A national analysis of untreated stage III non-small cell lung cancer in black and white patients.
Authors: Elimimian Elizabeth Blessing , Arteta-Bulos Rafael , Liang Hong , Bilani Nadeem , Elson Leah , Saravia Diana , Alley Evan W. 
Published: June 2021

e20561

Background: Stage III non-small cell lung cancer (NSCLC) is treatable and potentially curable with surgical resection and/or chemoradiotherapy (CRT). Factors such as medical comorbidities and access to care may impact treatment decisions, including the decision to give no treatment. Using the National Cancer Database (NCDB), we analyzed the clinical presentation and proportion of Black and White Stage III NSCLC patients who received no form of treatment and compared their overall survival to patients who received other forms of management. Methods: Black and White stage III NSCLC’s diagnosed between 2004 and 2015 in the NCDB were included. Cases with multiple tumors and who received surgery were excluded. Patients who received no form of treatment (No-RT-nor-CT) were compared to patients treated with (CRT), RT only (RT), and CT only (CT). Univariate, multivariate, and Kaplan-Meier models were performed. Results: A total of n=22,459 Black and n=138,477 White stage III NSCLC patients were analyzed. Concurrent CRT given within 0-30 days was the most common management for Black (42.3%) and White patients (43.9%). No-RT-nor-CT was the second largest management group among Black (21.2%) and White patients (21.5%). A higher proportion of Black patients (14.2%) had a contraindication to CT than White patients (12.9%), p=0.0016; the same was true for those not managed with RT (6.1% vs. 5.3%, p=0.0051). Among patients managed without CT, the most common reason for not receiving CT among Black (63.31%) and White patients (63.0%) was that CT was not part of the planned 1st treatment course. Among patients managed without RT, the most common reason for not receiving RT among Black (77.0%) and White patients (78.2%) was that RT was not part of the planned 1st treatment course. A higher proportion of White patients versus Black patients did not receive CT (17.4% vs 14.0%, p<0.0001) nor RT (8.8% vs 7.7%, p=0.0013) because it was refused by the patient or guardian. The 2- and 5-year overall survival (OS) rates were lowest among the No-RT-nor-CT cohort of Black (13.9%, 5.4%, respectively) and White (12.1%, 4.6%, respectively) patients versus all other treatments. Median OS with No-RT-nor-CT was 4 months for Black patients and 3 months for White patients (p<0.0001). Conclusions: Concurrent CRT with or without surgery is an established standard of care for stage III NSCLC, but a significant proportion of White and Black patients are not receiving potentially curative therapy. A higher proportion of Black patients had contraindications to CT and RT than a similar cohort of White patients, which may reflect a higher rate of medical comorbidities. A higher proportion of White patients or their guardians refused CT and RT than a similar cohort of Black patients. Assessing and addressing the challenges that affect access to care and the type of care delivered remains an essential component of health care in America and influences survival outcomes.