Racial and Ethnic Disparities in Early-Stage Lung Cancer Survival

doi:10.1016/j.chest.2017.03.059

Chest

Volume 152, Issue 3, September 2017, Pages 587-597

https://doi.org/10.1016/j.chest.2017.03.059 Get rights and content

Background

Black patients with lung cancer diagnosed at early stages—for which surgical resection offers a potential cure—experience worse overall survival than do their white counterparts. We undertook a population-based study to estimate the racial and ethnic disparity in death from competing causes and assessed its contribution to the gap in overall survival among patients with early-stage lung cancer.

Methods

We collected survival time data for 105,121 Hispanic, non-Hispanic Asian, non-Hispanic black, and non-Hispanic white patients with early-stage (IA, IB, IIA, and IIB) lung cancer diagnosed between 2004 and 2013 from the Surveillance, Epidemiology, and End-Results registries. We modeled survival time using competing risk regression and included as covariates sex, age at diagnosis, race/ethnicity, stage at diagnosis, histologic type, type of surgical resection, and radiation sequence.

Results

Adjusting for demographic, clinical, and treatment characteristics, non-Hispanic blacks experienced worse overall survival compared with non-Hispanic whites (adjusted hazard ratio [aHR], 1.05; 95% CI, 1.02-1.08), whereas Hispanics and non-Hispanic Asians experienced better overall survival (aHR, 0.93; 95% CI, 0.89-0.98; and aHR, 0.82; 95% CI, 0.79-0.86, respectively). Worse survival from competing causes of death, such as cardiovascular disease and other cancers—rather than from lung cancer itself—led to the disparity in overall survival among non-Hispanic blacks (adjusted relative risk, 1.07; 95% CI, 1.02-1.12).

Conclusions

Narrowing racial and ethnic disparities in survival among patients with early-stage lung cancer will rely on more than just equalizing access to surgical resection and will need to include better management and treatment of smoking-related comorbidities and diseases.

Section snippets

Methods

We obtained survival time data for patients with lung cancer from the Surveillance, Epidemiology, and End-Results (SEER) 18 registry database from 2004 to 2013. The SEER 18 registries, which cover approximately 25% of the US population, form the largest, most representative, and longest running national cancer incidence database. We analyzed 105,121 Hispanic, non-Hispanic Asian and Pacific Islander (hereafter referred to as Asian), non-Hispanic black (hereafter referred to as black), and

Patient Characteristics

Between 2004 and 2013, 4,412 Hispanic, 4,833 Asian, 10,038 black, and 85,838 white patients residing in SEER registry areas were diagnosed with stage IA, IB, IIA, or IIB lung cancer (early stage) (Table 1). The modal age at diagnosis was 70 to 74 years for Hispanics, Asians, and whites and 65 to 69 years for blacks. The proportion of patients with early-stage lung cancer diagnosed as stage IA was highest for whites (46%) and lowest for blacks (41%). Finally, adenocarcinoma was the most commonly

Discussion

Our study assessed racial and ethnic disparities in survival, both overall and by cause (lung cancer and all other diseases) among patients with early-stage lung cancer. First, surgery was recommended less often for black patients with early-stage lung cancer than for other racial/ethnic groups. Second, black patients with early-stage lung cancer who received lung cancer surgery still experienced worse overall survival than did their whites counterparts. Third, the source of this disparity in

Conclusions

We found that worse survival from competing causes of death, rather than from lung cancer itself, led to disparities in overall survival among black and white patients with early-stage lung cancer. In contrast, better survival from competing causes of death led to the overall survival advantage of Hispanic and Asian patients with early-stage lung cancer compared with their white counterparts. Narrowing racial disparities in survival among patients with early-stage lung cancer will rely on more

Acknowledgments

Author contributions: S. S., G. A. S., N. T. T., C. S. L., and W. B. were involved in the study design and preparation of the article. S. S. was involved in the data collection and statistical analysis.

