Reducing barriers to care in the treatment of lung cancer: a narrative review

Introduction

Over 125,000 people die each year secondary to lung cancer, which accounts for one in five of all cancer-related deaths in the United States (1-4). A significant decrease in the incidence and mortality of lung cancer has been seen over the last several years due to advancements in prevention, diagnosis, and treatment (5). This change may be attributable to a successful public health campaign which reduced the number of people who smoke cigarettes from 20.6% in 2009 to 13.9% in 2018 (6), decreasing the number of people at risk for developing lung cancer.

Improvements in lung cancer outcomes are also due to breakthroughs in the care of lung cancer patients, such as early detection, refined surgical techniques, and improved systemic therapy. Lung cancer screening with low-dose computed tomography (LDCT) identifies early-stage lung cancer in patients at high risk for lung cancer due to tobacco use. Two large, randomized trials demonstrated reduction in lung cancer mortality by 20–30% with LDCT (7,8). Following the increase in early detection of lung cancer, the extent of parenchymal resection was re-evaluated to determine if lobectomy is still required (9). For non-small cell lung cancer (NSCLC) ≤2 cm in size and node-negative, sub lobar resection (segmentectomy or wedge resection) provides an equivalent 5-year overall survival as lobectomy (10,11). Preserving lung parenchyma may improve quality of life and increase the number of patients who are candidates for surgical resection. For patients with locally advanced NSCLC, namely larger tumors and nodal disease, advancements in systemic therapies improve the outcomes of lung cancer resection. Immunotherapy administered in combination with chemotherapy, either neoadjuvant or perioperatively, results in better pathologic complete response and significant improvements in cancer-free and overall survival (12,13).

Despite these historic innovations in lung cancer care, there are still race-specific disparities in outcomes for patients. African American or Black, Hispanic, Multiracial, and American Indian patients experience a higher incidence of lung cancer and worse overall survival than non-Hispanic White patients (1,14). Disparate outcomes between minority and non-Hispanic White patients are multifactorial and previously attributed to differences in socioeconomic status (SES), stage at diagnosis, patient preferences, structural racism, and rates of surgical resection. Even after matching for stage of diagnosis, minority patients with lung cancer experience worse disease-free and overall survival outcomes than non-Hispanic White counterparts (1). Minority patients experience disparities throughout the continuum of a patient’s interaction with the health care system and are more likely to be diagnosed with advanced disease and experience delays in treatment (14-16).

The scope of this review is to delve into the known disparities, identify contributory barriers to care, and discuss current and potential strategies to mitigate them. It is critical to address these inequalities in racial minority patients and ensure that breakthroughs in lung cancer care are experienced by all patients. We present this article in accordance with the Narrative Review reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-1962/rc).

Methods

A narrative literature review focusing on healthcare disparities for patients with lung cancer was performed (Table 1). We initially included references we have used for previous research, publications, and grant proposals. Additionally, we conducted a literature search using the PubMed database and several key search terms. Specifically, we used the following search terms and strategies: Healthcare disparities AND lung cancer, racial disparities AND lung cancer, healthcare disparities AND lung cancer resection, racial disparities AND lung cancer resection. The searches were limited to those studies that included primary research, reviews, and meta-analyses published in English. The multiple searches resulted in 44 unique citations published between 2008 and 2024. One of the investigative team members (J.K.) reviewed the citations based on titles and abstracts and identified 18 of the 44 that had direct relevance to the current review. Many of those citations had already been identified from our initial literature. NSCLC is the focus of all the articles discussing the role of surgery.

Discussion

Lung cancer disparities for underrepresented minorities

In 2003, the Institute of Medicine released the landmark report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” which detailed the multitude of ways race and ethnicity remain significant predictors of poor quality of health care received after accounting for SES (17). Since publication in 2003, the fundamental causes of disparities, including systemic racism, are still present and need to be addressed (18). Lung cancer disparities in incidence, stage at diagnosis, access to treatment, perioperative complications, and mortality are highlighted in this article (19-21).

