for 121 White, 30 Asian, 26 Hispanic, 12 African American, and 17 mixed or other race patients. The impact of age, sex, median income of patient's household, national and state Area Deprivation Indices, insurance type, and distance between the patient's domicile and our hospital was evaluated. The influence of the referring physician's practice (hospital-based, hospital-affiliated, or private), internal or external referral, race/ethnicity, and level of specialization was also studied.

RESULTS

African American, Asian, Hispanic, and mixed/other race patients had significantly longer wait times between initial radiographic finding of a lung nodule/mass 1 cm or greater and surgical referral compared with White individuals (median days: African American, 78; Asian, 95; Hispanic, 92; mixed or other, 65; White, 35). Multiple linear regression analysis demonstrated that race/ethnicity was the only significant predictor of prolonged time to surgical referral when adjusted for age, sex, median household income level, national and state Area Deprivation Indices, insurance type, and distance between patient's home and our hospital. The referring physician's type of practice and internal versus external referral were not significant. However, the physician's race/ethnicity and level of specialization had an impact on referral times, with nonspecialists referring patients sooner to thoracic surgery compared with specialists who ordered more workup tests. For all patient races/ethnicities, there was no difference in time between surgical referral and day of operation.

CONCLUSIONS

Race and ethnicity have a major impact on the time from initial radiographic appearance of a lung nodule/mass 1 cm or greater to referral for surgical resection for cancer. This study suggests the need to develop strategies to reduce minority wait times and improve timely access to surgery for patients with thoracic malignancies.

VIDEO ABSTRACT

Discussion of how race and ethnicity impact referral time to thoracic surgery discussed by Dr Moises Hernandez.

Timely Curative Treatment and Overall Mortality Among Veterans With Stage I NSCLC

Introduction

Early stage lung cancer (LC) outcomes depend on the receipt of timely therapy. We aimed to determine the proportions of Veterans with stage I NSCLC in the age group eligible for LC screening (LCS) receiving timely curative treatment (≤12 wk after diagnosis), the factors associated with timely treatment and modality, and the factors associated with overall mortality.

Methods

Retrospective cohort study in Veterans aged 55 to 80 years when diagnosed with stage I NSCLC during 2011 to 2015. We used multivariate logistic regression models to determine factors associated with receiving timely therapy and receiving surgery versus stereotactic body radiation therapy (SBRT). We used multivariate Cox proportional hazards regression analysis to determine factors associated with overall mortality.

Results

We identified 4796 Veterans with stage I NSCLC; the cohort was predominantly older, White males, current or former smokers, and living in urban areas. Overall, 84% underwent surgery and 16% underwent SBRT. The median time to treatment was 63 days (61 d for surgery; 71 d for SBRT), with 30% treated more than 12 weeks. Unmarried Veterans with higher social deprivation index were less likely to receive timely therapy. Black race, female sex, and never smoking were associated with lower overall mortality. Older Veterans receiving treatment >12 wk, with higher comorbidity index, and squamous cell carcinoma had higher overall mortality.

Conclusions

A total of 30% of the Veterans with stage I NSCLC in the age group eligible for LCS received curative treatment more than 12 weeks after diagnosis, which was associated with higher overall mortality. Delays in LC treatment could decrease the mortality benefits of LCS among the Veterans.

Disparities in localized malignant lung cancer surgical treatment: A population‐based cancer registry analysis

BACKGROUND

Lung cancer (LC) continues to be the leading cause of cancer deaths in the United States. Surgical treatment has proven to offer a favorable prognosis and a better 5-year relative survival for patients with early or localized tumors. This novel study investigates the factors associated with the odds of receiving surgical treatment for localized malignant LC in Tennessee.

METHODS

Population-based data of 9679 localized malignant LC patients from the Tennessee Cancer Registry (2005-2015) were utilized to examine the factors associated with receiving surgical treatment for localized malignant LC. Bivariate and multivariate logistic regression analyses, cross-tabulation, and Chi-Square ( χ ² ) tests were conducted to assess these factors.

RESULTS

Patients with localized malignant LC who initiated treatment after 2.7 weeks were 46% less likely to receive surgery (adjusted odds ratio [AOR] = 0.54; 95% confidence interval [CI] = 0.50-0.59; p < 0.0001). Females had a greater likelihood (AOR = 1.14; CI = 1.03-1.24) of receiving surgical treatment compared to men. Blacks had lower odds (AOR = 0.76; CI = 0.65-0.98) of receiving surgical treatment compared to Whites. All marital groups had higher odds of receiving surgical treatment compared to those who were single/never married. Patients living in Appalachian county had lower odds of receiving surgical treatment (AOR = 0.65; CI = 0.59-0.71) compared with those in the non-Appalachian county. Patients with private (AOR = 2.09; CI = 1.55-2.820) or public (AOR = 1.42; CI = 1.06-1.91) insurance coverage were more likely to receive surgical treatment compared to self-pay/uninsured patients. Overall, the likelihood of patients receiving surgical treatment for localized malignant LC decreases with age.

CONCLUSION

Disparities exist in the receipt of surgical treatment among patients with localized malignant LC in Tennessee. Health policies should target reducing these disparities to improve the survival of these patients.

Racial Disparities in the Surgical Treatment of Clinical Stage I Non-Small Cell Lung Cancer Among Veterans

BACKGROUND

Prior studies in the civilian population have reported racial disparities in lung cancer outcomes following surgical treatment, including inferior quality of care and worse survival. It is unclear if racial disparities exist in the Veterans Health Administration (VHA), the largest integrated health care system in the United States.

RESEARCH QUESTION

Do racial disparities affect early-stage non-small cell lung cancer (NSCLC) outcomes following surgical treatment within the VHA?

STUDY DESIGN AND METHODS

This retrospective cohort study was conducted in veterans with clinical stage I NSCLC undergoing surgical treatment in the VHA system. Demographic characteristics, access to care, surgical quality measures, and short- and long-term oncologic outcomes between White and Black veterans were evaluated.

RESULTS

From 2006 to 2016, a total of 18,800 veterans with clinical stage I NSCLC were included. The rates of definitive surgical treatment were similar between Black (57.3%) and White (58.1%) veterans (P = .42). The final study cohort included 9,842 patients receiving surgical treatment, of whom 8,356 (84.9%) were White and 1,486 (15.1%) were Black. Black patients were younger and more likely to smoke, although comorbidities were similar between the two groups. Black patients were somewhat less likely to receive adequate lymph node sampling (30.6% vs 33.3%; P = .050); however, other access-to-care metrics and surgical quality measures, including rates of anatomic lobectomy (71.9% vs 69.4%; P = .189) and positive margins (3.2% vs 3.1%; P = .955), were similar between the two groups. Although Black veterans were less likely to experience major postoperative complications, there was no difference in 30-day readmission, 30-day mortality, or disease-free survival between the two groups. Black patients had significantly better risk-adjusted overall survival (hazard ratio, 0.802; 95% CI, 0.729-0.883; P < .001).

INTERPRETATION

Among veterans with NSCLC undergoing surgical treatment through the VHA, Black patients received comparable care with equivalent if not superior outcomes compared with White patients.

Facility-level national trends in racial disparities of surgical therapy for early-stage lung cancer

OBJECTIVE

The racial gap in surgical treatment for early-stage non-small cell lung cancer (NSCLC) has been narrowing at the population level, but it is unknown if this trend persists at the facility level.

PATIENTS AND METHODS

We queried the National Cancer Database Participant User File from 2006 to 2016 for patients with stage I NSCLC. Facilities were grouped by type, location, and resection volume. The cumulative surgery rate for Black and White patients in each group was calculated, and an incidence rate difference of receipt of surgery was determined. Logistic regression with estimation of marginal effects was used to assess the probability difference of receiving surgery in Black versus White patients in each year.