Financial/nonfinancial disclosures: None declared.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

References (72)

T.W. Shields
Surgical therapy for carcinoma of the lung
Clin Chest Med
(1993)
B. Balduyck et al.
Quality of life evolution after lung cancer surgery: a prospective study in 100 patients
Lung Cancer
(2007)
M. Kates et al.
Survival following lobectomy and limited resection for the treatment of stage I non-small cell lung cancer <=1 cm in size: a review of SEER data
Chest
(2011)
L. Paoletti et al.
A decade of advances in treatment of early-stage lung cancer
Clin Chest Med
(2011)
M.A. Harrison et al.
Racial disparity in in-hospital mortality after lobectomy for lung cancer
Am J Surg
(2015)
A.M. Morris et al.
Understanding racial disparities in cancer treatment and outcomes
J Am Coll Surg
(2010)
S.-H.I. Ou et al.
Asian ethnicity is a favorable prognostic factor for overall survival in non-small cell lung cancer (NSCLC) and is independent of smoking status
J Thorac Oncol
(2009)
Å. Helland et al.
EGFR gene alterations in a Norwegian cohort of patients with lung cancer selected for surgery
J Thorac Oncol
(2011)
C.D. Williams et al.
Impact of race on treatment and survival among U.S. veterans with early-stage lung cancer
J Thorac Oncol
(2016)
G.A. Bacio et al.
Differences in quit attempts between non-hispanic black and white daily smokers: the role of smoking motives
Addict Behav
(2014)

A.H. Levinson et al.

Latinos report less use of pharmaceutical aids when trying to quit smoking

Am J Prev Med

(2004)

A.H. Levinson et al.

An exploration of Latino smokers and the use of pharmaceutical aids

Am J Prev Med

(2006)

R.R. German et al.

The accuracy of cancer mortality statistics based on death certificates in the United States

Cancer Epidemiol

(2011)

L.E. Barker et al.

Geographic distribution of diagnosed diabetes in the U.S.: a diabetes belt

Am J Prev Med

(2011)

A. Bollig-Fischer et al.

Racial diversity of actionable mutations in non-small cell lung cancer

J Thorac Oncol

(2015)

N. Howlader et al.

SEER cancer statistics review, 1975-2012

(2015)

H.P. Greenwald et al.

Social factors, treatment, and survival in early-stage non-small cell lung cancer

Am J Public Health

(1998)

P.B. Bach et al.

Racial differences in the treatment of early-stage lung cancer

N Engl J Med

(1999)

J.P. Wisnivesky et al.

Ethnic disparities in the treatment of stage I non-small cell lung cancer

Am J Respir Crit Care Med

(2005)

C.S. Lathan et al.

Racial composition of hospitals: effects on surgery for early-stage non-small-cell lung cancer

J Clin Oncol

(2008)

D. Hardy et al.

Racial disparities and treatment trends in a large cohort of elderly black and white patients with nonsmall cell lung cancer

Cancer

(2009)

S. Cykert et al.

Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer

JAMA

(2010)

D.S. Ettinger et al.

NCCN non-small-cell lung cancer practice guidelines

J Natl Compr Canc Netw

(1996)

W.K. Lam

Management of non-small cell lung cancer according to staging—an update

Respirology

(1998)

S. Colby et al.

Projections of the size and composition of the U.S. population: 2014 to 2060

(2014)

J.P. Fine et al.

A proportional hazards model for the subdistribution of a competing risk

J Am Stat Assoc

(1999)

L. Scrucca et al.

Competing risk analysis using R: an easy guide for clinicians

Bone Marrow Transpl

(2007)

L. Scrucca et al.

Regression modeling of competing risk using R: an in depth guide for clinicians

Bone Marrow Transpl

(2010)

T.D. Yan et al.

Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non–small-cell lung cancer

J Clin Oncol

(2009)

P.B. Bach et al.

The influence of hospital volume on survival after resection for lung cancer

N Engl J Med

(2001)

F.L. Lucas et al.

Race and surgical mortality in the United States

Ann Surg

(2006)

J. Dimick et al.

Black patients more likely than whites to undergo surgery at low-quality hospitals in segregated regions

Health Aff (Millwood)

(2013)

M.I. Patel et al.