Structural racism

When discussing racial disparities in lung cancer care, it is important to address the role of structural racism. This refers to racism that is ingrained in government and cultural entities and affects the way that these entities treat underrepresented minority patients (18). Public policies such as residential segregation or ‘redlining’ made housing mortgages less available to Black families. These policies perpetuated Black disadvantage and led to worse health outcomes (18). Even today, Black neighborhoods have higher environmental exposures, such as air pollution, an important contributor to lung cancer development and outcomes (22,23). In her book Medical Apartheid, Harriet Washington discusses the harrowing history of scientific racism and its role in the health care that Black patients receive. From the use of skull size measurements to make baseless claims about racial differences in intelligence between Black and White people to the forced sterilization of African American women against their knowledge, dubbed in the 1950s as the Mississippi Appendectomy (24). Mistreatment of Black individuals is also seen in research environment such as the Untreated Syphilis Study at Tuskegee (25). The actions and beliefs of physicians who practiced inhumane medicine have continued to play a role in how patients interact and trust clinicians and the healthcare system.

Incidence and stage at diagnosis

Although the incidence has decreased over the past few decades, lung cancer is still the leading cause of cancer death in both men and women (3). In recent years, the gap in incidence between Black and White patients with lung cancer has narrowed, however racial disparities are still present (2). Research using the National Cancer Database has shown that when analyzing rates of diagnosis by race, Black patients in the highest income and education quartiles have a higher rate of diagnosis with advanced-stage lung cancer than White patients in the lowest income and education quartiles (26). This was also found among Black patients living in the neighborhoods with the highest SES when compared to White patients living in the neighborhoods with the lowest SES. These findings underscore the pervasive persistence of racial disparities in lung cancer despite downward trends.

Other social factors play a significant role in the increased incidence of lung cancer in specific communities. Men are more likely than women to be diagnosed with lung cancer, associated with their higher use of tobacco products (3). Additionally, individuals with less than a high school education or an annual income of less than $12,500 have higher incidences of lung cancer, regardless of patient gender (27). Low SES plays a significant role in the development of lung cancer, which could be due to the association of low SES and smoking tobacco (28). This is also associated with geographic regional differences in incidence. The impact of social determinants on cancer rates and the increased incidence of lung cancer in the Appalachian region, an area with overall lower SES, higher rates of tobacco smoking, and greater air pollution (29,30). The literature clearly describes a continuing problem with disparities in the risk factors associated with lung cancer.

Another factor that should be considered when discussing the importance of minimizing disparities in lung cancer diagnosis and care is the stage of disease at the time of diagnosis. Black patients are more likely to be diagnosed with advanced stage of lung cancer (31). Schwartz et al. found that lung cancer patients of lower SES are more likely to be diagnosed with advanced disease (32). Advanced stage of disease at diagnosis leads to worse overall survival and is another important factor in racial disparities for lung cancer.

Rate of surgery

The survival benefits of primary surgical resection are well established, and guidelines recommend surgical resection for all operable and medically fit patients with NSCLC (16,33). However, racial minority patients are less likely to receive surgical resection, which is associated with reduced overall survival (14,34-36). Even after matching underrepresented minority patients for the stage of diagnosis, they receive chemotherapy and lung cancer resection less often (14,37,38). An example of this is exhibited in patients enrolled in clinical trials. Even with a structured trial protocol, the rate of surgery is not racially equivalent. Balekian et al. analyzed the National Lung Screening Trial and found the receipt of surgery was significantly lower for Black males (65%) compared to White males (93%) (38). This finding was surprising because the authors hypothesized that patients enrolled in a clinical trial would have equal access to care and similar performance status.

One explanation for decreased lung cancer resection among racial minority patients could be the requirement for smoking cessation before surgery. In a poll of members of the Society of Thoracic Surgeons, 40% of respondents required patients to stop cigarette use before lung cancer resection to minimize postoperative complications (39). This policy is more likely to affect racial minorities who experience higher rates of tobacco product use (22.6% of American Indians, 19.1% of multiracial Americans, and 14.6% of African Americans) compared to the general United States population (13.7%). Our group recently analyzed our institutional lung cancer database (University of Cincinnati) and compared postoperative complications between patients who currently smoke cigarettes and those who previously smoked cigarettes. There was no difference in major morbidity (12.7% vs. 9.3%, P=0.19), operative mortality (0.9% vs. 1.9%, P=0.49), or composite major morbidity and mortality between groups (13.1% vs. 9.3%, P=0.14) (40). Based on these results our practice is to recommend smoking cessation prior to lung cancer resection, but not to require cessation or determine candidacy for lung cancer resection solely on smoking status. This may allow for more equitable care of underrepresented minority patients with lung cancer who currently smoke cigarettes.