RESULTS

In total, 315,474 patients were included; 287,585 (91.2%) were White and 27,889 (8.8%) were Black. The surgery rate was greater for White patients (60.2% vs 55.8%, P < .001). For most groups, the surgery disparity narrowed over the study period. The disparity widened in community cancer programs; facilities in the New England, West North Central, and Pacific regions; and the lowest volume facilities. The probability difference for receiving surgery was significantly smaller in 2016 versus 2006 in the Middle Atlantic region and community cancer programs; the difference was unchanged for all other groupings.

CONCLUSIONS

Trends in disparities in the use of resection for early-stage NSCLC are not universal across facility groupings. As efforts are made toward addressing racial disparities in surgical care for NSCLC, it will be important to remember that population-level analyses may mask lack of progress in certain facility groups.

Exploring the effects of racial and socioeconomic factors on timeliness of lung cancer diagnosis and treatment in Baltimore Veterans

OBJECTIVES

To characterize the effect of racial and socioeconomic factors on the timeliness of lung cancer diagnosis and treatment in a single-center Veterans Affair Medical Center (VAMC) pulmonary nodule clinic.

METHODS

We conducted a single-center retrospective review of all patients seen at the Baltimore VAMC pulmonary nodule clinic between 2013 and 2019 to identify key demographic factors, measures of neighborhood socioeconomic disadvantage, cancer staging and histopathologic information, and time elapsed between diagnosis and treatment. We excluded patients with pulmonary nodules undergoing active surveillance, prior history of lung cancer, metastases of a different primary origin, insufficient followup, or who had received care outside the VHA system.

RESULTS

Median times to diagnosis and treatment of lung cancer were 28 and 73 days. There were no statistically significant differences in overall timeliness of diagnosis and treatment when stratified by race or measures of neighborhood socioeconomic disadvantage.

CONCLUSIONS

The authors found no differences in timeliness of lung cancer care by race and socioeconomic status within the system. Despite general adherence to national standards in timeliness of care, there continues to be a need for improvements in the operational workflows to reduce time to diagnosis and treatment for all Veterans.

Patients undergoing colorectal surgery at a Veterans Affairs Hospital do not experience racial disparity in length of stay either before or after implementing an enhanced recovery pathway

Background

Enhanced Recovery Pathways (ERP) have been shown to reduce racial disparities following surgery. The objective of this study is to determine whether ERP implementation mitigates racial disparities at a Veterans Affairs Hospital.

Methods

A retrospective cohort study was conducted using data obtained from the Veterans Affairs Surgical Quality Improvement Program. All patients undergoing elective colorectal surgery following ERP implementation were included. Current procedural terminology (CPT) codes were used to identify patients who underwent similar procedures prior to ERP implementation.

Results

Our study included 417 patients (314 pre-ERP vs. 103 ERP), 97.1% of which were male, with an average age of 62.32 (interquartile range (IQR): 25–90). ERP patients overall had a significantly shorter post-operative length of stay (pLOS) vs. pre-ERP patients (median 4 days (IQR: 3–6.5) vs. 6 days (IQR: 4–9) days (p < 0.001)). Within the pre-ERP group, median pLOS for both races was 6 days (IQR: 4–6; p < 0.976) and both groups experienced a decrease in median pLOS (4 vs. 6 days; p < 0.009 and p < 0.001) following ERP implementation.

Conclusions

Racial disparities did not exist in patients undergoing elective surgery at a single VA Medical Center. Implementation of an ERP significantly reduced pLOS for black and white patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01647-3.

Socioeconomic Disparities in Pancreas Cancer Resection and Survival in the Veterans Health Administration

BACKGROUND

Disparities based on socioeconomic factors such as race, ethnicity, marital status, and insurance status are associated with pancreatic cancer resection, but these disparities are usually not observed for survival after resection. It is unknown if there are disparities when patients undergo their treatment in a non-fee-for-service, equal-access healthcare system such as the Veterans Health Administration (VHA).

METHODS

Patients having T1-T3 M0 pancreatic adenocarcinoma diagnosed between 2006 and 2017 were identified from the VHA Corporate Data Warehouse. Socioeconomic, demographic, and tumor variables associated with resection and survival were assessed.

RESULTS

In total, 2580 patients with early-stage pancreatic cancer were identified. The resection rate was 36.5%. Surgical resection was independently associated with younger age [odds ratio (OR) 0.94, p < 0.001], White race (OR 1.35, p = 0.028), married status (OR 1.85, p = 0.001), and employment status (retired vs. unemployed, OR 1.41, p = 0.008). There were no independent associations with Hispanic ethnicity, geographic region, or Social Deprivation Index. Resection was associated with significantly improved survival (median 21 vs. 8 months, p = 0.001). Among resected patients, survival was independently associated with younger age (HR 1.019, p = 0.002), geographic region (South vs. Pacific West, HR 0.721, p = 0.005), and employment (employed vs. unemployed, HR 0.752, p = 0.029). Race, Hispanic ethnicity, marital status, and Social Deprivation Index were not independently associated with survival after resection.

CONCLUSIONS

Race, marital status, and employment status are independently associated with resection of pancreatic cancer in the VHA, whereas geographic region and employment status are independently associated with survival after resection. Further studies are warranted to determine the basis for these inequities.

Racial Differences in Survival Among Advanced-stage Non-small-Cell Lung Cancer Patients Who Received Immunotherapy: An Analysis of the US National Cancer Database (NCDB)

Lung cancer is the most common cause of cancer death among men and women in the United States, with significant racial disparities in survival. It is unclear whether these disparities persist upon equal utilization of immunotherapy. The purpose of this study was to evaluate the association between race and all-cause mortality among non-small-cell lung cancer (NSCLC) patients who received immunotherapy. We obtained data from the 2016 National Cancer Database on patients diagnosed with advanced-stage (III-IV) NSCLC from 2015 to 2016. Multivariable Cox proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (95% CI) by race/ethnicity. A total of 2940 patients were included. Non-Hispanic (NH)-Black patients had a lower risk of death relative to NH-White patients (HR: 0.85; 95% CI: 0.73, 0.98) after adjusting for sociodemographic, clinical, and treatment factors. Formal tests of interaction evaluating race with Charlson-Deyo comorbidity score and race with area-level median income were nonsignificant. However, in stratified analyses, NH-Black versus NH-White patients had a lower risk of death in models adjusted for sociodemographic factors among those with at least 1 comorbidity (HR: 0.75; 95% CI: 0.57, 0.97), and those living in regions within the 2 lowest quartiles of median income (HR: 0.82; 95% CI: 0.68, 0.99). Among advanced-stage NSCLC patients who received immunotherapy, NH-Black patients experienced higher survival compared with NH-White patients. We urge the implementation of policies and interventions that seek to equalize access to care as a means of addressing differences in overall NSCLC survival by race.

Disparities in Lung Cancer Treatment

PURPOSE OF REVIEW

Despite an overall reduction in lung cancer incidence and mortality rates worldwide, Blacks still have higher mortality rates compared to Whites. There are many factors that contribute to this difference. This review seeks to highlight racial disparities in treatment and the possible reasons for these disparities.

RECENT FINDINGS

Factors attributing to racial disparities in lung cancer treatment include social determinants of health, differences in the administration of guideline-concordant therapy as well as molecular testing that is essential for most NSCLC patients. One way to circumvent disparities in lung cancer survivorship is to ensure equal representation of race in research at all levels that will provide insight on interventions that will address social determinants of health, differences in treatment patterns, molecular testing, and clinical trial involvement.