Racial and ethnic variations in lung cancer incidence and mortality: results from the Women’s Health Initiative

J Clin Oncol

(2016 Feb 1)

R.L. Siegel et al.

Cancer statistics for Hispanics/Latinos, 2015

CA Cancer J Clin

(2015)

D. Blackwell et al.

Summary health statistics for U.S. adults: national health interview survey, 2012

(2014)

M.J. Thun et al.

Lung cancer occurrence in never-smokers: an analysis of 13 cohorts and 22 cancer registry studies

PLoS Med

(2008)

Cited by (97)

Access to Guideline Concordant Care for Node-Positive Non-Small Cell Lung Cancer in the United States
2024, Annals of Thoracic Surgery
This study sought to determine whether seeking care at multiple Commission on Cancer (CoC) hospitals is associated with different rates of receiving guideline-concordant care (GCC) among patients with non-small cell lung cancer (NSCLC).
The National Cancer Database was queried for the years 2004 to 2018 for patients with margin-negative pT1 to pT3 N1 to N2 M0 noncarcinoid NSCLC without neoadjuvant therapy. GCC was defined as chemotherapy for pN1 disease and as chemotherapy with or without radiation for pN2 disease. Patients who received care at >1 facility were examined separately. Factors previously associated with barriers to care were compared between groups. Kaplan-Meier analysis with log-rank tests analyzed 5-year overall survival (OS). Propensity score matching was performed to compare the effect sizes of race, insurance status, and income.
In total 44,531 patients met inclusion criteria, 11,980 (26.9%) of whom sought care at >1 CoC institution. Among patients with pN1 disease, 5565 (76.7%) received GCC if they visited >1 facility vs 13,995 (68.5%) patients who sought care at 1 facility (P < .001). For patients with pN2 disease, 3991 (84.4%) received GCC if they visited >1 facility vs9369 (77.4%) patients receiving care at 1 facility (P < .001). Visiting >1 facility was associated with higher OS at 5 years (4784 [54.35%] vs 10,215 [45.62%]; P < .001).
Visiting >1 CoC institution is associated with higher rates of GCC for individuals with pN1 to pN2 lung cancer. Patients who received care at >1 facility had higher OS at 5 years. Further study is warranted to identify factors associated with the ability of patients to seek care at multiple facilities.
Overall survival in low-comorbidity patients with stage I non–small cell lung cancer who chose stereotactic body radiotherapy compared to surgery
2024, Journal of Thoracic and Cardiovascular Surgery
To evaluate trends in the utilization of stereotactic body radiotherapy (SBRT) and to compare overall survival (OS) of patients with early-stage non–small cell lung cancer (NSCLC) undergoing SBRT versus those undergoing surgery.
The National Cancer Database was queried for patients without documented comorbidities who underwent surgical resection (lobectomy, segmentectomy, or wedge resection) or SBRT for clinical stage I NSCLC between 2012 and 2018. Peritreatment mortality and 5-year OS were compared among propensity score–matched cohorts.
A total of 30,658 patients were identified, including 24,729 (80.7%) who underwent surgery and 5929 (19.3%) treated with SBRT. Between 2012 and 2018, the proportion of patients receiving SBRT increased from 15.9% to 26.0% (P < .001). The 30-day mortality and 90-day mortality were higher among patients undergoing surgical resection versus those receiving SBRT (1.7% vs 0.3%, P < .001; 2.8% vs 1.7%, P < .001). In propensity score–matched patients, OS favored SBRT for the first several months, but this was reversed before 1 year and significantly favored surgical management in the long term (5-year OS, 71.0% vs 41.8%; P < .001). The propensity score–matched analysis was repeated to include only SBRT patients who had documented refusal of a recommended surgery, which again demonstrated superior 5-year OS with surgical management (71.4% vs 55.9%; P < .001).
SBRT is being increasingly used to treat early-stage lung cancer in low-comorbidity patients. However, for patients who may be candidates for either treatment, the long-term OS favors surgical management.
Disparities in Access to Multidisciplinary Cancer Consultations and Treatment for Patients With Early-Stage Non-Small Cell Lung Cancer: A SEER-Medicare Analysis
2024, International Journal of Radiation Oncology Biology Physics
Disparities in access to a multidisciplinary cancer consultation (MDCc) persist, and the role of physician relationships remains understudied. This study examined the extent to which multilevel factors, including patient characteristics and patient-sharing network measures reflecting the structure of physician relationships, are associated with an MDCc and receipt of stereotactic body radiation therapy versus surgery among patients with early-stage non-small cell lung cancer (NSCLC).
In this cross-sectional study, we analyzed Surveillance, Epidemiology, and End Results (SEER)–Medicare data for patients diagnosed with stage I-IIA NSCLC from 2016 to 2017. We assembled patient-sharing networks and identified cancer specialists who were locally unique for their specialty, herein referred to as linchpins. The proportion of linchpin cancer specialists for each hospital referral region (HRR) was calculated as a network-based measure of specialist scarcity. We used multilevel multinomial logistic regression to estimate associations between study variables and receipt of an MDCc and multilevel logistic regression to examine the relationship between patient receipt of an MDCc and initial treatment.
