The Effect of Socioeconomic Status on Treatment and Mortality in Non-Small Cell Lung Cancer Patients

doi:10.1016/j.athoracsur.2019.07.017

The Annals of Thoracic Surgery

Volume 109, Issue 1, January 2020, Pages 225-232

Presented at the Poster Session of the Fifty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 26-29, 2019.

https://doi.org/10.1016/j.athoracsur.2019.07.017 Get rights and content

Background

Treatment decisions for patients with non-small cell lung cancer (NSCLC) are based on patient and tumor characteristics, including socioeconomic status (SES) factors. The objective was to assess the contribution of SES factors to treatment and outcomes among patients with stage I NSCLC.

Methods

The National Cancer Database was queried for operable patients with stage I NSCLC. Patients were divided into three treatment groups: primary resection (ie, surgery only); nonstandard treatments consisting of chemotherapy with or without radiation; and no therapy. The SES of patients who made up the treatment groups was assessed, and the 5-year survival of all groups was analyzed.

Results

The cohort included 69,168 patients with stage I NSCLC. Each of these patients had between zero and five SES risk factors. The factors associated with no surgery were low income, nonwhite race, low high school graduation rate, Medicaid or no insurance, rural residence, and distance less than 12.5 miles from treatment facility. Patients with several SES risk factors have linearly increasing odds of undergoing nonstandard treatments and quadratically increasing odds of having no therapy (for patients with five factors, to odds ratio 4.7; 95% confidence interval, 3.44 to 6.30). Surgery alone was associated with significantly longer 5-year survival (71.8%) compared with nonstandard treatments (22.7%) and no therapy (21.8%; P < .001).

Conclusions

Socioeconomic status factors increase the risk of undergoing guideline discordant therapy for stage I NSCLC. As the number of SES factors increases, the odds of no therapy rises quadratically whereas the odds of nonstandard treatments rises constantly. The surgery only group had significantly longer survival than the nonstandard treatment and no therapy groups.

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Data Source

The National Cancer Database (NCDB) is an oncology database assembled from hospital records that contains information about patient demographics, treatment modality, and outcomes.¹² More than 1,500 Commission on Cancer accredited treatment facilities contribute to the database. The collective data from these hospitals represents approximately 70% of the patients diagnosed with cancer annually in the United States and contains as many as 34 million historical records. The NCDB is sponsored by

Results

A total of 69,168 patients met inclusion criteria for this study. Of those patients, 74% (51,208) underwent SUR, 9% (6369) underwent NST, and 17% (11,591) had NoT (Figure 1, Table 1).

In a bivariate analysis of the dichotomized demographic factors comparing the higher risk group to its reference group the following factors were associated with patients undergoing surgery for their disease: female sex, younger age (69 years or less), higher income (greater than $38,000 per year), higher rates of

Comment

Characterizing SES is a challenging task. Many methods have been proposed to quantify SES, but no perfect system exists and each is subject to its own inherent bias. The model in this study sought to assess the association between SES and NSCLC outcomes based on the factors available in the NCDB. Rather than examine any one variable, the NCDB data were examined and stratified based on multiple SES factors. This assessment is unique because it allows for the possibility that multiple SES factors