Social determinants and facility type impact adherence to best practices in operable IIIAN2 lung cancer

OBJECTIVES

We aimed to identify patient- and facility-specific predictors of collective adherence to 4 recommended best treatment practices in operable IIIAN2 non-small-cell lung cancer (NSCLC) and test the hypothesis that collective adherence is associated with superior survival.

METHODS

We queried the National Cancer Database for clinical stage IIIAN2 NSCLC patients undergoing surgery during 2010-2015. The following best practices were examined: performance of an anatomic resection, performance of an R0 resection, examination of regional lymph nodes and administration of induction therapy. Multivariable regression models were fitted to identify independent predictors of guideline-concordance.

RESULTS

We identified 7371 patients undergoing surgical resection for IIIAN2 lung cancer, of whom 90.8% underwent an anatomic resection, 88.2% received an R0 resection, 92.5% underwent a regional lymph node examination, 41.6% received induction therapy and 33.7% received all 4 best practices. Higher income, private insurance and treatment at an academic facility were independently associated with adherence to all 4 best practices (P < 0.01). A lower level of education and residence in a rural county were associated with a lack of adherence (P < 0.05). Adherence to all 4 practices correlated with improved survival (P < 0.01).

CONCLUSIONS

National adherence to best treatment practices in operable IIIAN2 lung cancer was variable as evidenced by the majority of patients not receiving recommended induction therapy. Socioeconomic factors and facility type are important determinants of guideline-concordance. Future efforts to improve outcomes should take this into account since guideline concordance, in the form of collective adherence to all 4 best practices, was associated with improved survival.

Prognosis and Survival Analysis of 922,317 Lung Cancer Patients from the US Based on the Most Recent Data from the SEER Database (April 15, 2021)

Background

On April 15, 2021, the Surveillance, Epidemiology, and End Results (SEER) database released the latest lung cancer follow-up data. We selected 922,317 lung cancer patients diagnosed from 2000 to 2017 for survival analysis to provide updated data for lung cancer researchers.

Research Question

This study explored the latest trends of survival time in terms of gender, race, nationality, age, income, address, histological type and primary site.

Study Design and Methods

The SEER database covers 27.8% of the US population. We used life table, Kaplan-Meier, log-rank, Breslow and Tarone-Ware tests to calculate survival rate, time, and curve and to compare differences in survival distribution. We performed univariate and multivariate Cox proportional hazards analyses.

Results

The median survival time of all lung cancer patients diagnosed in 2017 increased by 41.72% compared to 2000. Median survival time of female patients diagnosed in 2017 increased by 70.94% compared to 2000. Median survival time of those diagnosed in 2017 for different primary sites was as follows: right middle lobe was the longest, then left lower lobe, right upper lobe, right lower lobe, and left upper lobe. Lung cancer patients older than 75 years had a significantly shorter median survival time. Patients living in metropolitan areas of 250,000 to 1 million had a longer median survival time. Median survival time in the adenocarcinoma group was significantly greater than other patients. Median survival of Asian and other races diagnosed in 2017 was 97.87% higher than those diagnosed in 2000. Survival rate of lung cancer increased gradually with the year of diagnosis.

Interpretation

The rapid improvement of the prognosis of female and young lung cancer patients contributes to the improvement of the overall prognosis. Primary lung cancer in the right middle lobe has the best prognosis.

Social Disparities in Lung Cancer

Social disparities in lung cancer diagnosis, treatment, and survival have been studied using national databases, statewide registries, and institution-level data. Some disparities emerge consistently, such as lower adherence to treatment guidelines and worse survival by race and socioeconomic status, whereas other disparities are less well studied. A critical appraisal of current data is essential to increasing equity in lung cancer care.

The impact of social determinants of health on management of stage I non-small cell lung cancer

BACKGROUND

Social Determinants of Health (SDOH) can be important contributors in health care outcomes. We hypothesized that certain SDOH independently impact the management and outcomes of stage I Non-Small Cell Lung Cancer (NSCLC).

STUDY DESIGN

Patients with clinical stage I NSCLC were identified from the National Cancer Database. The impact of SDOH factors on utilization of surgery, perioperative outcomes and overall survival were examined, both in bivariate and multivariable analyses.

RESULTS

A total of 236,140 patients were identified. In multivariate analysis, SDOH marginalization were associated with less frequent use of surgery, lower 5-year survival and, in surgical patients, more frequent use of open surgery and lower 90-day postoperative survival.

CONCLUSION

SDOH disparities have a significant impact in the management and outcomes of stage I NSCLC. We identified SDOH patient groups particularly impacted by such disparities, in which higher utilization of surgery and minimally invasive approaches may lead to improved outcomes.

Racial Differences in Adherence to Lung Cancer Screening Follow-Up: A Systematic Review and Meta-Analysis

BACKGROUND

In 2013 the United States Preventive Services Taskforce (USPSTF) instituted recommendations for annual lung cancer screening (LCS) with low dose chest computed tomography for high-risk individuals. LCS reduces lung cancer mortality, with greater reduction observed in Black participants in clinical trials. While racial disparities in lung cancer mortality have been well documented, less is known about disparities in LCS participation and adherence to follow-up in clinical practice.

RESEARCH QUESTION

What is the association between race and adherence to LCS follow-up?

STUDY DESIGN & METHODS

A systematic review was conducted through a search of published studies in MEDLINE, PubMed, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health Literature Database, from database inception through October 2020. We included studies that examined rates of adherence to LCS follow-up and compared rates by race. Studies were pooled using random-effects meta-analysis.

RESULTS

We screened 18,300 titles/abstracts and 229 studies were selected for full-text review. Nine studies met inclusion criteria; seven were included in the meta-analysis. Median adherent follow-up rate was 37% (range 16-82%). Notable differences among the studies included the proportion of the Black population (range 4-47%) and the structure of the LCS programs. The meta-analyses showed lower adherence to LCS follow-up in the Black population (Odds Ratio [OR]=0.67, [95% CI: 0.55, 0.80]). This disparity persisted across all malignancy risk levels determined by initial screening results.

INTERPRETATION

There is lower adherence to LCS follow-up in Black compared to White patients despite the higher potential lung cancer mortality benefit. Literature specifically addressing race-related barriers to LCS adherence is still limited. To ensure equity in LCS benefits, greater outreach to eligible Black patients should be implemented through increased physician education and utilization of screening program coordinators to focus on this patient population.

Narrative review of socioeconomic and racial disparities in the treatment of early stage lung cancer

Background

To review and discuss the current literature regarding socio-economic and racial disparities in the treatment of early-stage non-small cell lung cancer (NSCLC).

Methods

Narrative review of peer reviewed literature synthesizing findings retrieved from searches of computerized databases, primary article reference lists, authoritative texts and expert options.

Results

The current incidence of lung cancer appears to be similar between White and Black patients. However, Black patients are substantially less likely to receive curative intent surgery. Mitigation strategies do exist to narrow this inequity. Lower socioeconomic status (SES) is associated with a higher incidence of lung cancer, lower utilization of surgery and poorer outcomes after surgery.

Conclusions

Race and SES remain closely linked to outcomes in lung cancer. Outcomes are still worse when controlling for stage and specifically, in early-stage disease, surgical therapy is consistently underused in Black patients and patients of low SES.

