Treatment and Outcomes in Disparate Populations with Stage 3 Non-Small Cell Lung Cancer in the United States

E. Tham, K. Ryan, X. Luo, S. Campbell, P. Rothenberg, J. Lamb, S. Reddy, V. Badhwar, A. Toker, J. A.. Hayanga
West Virginia University, Morgantown, West Virginia

Purpose: The lack of treatment consensus for advanced non-small cell lung cancer (NSCLC) may further impact access to care due to socioeconomic status (SES) and geographic location. We sought to quantify the impact of SES and geography on the treatment and outcomes of patients with Stage 3 NSCLC.

Methods: We performed a multivariable multinomial logistic regression analysis on data from the National Cancer Database (NCDB) to evaluate outcomes in patients with Stage 3 NSCLC treated between 2004 and 2019. The groups were dichotomized based on income “High income” [≥USD35,000 annual household income] versus “Low income” (< USD35,000) and population density “High density” (Metropolitan counties with population ≥20,000) versus “Low density” (urban and rural counties with population < 20,000). Covariates included age, race, stage 3a or 3b, comorbidities, grade, tumor size, and histology. Outcomes of interest included treatment modality (no treatment, chemoradiation only, neoadjuvant treatment followed by surgery), surgical approach (open vs. minimally invasive [MIS]), 30-day mortality, readmission rate, length of stay (LOS), and overall survival. Cox proportional hazard models were used to compare survival between income and population density groups.

Results: Data pertaining to 279,962 patients were analyzed. The majority was male (57%), with median age 69 [61-76] years, with a diagnosis of adenocarcinoma (38%). There were 133,226 (52%) high income patients with 221,978 (81%) living in high density areas. Multivariable analysis demonstrated significant differences in age, sex, race, county population, stage, Charlson Deyo (CD) comorbidity score, tumor grade, and histology within income and population density groups. A larger proportion of patients with high income (6.9% vs 4.7%, p< 0.0001) and those living in high density areas (6.1% vs 4.9%, p< 0.0001) underwent surgery after neoadjuvant treatment than low-income patients or those living in low density areas. Minimally invasive surgery was performed more frequently in high-income patients (35.3% vs 32.5%, p< 0.05) and in those living in high density areas (35.8% vs 30.2%, p< 0.05) (TABLE) than in low-income patients or those living in low density areas. Additionally, high income patients were more likely to have shorter postoperative LOS (p=0.0003), lower 30-day mortality (aOR 0.8, 0.65-0.98, p=0.0278), and longer survival (p=0.003) (FIGURE).

Conclusion: There are disparities in outcomes among patients with Stage 3 NSCLC. High income patients and those living in high density areas have lower mortality, better survival, and are more likely to receive neoadjuvant therapy followed by minimally invasive surgery. Interventions to address health inequities may help to improve lung cancer outcomes in low-income and rural populations.

Identify the source of the funding for this research project: Supported by NIH NHLBI # 2UM1 HL088925 12