Receiving curative lung cancer surgery varies by state
ATLANTA — The likelihood of receiving curative-intent surgery for patients with early-stage non-small cell lung cancer (NSCLC) varies substantially from state to state, according to data presented at the Eighth American Association for Cancer Research (AACR) Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved, held Nov. 13-16.
"We do not have a uniform quality of health care in this country," said Helmneh M. Sineshaw, MD, MPH, senior epidemiologist and health services researcher with the American Cancer Society in Atlanta. "Curative surgery for NSCLC is one example, with disparities in health care across population subgroups."
Lung cancer is the second most common type of cancer, and the leading cause of cancer deaths for men and women in the United States, according to the National Cancer Institute. NSCLC is the most common kind of lung cancer. If it is caught at an early stage, when the cancer is localized, it can potentially be cured by surgery, which would typically involve resectioning part of the lung or the whole lung, Sineshaw said.
Sineshaw said that previous studies have shown significant racial and socioeconomic disparities in the receipt of curative surgery for early-stage NSCLC. For this study, he and colleagues sought to examine the extent of, and factors associated with, variations in receiving curative surgery for early-stage NSCLC across states in the United States and whether the racial disparity varies by state.
The researchers based their study on data from patients who were diagnosed with stage 1 or 2 NSCLC between 2007 and 2011 in 38 states and the District of Columbia, from population-based cancer registries compiled by the North American Association of Central Cancer Registries.
Sineshaw and colleagues found that Massachusetts, New Jersey, and Utah had the highest rates of receipt of curative surgery–about 75 percent in each state. They chose Massachusetts as the standard of comparison for all states.
The researchers found that the lowest likelihood of receipt was in Wyoming, where patients with early-stage NSCLC were 25 percent less likely than those in Massachusetts to receive curative surgery. The next largest gaps were in Oklahoma (20 percent less likely), New Mexico (19 percent less likely), Colorado (17 percent less likely), Louisiana (17 percent less likely), and Texas (16 percent less likely).
Sineshaw said some of the disparity in the receipt of NSCLC surgery could be explained by geography, as states with major medical centers generally had higher rates. Also, insurance coverage could be a factor, he added, although adjusting for insurance resulted in only minor statistical differences.
"From state to state, the quality of insurance coverage may be different, even as we move toward universal health care," he said. "Varying standards for copays, for example, can all add up and make a difference in the cost of treatment."
Sineshaw said one potential way to narrow the disparity would be to further standardize health-care coverage. Also, he suggested, doctors across the nation could be encouraged to share information on their practices.
Sineshaw and colleagues also evaluated data on race to see whether disparities persisted. The study showed that non-Hispanic blacks were less likely than non-Hispanic whites to receive the surgery in all states/registries, although the disparities were significant in only two states–Florida and Texas–after adjusting for socioeconomic factors and clinical characteristics. In Florida, non-Hispanic black patients had a 12 percent lower chance of receiving curative surgery, and in Texas, non-Hispanic black patients had an 11 percent lower chance of receiving curative surgery than non-Hispanic white patients.
Sineshaw said a limitation of the study is that it did not examine patient/physician communication, which he believes could influence a patient's willingness to undergo curative surgery. Also, the study did not control for comorbidity, so some patients may have been ruled ineligible for the surgery due to outstanding health issues. However, accounting for state-level chronic obstructive lung disease prevalence did not change the results.
To interview Helmneh M. Sineshaw, please contact Julia Gunther at [email protected] or 215-446-6896.
This study was supported by the American Cancer Society. Sineshaw declares no conflicts of interest.
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About the American Association for Cancer Research
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Title: Variations in receipt of curative surgery for early-stage non-small cell lung cancer (NSCLC) among racial/ethnic groups and within racial/ethnic group across states in the United States
Authors: Helmneh M. Sineshaw1, Xiao-Cheng Wu2, W Dana Flanders3, Raymond Uyiosa Osarogiagbon4, Ahmedin Jemal1. 1American Cancer Society, Atlanta, GA, 2Louisiana Tumor Registry, Louisiana State University Health Sciences Center, New Orleans, LA, 3Emory University, Rollins School of Public Health, Atlanta, GA, 4Baptist Cancer Center, Memphis, TN.
Background: Previous studies reported substantial racial and socioeconomic disparities in receipt of curative surgical resection for early-stage non-small cell lung cancer (NSCLC) in the US. However, it is unknown whether such disparities vary across states.
Methods: Invasive stage I and II NSCLC diagnosed in 2007-2011 were identified from the population-based North American Association of Central Cancer Registries (NAACCR). We calculated percentage for receipt of curative surgery for Non-Hispanic (NH) whites and NH blacks in each state. Adjusted risk ratios (RRs) were generated using modified Poisson regression to control for potential associated factors with receipt of curative surgery. NH whites and Massachusetts were taken as references for comparisons.
Results: Receipt of curative surgery for early-stage NSCLC in NH White and NH black patients substantially varied by state, ranging from 55.5% in Louisiana to 76.3% in New Jersey for NH whites and from 48.0% in Louisiana to 72.3% in Massachusetts for NH blacks. These variations remained unchanged after adjustment for demographic (i.e., age, sex, diagnosis year) and clinical (i.e., grade, stage, tumor size) characteristics although statistical significance was not consistent across states. Compared with NH white patients in Massachusetts, receipt of curative surgery for NH whites ranged from 6% less likely for those in California (RR, 0.94; 95% CI, 0.89-0.98) to 26% less likely for those in Wyoming (RR, 0.74%; 95% CI, 0.58-0.94). NH black patients in Louisiana were 21% less likely to receive curative surgery compared with NH black patients in Massachusetts (RR, 0.79; 95% CI, 0.62-0.99). Further adjustment for insurance, census tract-level poverty, and county-level metro/non-metro status significantly reduced the difference in the likelihood of receiving curative surgery in some states.
Conclusions: Receipt of curative surgery for early-stage NSCLC substantially varies across states in the United States, with the rate of receipt for both NH white and NH black patients generally lower and racial disparity higher in southern states.