County-Level Variations in Receipt of Surgery for Early-Stage Non-small Cell Lung Cancer in the United States

Abstract

BACKGROUND: Although counties are the smallest geographic level for comprehensive healthcare delivery analysis, little is known about county-level variations in receipt of curativeintent surgery for early-stage non-small cell lung cancer (NSCLC) and factors contributing to such variations in the United States.METHODS: A total of 179,189 patients aged $ 35 years who were diagnosed with stage I to II NSCLC between 2007 and 2014 in 2,263 counties were identified from 39 states, the District of Columbia, and Detroit population-based cancer registries; the data were compiled by the North American Association of Central Cancer Registries. The percentage of patients who underwent surgery was calculated for each county with $ 20 cases. Adjusted risk ratios were generated by using generalized estimating equation models with modified Poisson regression.RESULTS: Receipt of surgery for early-stage NSCLC during 2007 to 2014 according to county ranged from 12.8% to 48.6% in the lowest decile of counties, to 74.3% to 91.7% in the highest decile of counties. There were pockets of low surgery receipt rate counties within each state. For example, there was a 25% absolute difference between the lowest and highest surgery receipt rate counties in Massachusetts. Counties in the lowest quartile for receipt of surgery were those with a high proportion of non-Hispanic black subjects, high poverty and uninsured rates, low surgeon-to-population ratio, and nonmetropolitan status.CONCLUSIONS: Receipt of curative-intent surgery for early-stage NSCLC varied substantially across counties in the United States, with pockets of low receipt counties in each state. Low surgery receipt counties were characterized by unfavorable area-level socioeconomic and health-care delivery factors. CHEST 2020; 157(1):212-222

Socioeconomic Inequalities in Premature Cancer Mortality Among U.S. Counties During 1999 to 2018

“…Prior studies have reported the marked heterogeneity in these potentially modifiable factors across counties, and this heterogeneity may have partially contributed to socioeconomic inequalities in mortality. 46,47 Results of correlation analysis imply that these modifiable factors were linked to socioeconomic inequalities in mortality.…”

American Cancer Society's report on the status of cancer disparities in the United States, 2021

“…For example, in a study of >441,000 individuals diagnosed with any histologic subtype of lung cancer between 2010 and 2014, the receipt of guideline‐concordant treatment was lower among Black (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.76‐0.80) and Hispanic (OR, 0.94; 95% CI, 0.90‐0.98) people compared with White people 92 . Another study of approximately 180,000 individuals who had early stage nonsmall cell lung cancer diagnosed between 2007 and 2014 showed substantial variation in the receipt of curative‐intent surgery across counties, with the lowest rates in counties that had a high proportion of Black people who had nonsmall cell lung cancer or a high poverty or uninsured rate, and in nonmetropolitan areas 93 …”

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“…However, these differences have narrowed in recent years (12,13). Black patients still present with more advanced disease than their White counterparts (14,15). When accounting for the stage at presentation and other factors, Black patients still have lower five-year survival for local disease than their White counterparts.…”