Racial disparities in lung cancer start with research

During a routine visit to the Good Samaritan Clinic in Morganton, North Carolina, in 2018, Herbert Buff casually mentioned that he sometimes had trouble breathing.

He was 55 years old and had been smoking for decades. So the doctor recommended that Buff schedule an appointment on a 35-foot-tall bus operated by the Levine Cancer Institute that would roll into town later that week offering free lung cancer screenings.

Buff found the “lung bus” concept odd, but he’s glad he jumped on it.

“I learned that you can have lung cancer and not know it,” said Buff, who was diagnosed by stage 1 doctors at the clinic. “Early screening may have saved my life. It may have given me a few more years.”

The lung bus is struggling in this rural area of ​​western North Carolina because some people aren’t comfortable going to — and in many cases can’t get to — a hospital or doctor’s office, said Darcy Doege, coordinator of the screening program.

“Our team makes people feel welcome,” she said. “We can see up to 30 patients a day who are referred by their primary care physician or pulmonologist, but we also accept walk-ins.”

Lung cancer is the deadliest of all cancers. It grows quietly and is often not noticed until it spreads to other parts of the body. Early detection is key to survival, especially for a high-risk individual like Buff, who is African American and has a history of smoking.

Although it is well documented that black smokers develop lung cancer at a younger age than white smokers even if they smoke less, the guidelines doctors use to recommend patients get screened have been slow to show the difference. If Buff had had the same conversation with his doctor one year earlier, he would not have qualified for the CT scan that found a nickel-sized growth in his left lung.

But screening is only part of the problem, say experts who examine what happens before and after a person is screened for cancer symptoms.

Researchers are concerned about the lack of diversity representation in clinical studies on which test recommendations are based. For example, about 13% of the US population is Black, but Black people made up only 4.4% of participants in the National Lung Screening Trial, a large, multi-year study in the early 2000s that looked at whether screening with low-dose CT scans. it can reduce lung cancer deaths.

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Basing guidelines on tests with such small differences can lead to delayed diagnosis and high death rates, said Dr. Carol Mangione, chair of the US Preventive Services Task Force, a national panel of experts who make recommendations about services such as screening, behavioral counseling. , and preventive medicine. Its recommendations play a major role in determining which tests and procedures health insurance companies will be willing to pay for.

“We know that black people are diagnosed with cancer and die more often from colon cancer,” Mangione said. “But we don’t have enough evidence to say that there should be different recommendations for Black people, because Black people have historically been underrepresented in clinical trials.”

When Buff was diagnosed with lung cancer, the US Preventive Services Task Force recommended screening for people age 55 and older with a 30-pack-year smoking history, meaning a person smoked an average of one pack of cigarettes a day. three decades. Buff made the cut.

But a 2019 study published in JAMA Oncology found that under those parameters, 68% of black smokers were ineligible for screening when they were diagnosed with lung cancer, compared to 44% of white smokers. In 2021, the US Preventive Services Task Force lowered the recommended age for lung cancer screening to 50 and lowered the pocket age to 20.

The new guidelines make 8 million more Americans eligible for testing. But that’s not the only problem that needs to be solved, said Dr. Gerard Silvestri, a lung cancer specialist at the Medical University of South Carolina.

“It doesn’t matter if the majority of African Americans are eligible if they don’t have coverage, they don’t trust the health care system, and they don’t have access,” Silvestri said.

“You may widen this disparity,” he said, “because more whites will qualify and potentially have more access.”

Silvestri is leading the Medical University of South Carolina’s portion of a $3 million, four-year Stand Up to Cancer-funded project focused on tackling the lung cancer epidemic. Researchers in a multicenter collaboration — including the Lineberger Comprehensive Cancer Center at the University of North Carolina-Chapel Hill and the Massey Cancer Center at Virginia Commonwealth University — say better screening rates will improve outcomes in underserved communities.

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“Patients of color, particularly Black patients, tend to have less access to care, timely follow-up for abnormal findings, and later stages of diagnosis,” said epidemiologist Louise Henderson, the study’s principal investigator at the Lineberger Center.

A concerted community effort is needed to combat health disparities that lead to negative outcomes in communities of color, experts say. The lung bus that Buff visited is just one example of how cancer researchers are doing programs in rural communities. Atrium Health Levine Cancer Institute in Charlotte, North Carolina, launched an effort in March 2017 to make screening more accessible to underserved populations in at-risk communities who are uninsured or uninsured.

The bus operates in 19 counties in North and South Carolina. In an analysis published in the journal Oncologist in 2020, the Levine Cancer Institute said the project identified 12 cancers in 550 patients and called the results “policy changing.”

By September 2021, the researchers said, the bus had identified 30 cancers in 1,200 patients screened. “21 of them were in the curable stage,” said Dr. Derek Raghavan, president of the Levine Cancer Institute and lead author of the analysis. About 78% of the people tested are poor people and those from rural areas, he said, 20% are black Americans.

“You can overcome care disparities if you really want to,” says Raghavan.

The Lineberger Center also partnered with professional health centers in the Raleigh-Durham area and hired community health counselors to educate patients about lung cancer risk and the ease of screening. It also trained patient and financial navigators to help with the often frustrating results of a diagnosis.

Recent studies in JAMA Oncology and the Journal of the National Cancer Institute found that Medicaid expansion under the Affordable Care Act improves cancer survival across all races and ethnicities and reduces racial disparities in cancer survival. Among the three research centers participating in the lung cancer contrast program, the Massey Cancer Center in Virginia is the only one in the state that has expanded Medicaid.

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Vanessa Sheppard, director of public relations and health diversity at the center, said she has seen overwhelming evidence that expanding health coverage improves cancer screening rates.

However, awareness about screening remains low in the Black community. Sheppard believes that may be because mainstream healthcare providers are not educating patients about the screening tools available.

A low-dose CT scan, for example, is one of the most powerful tools available to detect lung cancer early and reduce mortality. But according to the 2022 Lung Health Barometer from the American Lung Association, nearly 70% of people don’t even know what type of screening is available. And according to Silvestri, only a small percentage of those eligible are tested.

Perhaps the last obstacle is disparity in who receives follow-up care after the test. A study published in 2020 in the journal BMC Cancer found that black patients referred to a lung cancer screening program were less likely to be screened than white patients and that they had a longer delay in seeking follow-up care when diagnosed. checked.

Henderson said some patients may mistakenly believe that lung cancer is incurable and don’t want to hear the bad news.

Sheppard said the test can be used to educate and build trust with patients.

“Once we get people into the program, it’s up to us to make sure they know what’s expected, it’s not a one-time thing, and that we put them in the care program,” she said. “I think that will help a lot.”




Kaiser Health NewsThis article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonprofit health care policy research organization that is not affiliated with Kaiser Permanente.

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