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Minimally invasive resection for non–small cell lung cancer has been linked to decreased postoperative morbidity. This work sought to characterize factors associated with receiving minimally invasive surgery for surgically resectable non–small cell lung cancer.
All adults undergoing lobectomy/sublobar resection for stage I non–small cell lung cancer were identified using the 2010-2020 National Cancer Database. Those undergoing thoracoscopic/robotic procedures comprised the minimally invasive resection cohort (others: open). Hospitals were stratified by minimally invasive resection procedure volume, with the top quartile considered high minimally invasive resection volume centers. Multivariable models were constructed to assess the independent association between the patients, diseases, and hospital factors and the likelihood of receiving minimally invasive resection.
Of 217,762 patients, 112,304 (52%) underwent minimally invasive resection. The proportion of minimally invasive resection procedures increased from 27% in 2010 to 72% in 2020 (P < .001). After adjustment, several factors were independently associated with decreased odds of receiving minimally invasive resection, including lower quartiles of median neighborhood income (51st-75th percentile adjusted odds ratio, 0.92, 95% CI, 0.89-0.94; 26th-50th percentile adjusted odds ratio, 0.86, CI, 0.83-0.89; 0-25th percentile adjusted odds ratio, 0.78, CI, 0.75-0.81; reference: 76th-100th percentile income) and care at community hospitals (adjusted odds ratio, 0.70, CI, 0.68-0.71; reference: academic centers). Among patients receiving care at high minimally invasive resection volume centers, lowest income remained linked with reduced likelihood of undergoing minimally invasive resection from 2010 to 2015 (adjusted odds ratio, 0.85, CI, 0.77-0.94), but did not alter the odds of minimally invasive resection in later years (adjusted odds ratio, 1.01, CI, 0.87-1.16; reference: highest income).
This study identified significant community income-based disparities in the likelihood of undergoing minimally invasive resection as definitive surgical treatment. Novel interventions are warranted to expand access to high-volume minimally invasive resection centers and ensure equitable access to minimally invasive surgery.
Diversity, Equity, and Inclusion: Visiting The Society of Thoracic Surgeons Priority
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Somatic mutation variant analysis in rural, resectable non‐small cell lung carcinoma patients
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Additionally, mortality due to lung cancer exhibited a dramatic swing from generally less mortality in rural patients in the 1990s to higher mortality in rural patients when compared to their matched urban dwelling counterparts in the 2000s [2]. Rural patients diagnosed with NSCLC, have significantly worse overall survival compared to urban dwellers with the largest disparity in early-stage patients [3–5]. Collectively, these factors signify a critical need for improved therapeutic outcomes in NSCLC, especially in states like Missouri, a predominantly rural state, where NSCLC has been given a high priority status [6].
Rural non-small cell lung cancer (NSCLC) patients do worse, largely related to lack of access to care. In this study, the mutational characteristics and potential for targeted therapy in rural, resectable NSCLC patients using whole exome sequencing (WES) were analyzed. WES was performed on tumor-adjacent normal pairs from rural patients undergoing resection for NSCLC. Sequencing alignment, variant-calling, annotation, and tumor mutational burden (TMB) calculations were performed using standard methods. cBioportal and OncoKB were used for comparisons of mutational frequencies and actionable targets. Thirty-four NSCLC patients underwent WES after surgical resection. The gene most frequently containing somatic variants was TP53. The median number of somatic variants was 188 (Range 11–1056), and median TMB was 3.30 (0.33–18.56) nonsynonymous mutations per Mb. Tumor stage and survival were not associated with number of variants, TMB or TP53 mutational status. Significant concordance among the most common mutations when cross-referenced to cBioportal (R = 0.78, p < 0.0001) was observed. 24% of patients had variants in actionable genes based on OncoKB annotation. In summary, we demonstrate baseline mutational frequency and establish foundations for targeted adjuvant trials in rural NSCLC patients with specific differences. Future studies must ensure to include rural patients to improve NSCLC patient outcomes.
Facility-level national trends in racial disparities of surgical therapy for early-stage lung cancer
2022, Journal of Thoracic and Cardiovascular Surgery
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The NCDB is a hospital-based registry that includes cases from Commission on Cancer–accredited cancer programs nationwide. It is currently the largest database available for cancer cases,18 including approximately 1500 institutions and accounting for more than 70% of all cancer diagnoses in the United States, and has been widely used to analyze racial disparities in treatment of lung and other cancers.15,19-23 We queried the NCDB Participant User File from 2006 to 2016 for patients diagnosed with American Joint Committee on Cancer seventh edition clinical stage I NSCLC, as determined by International Classification of Diseases for Oncology-3 codes.
The racial gap in surgical treatment for early-stage non–small cell lung cancer (NSCLC) has been narrowing at the population level, but it is unknown if this trend persists at the facility level.
We queried the National Cancer Database Participant User File from 2006 to 2016 for patients with stage I NSCLC. Facilities were grouped by type, location, and resection volume. The cumulative surgery rate for Black and White patients in each group was calculated, and an incidence rate difference of receipt of surgery was determined. Logistic regression with estimation of marginal effects was used to assess the probability difference of receiving surgery in Black versus White patients in each year.
In total, 315,474 patients were included; 287,585 (91.2%) were White and 27,889 (8.8%) were Black. The surgery rate was greater for White patients (60.2% vs 55.8%, P < .001). For most groups, the surgery disparity narrowed over the study period. The disparity widened in community cancer programs; facilities in the New England, West North Central, and Pacific regions; and the lowest volume facilities. The probability difference for receiving surgery was significantly smaller in 2016 versus 2006 in the Middle Atlantic region and community cancer programs; the difference was unchanged for all other groupings.
Trends in disparities in the use of resection for early-stage NSCLC are not universal across facility groupings. As efforts are made toward addressing racial disparities in surgical care for NSCLC, it will be important to remember that population-level analyses may mask lack of progress in certain facility groups.
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Social Determinants of Health (SDOH) can be important contributors in health care outcomes. We hypothesized that certain SDOH independently impact the management and outcomes of stage I Non-Small Cell Lung Cancer (NSCLC).
Patients with clinical stage I NSCLC were identified from the National Cancer Database. The impact of SDOH factors on utilization of surgery, perioperative outcomes and overall survival were examined, both in bivariate and multivariable analyses.
A total of 236,140 patients were identified. In multivariate analysis, SDOH marginalization were associated with less frequent use of surgery, lower 5-year survival and, in surgical patients, more frequent use of open surgery and lower 90-day postoperative survival.
SDOH disparities have a significant impact in the management and outcomes of stage I NSCLC. We identified SDOH patient groups particularly impacted by such disparities, in which higher utilization of surgery and minimally invasive approaches may lead to improved outcomes.
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Non-small cell lung cancer patients with multiple high-risk socioeconomic factors experience treatment and survival disparities. We aim to assess whether disparities in treatment and survival vary by region for patients with 3 or more high-risk socioeconomic factors.
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Original articleGeneral thoracicThe Effect of Socioeconomic Status on Treatment and Mortality in Non-Small Cell Lung Cancer Patients

Background

Methods

Results

Conclusions

Visual Abstract

Section snippets

Data Source

Results

Comment

Am J Med Sci

Lancet

Chest

Clin Lung Cancer

J Thorac Oncol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Natl Med Assoc

J Urol

American Cancer Society. Cancer Facts & Figures 2018

Survival of patients with stage I lung cancer detected on CT screening

N Engl J Med

Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer

JAMA

Racial differences pertaining to a belief about lung cancer surgery: results of a multicenter survey

Ann Intern Med

Racial differences in the treatment of early-stage lung cancer

N Engl J Med

Racial disparities in cancer therapy: did the gap narrow between 1992 and 2002?

Cancer

American Thoracic Society Disparities in Healthcare Group. An official American Thoracic Society systematic review: insurance status and disparities in lung cancer practices and outcomes

Am J Respir Crit Care Med

Cancer survival disparities by health insurance status

Cancer Med

Original article
General thoracic
The Effect of Socioeconomic Status on Treatment and Mortality in Non-Small Cell Lung Cancer Patients