Pragmatic system-based intervention can reduce racial disparities in early-stage lung cancer treatment

UNC School of Medicine's Samuel Cykert, MD, led a five-year, multi-institutional trial aimed at reducing the disparity in treatment and outcomes for black lung cancer patients versus white lung cancer

Results from a study published in the journal Cancer Medicine show that a pragmatic system-based intervention within cancer treatment centers can eliminate existing disparities in treatment and outcomes for black patients with early-stage lung cancer across the U.S. The treatment rates before this three-part intervention were 78 percent for white patients versus 69 percent for black patients. With the intervention in place, treatment rates climbed to 95 percent for white patients and 96.5 percent for black patients.

"These results show promise for all cancer treatment centers," said Samuel Cykert, MD, professor of medicine at the UNC School of Medicine and co-principal investigator of the trial. "One of our participating institutions, Cone Health in Greensboro, NC, is now working towards permanently implementing this intervention into its breast and lung cancer care, and we would like to do further testing with all cancer patient populations."

Cykert and his colleagues previously conducted studies in 2005 and 2009 to find out why race disparities in cancer treatment exist. They found multiple reasons that contribute to the overall reduction in treatment.

"We found there was an implicit bias with many clinicians that made them less willing to take the same risks with patients that were different from them," Cykert said. "A black and a white patient of the same age could require the same surgery, have the same comorbidities, have the same income and insurance, yet white patients were more likely to receive the surgery and get their cancer treated."

Cykert says they additionally found that black cancer patients who did not have a regular source of care might have trust issues or miscommunications with physicians, leading them to drop out of treatment altogether. They also found that denial of their diagnosis played a role in patients seeking treatment.

"With that knowledge, we wanted to build a system that pointed out these lapses in care or communication in real time to help us keep track of patients who would otherwise drop off the grid," said Cykert.

The intervention consisted of three parts: a real-time warning system derived from electronic health records, race-specific feedback to clinical teams on treatment completion rates, and a nurse navigator to engage with patients throughout treatment.

The real-time warning system notified nurse navigators when a patient missed an appointment or treatment milestone. The navigator then reached out to the patient to reengage and bring them back in for treatment. The nurse navigators were encouraged to become familiar with patients and build trust in case of a missed appointment, miscommunication between doctor and patient, or other circumstance that created a potential barrier to care.

Cykert, who is a member of the UNC Lineberger Comprehensive Cancer Center, says he and colleagues came up with the intervention model with help from the Greensboro Health Disparities Collaborative, an academic-community partnership experienced in community-based participatory research. Their goals were to create elements of real-time transparency, race-specific accountability, and enhanced patient-centered communication.

Cykert's team recruited patients aged 18-85 from two multi-institutional prospective trials using identical interventions. Nearly 240 patients were enrolled in an American Cancer Society sponsored study, and around 120 lung cancer patients enrolled in a study sponsored by the National Cancer Institute. Cykert was the principal investigator in the first trial, and co-principal investigator in the second trial along with Geni Eng, DrPH, in UNC Gillings School of Global Public Health, and a national expert in community participatory research.

Along with the UNC Lineberger Comprehensive Care Center and Cone Health Cancer Center, East Carolina University's Leo Jenkins Cancer Center, University of South Carolina School of Medicine, and University of Pittsburgh Medical Center's Hillman Cancer Center participated in the trial.

Researchers are in the process of submitting a grant proposal with the National Cancer Institute to implement this intervention to cover whole cancer center populations rather than study patients alone.

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