Leveraging research to address lung cancer disparities

Lung cancer remains the most common cause of cancer death in the United States.

Lung cancer remains the most common cause of cancer death in the United States. People who identify as black and/or Hispanic are at an even higher risk of mortality. Lung cancer screening (LCS) has been recommended since 2013, but remains underutilized, especially in economically and socially marginalized communities. Incidental lung nodules, commonly found on imaging performed for other purposes, such as trauma assessments, are often later diagnosed as cancers and represent a source of morbidity and mortality.

Many vulnerable groups and marginalized communities receive care in emergency departments, where follow-up of accidental nodules is fragmented and incomplete. Low levels of LCS and inappropriate follow-up of accidental pulmonary nodules (IPN) therefore represent 2 important factors of inequalities in cancer care. Research initiatives aimed at understanding and addressing the systemic inadequacies that contribute to these inequities have the potential to improve outcomes for populations in need.

Addressing Morbidity and Mortality in Minority Populations

Data from the Cancer Commission shows that a large proportion of people diagnosed with non-small cell lung cancer over a 4-year period identify as black (39%) or Hispanic (33%), compared to 23% who identified as white at the Montefiore Einstein Cancer Center (Montefiore) in the Bronx, New York. These numbers stand in stark contrast to other health care facilities in New York, where 81% of patients are white. Our patient population is also more likely to be diagnosed at later stages. Compared to other New York hospitals, the proportion of patients at Montefiore who are diagnosed with stage I lung cancer is significantly lower (25% versus 31%), and the proportion with stage IV disease is higher (45% versus 37%) (NUMBER1).

Other data from Montefiore demonstrated additional inequalities in patients with primary lung cancers diagnosed between 2013 and 2016. Only 417 (55%) were found in patients with an in-network primary care provider, illustrating the need a better support system and a systematic approach to identify and guide these patients. Moreover, of the 175 of these patients who were eligible for LCS, only 33 had completed the appropriate screening. Much of this population with lung cancers identified outside of screening was made up of black (46%) and Hispanic (34%) patients with a median per capita income of approximately US$20,000 (TABLE).1

Addressing shortcomings in lung cancer screening

Testing is particularly difficult among people from racial and ethnic minority groups and those who have been socioeconomically marginalized. For example, of more than 50,000 people enrolled in the seminal National Lung Screening Trial, only 4.5% of participants identified as black and 1.7% as Hispanic. This contrasts sharply with the screening population described at our institution.2

More work needs to be done to study and implement LCS in these patient populations. To that end, we have formed a collaboration with the LUNGevity Foundation with the goal of “Increasing access to lung cancer screening in the Bronx in Latino and African American communities”. Known as Project URBANA, the initiative aims to increase adoption and compliance with the LCS through educational initiatives and engagement with a unique community peer navigation program, the Bronx Oncology Living Program. Daily (BOLD). Drawing on the principles of community-based participatory research, the URBANA project focuses on improving access to care among members of African-American and Latino communities. At its core, this project is targeted outreach with educational materials developed in partnership with communities with content that is both relevant and language-appropriate. This content, coupled with trained peer navigators within the community, strives to address social concepts of healthcare that are often overlooked in daily practice.

Reduce the burden of accidental lung nodules

Each year, more than 1.5 million people are diagnosed with IPN.3 Guidelines exist for monitoring IPNs; however, adherence to treatment is often poor.4 This is especially true in black and Hispanic populations where approximately 50% of patients are informed about IPNs and have significantly lower rates of adherence to follow-up imaging. This population is also more likely to delay follow-up appointments.5

With continued support from LUNGevity, we designed a multi-pronged approach to developing an accidental lung nodule management program for our community. Through the incorporation of software to automatically detect lung nodule scoring in X-ray reports, we will transition to more active identification of individuals with nodules of concern who will be proactively referred to our high-risk lung nodule clinic. risk. Individual malignancy risk will be assessed using artificial intelligence-based calculators derived from the electronic medical record to facilitate guideline-compliant care.

Finally, we will evaluate a blood-based cancer biomarker to further stratify patient risk and apply it prospectively to people already enrolled in our nodule clinic. Our overall goal is to facilitate the early diagnosis of lung cancer in our community and reduce the risk of advanced disease and death.

Translating advocacy into action

Research initiatives enable us to advocate on behalf of historically marginalized people by generating hypotheses that aim to increase knowledge of inequalities in care. Studies on the implementation of care within the framework of racial and ethnic inequalities are essential.

Deficiencies in lung cancer care are multifactorial and occur in screening, diagnosis and management. Through research that incorporates culturally sensitive patient navigation, use of available technologies, and a multidisciplinary approach to patient care, there are significant opportunities to improve screening, cancer care, and outcomes for everyone.

References

  1. Su CT, Bhargava A, Shah CD, et al. Screening patterns and mortality differences among lung cancer patients in an underserved urban community. Lung cancer clink. 2018;19(5):e767-e773. doi:10.1016/j.cllc.2018.05.019
  2. National Pulmonary Screening Trials Research Team; Aberle DR, Adams AM, Berg CD, et al. Reducing lung cancer mortality through screening with low-dose computed tomography. N Engl J Med. 2011;365(5):395409. doi:10.1056/NEJMoa1102873
  3. Gould MK, Tang T, Liu IL, et al. Recent trends in the identification of accidental pulmonary nodules. Am J Respir Crit Care Med. 2015;192(10):1208-1214. doi:10.1164/rccm.201505-0990OC
  4. Farjah F, Monsell SE, Gould MK, et al. Association of diagnostic evaluation intensity with outcomes in incidentally detected lung nodules. Intern JAMA Med. 2021;181(4):480-489. doi:10.1001/ jaminternmed.2020.8250
  5. Schut RA, Mortani Barbosa EJ Jr. Racial/ethnic disparities in adherence to incidental lung nodule follow-up: an application of a cascade care framework. J Am Coll Radiol. 2020;17(11):1410-1419. doi:10.1016/j.jacr.2020.07.018

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