Impact of Residential Segregation and Structural Racism on Outcomes and Treatment of Black Patients With NSCLC

Compared with White patients, Black patients were more likely to be diagnosed with advanced stage non–small cell lung cancer (NSCLC), were less likely to receive surgery for early stages of disease, and had an increased cancer-specific mortality at a higher index of dissimilarity (IoD), according to findings from a study published in The Annals of Thoracic Surgery.

Compared with White patients, Black patients were diagnosed at a younger age (65.1 vs 69.6 years; P < .001). Black patients were also more proportionately male (54.0% vs. 50.6%; P < .001), lived in the South (32.4% vs. 13.4%) and Midwest (17.2% vs. 10.7%), were more likely to be diagnosed with Stage IV disease (38.3% vs 33.5%; P < .001), and less likely to receive surgery across all stages (14.9% vs 21.6%; P < .001) when compared with White patients.

Focusing on the unadjusted model, Black patients were more likely to present advanced stage disease than White patients. Moreover, for Black patients, IoD was associated with a 13% increased risk of advanced disease at diagnosis (relative risk [RR], 1.13; 95% CI, 1.08-1.20), while white patients had an 8% decreased risk of advanced stage disease associated with an increasing IoD (RR, 0.92; 95% CI, 0.87-0.98).

“Overall, we show that structural racism in the form of residential segregation is associated with disparate outcomes in stage at diagnosis, surgical resection, and mortality between Black and White patients,” the investigators wrote. “Segregation in the U.S. is largely a consequence of government-complicit discriminatory housing practices that have served to devalue Black communities, leading to countless disparities in health.”

In the retrospective cohort study, investigators analyzed a population of 229,018 patients, of whom 15.6% were Black (n = 35,649). Data for the study was pulled from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program’s 2018 registry. The registry covered 15 states and 18 cancer registries, and is one of the largest registries in the United States that provides patient-level geographic information.

Additional findings from the study indicated that, regarding surgery for localized disease, Black patients were 33% less likely to undergo surgery for stage I or II disease with increasing IoD (RR, 0.67; 95% CI, 0.61-0.74), although this did not reach a level of significance for White patients (RR, 1.00; 95% CI, 0.90-1.11).

After controlling for age at diagnosis, sex, region, and stage, 5% increased hazards of death were observed among Black patients who were in the highest quartile of IoD compared with White patients in the highest quartile of IoD (HR, 1.05; 95% CI, 1.03-1.08). Eight percent increased hazards of death were also observed among Black patients in the lowest quartile of IoD when compared with White patients in the lowest quartile of IoD (HR, 1.08; 95% CI, 1.05-1.12).

The study’s limitations include the use of a cancer registry, which might be subject to coding errors and is limited to available variables. Furthermore, the analyses were limited to populous regions included in the SEER registry, which might not be representative of the total urban population in the United States.

“Reinvestment in these devalued minoritized and marginalized communities through reparative actions for a long history of discrimination can serve to alleviate racial disparities in lung cancer. Broadly, urban policy can serve to address the structural factors leading to these outcomes. However, most immediately, clinicians and healthcare institutions can focus screening efforts in these minoritized communities and realize the racialized socioeconomic implications that may impact access to care, which may delay definitive care,” the investigators concluded.

Reference

Annesi CA, Poulson M, Mak KS, et al. The impact of residential racial segregation on non-small cell lung cancer treatment and outcomes. Ann Thorac Surg. Published online ahead of print, May, 22 2021. doi:10.1016/j.athoracsur.2021.04.096