Racial Disparities in Lung Cancer: Part 3 of a Special Series

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

In parts 1 and 2 of this 3-part series, we described findings from several recent studies examining racial disparities in lung cancer treatment and survival, as well as the American Lung Association’s State of Lung Cancer report. We also interviewed several experts to glean further insights.

For this final installment, we interviewed Samuel Cykert, MD, professor of medicine in the division of general internal medicine and clinical epidemiology at the University of North Carolina at Chapel Hill (UNC-CH), and director of the UNC School of Medicine Program on Health and Clinical Informatics.

In a 2019 study published in Cancer Medicine, Dr Cykert and colleagues from UNC-CH and several other universities conducted a 5-year pragmatic trial across 5 cancer centers to test a system-based intervention to improve rates of curative treatment (surgical resection or stereotactic radiation) among Black patients with stage I and II lung cancer. The study included 360 patients (32% Black) in the intervention group and 2841 patients (16% Black) in the retrospective control group.¹

The findings showed crude treatment rates of 69% for Black patients vs 78% for White patients (P <.001) in the retrospective group, compared to 96.5% and 95%, respectively (P =.56), in the intervention group. An adjusted analysis revealed an odds ratio of 2.1 (95% CI, 0.41‐10.4; P =.39) for Black vs White patients in the intervention group, which confirms treatment parity of the approach used, according to Dr Cykert et al.

Dr Cykert discussed these findings and additional points in the following interview.

What is known about racial disparities in lung cancer between Black patients and White patients?

The risk factors for Black and White patients are no different, except recent analyses of the Southern Community Cohort and other groups show Black patients tend to smoke less per day and start later than White patients but get lung cancer more often at younger ages.² This finding is important because the recommendations for screening computerized tomography (CT) scans for lung cancer were based on a study that enrolled very few Black patients, and the criteria derived from the study (ages 55-74 with ≥30 pack- year smoking history) would only include one-third of Black smokers likely to get lung cancer.³

In addition, early looks at who gets screened for lung cancer show populations that are overwhelmingly White despite the fact that Black men die of lung cancer nearly 20% more than any other group.⁴ Also of note, there is a 30-plus year history of Black patients not getting surgery for cure for early-stage lung cancer, with an associated higher mortality rate because of this. Recent studies show that Black patients with early-stage disease get less stereotactic radiation for cure and, in the area of precision medicine, Black patients with advanced disease get less biomarker testing and less therapy with biologic agents in situations where cancer can be controlled for longer periods and survival prolonged.

In summary, Black patients are more susceptible to the carcinogenic effects of smoking, lung cancer screening criteria for low radiation CT exclude two-thirds of susceptible patients, the screening test is ordered less frequently, and treatment for lung cancer is less aggressive.³ 

What are believed to be the reasons for these disparities?

It is currently not known why it seems that Black patients are more susceptible to tobacco smoke. It may be because of the biologic effects of experienced racism or because of the result of environmental factors — for example, many Black neighborhoods are affected more profoundly by pollution than White neighborhoods.

Regarding diagnosis and treatment, many studies have shown that staging tests and treatment for lung cancer occur less often in Blacks than Whites even when the analyses are controlled for comorbid illness, health insurance, age, and income. In a study that we published in the Journal of the American Medical Association in 2010, we showed that Black patients with 2 or more comorbidities, such as coronary artery disease and moderate renal insufficiency, almost never received surgery while White patients still did.⁵

This finding, combined with our physician survey results, showed that non-Black physicians were less willing to administer risky treatments to patients that they did not feel comfortable with. This approach represents an implicit bias in that, with patients who had moderate instead of absolute contraindications for surgery, the default in Black patients tended to be toward less aggressive treatment.⁵

Also, Black patients who did not have a primary care physician tended to be lost to follow-up more frequently than White patients, suggesting a lack of a systematic approach to engage or re-engage patients who either might be in denial or not understand the severity of their diagnosis.⁵  

What are the immediate implications for clinicians, and what long-term efforts are needed — including approaches like the one used in your study?

