Facing Disparities in Lung Cancer Mortality Rates

CURE, CURE® Lung Cancer 2021 Special Issue 2,

Looking deeper into mortality rates highlights the importance of eliminating disparities in lung cancer and expanding screening eligibility for at-risk populations.

Despite a decrease in lung cancer rates across the country, significant differences in disease rates and outcomes remain at the state level because of a variety of disparities, according to study results presented at the annual meeting.

In the presentation, Dr. Raymond U. Osarogiagbon, a medical oncologist at the Baptist Cancer Center in Memphis, Tennessee, discussed the geographic disparities in lung cancer mortality rates across the United States.

“We know that (lung cancer) is the oncologic challenge of our age. If one takes the perspective of the sheer cost in terms of human life, (it is) the No. 1 killer of men and women in the United States and in a lot of countries around the world. ... In the United States, the good news is it has been going down sequentially over time,” Osarogiagbon explained in an interview with CURE®. “The bad news, though, is in the United States, if you dug in a little bit deeper, you will find a very different picture. At the state level, if we disaggregated lung cancer as a cause of death, you will find a huge difference between the states ... with the cluster of highest per capita death risk in the Southern and Midwestern United States.”

States with the worst lung cancer mortality rates include Kentucky, Mississippi, Arkansas, Tennessee, West Virginia, Alabama, North and South Carolina and Louisiana, according to Osarogiagbon.

“At the county level, the difference is even worse,” he said, noting that there are some that have rising numbers of death due to lung cancer such as the Appalachian Regional Authority and Delta Regional Authority, while others have plateaued with no decrease.

Disparities that come into play include women and racial minorities being at a higher risk for lung cancer despite lower levels of tobacco exposure.

Dr. Kim Lori Sandler, an associate professor of radiology and radiological sciences and co-director of the Vanderbilt Lung Screening Program at Vanderbilt University School of Medicine in Nashville, Tennessee, emphasized that there are exposures other than smoking that can contribute to disparities. “We know that smoking is the No. 1 cause of lung cancer, but there’s also other causes. We know radon exposure and other types of exposures can be a cause of lung cancer. Certain populations are continuing to have those exposures like smoking and other high-risk exposures,” she told CURE®.

This is where the importance of lung screenings comes in, said Sandler, who was not associated with the study presented at the meeting. “The populations that were highlighted in the presentation, a lot of it looks at this Southeast region where we continue to have very high rates of smoking,” she said. “And unfortunately, our rates of lung cancer screening (in that region) have remained lower than other areas of the country, like in the Northeast. If you look at maps of the availability of lung cancer screening programs, you see them very highly localized in these Northeast centers where there are a lot of different programs available, and then when you get to the Southeast, they’re more spread out and patients need to travel further in order to be able to enroll in those programs.”

The Importance of Lung Screenings

According to Osarogiagbon’s presentation, keeping up with yearly lung cancer screenings, which are usually covered by insurance, would reduce the risk of dying from the disease by 20%.

“It is from the point of onset on, whether it is finding (lung cancer) early, whether it is receiving optimal treatment for it, whether it is receiving the proper surveillance for it after diagnosis and treatment ... there are highly preventable differences,” he said. “It is people who live in parts of the world, or parts of the country that have resources that are organized in a certain way, who do well and not others. It is White people who do well, better than racial minorities. It is oftentimes when we’re talking about interventions themselves and access to them, it is men who do better
than women. And these are all things that are all necessary — things that significantly inhibit the full benefits of discovered innovations.”

The lack of screenings taking place in those states with higher cases of death from the disease may also lead to later-stage diagnoses. In this circumstance, that means that not as many patients with lung cancer will be able to be cured with surgery. For example, 50% of patients with lung cancer in Wyoming can be cured by surgery versus 90% in states like New Jersey, Massachusetts and Utah.

“If you drill further down and go to the county level, it’s even uglier than that. There are counties at the low end as low as 12% of patients with early-stage lung cancer that can be cured by surgery,” Osarogiagbon added.

Of note, the five-year survival rate of an early-stage lung cancer diagnosis is 90%. But once the disease enters late-stage, the five-year survival rate drops to 10% or lower. “Ideally, when we detect lung cancer, we’d love to find it at its earliest stage where we could cure a patient with a minimally invasive surgery, not requiring chemo- therapy or radiation therapy,” Sandler explained. “In our screening program, it’s unusual to say finding cancer is a win. But if you can find it that early, and truly offer a curative option for the patient, that’s an enormous victory for us.”

Eliminating Disparities

These disparities must be confronted with a multipronged approach, according to Osarogiagbon.

“We (need to) begin to focus on preventing, narrowing (and) eliminating disparities. We have to understand that the solutions come from multiple levels. The least effective is the level of directly hectoring, nagging (and) blaming the victims of disparities. (Patients) don’t go in with the idea that they will do something to hurt themselves. A (patient with) lung cancer who is poor does not stand up in the morning and decide, ‘Yippee, I am going to make sure I get the wrong treatment today. I don’t care if I die.’” he said. “When we talk about disparities, it is very important for (providers) to get away from the traditional, narrow lens of who are these people or why do they have such terrible outcomes, and recognize that we have seen the enemy. It is us.”

Sandler agreed with the outlook, emphasizing the need to banish the stigma around smoking and lung cancer, especially when other factors could be at play.

Because of this, Sandler believes that further investigation on eligibility for screenings and expanding eligibility to at-risk populations would make an impact, along with engaging further with communities to enhance outreach and education.

She noted that there have been some steps forward. “In terms of the disparities, the guidelines were just updated earlier this year, and they did decrease the age to 50 (and the pack-year smoking history) to 20, from 55 and 30, respectively,” she said. “And if you look at the recommendations from the (United States Preventive Services Task Force), they specifically say that this is to address disparities in the African American community and for women, because those are the populations that we’re really going to see an increase in eligibility. It’s not perfect. It’s a first step. But I think having that conversation and seeing the readiness of different organizations to accept new guidelines and continue to work on new guidelines is a really, really positive step forward.”

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