“Our most profound finding was the fact that African Americans with two or more additional medical conditions had almost zero surgeries, only about four out of 100, whereas white patients in the same situation had surgery just as often as if they didn’t have these conditions,” said Samuel Cykert, MD, lead author of the American Cancer Society-funded study, which is published in the June 16, 2010 issue of the Journal of the American Medical Association.
“In addition, if an African-American patient in our study did not have a regular source of care, a primary care doctor, then the odds of going to surgery were only one-fifth that of white patients,” said Cykert, associate professor in the UNC School of Medicine, a clinician at the Greensboro Area Health Education Center and a member of UNC’s Cecil G. Sheps Center for Health Services Research.
Among patients newly diagnosed with early-stage lung cancer, surgery to remove the diseased portion of lung is the only reliable cure, Cykert said. With surgery, at least half will survive more than four years. Without it, most will die within a year. Studies looking back at patients through insurance claims and cancer registries have shown for years that black lung cancer patients get surgery much less often then whites but these studies have been unable to explain why.
Possible explanations suggested by his study for the differences in surgical rates for blacks compared to whites, Cykert said, include perceptions by black patients of poor doctor-patient communication. Also, black patients were less likely than whites to have primary care providers or other sources of support that could help them either reconsider the decision when they don’t fully understand their prognosis or challenge a clinical decision against surgery that was not based on absolute contraindications – complicating conditions that are considered to make surgery inadvisable.
In Cykert’s prospective cohort study, he and colleagues analyzed data from 386 lung cancer patients from five communities in North and South Carolina who met full eligibility criteria for lung resection surgery. Each participant, at the time of diagnosis, verbally completed a 106-item survey at the time of enrollment that included questions about their demographics (race, age, sex, income, etc.), perceptions of patient-physician communication, perceived certainty of diagnosis, attitudes about lung cancer, religiosity, past health care experiences, access to a regular source of care (such as a primary care doctor) and their medical decision makers (such as a spouse, child or spiritual advisor).
In addition, researchers reviewed the medical charts of each patient four months after enrollment. Information collected from the chart review included the date of lung cancer surgery (if performed) and pathological diagnosis, preoperative stage, medical comorbidities and preoperative lung function results. The primary outcome they were looking for was whether or not the patient received lung cancer surgery within four months of study enrollment.
The results show that 66 percent of white patients had surgery, compared to 55 percent for black patients. Surgical rates for blacks were especially low when they had two or more comorbid illnesses or lacked a regular source of care. For blacks with two or more comorbidities, the surgical rate was 13 percent, compared to 62 percent among black patients without comorbidities. When blacks lacked a regular source of care, their surgical rate was 42 percent, compared to 57 percent for blacks with regular care.
These results suggest that there may be thousands of black patients with lung cancer in the U.S. who should be getting surgery, but aren’t, Cykert said. “These differences in care go beyond what can be explained by differences between blacks and whites in health insurance, education, and income,” he said.
To correct this disparity, he said, physicians need to develop a sense of “paranoia” in cases where black patients with lung cancer, for whatever reason, have been steered away from surgery. In such cases, “We need to be paranoid about it and we need to push for second opinions or other fail-safe mechanisms,” he said. Also, “we need electronic records that follow patients so that when someone drops out of care, we can find them and re-offer surgery for cure. It’s also important for these electrical record systems to track treatments by race in real time so that we can ensure progress in this area.”
But that by itself is not the whole solution, he said. Several other interventions should also be considered, including the use of special navigators for patients who educate patients about risk numbers and calculations and how to relate to them, and using techniques such as the teach-back method to make sure that patients understand what their doctors have tried to communicate to them.
In addition to Cykert, UNC authors of the study were Peggye Dilworth-Anderson, PhD, Giselle Corbie-Smith, MD, MSc, Lloyd J. Edwards, PhD and Audrina Jones Bunton, MA.
Authors from outside UNC were Michael H. Monroe, MD of Carolinas Medical Center in Charlotte, N.C.; Paul Walker, MD of East Carolina University and Franklin R. McGuire, MD of the University of South Carolina.