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?