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1414 Racial ethnic differences in treatment of advanced non-small cell lung cancer with immune checkpoint inhibitors: analysis of a large real-world dataset
  1. Laura Oswald1,
  2. L Robert Gore1,
  3. Melanie Buhlmann1,
  4. Naomi Brownstein2,
  5. Kea Turner1,
  6. Andreas Saltos1,
  7. Jhanelle Gray1,
  8. Shirish Gadgeel3,
  9. Clement Gwede1,
  10. Susan Vadaparampil1,
  11. Brian Gonzalez1 and
  12. Heather Jim1
  1. 1Moffitt Cancer Center, Tampa, FL, USA
  2. 2Medical University of South Carolina, Charleston, SC, USA
  3. 3Henry Ford Cancer Center, Detroit, MI, USA


Background Immunotherapy is a promising treatment for advanced non-small cell lung cancer (advNSCLC), with several immune checkpoint inhibitors (ICIs) FDA-approved since 2015. As ICI indications expand, disparities in treatment selection could result in disparate lung cancer mortality. This study examined differences in ICI treatment by race/ethnicity using a large cohort of real-world advNSCLC patients.

Methods This study used the nationwide Flatiron Health electronic health record-derived de-identified database.1,2 Data included individuals diagnosed with advNSCLC between 2011-2021 with available treatment information. Logistic regression analyses assessed the likelihood of receiving an ICI (any line of therapy) by race/ethnicity before FDA-approval of the first ICI for advNSCLC (2011-2014) and after (2015-2021). Patients aged <65 years (younger) and 65+ (older) were assessed separately due to changes in Medicare eligibility at age 65. Significant racial/ethnic differences in ICI treatment accounting for covariates are reported as adjusted odds ratios (OR) with 95% confidence intervals. Covariates were: diagnosis year, geographic region, practice setting (academic/community), gender, age, insurance coverage within 90 days of treatment, smoking history, ECOG performance status within 60 days of diagnosis, documented biomarker testing (before ICI treatment/none), and PDL1 expressed (<1%/1%+).

Results Of 52,031 patients, most were non-Hispanic White (NHW) (68.7%) followed by unknown race/ethnicity (9.2%), Black/African American (AA) (8.6%), other race/ethnicity (8.1%), Hispanic/Latino (3.1%), and Asian (2.2%). Of patients treated before FDA-approval of ICIs for advNSCLC (N=16,219), 11.8% received ICI treatment. Relative to younger or older NHWs respectively, likelihood of ICI was higher among younger Asians (OR=1.94, 1.24-3.05) and lower among younger and older patients with unknown race/ethnicity (OR=0.50, 0.32-0.79; OR=0.45, 0.32-0.63, respectively). Of patients treated after FDA-approvals (N=35,812), 59.1% received ICI treatment. Relative to younger or older NHWs respectively, likelihood of ICI was lower among younger and older Asians (OR=0.48, 0.37-0.62; OR=0.64, 0.53-0.77, respectively), younger and older patients with unknown race/ethnicity (OR=0.83, 0.72-0.96; OR=0.77, 0.70-0.84, respectively), older Hispanic/Latinos (OR=0.85, 0.73-1.00), and older patients with other race/ethnicity (OR=0.90, 0.81-1.00).

Conclusions Most racial/ethnic disparities in ICI treatment were observed among older advNSCLC patients in the years after FDA-approval. Among younger patients, Asians were more likely than NHWs to receive an ICI before FDA-approvals, but this association reversed thereafter. Though not assessed, this was possibly due to differences in prevalence of EGFR mutations. There were no differences in likelihood of ICI treatment between Black/AAs and NHWs. These results suggest a need for concerted effort to offer all patients appropriate ICI treatment irrespective of race/ethnicity and/or age.


  1. Ma X, Long L, Moon S, Adamson BJS, Baxi SS. Comparison of Population Characteristics in Real-World Clinical Oncology Databases in the US: Flatiron Health, SEER, and NPCR. medRxiv. 2020:2020.03.16.20037143.

  2. Birnbaum B, NN Seidl-Rathkopf K, Agrawal M, Estevez M, Estola E, et al. Model-assisted cohort selection with bias analysis for generating large-scale cohorts from the EHR for oncology research 2020 [Available from:

Ethics Approval Institutional Review Board approval of the study protocol was obtained prior to study conduct and included a waiver of informed consent (WCG IRB; IRB00000533).

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