Disparities In Care For Early Stage Lung Cancer PowerPoint Presentation

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Funding Source Lung Cancer Surgery: Decisions Against Life Saving Care Sponsored by the American Cancer Society Grant #: RSGPB-05-217-01-CPPB

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Racial Disparities in the Treatment  of Early Stage Lung Cancer: Which Interventions Will Work?

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Case 1 A 53 year old African-American man presented to the emergency department with cough. A CXR was performed that revealed a 2.5 cm pulmonary nodule. A CT was immediately obtained and showed the nodule to be spiculated and not calcified. The patient was told that he might have a cancerous tumor and was referred for a follow-up appointment.

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Case 1 His cough resolved, so he did not keep the appointment. He returned 6 months later and had an 8cm tumor on CXR with mediastinal invasion. ***What could have been done differently?

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Case 2 A 67 year old smoker who had a CXR for a persisting cough after a URI was found to have a 2.1 cm lung nodule. Also has multiple blebs surrounding the nodule precluding a needle biopsy. PET CT shows the nodule is hot (18 SUV). There’s a 1.6 cm ipsilateral, hilar node on the CT that does not light up on the PET.

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Case 2 Other pertinent clinical data: FEV-1 45% of predicted Has known CAD with an LAD stent 6 months ago (no current sx) and a 50-60% RCA lesion EF – 35 to 40% Baseline Creatinine 2.4 ***Surgery yes or no?

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Proportion responding that they believe that clinically similar patients receive different care on the basis of race/ethnicity by proximity to practice (n=344) Lurie, N. et al. Circulation 2005;111:1264-1269

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Why Study Early Stage Lung Cancer? Fatal Disease Surgery only reliable chance of cure No treatment only 6% survive five-years A few absolute contraindications are defined Have to have strong reasons to refuse or recommend against

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Administrative data reveal lower surgical rates and survival for African-Americans diagnosed with Stages I and II, non-small cell lung cancer

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Bach et al. Racial differences in the treatment of early stage lung cancer. N Engl J Med 1999;341:1198. 44 excess deaths per 1000 lung cancer cases due to decisions against surgery!

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Lathan et al. J Clin Onc 2006;24:413-418 OR for Black patients to receive staging procedures compared to Caucasians 0.75 OR for Black patients who were actually staged to receive surgery compared to Caucasians 0.55

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Lathan, C. S. et al. J Clin Oncol; 24:413-418 2006 Fig 1. Reasons recorded in Surveillance, Epidemiology, and End Results for why surgery was not performed among patients who had undergone invasive staging

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Administrative data controlled for insurance, income, and co-morbidities. No specific reasons for treatment disparity despite near certain death within 4 years post-diagnosis

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Reference – Prospective Cohort Study Cykert, Dilworth-Anderson,Monroe, et al. Factors associated with decisions to undergo surgery among patients with newly diagnosed early stage lung cancer. JAMA 2010; 303:2368-2376.

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Methods 5 communities Pulmonary, Oncology, Thoracic Surgery, ED, and Generalist Practices Direct referral vs chest CT review protocol

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Inclusion Criteria > 18 years old Tissue diagnosis of non-small cell lung cancer or > 60% probability using a Bayesian Model Clinical / Radiological Stage I or II disease English Speaking

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Timing of Enrollment Patient informed of the diagnosis of definite or probable lung cancer Survey administered verbally by trained RA before treatment plan established

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The Questionnaire 106 items Including: Demographics SF-12 Mental Adjustment to Cancer Scale Trust Perceptions of provider-patient communication

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“Exposure to air” Perceived certainty of diagnosis Attitudes about lung cancer Dyspnea Decision participants Religiosity

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Chart Abstraction Timing: At least 4 months after diagnosis Surgery: Yes / No and Date PFT’s Co-Morbid Diagnoses Clinical Stage Surgical Stage

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Statistical Analysis Primary Outcome: Lung Cancer Surgery Within 4 Months of Diagnosis Independent variables a priori in models: - demographics - SF-12 component scores - tissue vs presumptive diagnosis - perception of diagnostic certainty - Mental Adjustment to Cancer scales - “air exposure” - trust - co-morbid conditions

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Variables entered after bivariate comparisons if p < 0.1 - attitudes about lung cancer - religiosity - other decision participant - perceptions of provider-patient communications

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Results Patients enrolled – 437 - 7 patients not Caucasian or AA - 32 with advanced cancer - 6 with benign dx - 6 with FEV-1 < 25% predicted (no surgeries below this level) 386 met entry criteria and remained eligible for lung resection surgery

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Results 67 percent (N = 257) with biopsy proven diagnosis at enrollment - 62% surgical resection 33 percent CT-defined probable disease - 64% surgical resection 88 percent tissue diagnosis confirmed

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Results: Demographic Data

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4 Month Surgery Rates All enrollees (N = 386) Caucasian 66%* African-American 55% *p = .05

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4 Month Surgery Rates Tissue confirmed only (N = 339) Caucasian 75%* African-American 63% *p = .03

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Lung Surgery Rates – Bivariate Comparisons

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Regression Analysis - All Patients

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Regression Analysis - All Patients

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Regression Analysis - African Americans

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Regression Analysis - African-Americans * The Trust Paradox

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Regression Analysis – White Patients

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Regression Analysis – White Patients No Regular Source of Care OR 1.3, 95% CI .32 – 5.3

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Co-morbidities Strand TE et al. Risk factors for 30-day mortality after resection of lung cancer and prediction of their magnitude. Thorax 2007;62:991-7. - Minimal effect of Charlson Co-morbidity Index on 30 day survival (3.8% CCI of 0, 5.8% CCI 1-2, only 6.5% of patients had CCI > 3)

