Funding Source
Lung Cancer Surgery: Decisions Against Life Saving Care
Sponsored by the American Cancer Society
Grant #: RSGPB-05-217-01-CPPB
Racial Disparities in the Treatment
of Early Stage Lung Cancer: Which Interventions Will
Work?
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.
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?
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.
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?
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
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
• Administrative data reveal lower surgical rates and survival for African-Americans diagnosed with Stages I and II, non-small cell lung cancer
Bach et al. Racial differences in the treatment of early stage lung cancer. N Engl J Med 1999;341:1198.
Race Lung Cancer Surgery
5-year survival
Caucasian 77% 34%
African-
American
64% 26%
44 excess deaths per 1000 lung cancer cases due to decisions against surgery!
Survival of Medicare Beneficiaries 65 Years of Age or Older Who Were Given a
Survival of Medicare Beneficiaries 65 Years of Age or Older Who Were Given a Diagnosis of Stage I or II Non-Small-Cell Lung Cancer between
1985 and 1993, According to Treatment and Race
Bach, P. B. et al. N Engl J Med 1999;341:1198-1205
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
Copyright © American Society of Clinical Oncology
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
• Administrative data controlled for insurance, income, and co-morbidities.
• No specific reasons for treatment disparity despite near certain death within 4 years post-diagnosis
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.
Methods
• 5 communities
• Pulmonary, Oncology, Thoracic Surgery, ED, and Generalist Practices
• Direct referral vs chest CT review protocol
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
Timing of Enrollment
• Patient informed of the diagnosis of definite or probable lung cancer
• Survey administered verbally by trained RA before treatment plan established
The Questionnaire
106 items Including:• Demographics
• SF-12
• Mental Adjustment to Cancer Scale
• Trust
• Perceptions of provider-patient communication
• “Exposure to air”• Perceived certainty of diagnosis• Attitudes about lung cancer• Dyspnea• Decision participants• Religiosity
Chart Abstraction
• Timing: At least 4 months after diagnosis
• Surgery: Yes / No and Date
• PFT’s
• Co-Morbid Diagnoses
• Clinical Stage
• Surgical Stage
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
• Variables entered after bivariate comparisons if p < 0.1
- attitudes about lung cancer
- religiosity
- other decision participant
- perceptions of provider-patient
communications
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
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
Results: Demographic Data
Characteristic Percent
African-American 29
Married 64
Male 56
Insured 92
Education > High School 35
Median Age 66 yrs (range 26 to 90)
4 Month Surgery Rates
• All enrollees (N = 386)
Caucasian 66%*
African-American 55%
*p = .05
4 Month Surgery Rates
• Tissue confirmed only (N = 339)
Caucasian 75%*
African-American 63%
*p = .03
Lung Surgery Rates – Bivariate Comparisons
Percent Surgery if Agree
Percent Surgery if Disagree
Faith alone can cure disease
52 70
One or more family members will have to approve surgery
57 66
If I have surgery and the cancer is exposed to air it will spread
53 70
My quality of life in 12 months will be better if I have lung cancer surg.
75 41
My doctor listened to me when I had something to say
71 36
Regression Analysis - All Patients
Independent
Variable
Odds Ratio for
Lung Ca Surg
95% Confidence
Interval
AA Race .75 .57 – .99
Comm. Score
(5 of 25 less)
.42 .32 – .74
Belief QOL worse in 12 months + surg
.27 .14 – .50
Regression Analysis - All Patients
Independent
Variable
Odds Ratio for
Lung Ca Surg
95% Confidence
Interval
Top quartile age (>73 yrs)
.32 .20 – .51
Bottom quartile MCS of SF-12
.51 .28 – .91
Religiosity (Faith alone q)
.56 .39 – .79
Regression Analysis - African Americans
Independent
Variable
Odds Ratio for
Lung Ca Surg
95% Confidence
Interval
Comm Score
(5 of 25 less)
.27 .15 – .51
Co-morbid illness
2 or more .04 .01 – 0.25
No Regular Source of Care
.20 .10 - .43
Regression Analysis - African-Americans
Independent
Variable
Odds Ratio for
Lung Ca Surg
95% Confidence
Interval
Belief QOL worse in 12 months with surg
.25 .08 – .79
Trust Scale – 10 point increase*
0.54* .35 – .85
* The Trust Paradox
Regression Analysis – White Patients
Independent
Variable
Odds Ratio for
Lung Ca Surg
95% Confidence
Interval
Co-morbid illness 2 or more
.45 .10 – 2.0
Comm Score (5 of 25 less)
.47 .24 – .93
Worse QOL in 12 months with surg
.25 .17 – .37
Trust Scale – 10 point increase
1.0 .76 – 1.4
Regression Analysis – White Patients
• No Regular Source of Care
OR 1.3, 95% CI .32 – 5.3
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)
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
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)
ResultsCharacteristic Percent Mortality at One-Year
AGE*
> 66 years 24
< 66 years 10
RACE
African-American 17
White 17
COMORBIDITIES*
> 2 31
< 2 15
LUNG CANCER SURGERY*
Yes 12
No 25
*P < 0.05
-------------------------------------------------------------------------- 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 2.506894dxcoronary~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 1.667122dxhyperten~n | .5987609 .1868083 -1.64 0.100 .3248522 1.103624comorbtotal3 | 2.785209 1.175041 2.43 0.015 1.218282 6.367485comorbtotal1 | 1.454711 .4823543 1.13 0.258 .7595123 2.786242------------------------------------------------------------------------------
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)
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
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
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.
Possible Solutions
• Know that disparities (beyond what is attributable to SES, education, and insurance) exist
• Think in the context of the ideal
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)
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.
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%
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)
Intervention Caveat
• Super-Navigator
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.
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?
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.
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?
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?