Outcomes Similar for Blacks and Whites with Lung Cancer When Surgery is Advised

Survival rates following a diagnosis of early-stage lung cancer tend to be lower among African American patients than among Caucasians. However, a study published in the January Archives of Surgery suggests that racial disparities in mortality are not seen when patients with health insurance are appropriately recommended surgical therapy, whether or not they actually undergo surgery.
According to Dr. David R. Flum, at the University of Washington in Seattle, and co-authors, "Health care system and provider biases and differences in patient characteristics are often thought to be predominant factors underlying racial disparities." They tested the theory that resection and survival rates would be similar regardless of race when patients with early-stage lung cancer were advised to have surgery.
They identified patients in the Surveillance, Epidemiology, and End Results-Medicare database who were diagnosed with stage I or II lung cancer between 1992 and 2002 and followed through the end of 2005. A total of 17,739 patients (median age 74 years; 89% white, 6% black) were recommended surgical therapy.
"Contrary to expectation, we observed a large...difference between black and white patients in the proportion of patients who actually underwent lung resection, even though all of the patients were recommended surgical therapy," the authors said. "Another surprising finding was that this large difference in receipt of optimal therapy did not appear to affect long-term survival."
Specifically, the researchers report, 69% of black patients and 83% of white patients underwent resection (p < 0.001). After adjustment for patient and cancer characteristics, black race was associated with lower odds of receiving surgery (hazard ratio 0.45).
In unadjusted analysis, black patients had a lower 5-year overall survival rate (36% vs 42%). However, after adjustment, there was no significant association between race and mortality (HR 1.03), or between race and lung cancer cause-specific mortality (HR 1.01).
These findings, the authors suggest, imply that factors such as perceptions and beliefs about lung cancer and its treatment, distrust of physicians, and limited access to subspecialty care may play a large role in racial health disparities.
On the other hand, they say, the absence of a survival difference could be explained "if white patients undergoing operations were at higher risk (defined by poorer pulmonary function) for death compared with black patients undergoing operations, counterbalancing the effect of more lung resections among white patients compared with black patients." Such a scenario could mean that surgery was overused in whites and/or underused in blacks.
Dr. Flum's team concludes: "Interventions designed to narrow gaps in health care should target structural aspects of care, providers, and patients and communities at risk for lung cancer and suboptimal care."