Disparities in Lung Cancer Screening: A Review

Lung cancer is the leading cause of cancer mortality in the United States. Certain groups are at increased risk of developing lung cancer and experience greater morbidity and mortality than the general population. Lung cancer screening provides an opportunity to detect lung cancer at an early stage when surgical intervention can be curative; however, current screening guidelines may overlook vulnerable populations with disproportionate lung cancer burden. This review aims to characterize disparities in lung cancer screening eligibility, as well as access to lung cancer screening, focusing on underrepresented racial/ethnic minorities and high-risk populations, such as individuals with human immunodeficiency virus. We also explore potential system- and patient-level barriers that may influence smoking patterns and healthcare access. Improving access to high-quality health care with a focus on smoking cessation is essential to reduce the burden of lung cancer experienced by vulnerable populations.

Early-Stage Non-Small Cell Lung Cancer Stereotactic Body Radiation Therapy (SBRT) Outcomes in an Equal Access Military Setting

Introduction Lung stereotactic body radiation therapy (SBRT) is a first-line treatment for early-stage lung cancer in non-surgical candidates or those who refuse surgery. We compared our institutional outcomes from a unique patient population with decreased barriers to care with a recently published prospective series. Materials and methods  We retrospectively reviewed all patients who received definitive lung SBRT at the Walter Reed National Military Medical Center from 2015 to 2020. All patients underwent a positron emission tomography-computed tomography (PET-CT) and all were presented at a multidisciplinary tumor board. Patients were treated on a Trubeam linear accelerator (LINAC)-based system with daily cone-beam CT. The results were qualitatively compared to outcomes from prospective studies including RTOG 0236 and RTOG 0618. Results A total of 105 patients with 114 lesions were included. Median age was 77 years and 54.7% had ≥ 40-pack year smoking history. 36.8% did not have pathologic confirmation. With a median follow-up of 24 months, three-year local control (LC), disease-free survival (DFS) and overall survival (OS) rates were 92.4%, 81.0%, and 80.0%, respectively. Rates of Grade 1 and 2 toxicity were 21.9% and 6.7% and no patients experienced Grade ≥ 3 toxicity. Conclusions In our military setting with universal coverage and routine multidisciplinary care, lung SBRT provides outcomes comparable to prospective studies conducted at high-volume academic centers. More than one-third of patients were treated empirically without pathologic confirmation of disease, demonstrating a difference between clinical trials and community practice. Further investigation is warranted to integrate multidisciplinary management and achieve equal access to care to bridge existing health disparities in the community setting.

Does Race or Ethnicity Impact Complications After Pulmonary Lobectomy for Patients With Lung Cancer?

BACKGROUND

Racial disparity in surgical access and postoperative outcomes after pulmonary lobectomy continues to be a concern and target for improvement; however, evidence of independent impact of race on complications is lacking. The objective of this study was to investigate the impact of race/ethnicity on surgical outcomes after lobectomy for lung cancer and estimate the distribution of racial/ethnic groups among expected resectable lung cancer cases using a large national database.

METHODS

Patients who underwent lobectomy for lung cancer between 2005 and 2016 were identified in the American College of Surgeon National Surgical Quality Improvement Program. Preoperative characteristics and postoperative outcomes were compared between race/ethnicity groups in all patients and in propensity-matched cohorts, controlling for pertinent risk factors. Distribution of each race/ethnicity in the database was calculated relative to estimated numbers of patients with resectable lung cancer in the United States.

RESULTS

A total of 10,202 patients (age 67.6 ± 9.7, 46.7% male, 86.4% white) underwent nonemergent lobectomy (46.8% thoracoscopic). Blacks had higher rates of baseline risk factors. In propensity score-matched cohorts of whites, blacks, and Hispanics/Asians (n = 498 each), postoperatively, blacks had higher rates of prolonged intubation and longer hospital stay while whites had a higher rate of pneumonia. Race was independently associated with these adverse outcomes on multivariate analysis. Proportion of blacks and Hispanics in the American College of Surgeon National Surgical Quality Improvement Program was lower than their respective proportion of resectable lung cancer in the United States.

CONCLUSIONS

In a large national-level surgical database, there was lower than expected representation of black and Hispanic patients. Black race was independently associated with extended length of stay and prolonged intubation, whereas white was independently associated with postoperative pneumonia.

Racial Disparity in Surgical Therapy for Thymic Malignancies

BACKGROUND

The primary curative treatment for thymic malignancies is surgery. For lung and esophageal cancer, substantive disparities in outcomes by race exist. Many of these disparities are attributed to the decreased use of surgery in non-White patients. Although thymic malignancies are treated by the same specialists as lung and esophageal cancer, it is unknown if there are racial disparities in the treatment of thymic malignancies.

RESEARCH QUESTION

Do racial disparities exist in the surgical treatment of thymic malignancies?

STUDY DESIGN AND METHODS

A retrospective cohort analysis was performed using the National Cancer Data Base of patients diagnosed with thymoma and thymic carcinoma between 2004 and 2016. Univariate comparisons of demographics were compared using χ ² and rank-sum tests. Multivariable analysis was performed to determine if race was an independent variable associated with receiving surgical resection. Preoperative and postoperative care was compared between races.

RESULTS

Seven thousand four hundred eighty-nine patients met inclusion criteria. Four thousand nine hundred sixty-two (66%) were White, 1,311 (18%) were Black, 487 (7%) were Hispanic, 580 (8%) were Asian or Pacific Islander, and 143 (2%) were other races. Black patients with thymic malignancies were more likely to have a median income < $38,000 and not received surgery. Black and Hispanic patients had the lowest median age (54.3 and 53.6 years, respectively) and were most likely to be uninsured (8.2% and 12.5%, respectively). White patients received surgical therapy 1 week sooner and had a postoperative length of stay 1.5 days shorter than Black patients. Multivariable analysis controlling for age, sex, tumor size, insurance status, comorbidity score, histology, and facility type showed that race remained independently associated with the receipt of surgical resection. White patients had the greatest likelihood of receiving surgery with Black patients being least likely to receive surgery (OR, 0.60).

INTERPRETATION

A racial disparity exists in surgical therapy for thymic malignancies.

Prognostic factors for survival in patients with metastatic lung adenocarcinoma: An analysis of the SEER database

Background

Lung adenocarcinoma (ADC) is the main cause of death related to lung cancer. The aim of this study was to identify poor prognostic factors for overall survival (OS) in patients with stage IV lung ADC in real‐world clinical practice.

Methods

Patients were selected from the Surveillance Epidemiology and End Results (SEER) database. Chi‐square bivariate analysis was used for the association of binary qualitative variables. A multivariate Cox regression analysis was performed to determine the impact of these prognostic factors on OS.

Results

A total of 46 030 patients were included (51.3% men, mean age 67.03 ± 11.6), of whom 41.3% presented with metastases in bone, 28.9% in brain, 17.1% in liver and 31.8% in lung. Patients with liver metastases presented with two or more metastatic sites more frequently than patients without liver metastases (P < 0.001). Male sex (HR 0.78, 95% CI: 0.76–0.80), age ≥ 65 years (HR 1.37, 95% CI: 1.33–1.40), lack of family support (HR 0.80, 95% CI: 0.78–0.81) and presence of liver (HR 1.45, 95% CI: 1.40–1.50), bone (HR 1.21, 95% CI: 1.18–1.24) or brain metastases (HR 1.18, 95% CI: 1.15–1.21) were identified as poor prognostic factors for OS. Patients with liver metastasis showed the highest hazard ratio value (P < 0.001).

Conclusions

The presence of liver metastases was the worst prognostic factor for patients with metastatic lung ADC. This factor should be considered as a stratification factor for future studies evaluating new cancer treatments including immunotherapy.

