Racial Disparities in Lung Cancer: Part 2 of a Special Series

This is part 2 of a 3-part series related to the American Lung Association’s 2020 State of Lung Cancer report.

In part 1 of this 3-part series, we review findings from several recent studies investigating racial disparities in lung cancer treatment and survival, and present interviews with 2 authors of those studies regarding their findings and various aspects of this topic. In part 3, we present an interview with one of the investigators who conducted a trial to develop a system-based intervention to improve rates of curative treatment.

In part 2, we focus on the most recent State of Lung Cancer (SOLC) report by the American Lung Association (ALA), which included state-level and national-level data on lung cancer in people of color for the first time.

The SOLC data demonstrate overall improvement in early diagnosis and survival rates in patients with lung cancer. However, in line with previous research, significant gaps remain between White patients and those of other racial and ethnic groups. Compared to White patients, for example, rates of early diagnosis were 16% lower among Black patients and 13% lower among Latino patients. In addition, both Black and Indigenous patients received surgical treatment 19% less often than White patients, and Latinos were 39% more likely to receive no treatment compared to White patients. 

We discuss these disparities with Zach Jump, national director of epidemiology and statistics for the ALA and lead author of the SOLC report; and Albert Rizzo, MD, FACP, chief medical officer for the ALA.

What is known about racial and ethnic disparities in lung cancer?

Mr Jump: Historically, Black men were more likely to be diagnosed with lung cancer than White men, despite a lower smoking rate. This disparity still exists, although smoking rates for the 2 groups are now similar, mostly due to decreases among White men. Indigenous peoples also have the highest rates of commercial tobacco product use. People of color are also more likely to live in areas with high levels of air pollution, including particle pollution which increases lung cancer risk.

This report found that people of color faced worse outcomes compared to White Americans after being diagnosed with lung cancer, including a lower likelihood of being diagnosed early, undergoing surgical treatment, or receiving any form of treatment.

Nearly 1 in 6 (15.2%) patients with lung cancer do not receive any type of treatment. No one should go untreated because of lack of access to care, poor provider knowledge of cutting-edge treatments, stigma associated with lung cancer, fatalism after diagnosis, or cost of treatment. Lack of treatment rates are highest in Arizona (29.5%), New Mexico (23.8%), and California (22.9%), while lack of treatment rates are lowest in North Dakota (7.5%), Massachusetts (9.4%), and Missouri (9.5%).

What are believed to be the reasons for these disparities?

Mr Jump: The ongoing effects of systemic racism, inequities, and segregation play a role in health disparities overall. These historical inequalities contribute to poor living conditions, including asthma, tobacco use, exposures to air pollution, violence, stress, a shortage of primary care physicians in historically underrepresented communities, and lack of access to affordable, quality healthcare and nutrition. Sadly, as the 2020 SOLC illustrates, these disparities also result in poorer lung cancer patient outcomes for racial and ethnic groups.

As the nation’s longest-standing public health organization, the American Lung Association has a long history of health promotion and advocacy work to reduce health disparities — both in raising awareness of disparities and taking action to address them. So, in our work to improve the lung health of Americans, we want to reach all Americans but especially those who are most vulnerable.

What are the immediate implications for clinicians, and what long-term efforts are needed?

Dr Rizzo: Our SOLC report provides state data not previously available, with important new results on lung cancer disparities among racial and ethnic groups. We believe this report will provide policy makers, researchers, health care practitioners, and anyone committed to ending lung cancer a foundation for identifying where their state can best focus its resources to decrease the burden of lung cancer.

Through this report we believe we can empower the public with information they can leverage to start the local change we need to see. And since knowledge is power, these data can be used to galvanize policy change. 

The immediate implication for clinicians is to recognize where their particular state is lacking compared to others. Why are their patients not being diagnosed in early stages compared to others — do they need to help facilitate more awareness and implementation of low-dose CT [computed tomography] screening? Why are their patients not being offered treatment as frequently as they should be — is it stigma, lack of access to care, inadequate shared decision making processes?

So, clinicians need to realize that some things can improve based on how they care for patients on a day-to-day basis, but other larger factors will require them to be active, vocal advocates for policy changes with regard to access to care, insurance coverage, resources to track data accurately, and more attention paid to breaking down equity barriers for those communities of color and socioeconomically deprived populations in their states.

Are there any further points you would like to mention about the topic?

Mr Jump: Screening gives us the opportunity to catch lung cancer earlier, when it’s more likely to be curable. Lung cancer screening gives us hope and represents an opportunity to save lives and turn the tide against this horrible disease.

In 2019, more than one-half million people at high risk (558,000) were screened for lung cancer, although this comprised only 5.7% of those recommended for annual screenings. Improving the screening rate would lead to more early diagnoses when surgery is more likely to be a curable treatment option.

Screening rates were best in Massachusetts (18.5%), Vermont (13.8%), and New Hampshire (12.1%), and rates were worst in New Mexico (1.6%), California (1.2%), and Nevada (1.0%).

If everyone at high risk were screened, close to 48,000 lives would be saved. States that cover screening through fee-for-service Medicaid have a higher screening rate. Medicare, most private insurance plans, and the majority of state fee-for-service Medicaid programs cover screening. However, more can be done to improve coverage, remove barriers, and educate patients and providers about screening.

Reference

American Lung Association. State of Lung Cancer 2020 Report. Published November 17, 2020. Accessed January 8, 2021. https://www.lung.org/research/state-of-lung-cancer