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Social determinants of health influenced the achievement of textbook oncological outcomes and overall survival in non-small cell lung cancer.
Marjory Charlot, MD, MPH, MSc, delivered the opening keynote at the IASLC 2023 North America Conference on Lung Cancer. Dr. Charlot discussed equities and disparities in the management of lung cancer.
Dao M. Nguyen, MD, and colleagues explored this topic for a paper published in JTCVS Open. Dr. Nguyen and colleagues looked specifically at how social determinants of health (SDH) influence textbook oncological outcomes and overall survival in locally advanced non–small cell lung cancer (NSCLC).
“Textbook oncological outcome (TOO) is a composite metric for surgical outcomes, including NSCLC,” the researchers wrote. “We hypothesized that SDH can affect both the attainment of TOO and the overall survival (OS) in surgically resected [patients with NSCLC] with pathological nodal disease.”
The study utilized the National Cancer Database to identify preoperative therapy-naïve lobectomies for locally advanced NSCLC performed from 2010-2017. Socioeconomic factors comprised SDH scores. The researchers determined that participants were SDH-negative (−) if they had two or more SDH (disadvantage); otherwise, SDH was considered positive (+). The study team defined a textbook oncological outcome (TOO+) as an R0 resection, five or more lymph nodes resected, a hospital stay in less than the 75th percentile, no 30-day mortality, the start of adjuvant chemotherapy initiation within 3 or less months, and no unplanned readmission. Dr. Nguyen and colleagues defined a case as TOO– if one of these factors was not reached.
SDOH Influence Overall Survival & Mortality
The study included 11,274 patients in its analysis (mean age, 68±10). The patient population included more patients who were women (57%) and White (84%); Black, Hispanic, and Asian patients accounted for 8.8%, 3.0%, and 3.3% of the sample, respectively.
Regarding SDH, 36% of patients resided in areas with an income level greater than 150% of the federal poverty level (FPL), 33% lived in areas with high educational achievements, and 84% resided in metropolitan areas. More than half of patients (61%) had Medicare or other government insurance, 32% had private insurance, and 7.1% had Medicaid or were not insured.
The researchers determined almost half (47.8%) of the cases were TOO+, and 38% were SDH+.
Patients who were SDH– (15%) were less likely (adjusted OR, 0.85; 95% CI, 0.78-0.92) to achieve TOO+ than patients who were SDH+. After accounting for confounders, patients who were TOO+ experienced 22% lower overall mortality than patients who were TOO– (adjusted HR [aHR], 0.78; 95% CI, 0.73-0.82).
SDH– remained an independently significant risk factor, decreasing survival by 24% compared with SDH+ (aHR, 1.24; 95% CI, 1.17-1.32). The impact of SDH on OS was significant for both patients who were TOO+ and TOO–, with the best OS for SDH+/TOO+ and the worst for SDH–/TOO–.
Key Disparities in NSCLC Require Further Study
The findings highlight the influence of SDH on TOO-driven OS, according to Dr. Nguyen and colleagues.
“Our analysis elucidates the value of an SDH score in successfully identifying patients with increased mortality risk despite adequate initial treatment,” they wrote.
The researchers also identified six areas for future research.
- Validate and refine the SDH score, including using SDH in another NSCLC cohort, and potentially customize it for individual patients to make it more actionable in NSCLC.
- Examine interactions between SDH and clinical factors via advanced machine-learning predictive models.
- Consider SDH in longitudinal and multilevel analyses to follow patients, as SDH’s “dynamic nature” could determine prevention measures and collaborative and educational efforts.
- Work with local cancer communities to improve NSCLC outcomes.
- Address SDH in future clinical trials, which remain “the gold standard” for evaluating interventions to improve patient outcomes.
- Develop educational programs to facilitate timely screening and referral for disadvantaged patients.
“There remain key healthcare access and sociodemographic disparities to be studied under the SDH paradigm in addition to optimal therapy when treating NSCLC,” Dr. Nguyen and colleagues wrote. “Future research fosters discussions on SDH, contributing to effective health disparities management.”