Key points

Significant findings of the study

Regression analysis identified poor prognostic factors for overall survival. Factors were male sex, age ≥ 65 years, lack of family support and presence of liver, bone and brain metastases.

Patients with liver metastasis showed the highest HR (HR = 1.45 95% CI: 1.40–1.50).

This study included the highest number of adenocarcinoma patients analyzed so far (N = 46 030).

What this study adds

The presence of liver metastases should be considered as a stratification factor for future studies evaluating new cancer treatments including immunotherapy.

Racial disparities in local therapy for early stage non-small-cell lung cancer

OBJECTIVES

This study investigated disparities in the delivery of definitive therapy for early stage non-small-cell lung cancer (ESNSCLC) between Caucasian (CS) and African American (AA) populations.

METHODS

The National Cancer Data Base was queried for AA and CS patients, diagnosed with c stage I Non small cell lung cancer between 2004 and 2015. Trends in surgery, stereotactic ablative radiotherapy (SABR), or external beam radiation therapy (EBRT) were compared. Kaplan-Meier and Cox hazards models were used to compare 5-year overall survival (5YOS).

RESULTS

A total of 174,338 (90.6%) patients were CS and 18,077 (9.4%) patients were AA. AA patients were less likely to receive surgery (60.3% vs. 66.9%; p < .001) and more likely to receive EBRT (12.4% vs. 10.6%; p < .001); however, there was no significant difference in rates of SABR (8.8% vs. 9.2%; p = .066). From 2004 to 2015, the surgery rates increased for AA patients from 44.4% to 61.8% and for CS patients from 57.6% to 65.6%. AA patients had worse 5YOS on an unadjusted analysis (46.7% vs. 47.9%; p = .009). When adjusted for definitive treatment, AA patients had improved survival (hazard ratio = 0.97, 95% confidence interval = 0.94-0.99).

CONCLUSION

Improvements in the delivery of surgery and equal utilization of definitive radiation therapy are at least partially responsible for closing the survival gap between AA and CS patients with ESNSCLC.

The Positive Lymph Node Ratio Predicts Survival in T1-4N1-3M0 Non-Small Cell Lung Cancer: A Nomogram Using the SEER Database

Background: An increasing number of studies have shown that the positive lymph node ratio (pLNR) can be used to evaluate the prognosis of non-small cell lung cancer (NSCLC) patients. To determine the predictive value of the pLNR, we collected data from the Surveillance, Epidemiology, and End Results (SEER) database and performed a retrospective analysis. Methods: We collected survival and clinical information on patients with T_1-4N_1-3M₀ NSCLC diagnosed between 2010 and 2016 from the SEER database and screened them according to inclusion and exclusion criteria. X-tile software was used to obtain the best cut-off value for the pLNR. Then, we randomly divided patients into a training set and a validation set at a ratio of 7:3. Pearson's correlation coefficient, tolerance and the variance inflation factor (VIF) were used to detect collinearity between variables. Univariate and multivariate Cox regression analyses were used to identify significant prognostic factors, and nomograms was constructed to visualize the results. The concordance index (C-index), calibration curves, and decision curve analysis (DCA) were used to assess the predictive ability of the nomogram. We divided the patient scores into four groups according to the interquartile interval and constructed a survival curve using Kaplan-Meier analysis. Results: A total of 6,245 patients were initially enrolled. The best cut-off value for the pLNR was determined to be 0.55. The nomogram contained 13 prognostic factors, including the pLNR. The pLNR was identified as an independent prognostic factor for both overall survival (OS) and cancer-specific survival (CSS). The C-index was 0.703 (95% CI, 0.695-0.711) in the training set and 0.711 (95% CI, 0.699-0.723) in the validation set. The calibration curves and DCA also indicated the good predictability of the nomogram. Risk stratification revealed a statistically significant difference among the four groups of patients divided according to quartiles of risk score. Conclusion: The nomogram containing the pLNR can accurately predict survival in patients with T_1-4N_1-3M₀ NSCLC.

Construction of a nomogram to predict the prognosis of non-small-cell lung cancer with brain metastases

Patients with non-small-cell lung cancer (NSCLC) often have a poor prognosis when brain metastases (BM) occur. This study aimed to evaluate the prognostic factors of BM in newly diagnosed NSCLC patients and construct a nomogram to predict the overall survival (OS).We included NSCLC patients with BM newly diagnosed from 2010 to 2015 in Surveillance, Epidemiology, and End Results database. The independent prognostic factors for NSCLC with BM were determined by Cox proportional hazards regression analysis. We then constructed and validated a nomogram to predict the OS of NSCLC with BM.We finally included 4129 NSCLC patients with BM for analysis. Age, race, sex, liver metastasis, primary site, histologic type, grade, bone metastasis, T stage, N stage, surgery, chemotherapy, and lung metastasis were identified as the prognostic factors for NSCLC with BM and integrated to establish the nomogram. The calibration, receiver operating characteristic curve, and decision curve analyses also showed that the clinical prediction model performed satisfactorily in predicting prognosis.A clinical prediction model was constructed and validated to predict individual OS for NSCLC with BM. The establishment of this clinical prediction model has great significance for clinicians and individuals.

Black patients referred to a lung cancer screening program experience lower rates of screening and longer time to follow-up

BACKGROUND

Racial disparities are well-documented in preventive cancer care, but they have not been fully explored in the context of lung cancer screening. We sought to explore racial differences in lung cancer screening outcomes within a lung cancer screening program (LCSP) at our urban academic medical center including differences in baseline low-dose computed tomography (LDCT) results, time to follow-up, adherence, as well as return to annual screening after additional imaging, loss to follow-up, and cancer diagnoses in patients with positive baseline scans.

METHODS

A historical cohort study of patients referred to our LCSP was conducted to extract demographic and clinical characteristics, smoking history, and lung cancer screening outcomes.

RESULTS

After referral to the LCSP, blacks had significantly lower odds of receiving LDCT compared to whites, even while controlling for individual lung cancer risk factors and neighborhood-level factors. Blacks also demonstrated a trend toward delayed follow-up, decreased adherence, and loss to follow-up across all Lung-RADS categories.

CONCLUSIONS

Overall, lung cancer screening annual adherence rates were low, regardless of race, highlighting the need for increased patient education and outreach. Furthermore, the disparities in race we identified encourage further research with the purpose of creating culturally competent and inclusive LCSPs.

Screening Adherence in the Veterans Administration Lung Cancer Screening Demonstration Project

BACKGROUND

Adherence to annual low-dose CT was 95% in the National Lung Screening Trial and must be replicated to achieve mortality benefit from screening.

RESEARCH QUESTION

How do we determine adherence rates within the Veterans Affairs Lung Cancer Screening Demonstration Project and identify factors predictive of adherence?

STUDY DESIGN AND METHODS

A secondary data analysis of the Lung Cancer Screening Demonstration Project that was conducted at eight Veterans Affairs medical centers was performed to determine adherence to follow up imaging and to determine factors predictive of adherence.

RESULTS

A total of 2,103 patients were screened. The adherence to screening from baseline scan (T0) to first follow-up scan (T1) was 82.2% and 65.2% from T1 to second follow-up scan (T2). Logistic regression modeling showed that presence of a nodule and the site of lung cancer screening were predictive of adherence. After three rounds of screening, 1,343 patients (64%) who underwent baseline screening underwent both subsequent annual low-dose CT scans; 225 patients (11%) had only one subsequent low-dose CT; 0.4% did not have a T1 scan but did have a T2 scan; 70 patients (3%) died, and 36 patients (1.7%) were diagnosed with lung cancer. There was significant variation in screening adherence across the eight sites, which ranged from 63% to 94% at T1 and 52% to 82% at T2 (P < .05).

