Racial disparities exist at ‘every step’ along continuum of lung cancer care
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As medicine as a whole reexamines the racism – implicit and explicit – within the structure of treatment and the health care system, the resulting disparities exist as focal points for all specialties, lung cancer not withstanding.
For clinicians and providers, reversing and combatting personal, and sometimes unknown or unexamined biases, on top of institutionalized and structural racism and sexism may seem daunting.
“Unfortunately, racial disparities in lung cancer incidence and mortality persist in 2021 and exist at every step along the continuum of care for lung cancer,” Yehoda M. Martei, MD, MSCE, assistant professor of medicine and vice chief of diversity, inclusion and health equity in the division of hematology and oncology at the University of Pennsylvania, told Healio. “Black men have a higher incidence of lung cancer compared with their white counterparts and have the highest lung cancer mortality among all racial and ethnic groups in the United States. Additionally, Black men have a younger median age at diagnosis and are diagnosed with more advanced-stage disease compared with their white counterparts. Of note, these disparities have been documented for both squamous cell and adenocarcinoma non-small cell lung cancers.”
Moreover, Black individuals have lower rates for lung cancer screening.
“Earlier this year, the USPSTF updated their draft screening guidelines to start at age 50 years. However, the previous USPSTF guidelines missed most Black patients with the recommendation to initiate screening with low-dose CT beginning at age 55 years,” Martei said. “We know that Black individuals present with lung cancer at a younger median age, thereby exacerbating the disparities in lung cancer presentation and outcomes. Retrospective analysis conducted using data from the Lung Cancer Screening Trial database also showed that Black patients were less likely to follow-up on positive lung cancer scan results. Furthermore, once diagnosed, even with equal insurance status, there are data showing that Black patients receive less invasive staging and are less likely to undergo surgical intervention and radiation therapy.
Contributing factors
Factors contributing to these disparities are complex and multifactorial, according to Martei.
“These factors include structural racism, which contributes to disparities in health care access, insurance status, socioeconomic status, education and health literacy,” she said. “Providers’ implicit bias also affects the way patients are treated and leads to some of these disparities as well.” More recently, the COVID-19 pandemic brought to light and intensified racial disparities that already existed across health care, including access to lung cancer care.
“Black men who had already presented with advanced-stage lung cancer prior to the pandemic are now more likely to be adversely impacted by the pandemic through stage shifting, or upstaging and worsened health care access disparities,” Martei said. “At the beginning of the pandemic, cancer care was significantly disrupted for all cancer types. We witnessed a steep decline across the board for all cancer screening modalities but specifically for lung cancer there were data recently published from the University of Cincinnati that confirmed the decrease in lung cancer screening rates.”
While lung cancer screening rates appear to have begun to trend upward, they are not at pre-pandemic levels.
“More follow-up is needed to evaluate the full impact of how these disruptions in care will impact lung cancer outcomes,” Martei said. “It is perceivable that there will be more advanced-stage disease because of delays in lung cancer screening and hence worse survival outcomes.”
Another potential factor impacting the care of Black patients with lung cancer is the ongoing shortage of Black oncologists.
“Diversity in the cancer care workforce should reflect the diversity of the patient population we treat in oncology, especially those at high risk for cancer incidence and mortality,” Martei said. “This is critical to addressing disparities along the cancer care continuum by improving patient-provider engagement, patient experience and trust, as well as improving the delivery of culturally-competent care. Furthermore, Black physicians are more likely to practice in underserved communities that experience health access challenges. Studies in other medical specialties have shown that racial concordant care can improve outcomes for Black patients, which may be similar for outcomes in cancer care. With that said, there are interventions that we can implement today to improve these disparities — in parallel to investing in the Black oncologists’ pipeline.”
Potential solutions
Borrowing from other disciplines, potential interventions include the use of patient navigation, community health care workers, development of language and culturally adapted patient education materials on lung cancer screening and treatment, Martei said.
“There is a deficit of implementing science research on potential interventions and protocols that are evidence-based and specifically address disparities in lung cancer screening, care, delivery and outcomes. At the institutional level, health equity dashboards should be developed to evaluate equity in lung cancer care delivery,” she added. “These are important not only for identifying health care delivery gaps, but also to help identify communities at high risk for worse outcomes and the specific needs of these communities. These data can then guide community partnerships and interventions to improve community engagement.”
Provider education is also needed.
“Unique to lung cancer compared with other cancer types that we currently screen for are increased stigma and treatment nihilism among providers,” Martei said. “Provider education is needed to address this, especially in the changing therapeutic landscape with the approval of newer targeted medicines and improving lung cancer survival outcomes.”
Opportunity to enact change
Lung cancer mortality is declining in the U.S. due to the availability of newer targeted agents. However, racial disparities also exist in enrollment on the exact clinical trials testing these agents.
“Unfortunately, lack of access to newer therapies that disproportionately affect Black patients may only widen the disparities in mortality,” Martei said. “There is an opportunity here to enact changes that could potentially improve outcomes for these patients, especially Black men who have the worst lung cancer survival among all racial and ethnic groups. It is important for oncologists across institutions to begin to develop a health equity dashboard to strategize and review internally the quality of care and racial and ethnic disparities in treatment outcomes across institutions so that we can use the data to create solutions that specifically target the communities that we serve.”
For more information:
Yehoda M. Martei, MD, MSCE, can be reached at Yehoda.martei@pennmedicine.upenn.edu.
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