Our study included 6120 patients with stage I-IIA NSCLC, of whom 751 (12.3%) received an MDCc, 1729 (28.3%) consulted only a radiation oncologist, 2010 (32.8%) consulted only a surgeon, and 1630 (26.6%) consulted neither specialist within 2 months of diagnosis. Compared with patients residing in an HRR with a low proportion of linchpin surgeons, those residing in an HRR with a high proportion of linchpin surgeons had a 2.99 (95% CI, 1.87-4.78) greater relative risk of consulting only a radiation oncologist versus receiving an MDCc and a 2.70 (95% CI, 1.68-4.35) greater relative risk of consulting neither specialist versus receiving an MDCc. Patients who received an MDCc were 5.32 times (95% CI, 4.27-6.63) more likely to receive stereotactic body radiation therapy versus surgery.
Physician networks are associated with receipt of an MDCc and treatment, underscoring the potential for leveraging patient-sharing network analysis to improve access to lung cancer care.
National enrollment of lung cancer clinical trials is disproportionate based on race and health care access
2024, Journal of Thoracic and Cardiovascular Surgery
Despite declining lung cancer mortality in the United States, survival differences remain among racial and ethnic minorities in addition to those with limited health care access. Improvements in lung cancer treatment can be obtained through clinical trials, yet there are disparities in clinical trial enrollment of other cancer types. This study aims to evaluate disparities in lung cancer clinical trial enrollment to inform future enrollment initiatives.
We analyzed patients with non–small cell lung cancer from the National Cancer Database (2004-2018), categorizing them as enrolled or not enrolled in clinical trials based on “rx_summ_other” data element. Clinical, demographic, and institutional factors associated with trial enrollment were assessed using bivariate and multivariate analysis, adjusting for institutional-level clustering.
A total of 1924 (0.12%) patients with lung cancer were enrolled in clinical trials. Enrolled patients were predominantly non-Hispanic White (82%), with greater socioeconomic status, treated at academic programs (67%), and had private insurance (42%) or Medicare (44%). They also traveled further for treatment compared with unenrolled patients (56 vs 27 miles, P < .001). After adjusting for demographic and clinical factors, lung cancer trial enrollment was significantly less likely among Black (odds ratio, 0.55; 95% confidence interval, 0.5-0.7, P < .001) and Hispanic (0.66; 95% confidence interval, 0.5-0.9, P = .01) patients. Patients with Medicaid or uninsured, in the lowest socioeconomic status group, and those treated at community-based cancer programs were the least likely to enroll.
Enrollment in lung cancer trials disproportionally excludes minority patients, those in the lowest socioeconomic status, community cancer programs, and the underinsured. These disparities in demographic and access for trial participation show a need for improved enrollment strategies.
A decade of surgical outcomes in a structured lung cancer screening program
2023, Journal of Thoracic and Cardiovascular Surgery
Lung cancer screening can decrease mortality. The majority of screen-detected cancers are early stage and undergo surgical resection. However, there are little data regarding the outcomes of surgical treatment outside of clinical trials. The purpose of this study was to compare the outcomes of curative resection for screen-detected lung cancers with nonscreened, incidentally detected cancers at an institution with a structured screening program.
Patients undergoing lung cancer curative resection from January 2012 to June 2021 were identified from a prospective database. Baseline patient characteristics, tumor characteristics, and outcomes were compared between cancer detected from screening and cancer detected incidentally.
There were 199 patients in the incidental group and 82 patients in the screened group. Mean follow-up was 33.3 ± 25 months. The screened group had more African Americans (P = .04), a higher incidence of emphysema (P = .02), less prior cancers (P < .01), and more pack-years smoked (P < .01). The screened group had a smaller size (1.74 vs 2.31 cm, P < .01); however, pathologic stage was similar, with the majority being stage I. Postoperative morbidity, 30-day mortality, and overall and recurrence-free survival were similar between groups. Only 48.7% of the incidental group met current US Preventative Services Task Force screening criteria (age 50-80 years, ≥20 pack-year smoking history).
Screen-detected lung cancers have excellent postoperative and long-term outcomes with curative resection, similar to incidentally detected cancers. A large portion of incidentally detected lung cancers do not meet current screening guidelines, which is an opportunity for further refinement of eligibility.
Structural and Social Determinants of Inequitable Environmental Exposures in the United States
2023, Clinics in Chest Medicine

