In early-stage NSCLC, it has been documented in cancer epidemiology studies that cancer mortality rates are higher in black patients. Why is this? Several possible mechanisms may be at play. First, racial and ethnic minorities are more likely to present for healthcare with their disease at a more advanced stage. However, when controlling for advanced stage and other factors, persistent differences in cancer survival exist. Another possible mechanism could be that standardized treatments may have differential efficacy across patient demographics. In NSCLC, this has been debunked by at least two studies, one from the Veterans Affairs health system, and the other from SWOG. The mechanism that Dr. Esnaola focused much of the rest of his talk on is a failure to provide optimal cancer treatment.
To illustrate differences in cancer treatment utilization, Dr. Esnaola reviewed that surgical resection of the primary tumor can be curative for a large proportion of early-stage NSCLC patients. Two data sets suggest that there are lower rates of surgical resection in black patients relative to white patients, with the numbers shown below, even when controlling for other factors.
What are the factors underlying the underuse of cancer treatments? These were divided into patient factors such as misconceptions about cancer and treatment as well as patient preferences, and health care system factors such as access to care, physician-patient communication, and physician beliefs and biases.
With regards to patient misconceptions about cancer and his treatment, Dr. Esnaola discussed that this is actually quite common and drives patient decision-making. He highlighted a study1 showing that 45% of patients in the Carolinas believed that lung surgery causes lung cancer to spread, and this belief was associated with subsequent failure to undergo resection. That same study also illustrated black patients were more likely to believe that their quality of life would be worse a year after surgery relative to white patients, and this was also associated with subsequent failure to undergo resection. This belief persists in patients despite data to the contrary.
The main healthcare system factor discussed was access to care. Medicare data suggests that black patients tend either not to have primary care physicians or be cared for by PCPs with more limited access to specialists, ancillary services, and high-quality imaging services, which may explain lower rates of undergoing thoracic resection. Data suggests that in at least one equal access care system (Veterans Affairs), equivalent rates of white and black patients received appropriate therapy for their lung cancer, albeit in a more advanced disease state. Interestingly, in another potential equal care coverage situation (Medicare), researchers uncovered lower rates of surgical resection for black patients with NSCLC even after a surgical consultation was done and invasive staging with mediastinoscopy was completed.2
Further work is required to understand how suboptimal physician/patient encounters could contribute to disparities. Part of this may result from physician failure to adequately acknowledge or weigh the values and beliefs of a patient. One example is religiosity, an extreme example of which are patients who believe that faith alone cures cancer. Many minority patients also believe that they are going to receive worse medical care because of their race, which makes them less likely to follow the advice of their physicians.
Minority patients also likely have suboptimal access to physicians with specialized knowledge and expertise. As an example, one study from South Carolina found that over half of lung lobectomies and thoracotomies for lung cancer were performed by general surgeons rather than thoracic surgeons, which was associated with a higher risk of perioperative mortality. Additionally, it may be more difficult for minority patients to commute into “high volume” centers of care, limiting their access to the most experienced and focused care providers.
To understand how to address cancer disparities, the most important first step is to survey patients who receive disparate care. This can help identify reasons for mistrust in the system, as well as clarify measures like transportation assistance or patient testimonials that may promote trust in an intervention. One potential intervention is the use of patient navigation, which is based on social support theory to focus on overcoming barriers to ensure timely and efficient access to needed health services. Dr. Esnaola is a principal investigator on a randomized controlled trial comparing usual care to patient navigation for individuals diagnosed with NSCLC.
Dr. Esnaola summarized that while we have learned much, future studies to identify modifiable patient and health care system factors that promote disparities and intervene on them remain needed.
Presented by: Nestor F. Esnaola, MD, Professor of Surgery and Associate Director, Cancer Control and Population Science, Houston Methodist Cancer Center, Houston, TX
Written by: Alok Tewari, MD, PhD, Medical Oncologist at the Dana-Farber Cancer Institute, at the 2021 American Society of Clinical Oncology (ASCO) Annual Meeting, Virtual Annual Meeting #ASCO21, June, 4-8, 2021
- Samuel Cykert, Peggye Dilworth-Anderson, Michael H. Monroe, et al. "Factors Associated With Decisions to Undergo Surgery Among Patients With Newly Diagnosed Early-Stage Lung Cancer." JAMA. 2010;303(23):2368-2376.
- Christopher S. Lathan, Bridget A. Neville, Craig C. Earle et al. "The Effect of Race on Invasive Staging and Surgery in Non–Small-Cell Lung Cancer." Journal of Clinical Oncology. 2006. 413-418.