Internal study of lung cancer treatment disparities in at-risk populations

Early cancer screening and diagnosis are most likely to give patients a positive result, but especially eligibility for screening. lung cancerHas historically overlooked the increased risk associated with minority groups.

Function as Major cause Data show that black men and women are at increased risk of lung cancer at a young age, even though they smoke less than white men among cancer-related deaths.

In fact, these concerns were a recent focus Has been updated The United States Preventive Services Task Force (USPSTF) recommendations for lung cancer screening have made two notable changes to increase eligibility for high-risk patients.

• Annual low-dose computed tomography (LDCT) scans for people aged 50-80, not 55
• Targeted at individuals with 20 pack years of smoking history, expanded from 30 pack years

Consider the potential impact of these updated guidelines, M. Patricia Rivera, MD, Professor of Medicine, Department of Lung Disease and Emergency Medicine, Director of Interdisciplinary Lung Cancer Screening Program, and Co-Director of the North Carolina Lung Screening Registry at the University of Nascarolina, Carolina, of Chapel Hill. AJMC^® What has been achieved and what has not been met will persist in managing lung cancer treatment disparities.

Are the updated guidelines sufficient?

“The new recommendation to lower age and pack year requirements actually results in a relative increase in eligibility for women and men, and blacks, Hispanics, Native Americans and whites,” published in. editorial JAMA About updated recommendations. “The important observation is that these new recommendations result in a higher relative increase in eligibility, but that does not mean that the inequality will be closed.”

Cite another study published in JAMA network open Examining the updated guidelines, Rivera suggests that screening eligibility is improved for women and minorities, but odds ratio findings suggest that eligibility remains in favor of white men. Said.

“Currently, 14.5 million US adults are expected to be screened, with a 2013 recommendation of 8 million, so I think it’s like an 81% increase in individuals. More patients are now eligible, “says Rivera. “But just because you’re younger and have a history of smoking doesn’t mean that you’re going to increase that percentage. This means that eligibility or eligibility has improved access to lung cancer screening. Access to care is not always the case. “

Ultimately, there are several underlying factors that contribute to the inequality that exists in lung cancer treatment.In evaluating one of the main ones type Published in a recent study of lung cancer, non-small cell lung cancer (NSCLC) Annual report of thoracic surgery We investigated the differences in racial and resident segregation results measured by agents of historical housing discrimination and related structural racism in the 100 most populous US counties.

Deriving data from surveillance, epidemiology, and end-result programs for black and white patients diagnosed with NSCLC between 2004 and 2016, the results show that black patients with NSCLC who lived in the most isolated US counties. It was shown to be 49% more likely to be diagnosed in advanced patients. Stage-a tendency not seen in Caucasian patients compared to those living in the least isolated counties.

Although the overall incidence is low, black patients in highly isolated counties diagnosed with NSCLC early are more likely to undergo surgery, in addition to being more likely to be diagnosed in advanced stages than white patients. Was found to be 47% lower.

Multiple reasons to support inequality

To address these disparities in surgery, the corresponding research author, Dr. Kei Suzuki, MD, Associate Professor of Surgery, Boston University School of Medicine, said: AJMC^® Although this study was not designed to identify relevant details and causes, he and other authors believe that the reason for the link is multifactorial.

“This could be due to system issues such as access to care. It could be a provider issue as it is unlikely to recommend surgery to black patients,” Suzuki said. He said in an email. “This can be due to patient factors, whether distrustful or the patient’s physiologic condition does not allow surgery. For patients being seen at the Boston Medical Center. Local data was used to further show the association with the resident. Separation in the form of. Redlining And the disparity in lung cancer screening. “

Recognizing the update of the USPSTF Lung Cancer Screening Guidelines as an important step in improving screening for at-risk populations, Suzuki said further research on risk factors is needed and there is another important issue in screening inclusion. ..

“The nationally published screening rates / uptakes range from 5% to 10%, meaning those who meet the criteria, and only a handful are actually undergoing screening LDCT scans. That’s one thing, but there are still unanswered questions. How can we better screen those who meet the criteria? “

Possibility of target screening to fill the coverage gap of Medicaid screening

As Rivera pointed out, there are some issues that contribute to the lack of national compliance with the USPSTF Lung Cancer Screening Guidelines. That is, socio-economic barriers such as approval from well-known medical institutions and insurance status.