Declining surgery

Another reason for racial disparities is due to patients declining recommended lung cancer resection. Previous studies have evaluated “patient refusal”, where patients are offered lung cancer resection, but the patient decides not to undergo surgery (37,41,42). Declining recommended lung cancer resection is more common among Black or Asian Pacific Islander patients (37,43). Our group performed a prospective mixed-methods analysis of patients with a new cancer diagnosis being evaluated for surgery resection. Social barriers to cancer care, such as food insecurity, lack of reliable transportation, and housing instability, were common in the cohort. Qualitative analysis identified several important themes for optimal cancer care, such as communication, trust, and decision-making. This cohort had a very high rate (21%) of declining recommended cancer surgery. Those who declined surgery were more likely Black males, had a lower income, and reported a poor patient-physician relationship (42). This work highlights the importance of social determinants of health (SDOH) and the patient-clinician relationship in lung cancer treatment. Declining recommended surgery is a complex decision. Interventions to increase the trust between physicians and patients could improve this relationship and might allow more patients to pursue lung cancer resection.

Quality of surgery

Even when underrepresented minority patients undergo lung resection for NSCLC, there are disparities in the quality of surgery. Black and Native American/Alaskan patients were less likely to undergo mediastinal lymph node evaluation, which is a standard component of all lung cancer surgery (14,44,45). Bonner et al. performed an analysis of the Michigan statewide quality collaborative group and found that Black patients had more non-anatomic wedge resections, fewer lymph node stations sampled, and fewer lymph nodes resected (46). Substandard surgical treatment for underserved minority patients is likely to contribute to worse cancer-specific and overall survival. Another factor in the quality of surgery is the hospital where the surgery is performed. Safety net hospitals provide care for underserved patients who are uninsured and underinsured. Lung resection at safety net hospitals is associated with reduced treatment quality such as greater likelihood of not receiving surgery, undergoing a thoracotomy, less lymph node dissection, and longer length of stay (47). There is also increased risk of perioperative complications and greater health care expenditure at safety net hospitals (48). Further research needs to be done to examine if the lower incidence and poorer quality of resection in underserved patients may be due to patients being seen at safety net hospitals.

SDOH

Race is one social determinant that plays a powerful role in the care lung cancer patients receive. SDOH are defined as the conditions in which people are born, grow, live, and age. SDOH are associated with worse oncologic outcomes, increased complications, and mortality after cancer resection (49). Socioeconomic factors, such as insurance payer status and poverty at the individual and community level, are risk factors for patients declining cancer resection and worse overall survival (34).

Unmet socioeconomic and supportive care needs, such as housing instability, are also associated with missed oncology appointments in underrepresented minority patients (50). Race and ethnicity are often closely related to SDOH. The diagnosis, treatment, and health outcomes for patients with cancer are directly impacted by various factors of a patients’ social environment. SDOH also influences the patient-clinician relationship, and studies have shown that addressing SDOH improves the patient-clinician relationship and health outcomes (51,52).

Strategies to overcome barriers to care

Overcoming lung cancer disparities requires clinicians to holistically treat patients with lung cancer, rather than solely focusing on their lung cancer diagnosis. The Institute of Medicine report “Cancer Care for the Whole Patient” highlights this concept and the importance of supportive care, describing that failure to address psychosocial concerns adversely affects healthcare delivery and the patient’s health. Psychological and social problems that can be caused or exacerbated by cancer (depression, emotional problems, lack of information or skills related to illness management, lack of transportation or other resources), along with disruptions in work, school, and family life, cause additional distress, weaken treatment adherence, and threaten patients return to health (53). Supportive services and patient-clinician relationship are strategies that can improve lung cancer disparities.

Supportive services

Supportive services for patients involve a multidisciplinary team to provide relief of suffering and support for the best possible quality of life, with a focus on physical, psychological, spiritual, and practical burdens of an individual’s illness (54). All patients with cancer and their families should receive quality comprehensive cancer care that ensures the provision of appropriate supportive services. However, prior research has shown a low uptake of psychosocial supportive services in individuals living with cancer). The low uptake of referrals for supportive care services suggests a disconnect between the level of unmet needs in individuals affected by cancer and their engagement with services that may help to address these needs (55). One way to bridge this gap is the implementation of a patient navigator. Patient navigation bridges the gap between patients and direct care providers to overcome challenges patients face regarding limited resources and lack of understanding of the current healthcare delivery system.