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Co-morbidities Battafarano et al. Impact of comorbidity on survival after surgical resection in patients with stage I non-small cell lung cancer. Journal of Thoracic and Cardiovascular Surgery 2002;123:280-7. - Average 3-year survival – no comorbidities 86% - Average 3-year survival – severe comorbidities 70% - Average 3-year survival without surgery* 10 – 15% * Bach N Engl J Med 1999; 341:1198

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Results N = 386 66 deaths at one year 100% follow up AA patients 4.4 years younger than W Average age of survivors 65.6 years; average age died 70.1 years (p = 0.002)

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Results *P < 0.05

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-------------------------------------------------------------------------- pt_died | Odds Ratio Std. Err. z P>|z| [95% Conf. Interval] -------------+---------------------------------------------------------------- d_demomari2 | .5643592 .175378 -1.84 0.066 .3069302 1.037699 medincy1 | .8405706 .2744353 -0.53 0.595 .4432697 1.593971 d2_demoedu | 1.124134 .350837 0.37 0.708 .6097647 2.072403 d_demorace | 1.097042 .3950806 0.26 0.797 .5415986 2.222126 age50th | 3.445103 1.14981 3.71 0.000 1.791067 6.626626 dxdiabetes | 1.255789 .4429175 0.65 0.518 .629068 2.506894 dxcoronary~e | 1.121822 .3708338 0.35 0.728 .5868777 2.144374 demosex | 1.288879 .3964429 0.83 0.409 .7053315 2.355217 had_surg | .5193712 .1558765 -2.18 0.029 .2884102 .9352874 rscy | .6981523 .3100482 -0.81 0.418 .2923701 1.667122 dxhyperten~n | .5987609 .1868083 -1.64 0.100 .3248522 1.103624 comorbtotal3 | 2.785209 1.175041 2.43 0.015 1.218282 6.367485 comorbtotal1 | 1.454711 .4823543 1.13 0.258 .7595123 2.786242 ------------------------------------------------------------------------------

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Results Factors associated with one-year mortality for early stage lung cancer - Age over 66 (OR 3.4, 1.8 – 6.6) - >2 comorbidities (OR 2.8, 1.2 – 6.4) - lung cancer surgery (OR 0.52, 0.29 – 0.93)

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Conclusions Excluding patients with PFT defined absolute contra-indications, disparities in treatment for early stage, non-small cell lung cancer remain The impact of poor communication is apparent in both White patients and African-Americans Lack of a regular source of care exacerbates the effect on African-Americans

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Conclusions Co-morbid conditions are markedly associated with decisions against surgery for African-American patients This impact is NOT apparent with White patients This finding suggests a systematic or implicit bias when considering higher risk African-American patients for lung cancer surgery

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Implicit (Unintended) Bias Schulman et al. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med 1999;340:618-26. Green et al. Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients. Journal of General Internal Medicine 2007;22:1231-8.

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Possible Solutions Know that disparities (beyond what is attributable to SES, education, and insurance) exist Think in the context of the ideal

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Communication Johnson RL et al., Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health 2004;94:2084-90. Gordon HS et al. Racial differences in doctors' information-giving and patients' participation. Cancer 2006;107:1313-20. Williams SW, et al. Communication, Decision Making, and Cancer: What African Americans Want Physicians to Know. Journal of Palliative Medicine 2008:1221-6. (Interest on a human level person and family - appropriate language)

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Communication Paasche-Orlow MK et al. Tailored education may reduce health literacy disparities in asthma self-management. Am J Respir Crit Care Med 2005;172:980-6. Clever SL, Ford DE, Rubenstein LV, et al. Primary care patients' involvement in decision-making is associated with improvement in depression. Med Care 2006;44:398-405.

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Communication Rosenzweig et al. The attitudes, communication, treatment, and support intervention to reduce breast cancer disparity. Oncol Nurse Forum 2011;38: 85-89. - Pilot delivered by AA breast cancer survivor 1. Discussion chemotherapy 2. Importance of communicating knowledge needs and distress 3. Explanation of path results and rx plan 4. Survivor video - (N = 24) % total dose chemo received / prescribed 94% vs. 74%

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Intervention Design Provider education: Lung cancer disparity data and local surgical and co-morbidity data by race Co-morbidity checklist with individual patients Real time registry with warning indicators Provider receives race-specific data feedback Super-navigator – Enhanced communication; dropout interventions (stratify by low health literacy)

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Intervention Caveat Super-Navigator

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Case 1 A 53 year old African-American man presented to the emergency department with cough. A CXR was performed that revealed a 2.5 cm pulmonary nodule. A CT was immediately obtained and showed the nodule to be spiculated and not calcified. The patient was told that he might have a cancerous tumor and was referred for a follow-up appointment.

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Case 1 His cough resolved, so he did not keep the appointment. He returned 6 months later and had an 8cm tumor on CXR with mediastinal invasion. ***What could have been done differently?

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Case 2 A 67 year old smoker who had a CXR for a persisting cough after a URI was found to have a 2.1 cm lung nodule. Also has multiple blebs surrounding the nodule precluding a needle biopsy. PET CT shows the nodule is hot (18 SUV). There’s a 1.6 cm ipsilateral, hilar node on the CT that does not light up on the PET.

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Case 2 Other pertinent clinical data: FEV-1 45% of predicted Has known CAD with an LAD stent 6 months ago (no current sx) and a 50-60% RCA lesion EF – 35 to 40% Baseline Creatinine 2.4 ***Surgery yes or no?

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For Discussion The role of implicit bias – how do we affect providers biases? Should we be pushing African-American patients toward lung cancer surgery? Is this a violation of the principle of autonomy? Do you see anything applicable here to other health disparities?