Medicare is currently reviewing updated USPSTF guidelines and approved screening in 2015, but in the case of Medicaid, recipients Double chance The program does not need to cover screening as it currently smokes more than those with private insurance. Even if it covers it, the program may use criteria different from those recommended by the guidelines.

“There is [9] He states that he did not expand the scope of Medicaid for lung cancer screening. As a result, there are many individuals in this country who are at risk for lung cancer due to smoking. These individuals may be uninsured by Medicaid or may be in areas that are not insured and are not covered by Medicaid. This is a major barrier to our health. “Care system,” said Rivera.

Updated guidelines may exacerbate screening access disparities, as they are not applicable to a significant proportion of US residents covered by recent Medicaids. review Developed by the Health Policy Partnership for the Lung Ambition Alliance, it suggests that targeted screening with LDCT scans in high-risk populations can significantly reduce mortality and associated financial burden.

This review, approved by the International Association for the Study of Lung Cancer (IASLC), Nelson StudyAmong a cohort of more than 13,000 Europeans who were shown to be at high risk for lung cancer, the intervention group (18.4%) who underwent LDCT scan had a significant mortality rate compared to the unscanned control group. (24.4%) after 10 years of follow-up.

Talk to AJMC^®Giorgio Scagliotti, a former chairman and interim chief science officer of the IASLC and a professor of oncology at the University of Turin School of Medicine, said that screening recommendations focus primarily on current and previous heavy smokers and ages. Factors such as family history, occupational exposure, and ethnicity of cancer or lung cancer that emphasize increasing evidence of risk are of paramount importance in determining the risk of lung cancer.

“Early stage lung cancer can be managed with a more complex and less expensive clinical pathway than if it were diagnosed in the later stages,” Skagliotti said in an email. “As lung cancer progresses, medical costs increase due to increased frequency of hospitalizations, additional treatment rounds, additional care requirements, and increased potential for palliative care.”

The report shows barriers that patients may face, as data show that underserved people and people with low socioeconomic status are less likely to participate in cancer screening programs. And appreciated reform opportunities in three key areas.

• Improving information and awareness
• Reduce physical and economic barriers to access
• Break down psychological and social barriers that prevent participation in screening

“Screening with LDCT technology is the next big opportunity to improve survival from cancer, and large-scale implementation can bring us closer to our goal of eliminating lung cancer as a cause of death,” Scagliotti said. Added.

Early detection of cancer may justify federal intervention

A scaled LDCT screening approach is ideal for expanding reach to high-risk populations, but Rivera can be exacerbated by simply revising the guidelines to include requirements such as shared decision making. I pointed out that there is. Workflow concerns As a result, intake may be restricted for doctors who are already time-constrained.

“When considering strategies that may facilitate workflows, it is very helpful for patients to have a shared decision-making television visit before seeing a doctor,” Rivera suggested. “But perhaps one of the most important interventions is that the healthcare system really needs to provide resources like a nurse navigator to help facilitate the screening process. And in addition to the navigator, Community navigators deploy and reach nurse navigators in the community Underserved group The number of individuals living in areas with low socioeconomics will be very helpful. “

Ultimately, Skagliotti, Rivera, and Suzuki all agree that federal intervention by policy makers is needed to make a significant impact on the disparity in lung cancer treatment.

In fact, Rivera states that similar measures have been taken for breast and cervical cancer. Breast and cervical cancer mortality prevention law in 1990Was established to ensure that the availability and quality of screening for these cancers is available to all women from each state, regardless of their financial position.

“We need state involvement and individual state obligations, such as extending Medicaid to all states, so that all individuals have access to this important preventive service,” Rivera added.

Looking at recent data on U.S.-wide screening rates by state, Kentucky Highest incidence of lung cancer Nationally, smoking rates have been shown to be significantly higher than nationally.

In response, the state has implemented a very aggressive lung cancer screening initiative. Rivera states that she took the initiative a few years ago, primarily through her GP. Through this initiative, Kentucky’s lung cancer screening rate rose to 15% in 2018, significantly higher than North Carolina’s 4% screening rate in the same year, highlighting the possibility of undiagnosed ongoing lung cancer. doing.

“It’s very helpful to have these initiatives to screen the most needed communities and to learn / try to mimic or extend those types of initiatives across other states,” she concludes. I attached it.