View all citing articles on Scopus

: FUNDING/SUPPORT: This work was supported by the National Institutes of Health (R21-CA197912 to S. S.) and the American Lung Association (to S. S.).

View full text

Chest

Original Research: Lung CancerRacial and Ethnic Disparities in Early-Stage Lung Cancer Survival

Background

Methods

Results

Conclusions

Section snippets

Methods

Patient Characteristics

Discussion

Conclusions

Acknowledgments

Clin Chest Med

Lung Cancer

Chest

Clin Chest Med

Am J Surg

J Am Coll Surg

J Thorac Oncol

J Thorac Oncol

J Thorac Oncol

Addict Behav

Am J Prev Med

Am J Prev Med

Cancer Epidemiol

Am J Prev Med

J Thorac Oncol

SEER cancer statistics review, 1975-2012

Social factors, treatment, and survival in early-stage non-small cell lung cancer

Am J Public Health

Racial differences in the treatment of early-stage lung cancer

N Engl J Med

Ethnic disparities in the treatment of stage I non-small cell lung cancer

Am J Respir Crit Care Med

Racial composition of hospitals: effects on surgery for early-stage non-small-cell lung cancer

J Clin Oncol

Racial disparities and treatment trends in a large cohort of elderly black and white patients with nonsmall cell lung cancer

Cancer

Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer

JAMA

NCCN non-small-cell lung cancer practice guidelines

J Natl Compr Canc Netw

Management of non-small cell lung cancer according to staging—an update

Respirology

Projections of the size and composition of the U.S. population: 2014 to 2060

A proportional hazards model for the subdistribution of a competing risk

J Am Stat Assoc

Competing risk analysis using R: an easy guide for clinicians

Bone Marrow Transpl

Regression modeling of competing risk using R: an in depth guide for clinicians

Bone Marrow Transpl

Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non–small-cell lung cancer

J Clin Oncol

The influence of hospital volume on survival after resection for lung cancer

N Engl J Med

Race and surgical mortality in the United States

Ann Surg

Black patients more likely than whites to undergo surgery at low-quality hospitals in segregated regions

Health Aff (Millwood)

Racial and ethnic variations in lung cancer incidence and mortality: results from the Women’s Health Initiative

J Clin Oncol

Cancer statistics for Hispanics/Latinos, 2015

CA Cancer J Clin

Summary health statistics for U.S. adults: national health interview survey, 2012

Lung cancer occurrence in never-smokers: an analysis of 13 cohorts and 22 cancer registry studies

PLoS Med

Original Research: Lung Cancer
Racial and Ethnic Disparities in Early-Stage Lung Cancer Survival