Racial disparities in the treatment of unresectable, stage III non-small cell lung cancer: An analysis of the National Cancer Database.
Authors: Mohanna Mohamed , Sabbagh Saad , Dominguez Barbara , Iska Sindu , Itani Mira , Arteta-Bulos Rafael , Liang Hong , Nahleh Zeina A. , Alley Evan W 
Published: June 2023

e20560

Background: The standard of care (SOC) for treatment of unresectable, stage III non-small cell lung carcinoma (NSCLC) utilizes both chemotherapy and radiation therapy. Historically, concurrent chemo-radiation therapy (CCRT) has been associated with improved survival outcomes compared to sequential chemotherapy and radiation therapy (SCRT). Using data extracted from the National Cancer Database (NCDB). Our primary objective was to assess if a particular race cohort received less than the standard of care treatment (CCRT) and any impact on survival outcomes in unresectable, stage III NSCLC. Methods: From the complete dataset years of 2010-2016 of the NCDB, we extracted patients diagnosed with stage III NSCLC according to the AJCC 7th edition. Patients were classified according to the treatments received and include CCRT, SCRT, radiotherapy alone (RT), chemotherapy alone (CT) and no treatment. Chi-square test was performed to evaluate the baseline sociodemographic and clinico-pathologic categorical characteristics between the different treatment arms. Multivariable Cox regression analysis was utilized to identify the independent survival factors. In addition, Kaplan-Meier survival curves for different treatments in White and Black patients were evaluated. Multinominal logistic regression analysis was utilized to establish association of different treatment modalities with race. SAS version 9.4 was used to analyze the data. Results: There was 52,677 patient who met inclusion criteria. Multinominal logistic regression revealed that Black patients were 21% more likely to receive CT alone than standard CCRT compared to White patients (p < 0.0001, OR 1.21 and CI 1.10-1.32). In addition, Black patients were 27% more likely to receive RT alone than standard CCRT compared to White patients (OR = 1.27 and CI 1.13-1.42 and p < 0.0001). There was no statistically significant difference between the use of CCRT vs. SCRT among White and Black patients. Based on Kaplan-Meier survival curves, CCRT and SCRT were found to have superior median overall survival (mOS) in both Black patients (23 month for CCRT and 19 month for SCRT) and White patients (19 month for both) compared to other treatment modalities (P < 0.001). Multivariable Cox regression analysis method revealed that there were several significant independent survival factors, such as age, Charlson-Deyo Score (CDS), histologic grade, insurance status, stage, and race. Conclusions: The use of either CCRT or SCRT was associated with improved overall survival in both Black and White patients with unresectable, stage III NSCLC compared to other treatment modalities. Interestingly, Black patients appear to benefit more from CCRT than SCRT compared to White patients. However, Black patients were less likely to receive standard CCRT and more likely to receive less effective RT or CT alone compared to White patients.