Socioeconomic Status Linked to Lung Cancer Outcomes

A newly developed scoring system provides a composite view reflecting income, education, geographical location, access to specialized care, race and other factors.

Researchers at Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine discovered an association between social determinants of health and outcomes and survival in patients undergoing surgery and treatment for non-small cell lung cancer (NSCLC).

The findings are based on a statistical scoring system the researchers developed that consolidates and analyzes several measures, including income, education, geographical location, access to specialized care, race and others.

“We believe our social determinants of health scoring system is the first to provide a composite perspective on many of the non-medical factors that affect outcomes in patients receiving treatment for non-small cell lung cancer,” said Dao Nguyen, M.D., Sylvester Thoracic Cancers Group co-leader and the senior author of an article in The Journal of Thoracic and Cardiovascular Surgery. The study focused on patients with stage 2 or stage 3 non-small cell lung cancer, with surgically confirmed metastasis to regional lymph nodes within the chest cavity.

Ideally, Dr. Nguyen said, patients with these cancers should receive “multimodal” care – chemotherapy, immunotherapy and, in some cases, radiotherapy. The elevated level of expertise and care may best be provided by specialized, comprehensive centers like Sylvester, a National Cancer Institute-designated center. However, studies have shown that outcomes rely on more than just medical and surgical treatments.

Social Determinants of Health

Socioeconomic disadvantages, for example, have been associated with lower-quality care and suboptimal outcomes. Social determinants of health, or SDH, include income, wealth, education, geographical location, access to specialized care and other nonmedical factors that influence health outcomes.

“Our analysis shows that SDH scores can identify patients who are at increased risk even if they undergo adequate initial treatment. Our research also may help point the way toward improving strategies and care for patients with lung cancer who are socioeconomically disadvantaged,” said Dr. Nguyen, a thoracic surgeon who treats and studies lung and other cancers.

The Data Analysis

Dr. Nguyen and colleagues analyzed National Cancer Database (NCDB) data from 11,274 patients with locally advanced NSCLC. Patients with locally advanced disease make up about one-third of the NSCLC population. In the study sample, the average patient age was about 68, and 57% of patients were female. Eighty-four percent of patients in the sample were non-Hispanic white, 8.8% Black, 3.0% Hispanic, and 3.3% Asian.

The researchers quantified results based on the “textbook oncological outcome,” which considers several metrics and identifies the optimal outcome for patients undergoing surgery to remove a primary cancer. These factors include complete resection, adequate lymph node removal, timely initiation of other therapies when needed, and short hospital stays. Textbook outcomes also are reflected in statistics on mortality, re-intervention, readmission and major complications.

The Study’s Focus

The Sylvester study aimed to determine the rate of achieving ideal outcomes in relation to social determinants of health scores, the association between these scores and optimal outcomes, and the association between SDH and overall survival.

The researchers focused on income, place of residence, level of education, and hospital proximity to the patient’s residence. Other variables of interest included patient demographics, types of treatment facilities, surgical volumes at treatment facilities (representing experience and expertise), and the presence of other medical conditions or diseases, in addition to NSCLC.

“In this cohort, we found that socioeconomic status – indicated by SDH score – has an important association with both textbook outcomes and survival,” said Ahmed Alnajar, M.D., the paper’s first author. “Significant socioeconomic disadvantage was associated with a 21% decrease in textbook outcomes and a 32% decrease in overall survival when compared to a patient subgroup that was not disadvantaged. Vulnerable patient population groups living in areas with limited income, limited education, rural locations and areas with limited access to specialized cancer care settings are at increased risk of poor outcomes and long-term mortality.”

Highlights from the published study include:

• Patients living in rural areas had a 30% decreased likelihood of overall survival and long-term outcomes.
• Access to only community hospitals adversely affected survival.
• Surgery performed in a high-volume hospital decreased mortality risk by 31% and increased textbook outcome likelihood by 93%, compared to surgery in a low-volume hospital.
• Black patients were 31% less likely to achieve optimal, textbook outcomes than white patients.

The authors recommend policymakers ensure equitable access to surgery and multimodality therapy to ensure all patients receive the best care, and add that surgeons and other care providers can strategically allocate resources and target interventions to counter the effects of SDH inequities.

Karishma Kodia, M.D., and Nestor Villamizar, M.D., from Sylvester and the Miller School, and Syed Razi, M.D., from Hackensack Meridian Health, also contributed to the study.

Tags: Dr. Dao Nguyen, lung cancer, Sylvester Comprehensive Cancer Center