Patient navigation is a strategy to overcome barriers, reduce disparities, improve access to care, and enhance health outcomes. Emerging evidence suggests that patient navigation improves quality of life, satisfaction with care, and reduces hospital readmission during active treatment. Navigation is also effective in improving participation in cancer screenings and reducing time between screening to diagnosis and diagnosis to initiation of treatment (56). Patient navigation can be delivered by healthcare professionals such as nurses, lay workers with different educational backgrounds, or through digital systems. The organized use of lay workers, such as community navigators, to support cancer center navigation programs is a new concept reflecting the need to reframe patients’ healthcare experiences to incorporate SDOH into the disease treatment process (57). Patient navigators focus on four major areas: (I) overcoming barriers in the health system, (II) providing health education and informational support, (III) instrumental support addressing patient barriers, and (IV) providing psychosocial support (58). Depending on the patient’s needs, barriers, and cancer care goals, navigators provide a wide range of services to help patients overcome barriers and obtain optimal and timely cancer services while promoting the effective use of resources. Navigators also play an important role as liaisons between the patient and the care team.

Navigation is most effective in promoting early diagnosis and treatment and improving health outcomes when implemented with patients more likely to encounter significant barriers to quality care (59). Patient navigation is shown to build trust, which is particularly important for Black patients, given previous experiences of mistreatment and disrespect from health systems (60). The Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) trial is a randomized pragmatic clinical trial for lung cancer patients that implemented a system-based multi-faceted intervention involving patient navigation. They found that, on average, patients received surgery nearly two weeks sooner than retrospective control patients. There was also a reduction in the racial gap between the time from diagnosis to surgery, and over 85% of Black and White patients received surgery in the recommended eight-week period associated with better survival outcomes (61).

Hospital systems should support the role of patient navigators to assist all patients with lung cancer. Certain patient populations will have more barriers to care and will require more support from the patient navigation team. Screening for SDOH is important to determine at risk populations. The funding of these programs is critical, but challenging. There is bipartisan legislation entitled the Comprehensive Cancer Survivorship Act that addresses the entire continuum of care—from diagnosis to active treatment and post-treatment—to improve survivorship, treatment, and transition for all survivors. Supporting policy changes such as the Comprehensive Cancer Survivorship Act provide an opportunity to improve the patient navigation for underserved patients with lung cancer (https://canceradvocacy.org/policy/comprehensive).

Patient-clinician relationship

Patient-clinician relationship includes many elements such as rapport, trust, communication, empathy, unconscious bias, cultural competency, language use, motivation, and awareness of health disparities. All these factors can contribute to poor outcomes in underrepresented minority patients with lung cancer (62). Additionally, many clinicians are unaware of how their communication and cultural patterns contrast with their patients, which can lead to conscious and unconscious biases, stereotypes, and assumptions (63). Culture-related factors, including cultural differences in health and illness, values, patients’ preferences for physician-patient relationships, racism, bias, and linguistic barriers all impact a patient’s healthcare (62).

In oncology, differences in culture and communication are especially difficult to navigate, given the sensitivity and severity of the illness (62). A cancer diagnosis may intensify psychological and physical suffering, impacting the way patients, providers, and communities deal with communication and cultural differences in the clinical setting. Physicians should recognize that the interactions between patients, other members of their team (nurse practitioners, advanced practice providers, nurses, medical assistants, schedulers, etc.), and the broader healthcare system also impact the patient-clinical relationship. The relationship between patients and their care team is crucial to the quality of care delivered. Improving the cultural sensitivity and competence of the care team and developing a comprehensive care plan will build trust and address common barriers to care.

However, one challenge remains: identifying patients with needs and connecting them with supportive services. Strategies are needed to improve effective communication, increase trust, and develop care plans sensitive to patients’ social and cultural experiences, which may be addressed through educational interventions and coordination across the healthcare team. Building culturally competent educational programs and systematic interventions can potentially address clinician-based factors to better care for underrepresented minority patients and marginalized populations.

Conclusions

In the next year, over 235,000 people in the United States will be diagnosed with lung cancer, and underserved minority patients will have worse outcomes. In this review, we highlighted racial disparities in the incidence, diagnosis, and surgical treatment of lung cancer and strategies to overcome them. Interventions are needed to improve the delivery of equitable care, particularly for underserved minority patients with lung cancer.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-1962/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-1962/prf

Funding: This work was supported by the University of Cincinnati Cancer Center Pilot Grant Program.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-1962/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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