Designed to identify the causes of racial discrepancies in lung cancer treatment in the United States, the research ruled out unequal access to medical care as the sole explanation. It did show that blacks were somewhat less likely to be offered lung cancer surgery, and were slightly more likely to refuse it than were whites. Overall, the study found that blacks who had equal access to care were 45 percent less likely than whites to have lung cancer surgery.
These findings point to a subtle and complex "communications problem" underlying the inequality, said Christopher Lathan, MD, of Dana-Farber and lead author of the report that is published online by the Journal of Clinical Oncology and is scheduled to run in the journal's Jan. 20 print issue. "Something's not happening. There was no specific reason that could be found, but there needs to be more attention paid to the doctor-patient interaction."
The generally poorer health of blacks and other racial minorities is often blamed on social and financial obstacles to obtaining medical care. The new study, however, documents that the lower rate of surgery for black lung cancer patients "is not just about access to care or not being physically able to undergo treatment," said Craig Earle, MD, of Dana-Farber and the paper's senior author. "There still seems to be a racial disparity."
According to the American Cancer Society, lung cancer is the leading cause of cancer deaths among blacks Americans, and blacks have the highest lung cancer mortality rate in the United States. It is estimated that 15,500 blacks will die from lung cancer in the United States in 2005 (accounting for nearly a quarter of all cancer deaths), and that more than 19,000 will be diagnosed with the disease, which is approximately 14 percent of all new cancer cases among blacks.
Yet, blacks have been previously found less likely to get surgical treatment. Someone who is diagnosed before the cancer has spread very far - Stage I or II - has up to a 50 percent chance of being alive at five years if surgery is performed. Untreated, the disease is almost always fatal.
The researchers, who also included Bridget Neville, MPH, of Dana-Farber, analyzed cancer registry records and insurance claims of 21,219 Medicare-eligible patients diagnosed with non-metastatic lung cancer between 1991 and 2001. With Medicare, inequalities due to insurance coverage were eliminated. Of these patients, 14,224 had undergone invasive procedures to "stage" the disease by its extent, which is a guide to treatment decisions.
The procedures included bronchoscopy, the insertion of a viewing tube into the lungs, and mediastinoscopy and thoracoscopy, where surgeons make incisions in the chest wall under general anesthesia, through which viewing scopes are placed. Blacks were 25 percent less likely than whites to have staging examinations.
But even after being referred for and undergoing staging, only 36 percent of blacks - but 50 percent of whites - were among the 6,972 who went on to receive surgical treatment. The difference in surgery rates was 45 percent.
"We thought that if all the patients had been staged - which suggests that they had access to the appropriate specialists and implies some level of trust in the medical system - that they would have the same rate of surgery," said Lathan. "We were quite surprised to find this was not the case."
The study did not address cultural factors, but Lathan said blacks might be mistrustful of the medical system and less aware of the potential benefits of the invasive surgery. Lathan, who is black and treats lung cancer patients, added that physicians may be less inclined to try and persuade reluctant black patients to strongly consider the surgery, particularly if a patient lacks good social support during recovery.
While urging further study, Lathan advised all patients to "make sure they're getting all the resources they need, even if it means challenging their physicians a little bit." For physicians, he added, "it's really important that we spend as much time thinking about how we communicate with our patients as we do about how to treat them."
The study was funded by Dana-Farber and by a National Institutes of Health training grant.
Dana-Farber Cancer Institute (www.dana-farber.org) is a principal teaching affiliate of the Harvard Medical School and is among the leading cancer research and care centers in the United States. It is a founding member of the Dana-Farber/Harvard Cancer Center (DF/HCC), designated a comprehensive cancer center by the National Cancer Institute.