Addressing Disparities in Lung Cancer from a Geographic Perspective
During an interview, Raymond U. Osarogiagbon, MD, discussed the disparities between long term care and lung cancer outcomes in the United States.
Raymond U. Osarogiagbon, MD of the Baptist Cancer Center in Memphis, Tennessee, shared his thoughts on the disparities in long-term care and lung cancer outcomes in the United States at the International Association’s Global Conference for the 2021 Lung Cancer Study on Lung Cancer in an interview with Targeted therapies in oncology™ (BTT).1
To address these disparities, he stressed the need for a holistic and proactive approach to corrective interventions, highlighted innovative solutions to the problem of inequality of care and identified social policy interventions as the best way to address these disparities. ‘make improvements.
BTT: What are we observing at the state level regarding lung cancer deaths?
OSAROGIAGBON: If we disaggregate lung cancer as a state-level cause of death, you’ll see a huge difference between the states with the highest per capita risk of death from cancer in the southern and midwestern United States. In the lung cancer mortality rankings, Kentucky is number 1, Mississippi is number 2, Arkansas number 3, and Tennessee and West Virginia is number 4 and 5. At number 6 is Alabama, then you have them. Carolinas and Louisiana.
What are the differences in lung cancer between men and women and what racial disparities do you see?
We know that the risk of developing lung cancer with the same level of exposure to tobacco is different between men and women; women are more likely to be less exposed to tobacco. It is often when we talk about the interventions themselves and their access, it is the men who do better than the women.
And if we look at the incidence and prevalence by race, we know that racial minorities, especially African Americans and Native Americans, are particularly at risk for lung cancer, even at lower levels of tobacco exposure. .
Of particular concern, however, is the emergence of disparities after the cut-off point. [diagnosis]- that he finds [lung cancer] early, whether the patient is receiving optimal treatment for them, and whether appropriate follow-up care is provided after diagnosis and treatment. There are striking differences between people on the basis of socioeconomics, race, and other unnecessary factors that are not central to biology.
How do you approach the issues surrounding lung cancer screening?
The lung cancer problem is most often by the time we find it out, it is too advanced to cure it. Well, now we know lung cancer screening saves lives. If you find someone who is at risk for lung cancer because of their age and smoking history, you can have a low-dose CT scan once a year. This projection is covered [by most insurance] in the USA. And this once-a-year test doesn’t just allow us to detect lung cancer in people who appear to be doing very well. Corn [screening allows] you find the cancer at a much earlier stage where you can cure it. And when you do that, we have good evidence that you reduce the risk of dying from lung cancer by 20%.2
Despite the evidence of the benefit associated with screening, why has it not become routine?
You would think that with such an exciting discovery that suddenly everyone at risk would be lining up to take these tests and every healthcare provider and healthcare organization would offer them. At the time our public policy has said that we will pay you to do these tests on these people, [you would think] that everyone would have.
The challenge is that the average penetration of screening among eligible people in the United States is around 5%. Only 5% of eligible people have had this screening test in the past few years. Conversely, 95% did not.
If you look at where testing facilities are available and where people are eligible for testing and have been tested, the highest states are in the Northeast, where up to 15% to 17 % of eligible people were screened.
In places with the highest lung cancer death rates, screening is consistently below 5% of those eligible, sometimes up to 2%. The only exception is Kentucky, the number one state, where they are an outlier, with 15-16% of eligible patients screened. There is a geographic disparity in access to life-saving technology covered by insurance.
How to define who is eligible for screening?
A person’s risk determines whether they should be screened and the most reliable factor in defining who is a candidate is the patient’s age. In addition, smoking history, which takes into account the intensity of smoking (i.e., number of pack-years smoked) and time since quitting, are other factors.
White men are more likely to be eligible for screening than white women, blacks, Hispanics, and Asians, even though screening is covered by insurance and can save lives. There is also a striking disparity in access to the curative intention, that is, surgery for lung cancer. Access to surgery is approximately 50% in Wyoming and up to 90% in New Jersey, Massachusetts and Utah.
Are these disparities observed in clinical trials?
Treatment innovations stem from the results of clinical trials, but if you assess the patient population participating in the trials, the proportion of black patients involved in lung cancer trials reflects geographic, demographic, and socio-economic disparities. (FIGURE1).
What would be your take home messages for oncologists?
First, disparities are preventable. Second, the disparities are incredibly expensive. The third thing is that when we start to focus on preventing, reducing and eliminating disparities, we have to understand that the solutions come from many levels.
The less effective is the level of blaming the victims for disparities. Patients don’t come in with the idea that they are going to do something to hurt themselves. A poor lung cancer patient who doesn’t get up in the morning decides, “So I’m going to make sure I get the wrong treatment today. I don’t care if I die.
Where is our intervention deployed most successfully? I think it’s important to recognize that the level at which we can have the most impact is at the political level. The second most important level of impact is at the organizational level.
So let’s take the example of screening. If my organization hasn’t bothered to offer low-dose screening, a lung cancer screening CT program, whatever the patient wants, they won’t get it. It’s not there to get it. And then of course, if the provider, who is the next most influential person, isn’t actively seeking, advising, advising, and ordering the right patient care, well, that’s not going to happen either. more. If the provider has not bothered to share the knowledge they have with the patient, the patient is unlikely to have access to that knowledge. So when we talk about disparities, I think it’s very important for us to step away from the traditional narrow lens that asks, “Who are these people or why are they having such terrible results? We have to recognize that we have seen the enemy, and that is us.
1. Osarogiagbon R. Disparities in lung cancer care in the population. Presented at: IASLC 2021 Global Lung Cancer Conference. September 8-14, 2021. Summary PL01.2. virtual.
2. Cheung LC, Katki HA, Chaturvedi AK, Jemal A, Berg CD. Prevention of Lung Cancer Mortality by CT Scanning: The Effect of Risk-Based Eligibility Criteria Against US Preventive Services Task Force Eligibility Criteria, 2005-2015. Ann Med Intern. 2018; 168 (3): 229-232. doi: 10.7326 / M17-2067