INTERPRETATION

Despite a centralized program design with dedicated navigator and registry to assist with adherence to annual lung cancer screening, variations between sites suggest that active follow-up strategies are needed to optimize adherence. For the mortality benefit from lung cancer screening to be recognized, adherence to annual screening must achieve higher rates.

Racial and Insurance-related Disparities in Delivery of Immunotherapy-type Compounds in the United States

Racial and/or socioeconomic factors affect the type of therapies delivered for non-small cell lung cancer (NSCLC). Given the rapid expansion of immunotherapy for NSCLC, it is a crucial public health priority to evaluate disparities in administration thereof. The National Cancer Database (NCDB) was queried for newly diagnosed metastatic NSCLC. Patients were dichotomized based on receipt of immunotherapy-type compounds (ICs) based on NCDB coding. Multivariable logistic regression ascertained factors associated with IC delivery. Subgroup analysis, performed by univariate logistic regression modeling, evaluated the effect of race while stratifying for insurance type. Of 504,447 patients, 11,420 (2.3%) received ICs, and 493,027 (97.7%) did not. From 2004 to 2012, ≤1% of patients received ICs; however, 4.9% did so in 2013, 6.6% in 2014, and 8.7% in 2015. ICs were more likely administered to younger and healthier patients, those living farther from treating facilities, and in more educated areas (P<0.05 for all). ICs were more often delivered to adenocarcinomas, and patients who received chemotherapy but not radiotherapy (P<0.05 for all). In addition to geographic differences, uninsured and Medicaid populations received ICs less often, along with African Americans. On subgroup analysis, African Americans were less likely to receive ICs even when stratified for Medicare, Medicaid, or private insurances. Because IC utilization is expected to amplify even further going forward, these public health and economic issues are essential to identify and address appropriately, and have implications on pharmaceutical/insurance companies, value-based oncology, and public health policy. Methods to address these inequalities are also discussed.

Racial Differences in Treatment and Survival among Veterans and Non-Veterans with Stage I NSCLC: An Evaluation of Veterans Affairs and SEER-Medicare Populations

BACKGROUND

Surgery is the preferred treatment for stage I non-small cell lung cancer (NSCLC), with radiation reserved for those not receiving surgery. Previous studies have shown lower rates of surgery among Blacks with stage I NSCLC than among Whites.

METHODS

Black and White men ages ≥65 years with stage I NSCLC diagnosed between 2001 and 2009 were identified in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database and Veterans Affairs (VA) cancer registry. Logistic regression and Cox proportional hazards models were used to examine associations between race, treatment, and survival.

RESULTS

Among the patients in the VA (n = 7,895) and SEER (n = 8,744), the proportion of Blacks was 13% and 7%, respectively. Overall, 16.2% of SEER patients (15.4% of Whites, 26.0% of Blacks) and 24.5% of VA patients received no treatment (23.4% of Whites, 31.4% of Blacks). In both cohorts, Blacks were less likely to receive any treatment compared with Whites [ORadj = 0.57; 95% confidence interval (CI), 0.47-0.69 for SEER-Medicare; ORadj = 0.68; 95% CI, 0.58-0.79 for VA]. Among treated patients, Blacks were less likely than Whites to receive surgery only (ORadj = 0.57; 95% CI, 0.47-0.70 for SEER-Medicare; ORadj = 0.73; 95% CI, 0.62-0.86 for VA), but more likely to receive chemotherapy only and radiation only. There were no racial differences in survival.

CONCLUSIONS

Among VA and SEER-Medicare patients, Blacks were less likely to get surgical treatment. Blacks and Whites had similar survival outcomes when accounting for treatment.

IMPACT

This supports the hypothesis that equal treatment correlates with equal outcomes and emphasizes the need to understand multilevel predictors of lung cancer treatment disparities.

Disparities in guideline-concordant treatment for node-positive, non-small cell lung cancer following surgery

OBJECTIVES

To examine guideline concordance across a national sample and determine the relationship between socioeconomic factors, use of recommended postoperative adjuvant therapy, and outcomes for patients with resected pN1 or pN2 non-small cell lung cancer.

METHODS

All margin-negative pT1-3 N1-2 M0 non-small cell lung cancers treated with lobectomy or pneumonectomy without induction therapy in the National Cancer Database between 2006 and 2013 were included. Use of guideline-concordant adjuvant treatment, defined as chemotherapy for pN1 disease and chemotherapy with or without radiation for pN2 disease, was examined. Multivariable regression models were developed to determine associations of clinical factors with guideline adherence. Survival was estimated using Kaplan-Meier and Cox proportional hazard analyses.

RESULTS

Of 13,462 patients, 10,113 had pN1 disease and 3349 had pN2 disease. Guideline-concordant adjuvant therapy was used in 6844 (67.7%) patients with pN1 disease and 2622 (78.3%) patients with pN2 disease. After multivariable adjustment, insurance status, older age, pneumonectomy, readmission, and longer postoperative stays were associated with lower likelihood of guideline concordance. Conversely, increased education level, later year of diagnosis, and greater nodal stage were associated with greater concordance. Overall, patients treated with guideline-concordant therapy had superior survival (5-year survival: 51.6 vs 36.0%; hazard ratio, 0.66; 95% confidence interval, 0.62-0.70, P < .001).

CONCLUSIONS

Socioeconomic factors, including insurance status and geographic region, are associated with disparities in use of adjuvant therapy as recommended by National Comprehensive Cancer Network guidelines. These disparities significantly impact patient survival. Future work should focus on improving access to appropriate adjuvant therapies among the under insured and socioeconomically disadvantaged.

Hispanics/Latinos in the Bronx Have Improved Survival in Non-Small Cell Lung Cancer Compared with Non-Hispanic Whites

BACKGROUND

Hispanics/Latinos are a growing yet understudied population in the United States (US). Despite lower socioeconomic status, Hispanics/Latinos tend to have similar or better health outcomes than Non-Hispanic Whites (NHWs). This phenomenon has not been conclusively studied for lung cancer.

METHODS

Using a cohort of patients at Montefiore Medical Center (MMC) in the Bronx, NY, we examined factors related to lung cancer survival by race/ethnicity with an emphasis on Hispanics/Latinos. Subjects were diagnosed with non-small cell lung cancer (NSCLC) between 2004 and 2017. Demographic and clinical data were obtained from MMC's clinical systems and tumor-related information from MMC/Einstein's Cancer Registry. Survival was assessed using Cox proportional hazards modeling adjusted for clinical and sociodemographic factors including smoking. Factors related to survival within each major racial/ethnic group were examined.

RESULTS

Hispanics/Latinos experienced decreased risk of death relative to NHWs [hazard ratio (HR) = 0.70, 95% confidence interval (95%CI) 0.57-0.86] overall and by sex (males: HR = 0.78, 95%CI 0.59-1.03, females: HR = 0.61, 95%CI 0.44-0.86). Decreased risk among Hispanics/Latinos relative to NHWs was evident in never-smokers (HR = 0.55, 95%CI 0.29-1.01), ever-smokers (HR = 0.72, 95%CI 0.57-0.90), younger subjects (HR = 0.73, 95%CI 0.54-0.99), and older subjects (HR = 0.72, 95%CI 0.53-0.97). Surgery was associated with improved survival in Hispanics/Latinos (HR = 0.60, 95%CI 0.43-0.85), and smoking with worse survival (HR = 1.56, 95%CI 1.02-2.39). Survival did not differ between Non-Hispanic Blacks and NHWs.

