Health Inequities in Early-Stage Lung Cancer

Racial disparities in cancer care are well-documented.Although a variety of interventions have been implemented to address these disparities, the extent to which they have narrowed gaps in treatment remains an area of active research.In this context, Lynch et al 1 examined whether previously observed racial disparities in treatment of early-stage lung cancer persist in more contemporary practice.They used the Surveillance, Epidemiology, and End Results Program-Medicare database from 2005 to 2019. 1 Their primary outcome was receipt of curative therapy, defined as either surgical resection or radiotherapy, with a secondary outcome of receiving preferred treatment, defined as either lobectomy or stereotactic body radiation therapy (SBRT).Using multivariable analysis, the authors adjusted for race, year of diagnosis, a race-year interaction term, variables reflecting access to primary care, and additional clinical and sociodemographic characteristics.They found that non-Hispanic Black patients with early-stage lung cancer were less likely than their non-Hispanic White counterparts to undergo curative therapy, largely owing to lower rates of surgical resection. 1Black patients were also less likely to undergo SBRT during its early adoption (2011-2013); this disparity narrowed and was no longer statistically significant in the 2017 to 2019 study period.Overall, rates of radiotherapy were not consistently different by race.These associations persisted after adjustment for clinical and sociodemographic factors, highlighting the need for additional progress before achieving racial equity in cancer care.Taken together, this study 1 suggests that the largest and most persistent inequity is not in the type of radiation or surgery delivered once a modality is chosen, but in whether Black patients access surgical treatment at all, and whether they shared equitably in SBRT adoption in earlier years.These findings of racial disparities in the rate of surgical resection, with no consistent racial differences in radiotherapy receipt, invite comparison between the 2 modalities.Upstream factors are multifaceted, with patient factors such as comorbidities and frailty and system factors such as referral patterns and support for navigating treatment, all likely contributing.Regarding patient factors, the authors found that, on average, Black patients had higher rates of medical comorbidities and were less likely to have a primary care physician. 1ack patients who are less connected to primary care may be referred later, less frequently, or not at all for surgical evaluation.However, access to a primary care physician alone may not fully mitigate these difficulties.Recent work showed differential specialty referral patterns based on race. 2 These disparate referral patterns may negatively affect a patient's surgical candidacy, with downstream consequences for the likelihood of receiving curative oncologic treatment.Relatedly, social determinants of health such as financial toxicity or health literacy may play a role in influencing adherence to curative treatment for lung cancer, highlighting the need for financial navigation and assistance with transportation and other nonmedical costs to reduce financial toxicity and address cost-related barriers that undermine adherence to curative treatment. 3nch et al 1 also utilized a claims-based frailty measure that was validated with patient-reported outcomes.This approach may partially mitigate, but not fully eliminate, the influence of clinical bias in preoperative decision-making.Recent work demonstrating that racially and ethnically minoritized patients are rated as more frail on subjective than objective measures would suggest that subjective assessments could disproportionately disqualify Black patients from surgery, even when claimsbased frailty appears similar.Therefore, broader use of objective frailty measures in both practice and research is an important step toward equitable cancer care.