Racial Disparities in Lung Cancer Resection
Authors: Gene L. Colice
Journal: JAMA (2010)

MAJOR ADVANCES HAVE BEEN MADE IN THE ABILITY to image and identify lung tumors and metastases, diagnose and stage lung cancer with minimally invasive techniques, andsafely resect earlystage lung cancers in medically tenuous patients. However, despite remarkable technological achievements, lung cancer is the leading cause of cancer death in the United States and 5-year survival is poor at 15.8%. In response to this situation in which advanced techniques have not resulted in meaningfully better outcomes, Cykert and colleagues, in this issue of JAMA, explore fundamentally important questions about current management of lung cancer. The authors begin with the accepted premise that surgical resection is the preferred approach to managing stage I or II non–small cell lung cancer, and hypothesize that fewer blacks than whites will undergo curative-intent resection. Based on their study of 437 patients with biopsy-proven or probable early-stage lung cancer, the investigators confirmed their hypothesis and suggest that cultural differences might be the explanation. These provocative findings raise 4 points. Are the findings real? How are they explained? What information do the findings provide about community standards for managing lung cancer? What implications do these findings have for the controversial issue of lung cancer screening? Are there reallydisparities insurgical resectionratesof stage I or II non–small cell lung cancer between blacks and whites? In theprospective studybyCykert et al, the surgical resection ratesforpatientswithtissue-confirmednon–smallcell lungcancer were 63% for blacks vs 75% for whites (P=.03). In a retrospective analysis using Surveillance, Epidemiology, and End Results cancer registry data between 1985 and 1993, Bach et al also had reported that blacks were significantly less likely to undergo surgical resection than whites for non–small cell lung cancer (64.0% vs 76.7%; P .001). In addition, Bach et alreportedthat5-yearsurvivalwassignificantlylowerforblacks, a finding associated with the difference in resection rates. Disparitiesinlungcancercarealsohavebeenfoundinothergroups. Forexample,Wisniveskyetal foundthatcomparedwithwhite patients,HispanicpatientswithstageInon–smallcell lungcancer had lower rates of surgical resection and poorer survival. How are these lower surgical resection rates in blacks explained? Bach et al did not find differences in comorbidities between blacks and whites diagnosed with lung cancer, but noted that blacks with lung cancer were younger than whites. Cykert et al also found that among patients diagnosed with lung cancer, blacks were younger than whites and comorbidities were associated with surgical resection, but disproportionately for black patients. Differences in tumor resection rates between black and white patients were not explained by either baseline lung function or access to insurance. Findings from the questionnaires administered to study participants after discussion of the diagnosis but prior to treatment revealed that worse perceptions of patientphysician communication, anticipation of a worse overall quality of life after surgery, and a lower certainty of the lung cancer diagnosis were associated with a lower likelihood of surgery. Cykert et al suggest that these factors might reflect cultural differences and biases between nonblack physicians and black patients. Fortunately, these factors are potentially reversible through a concentrated effort on improving patient-physician communication. One important issue not addressed in the report by Cykert et al is the perspective of the health care practitioner. In telephoneinterviewswith100primarycarephysiciansand250specialists about treatments and outcomes in non–small cell lung cancer,Perez foundthatmorethan90%ofgeneralistsandspecialists favoredsurgical resectionforstageInon–smallcell lung cancer, but with stage II non–small cell lung cancer there was greaterheterogeneity in treatmentapproaches.More than35% ofprimarycarephysiciansfavorednonsurgicaltherapy;although thesephysicianssawfar fewerpatientswithnon–smallcell lung cancer thanspecialists. Schroenetal administeredaquestionnaire to 577 pulmonologists and 394 thoracic surgeons about the therapeutic approach to non–small cell lung cancer, and foundthat22%ofpulmonologistsand10%ofthoracicsurgeons substantially underestimated the 5-year survival rates for patientswithsurgically resectednon–smallcell lungcancer.Physiciansunderestimatingsurvivalwereolder, sawfewerpatients with lungcancer,andpracticedinnonacademicenvironments. Thesestudiessuggest thatprimarycarephysiciansandspecialists might suggest surgery less often for stage I or II non–small cell lung cancer if they see fewer patients with lung cancer and consequently are less familiar with current treatment recommendations and expected results.