CONCLUSIONS

In a poor urban community, Hispanics/Latinos experience improved survival from NSCLC compared to NHWs, which is not entirely explained by smoking. Future research should investigate the drivers of this benefit and differences in survival by Hispanic/Latino origin.

A nomogram for the prediction of overall survival in patients with stage II and III non-small cell lung cancer using a population-based study

As a malignant tumor with poor prognosis, accurate and effective treatment of non-small cell lung cancer (NSCLC) is crucial. To predict overall survival in patients with stage II and III NSCLC, a nomogram was constructed using data from the Surveillance, Epidemiology and End Results database. Eligible patients with NSCLC with available clinical information diagnosed between January 1, 2010 and November 31, 2015 were selected from the database, and the data were randomly divided into a training set and a validation set. Univariate and multivariate Cox regression analyses were used to identify prognostic factors with a threshold of P<0.05, and a nomogram was constructed. Harrell's concordance indexes and calibration plots were used to verify the predictive power of the model. Risk group stratification by stage was also performed. A total of 15,344 patients with stage II and III NSCLC were included in the study. The 3- and 5-year survival rates were 0.382 and 0.278, respectively. The training and validation sets comprised 10,744 and 4,600 patients, respectively. Age, sex, race, marital status, histology, grade, Tumor-Node-Metastasis T and N stage, surgery type, extent of lymph node dissection, radiation therapy and chemotherapy were identified as prognostic factors for the construction of the nomogram. The nomogram exhibited a clinical predictive ability of 0.719 (95% CI, 0.718–0.719) in the training set and 0.721 (95% CI, 0.720–0.722) in the validation set. The predicted calibration curve was similar to the standard curve. In addition, the nomogram was able to divide the patients into groups according to stage IIA, IIB, IIIA, and IIIB NSCLC. Thus, the nomogram provided predictive results for stage II and III NSCLC patients and accurately determined the 3- and 5-year overall survival of patients.

Effects of different metastasis patterns, surgery and other factors on the prognosis of patients with stage IV non-small cell lung cancer: A Surveillance, Epidemiology, and End Results (SEER) linked database analysis

The surgical treatment of patients with advanced lung cancer remains controversial. The current study aimed to identify the factors affecting the prognosis of patients with stage IV non-small cell lung cancer (NSCLC) and to clarify the surgery guidelines. A total of 27,725 patients diagnosed with stage IV NSCLC were selected from the Surveillance, Epidemiology, and End Results program between 2010 and 2013. The sex, age, ethnicity, marital status, Tumor-Node-Metastasis stage, radiation therapy received and surgical status of each patient were recorded. Patients were followed up to November 2015. Survival rates were estimated by the Kaplan-Meier method. Single- and multi-factor analyses were performed using the log-rank test and multivariate Cox regression analysis respectively. In the isolated organ metastasis cohort, patients with liver metastasis alone had the worst prognosis, with a median overall survival (OS) of 4 months (liver metastasis vs. other organ metastases; P<0.001). Patients with lung metastasis only had the best prognosis, with a median OS of 8 months (lung metastasis vs. other organ metastases; P<0.001). Furthermore, patients with only one metastasis had the best prognosis, with a median OS of 6 months (single metastasis vs. multiple-organ metastases; P<0.001). The multivariate Cox regression analysis of the isolated-organ metastasis cohort and the multiple-organ metastases cohort revealed that patients who were ≤60 years, female, married, Asian, with N₀ stage, had only bone metastasis, accepted wedge resection or lobectomy of the primary tumor, had surgical procedure to distant lymph node(s), and received beam radiation had an improved prognosis compared with the other patients. Age, sex, tumor type, ethnicity, N stage, number and type of metastatic lesions, surgical treatment of primary and metastatic lesions and radiation therapy are factors which influence the prognosis of patients with stage IV NSCLC. Furthermore, surgery may still benefit these patients.

Cancer statistics for African Americans, 2019

In the United States, African American/black individuals bear a disproportionate share of the cancer burden, having the highest death rate and the lowest survival rate of any racial or ethnic group for most cancers. To monitor progress in reducing these inequalities, every 3 years the American Cancer Society provides the estimated number of new cancer cases and deaths for blacks in the United States and the most recent data on cancer incidence, mortality, survival, screening, and risk factors using data from the National Cancer Institute, the North American Association of Central Cancer Registries, and the National Center for Health Statistics. In 2019, approximately 202,260 new cases of cancer and 73,030 cancer deaths are expected to occur among blacks in the United States. During 2006 through 2015, the overall cancer incidence rate decreased faster in black men than in white men (2.4% vs 1.7% per year), largely due to the more rapid decline in lung cancer. In contrast, the overall cancer incidence rate was stable in black women (compared with a slight increase in white women), reflecting increasing rates for cancers of the breast, uterine corpus, and pancreas juxtaposed with declining trends for cancers of the lung and colorectum. Overall cancer death rates declined faster in blacks than whites among both males (2.6% vs 1.6% per year) and females (1.5% vs 1.3% per year), largely driven by greater declines for cancers of the lung, colorectum, and prostate. Consequently, the excess risk of overall cancer death in blacks compared with whites dropped from 47% in 1990 to 19% in 2016 in men and from 19% in 1990 to 13% in 2016 in women. Moreover, the black-white cancer disparity has been nearly eliminated in men <50 years and women ≥70 years. Twenty-five years of continuous declines in the cancer death rate among black individuals translates to more than 462,000 fewer cancer deaths. Continued progress in reducing disparities will require expanding access to high-quality prevention, early detection, and treatment for all Americans.

Mortality Disparities in Racial/Ethnic Minority Groups in the Veterans Health Administration: An Evidence Review and Map

BACKGROUND

Continued racial/ethnic health disparities were recently described as "the most serious and shameful health care issue of our time." Although the 2014 US Affordable Care Act-mandated national insurance coverage expansion has led to significant improvements in health care coverage and access, its effects on life expectancy are not yet known. The Veterans Health Administration (VHA), the largest US integrated health care system, has a sustained commitment to health equity that addresses all 3 stages of health disparities research: detection, understanding determinants, and reduction or elimination. Despite this, racial disparities still exist in the VHA across a wide range of clinical areas and service types.

OBJECTIVES

To inform the health equity research agenda, we synthesized evidence on racial/ethnic mortality disparities in the VHA.

SEARCH METHODS

Our research librarian searched MEDLINE and Cochrane Central Registry of Controlled Trials from October 2006 through February 2017 using terms for racial groups and disparities.

SELECTION CRITERIA

We included studies if they compared mortality between any racial/ethnic minority and nonminority veteran groups or between different minority groups in the VHA (PROSPERO# CRD42015015974). We made study selection decisions on the basis of prespecified eligibility criteria. They were first made by 1 reviewer and checked by a second and disagreements were resolved by consensus (sequential review).

DATA COLLECTION AND ANALYSIS

Two reviewers sequentially abstracted data on prespecified population, outcome, setting, and study design characteristics. Two reviewers sequentially graded the strength of evidence using prespecified criteria on the basis of 5 key domains: study limitations (study design and internal validity), consistency, directness, precision of the evidence, and reporting biases. We synthesized the evidence qualitatively by grouping studies first by racial/ethnic minority group and then by clinical area. For areas with multiple studies in the same population and outcome, we pooled their reported hazard ratios (HRs) using random effects models (StatsDirect version 2.8.0; StatsDirect Ltd., Altrincham, England). We created an evidence map using a bubble plot format to represent the evidence base in 5 dimensions: odds ratio or HR of mortality for racial/ethnic minority group versus Whites, clinical area, strength of evidence, statistical significance, and racial group.

