African Americans and members of other communities of lower socioeconomic status have higher burdens of lung cancer mortality. Therefore, targeting underserved patient populations with lung cancer screening is of the utmost importance, according to Christopher Lathan, MD, MS, MPH, a medical oncologist at Dana-Farber Cancer Institute in Boston.
“If we are unable to broaden access to the most vulnerable urban and rural underserved, then we will exacerbate disparities in lung cancer care,” he said at the 10th Annual American Association for Cancer Research (AACR) Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved in Atlanta.1
Although all races have seen a decrease in lung cancer incidence and mortality over the past 40 years due to an overall decrease in smoking rates, black men are still more likely to have and die of lung cancer, even after adjusting for smoking. “We haven’t really gotten to the biology of that yet, but there’s a lot of good research yet to come,” added Dr. Lathan.
Expanding Lung Cancer Screening to the Underserved
According to Dr. Lathan, tobacco cessation should be provided and modified for communities of color. “Before screening was recommended [by the U.S. Preventive Services Taskforce], we were interested in perceptions of lung cancer and the differences in perception by race, specifically because we kept being told that black patients would refuse surgery more than white patients,” he said. “But we didn’t find that. When it’s explained appropriately to people that they have lung cancer, they’ll go for surgery.”
Don’t let the cynicism, nihilism, and judgment about tobacco smoking keep us from doing what we need to do, which is to counsel people to stop smoking and to get them the care they need.— Christopher Lathan, MD, MS, MPH
Dr. Lathan helped to administer the Health Information Trends Survey (HINTS), which revealed that overall knowledge of lung cancer among all races is limited. Neither black nor white respondents realized mortality was so high, and both groups had general misconceptions about prevalence. However, black patients were more likely than white patients to agree that it is difficult to follow recommendations about preventing lung cancer, to avoid an evaluation for lung cancer for fear they have the disease, and to believe patients with lung cancer would have pain or other symptoms before diagnosis.2
Following the quantitative analysis, Dr. Lathan conducted a focus group consisting of African American patients in a housing project in Boston. The qualitative results from the study suggested that African American smokers are aware of the relationship between smoking and lung cancer, are interested in smoking-cessation treatment, and desire more compassion from their physicians. According to Dr. Lathan, the topic of lung cancer screening came up organically and without any prompting.
“At the time, we didn’t have any data, and I just thought it was interesting. But by the time it was published,3 it did seem to be relevant,” he said. “Let’s just suffice it to say that not only are the data robust for all races, but when we looked retrospectively at the data, we found African Americans benefited disproportionately from lung cancer screening. This is important, so why is it underutilized?”
Creating Lung Cancer Screening Program
To address these disparities in cancer care, Dr. Lathan and his colleagues established a Cancer Care Equity Program at Dana-Farber (inclusive of a lung cancer screening program), with the goal of improving local outcomes for the underserved across the spectrum of cancer-related disease, by facilitating clinical access to the spectrum of preventive medicine, treatment, and clinical trials. The lung cancer–screening program was embedded in a federally qualified health center. According to Dr. Lathan, this partnership allows a screening program to reach more individuals in urban and rural underserved populations.
“I don’t want to pretend this has been easy, and utilization of our program hasn’t reached its peak,” he said. “We’re probably under 50% of the people who should be seeing us.” They determined the reasons for lack of referrals to the lung cancer–screening program to be complex, including issues with communication, provider knowledge, administrative support, and problems with the electronic medical record (ie, determining pack-year history).
But even when patients did come in for screening, the major issue was follow-up. An analysis revealed that of 70 patients referred to the program by a primary care provider, the majority showed up and consented to research. Of those recommended for low-dose computerized tomography (CT) screening, the no-show rate was only 8%. Current smokers were referred to a tobacco cessation program, and willingness to enroll in that program was 95%. However, the no-show rate for smoking-cessation counseling after low-dose CT was 65%. “This was after ‘yes,’ after ‘yes,’ after ‘yes,’” he said. “But they came for the CT scan, and then they disappeared.”
“[The CT scan visit] is another chance to see if people are in the acceptance phase and are ready to quit,” revealed Dr. Lathan. “Perhaps it’s a social acceptability thing. They want to say they’re ready, but they’re not really ready yet. This is something we’re not done working on.”
Lung cancer screening must have an effective and sustained smoking cessation program, and many current smokers are not able to quit the first time, he cautioned. “Do not forget that lung cancer is still the cancer with the highest mortality, and screening is really the only way to decrease mortality for these patients,” he said. “Don’t let the cynicism, nihilism, and judgment about tobacco smoking keep us from doing what we need to do, which is to counsel people to stop smoking and to get them the care they need.” ■
DISCLOSURE: Dr. Lathan reported no conflicts of interest.
1. Lathan CS: Disparities in lung cancer screening utilization: Effective outreach to the community. 2017 AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved. Presented September 27. 2017.
2. Lathan CS, Okechukwu C, Drake BF, et al: Racial differences in the perception of lung cancer: 2005 Health Information National Trends Survey. Cancer 116:1981-1986, 2010.
3. Lathan CS, Waldman LT, Browning E, et al: Perspectives of African Americans on lung cancer: A qualitative analysis. Oncologist 20:393-399, 2015.