Drilling Down to the Causes of Racial Disparities in Lung Cancer

Abstract

A recent study of early-stage lung cancer patients found that African Americans are statistically significantly less likely than whites to receive definitive—i.e., potentially curative—surgery. That finding, which the Journal of the American Medical Association published in June, appeared soon after an American Lung Association (ALA) report that also underscored the need for systematic change in the approach to lung cancer in African Americans. Together, the two reports confirm the disparity between blacks and whites in lung cancer rates, treatment, and outcomes while exploring some of the reasons—biological, clinical, and socioeconomic—that may explain these differences. African Americans are more likely to develop lung cancer and less likely to respond to available treatments than whites. Cigarette smoking rates can’t account for the disparity, because although white men smoke 30%–40% more cigarettes, African American men have a higher incidence of lung cancer (75 per 100,000 vs. 64 per 100,000). According to a meta-analysis published in the September 2008 issue of PLoS Medicine , the disparity exists even among nonsmokers (16 per 100,000 among blacks vs. 12 per 100,000 among whites). This disproportionate burden prompted the April 2010 ALA report, which called for a concerted effort to examine underlying biological differences; to reduce cigarette advertising, particularly for menthol cigarettes, in African American communities ( see sidebar); and to educate physicians on how to overcome communication barriers with African American patients. The role of physicians in disparate treatment is particularly hard to address. Despite a 2003 Institute of Medicine report on the subject and many studies documenting racial disparities in cancer treatment, “nobody thinks it happens to them,” said Samuel Cykert, M.D. , an investigator at the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, who led the JAMA study. “We have to kind of hammer the message: Yes, it can happen in your practice, and yes, you have to be very cognizant of it all the time.” Samuel Cykert, M.D. Cykert and his colleagues monitored 437 patients with early-stage, non–small cell lung cancer (NSCLC) from five communities between 2005 and 2008. Among those who were fully eligible for resection, 66% of whites had surgery, compared with 55% of blacks. In early-stage lung cancer, surgery to remove the diseased portion of lung is the only reliable treatment for cure, Cykert said. With surgery, at least half of patients survive more than 4 years. Without surgery, most will die within a year. A 2009 study from the University of Texas, using the Surveillance, Epidemiology, and End Results (SEER) Medicare database, found that African Americans with stage I and II lung cancer have surgery 37% less often than whites. Cykert and his colleagues confirmed this finding in their prospective study and looked at factors associated with decisions against surgery. Surgical rates for blacks were particularly low when they had two or more other illnesses and when they lacked a regular source of care. “To me, the most startling finding is that if [you] had two or more other significant medical conditions other than the lung cancer, if you were an African American your chance of going to surgery was almost zero,” said Cykert, “whereas two or more medical conditions did not affect the surgery rates of white patients… . I think what that tells us is that, whether through stereotyping or the way we communicate, the way we are socialized, if you can communicate with the patient and you see that patient as compliant, you are more likely to push on through to surgery.” The other major factor affecting which patients had surgery was the lack of a primary-care provider. “If an African American patient in our study did not have a regular source of care, a primary-care doctor, then the odds of going to surgery were only one-fifth that of white patients,” Cykert said. He cited one particular patient enrolled in the study as emblematic of the problem. This individual was diagnosed with a 2-cm lung mass by computed tomography scan during a visit to the hospital emergency department for an unrelated problem. He received a referral to a pulmonologist but did not see one. Six months later, he reentered the system with an 8-cm inoperable tumor. That patient had no primary-care physician, said Cykert. Cykert noted that this patient and more than 90% of all patients in the study had either private or public health insurance, yet one-fifth lacked a regular source of care. “Minority populations … have more difficulty getting health care and fewer choices of where they can receive care even if they have health insurance,” said William Hicks, M.D., professor of clinical medicine at the Ohio State University Comprehensive Cancer Center in Columbus and spokesman for the ALA report. Another recent publication—a July review article in the Journal of the A