MAIN RESULTS

From 2840 citations, we included 25 studies. Studies were large (n ≥ 10 000) and involved nationally representative cohorts, and the majority were of fair quality. Most studies compared mortality between Black and White veterans and found similar or lower mortality for Black veterans. However, we found modest mortality disparities (HR or OR = 1.07, 1.52) for Black veterans with stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, or stroke; for American Indian and Alaska Native veterans undergoing noncardiac major surgery; and for Hispanic veterans with HIV or traumatic brain injury (most low strength).

AUTHOR'S CONCLUSIONS

Although the VHA's equal access health care system has reduced many racial/ethnic mortality disparities present in the private sector, our review identified mortality disparities that have persisted mainly for Black veterans in several clinical areas. However, because most mortality disparities were supported by single studies with imprecise findings, we could not draw strong conclusions about this evidence. More disparities research is needed for American Indian and Alaska Native, Asian, and Hispanic veterans overall and for more of the largest life expectancy gaps. Public Health Implications. Because of the relatively high prevalence of diabetes in Black veterans, further research to better understand and reduce this mortality disparity may be prioritized as having the greatest potential impact. However, other mortality disparities affect thousands of veterans and cannot be ignored.

Disparities in the surgical management of early stage non-small cell lung cancer: how far have we come?

It is currently estimated that nearly one-third of patients with newly diagnosed non-small cell lung cancer (NSCLC) have stage I-II disease on clinical evaluation. Curative-intent surgical resection has been a cornerstone of the therapeutic management of such patients, offering the best clinical and oncologic outcomes in the long-term. In 1999, Peter Bach and colleagues brought attention to racial disparities in the receipt of curative-intent surgery in the NSCLC population. In the time since this seminal study, there is accumulating evidence to suggest that disparities in the receipt of definitive surgery continue to persist for patients with early stage NSCLC. In this review, we sought to provide an up-to-date assessment of 20 years of surgical disparities literature in the NSCLC population. We summarized common and unrecognized disparities in the receipt of surgical resection for early stage NSCLC and demonstrated that demographic and socioeconomic factors such as race/ethnicity, special patient groups, income and insurance continue to impact the receipt of definitive resection. Additionally, we found that discrepancies in patient and provider perceptions of and attitudes toward surgery, access to invasive staging, distance to treatment centers and negative stigmas about lung cancer that patients experience may act to perpetuate disparities in surgical treatment of early stage lung cancer.

Patterns of Care and Survival in Stage III NSCLC Among Black and Latino Patients Compared With White Patients

BACKGROUND

Race and socioeconomic status have continued to affect the survival and patterns of care of patients with non-small-cell lung cancer (NSCLC). However, data evaluating these associations in patients with stage III disease remain limited. Therefore, we investigated the patterns of care and overall survival (OS) of black and Latino patients with locally advanced NSCLC compared with white patients, using the National Cancer Database.

MATERIALS AND METHODS

All patients with stage III NSCLC from 2004 to 2013 who had undergone external beam radiotherapy (RT) alone, RT with chemotherapy (bimodality), or RT with chemotherapy followed by surgery (trimodality) were analyzed within the National Cancer Database according to race (n = 113,945). Univariate associations among the demographic, disease, and treatment characteristics within the 3 cohorts were assessed using χ² tests. The OS between cohorts were analyzed using the log-rank test and multivariate Cox proportional hazards regression.

RESULTS

The black and Latino patients were younger at diagnosis, had lower median household incomes, and were less likely to be insured than were the white patients. The black patients were more likely to receive RT alone (19.3% vs. 18%; P < .001) and less likely to have undergone concurrent chemo-RT (53.6% vs. 56.1%; P < .001) compared with the white patients. Black patients had improved OS (P < .001). In contrast, the Latino patients had survival equivalent to that of the white patients (P = .920).

CONCLUSIONS

Despite epidemiologic differences and a propensity for less aggressive treatment, black patients with locally advanced NSCLC had better OS than white patients and Latino patients had equivalent outcomes. Additional research is needed to elucidate this finding, perhaps focusing on biological differences among the cohorts.

Persistence of racial disparities in early-stage lung cancer treatment

OBJECTIVE

Although the incidence of lung cancer has decreased over the past decades, disparities in survival and treatment modalities have been observed for black and white patients with early-stage non-small cell lung cancer, despite the fact that surgical resection has been established as the standard of care. Possible contributors to these disparities are stage at diagnosis, comorbidities, socioeconomic factors, and patient preference. This study examines racial disparities in treatment, adjusting for clinicodemographic factors.

METHODS

The Surveillance, Epidemiology, and End Results-Medicare dataset was queried to identify patients diagnosed with primary stage I non-small cell lung cancer between 1992 and 2009. Multivariable logistic regressions were performed to assess the association between race and treatment modalities within 1 year of diagnosis, adjusted for clinical and demographic factors. Adjusted Cox proportional hazards models were performed to evaluate disparities in survival, accounting for mode of treatment.

RESULTS

We identified 22,724 patients; 21,230 (93.4%) white and 1494 (6.6%) black. Black patients were less likely to receive treatment (odds ratio [OR]_adj, 0.62; 95% confidence interval [CI], 0.53-0.73) and less likely to receive surgery only when treated (OR_adj, 0.70, 95% CI, 0.61-0.79). Although univariate survival for black patients was worse, when accounting for treatment mode, there was no difference in survival (hazard ratio_adj, 0.97; 95% CI, 0.90-1.04 for all patients, hazard ratio_adj, 0.98; 95% CI: 0.90-1.06 for treated patients).

CONCLUSIONS

Treatment disparities persist, even when adjusting for clinical and demographic factors. However, when black patients receive similar treatment, survival is comparable with white patients.

Access to innovative medicines for metastatic melanoma worldwide: Melanoma World Society and European Association of Dermato-oncology survey in 34 countries

According to data from recent studies from Europe, a large percentage of patients have restricted access to innovative medicines for metastatic melanoma. Melanoma World Society and European Association of Dermato-oncology conducted a Web-based survey on access to first-line recommended treatments for metastatic melanoma by current guidelines (National Comprehensive Center Network, European Society for Medical Oncology [ESMO] and European Organization for Research and Treatment of Cancer/European Association of Dermato-oncology/European dermatology Forum) among melanoma experts from 27 European countries, USA, China, Australia, Argentina, Brazil, Chile and Mexico from September 1st, 2017 to July 1st, 2018. Data on licencing and reimbursement of medicines and the number of patient treated were correlated with the data on health expenditure per capita (HEPC), Mackenbach score of health policy performance, health technology assessment (HTA), ASCO and ESMO Magnitude of clinical benefit scale (ESMO MCBS) scores of clinical benefit and market price of medicines. Regression analysis for evaluation of correlation between the parameters was carried out using SPSS software. The estimated number of patients without access in surveyed countries was 13768. The recommended BRAFi + MEKi combination and anti-PD1 immunotherapy were fully reimbursed/covered in 19 of 34 (55.8%) and 17 of 34 (50%) countries, and combination anti-CTLA4+anti-PD1 in was fully covered in 6 of 34 (17.6%) countries. Median delay in reimbursement was 991 days, and it was in significant correlation with ESMO MCBS (p = 0.02), median market price (p = 0.001), HEPC and Mackenbach scores (p < 0.01). Price negotiations or managed entry agreements (MEAs) with national authorities were necessary for reimbursement. In conclusion, great discrepancy exists in metastatic melanoma treatment globally. Access to innovative medicines is in correlation with economic parameters as well as with healthcare system performance parameters. Patient-oriented drug development, market access and reimbursement pathways must be urgently found.