The purpose of this article was to test whether black patients were less likely to receive surgical resection for stage I or stage II non-small-cell lung cancer than white patients, and if so, to test whether this difference resulted in lower survival rates for black patients.

The data were derived from the Surveillance, Epidemiology and End Results cancer registry for patient diagnoses from 1985 to 1993. Three important findings were reported:

1. The rate of surgery was lower for black than white patients (64.0% versus 76.7% received surgery), and the differences remained statistically significant after adjusting for age, gender, stage of disease, median income in the ZIP code of residence, and coexisting illness. Also, health care service area and year of study did not appear to explain this finding. The odds ratio (OR) for surgery for blacks compared with whites was 0.53-0.54 depending on the measure used to control for coexisting illness.

2. The rate of survival was lower for black than white patients. The authors found a 7.7% lower five-year survival rate among black patients compared with white patients, and 4.4% could be attributed to the failure to provide surgical treatment for a curable disease.

3. Even among patients who received surgery, black patients were slightly less likely to survive compared with white patients (the five-year survival was 39.1% for blacks and 42.9% for whites). Multivariate analysis controlling for factors associated with survival also showed a slightly increased risk of death among black patients after surgery (RR=1.10, p=0.18), but showed a slightly decreased risk of death among black patients not receiving surgery (RR=0.84, p=0.02). Risk factors associated with lower survival after controlling for treatment included residence in an area with lower median income, male gender, older age, higher stage of disease, and more co-existing illness.

There were important limitations that make replication of this study crucial:

1. The sample included only Medicare beneficiaries; the results might not be generalizable to persons under 65 years of age.

2. Data on co-morbidity were only available for about 25% of the patients. Although the authors argue that including these missing data would only strengthen the result, specific information about co-morbidity and/or appropriateness for surgery would be useful.

3. The study excluded patients who did not have a thorough evaluation to determine the stage of disease and patients who were assigned a diagnosis on autopsy. Lack of evaluation to determine stage of disease and lack of a diagnosis might indicate less extensive involvement with the health care system. It is possible that racial patterns in cancer treatment differ for patients with less contact with the health care system. Additionally, patients with a secondary cancer within two months of the primary cancer were excluded; therefore, it is unclear whether racial differences in this factor might have influenced the findings.

The authors conclude that, while “others have argued that the preferences of black patients may differ from those of white patients or that black patients may weigh the risks of surgical therapy differently…an alternative explanation is that black patients are offered optimal treatment less frequently than their white counterparts.”

Introductory lettter to article

King TE, Brunetta P.
Racial disparity in rates of surgery for lung cancer.
N Engl J Med 1999;341(16):1231-3.

This letter introduces the study by Bach PB, et al. in this issue of the New England Journal of Medicine. The letter states that the implications of this study are that the findings suggest differences in how physicians manage cancer based on the patients race, regardless of other attributes, and that the consequence of these lapses in care is reduced survival among blacks.

The 35.4% exclusion rate in this study due to lack of information on cancer stage indicates that physicians "do not know or fail to adhere to established standards for the diagnosis and staging of lung cancer" and "underscores the effects of poor pretreatment evaluation."

The authors make several recommendations for addressing the inadequate care of black patients with cancer. First, poor communication between physicians and patients of different racial backgrounds is common. Thus, both the widespread use of cultural competency training and efforts to increase the number of racial minority physicians should be pursued. Second, preventive services and screening should be better integrated into the U.S. healthcare system, and education about these services should target minority populations. Third, financial barriers to receiving appropriate care should be addressed. Finally, adequate representation of ethic minority groups in medical treatment trials should be sought to ensure standards are set that are appropriate to all racial groups.