The implications are that we all suffer from implicit biases and these affect us most prominently when we are in gray areas of our decision-making. Our group partnered with a diverse community group called the Greensboro Health Disparities Collaborative, and their suggestions to offset these systematic disparities were to have real-time transparency in care, accountability among the care givers, and better communication with patients. We performed a study to operationalize these concepts.¹

First, we built a real-time registry that did 2 things. If a patient missed an appointment, a warning came up that the patient needed to re-engaged. However, because of our findings that not all patients progressed in their care journey, we worked with clinicians to program expected milestones of care in the system. So, if a patient was coming for all their treatments but they were not scheduled for their PET [positron emission tomography] scan, biopsy, or surgery in a timely manner, a warning about clinical inertia was generated.¹

When a missed appointment occurred, we had a specially trained navigator activated to engage the patient to overcome typical barriers to care like cost or transportation, but also to engage on barriers that might be more race specific like distrust or an experience of perceived racism. When the warning about clinical inertia came up, we had the navigator or a physician champion engage the cancer care team to reassess the pace and completeness of care. This warning system is the real-time transparency part, and the navigator represents the enhanced communication.¹

For accountability, we used race-specific audit and feedback on a quarterly basis to inform the clinical teams about how their White and Black patients were doing in terms of their completion of care. This intervention erased an 8 percentage-point care completion gap between Black and White patients and markedly improved care for everyone.¹

This solution is very pragmatic. First, the universal use of Electronic Health Records (EHRs) makes programing of the real-time registry extremely doable and cost-effective. Second, almost all cancer centers are hiring navigators, so training these navigators and physician champions about implicit bias and race-specific barriers is pretty economic. Third, everyone is developing a quality improvement/learning health system culture, so the race-specific audit and feedback approach fits into this environment. These same methods could be used for the tests and treatments recommended for advanced cancer.

On the diagnostic side, we need to adjust the lung cancer screening criteria to account for the different epidemiology on smoking risk for Black patients. We also need to come up with systems of more consistent ordering, outreach, and smoking cessation programs that engage Black men — the highest-risk group for death from lung cancer.⁴

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

Community input is invaluable in seeking solutions and creating accountability for disparities. I give special credit to my co-principal investigator Geni Eng, DrPH, who is an expert in community-based participatory research, and the Greensboro Health Disparities Collaborative who remains engaged in this work. Both UNC and Cone Health are building this solution for their cancer center in their EHRs.

References

1. Cykert S, Eng E, Walker P, et al. A system-based intervention to reduce Black-White disparities in the treatment of early stage lung cancer: a pragmatic trial at five cancer centers. Cancer Med. 2019;8(3):1095-1102. doi:10.1002/cam4.2005
2. Aldrich MC, Mercaldo SF, Sandler KL, Blot WJ, Grogan EL, Blume JD. Evaluation of USPSTF Lung Cancer Screening Guidelines among African American adult smokers. JAMA Oncol. 2019;5(9):1318-1324. doi:10.1001/jamaoncol.2019.1402
3. National Institutes of Health – National Cancer Institute. Study suggests reviewing lung cancer screening criteria for African Americans.Published July 31, 2019. Accessed December 18, 2020.https://www.cancer.gov/news-events/cancer-currents-blog/2019/lung-cancer-screening-criteria-african-americans
4. American Cancer Society. Cancer Facts & Figures for African Americans, 2019-2021. Atlanta: American Cancer Society, 2019. Accessed January 8, 2021. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-african-americans/cancer-facts-and-figures-for-african-americans-2019-2021.pdf
5. Cykert S, Dilworth-Anderson P, Monroe MH, et al. Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer. JAMA. 2010;303(23):2368-2376. doi:10.1001/jama.2010.79