Identifying Health Disparities in the Treatment of Lung Cancer – with Dr. Sam Cykert

Topics in this conversation include:

• Findings from Dr. Cykert’s study published in JAMA on lung cancer and differences in treatment
• Why health disparities exist in this area
• The risks that African Americans face in the development of lung cancer
• Interventions that UNC is using to help improve the risks, using electronic health data

This is the second part of Dr. Falk’s conversation with Dr. Cykert. If you missed the first part of the discussion focused on “Heart Health Now,” you may listen to it here.

Falk: Another major undertaking that you’ve been participating in is the concern about lung cancer and health disparities. The springboard for this was a study that is yours, it was published in the very prestigious Journal of the American Medical Association–JAMA. Patients who are diagnosed with early stage lung cancer and the differences among those who decided to have surgery, and those who did not. That’s a really important question for every patient confronting early stage lung cancer. What did you find?

Cykert: First of all, what we found was very similar to what other investigators found, in that African American patients with curable lung cancer, get surgery 10-15% less often than white patients do. What we did in the JAMA study is we followed patients prospectively over time to figure out why this happened.

As far as the major reasons, there were really three things. Number one is that an African-American patient who had 2 or more significant co-morbidities almost never went to surgery whereas white patients still did. The second thing was that African-American patients who did not have a primary care doctor were often lost to follow-up. Third, there were more communication issues with more African-American patients in that there was less shared communication where the patient would ask questions and the physician would answer questions, and when there was less shared communication, the patients were 75% less likely to go to surgery.

Falk: How does that finding happen in the United States, in 2016? It’s almost unbelievable to fathom that that degree of disparity between ethnicities would still occur.

Cykert: Well, it actually happens in a lot of things, but as far as why it would still occur, there are multiple factors. First of all, very few providers, only about 3 percent of providers are African American, and there tends to be a discomfort from providers of other races to communicate to African Americans – something that we call implicit or unintended bias.

What we found in the lung cancer study, that in high-risk situations, providers were less apt to take risk on African-American patients. A lot of that had to do with the communication discomfort. That’s one reason. The second reason is that African-Americans tend to trust providers less, because of Tuskegee and other institutional issues over time. Let’s say you have an African-American patient who goes to the emergency room and an abnormal finding was seen on a chest x-ray when the patient has a cough and a cold. All of a sudden the cough and cold goes away, so the patient may think they’re okay. So there’s a break-down in communication and also a break-down in trust, in that the patient thinks, “Well, I don’t really have cancer. I’m better now.” It’s really multi-factorial.

Falk: Education on both sides of that equation are important. Education for the providers, education for the patient.

Cykert: Yes, education is important. But also, right now, we’re in the process of doing some intervention studies –we’re making system changes to make these situations less likely to happen.

Falk: The worrisome thing is there are so many early lung cancers being discovered as a consequence of the frequency of computerized tomography or CT scanning, to pick up lung cancers—As the screening program continues to roll out, this process could potentially become worse.

Cykert: There are two problems there. First of all, in terms of populations that die the most of lung cancer, African-American men die 30 percent more often than any population of patients with lung cancer. The reasons for that are, that African-American men are less likely to engage in the medical system, so they don’t get screening CT’s. Then you also have this surgical and treatment gap that I talked about before. In order to solve that problem, there needs to be specific outreach to African-American smokers where you get the appropriate people involved with screening CAT scans and also do smoking cessation counseling. Also in the treatment system, these interventions that we’re working on right now have great potential for improving the situation.

Falk: Let’s talk about those interventions. One of them is to use the electronic health record to use it as a tool to communicate with physicians. Especially, in this case, physicians caring for a patient with newly-diagnosed cancer, right? You would hope to be able to use the electronic medical record as a reminder at least.

Cykert: Yes. So we’ve created a real-time registry for patients with abnormal CAT scans who are likely to have lung cancer. In this registry, two things happen. Number one is if a patient misses an appointment that they’re scheduled for, a warning comes up and then we have a teaching system that re-engages patients who missed their appointments and engages and re-engages them to bring them back into care.

The second thing that we do is we have a warning come up if a patient hasn’t reached expected milestones. I mentioned some of the reluctance that providers have to be aggressive in higher-risk situations, so what we do is if a patient doesn’t reach a milestone in care, we re-engage the providers, and we say, “Did you really mean for this patient to get less aggressive treatment?” With the combination of those two things, our early results are really looking very promising.

Falk: That’s absolutely fantastic. If you’re a patient who has recently been diagnosed with a lung cancer and you’re wondering if you should have a surgical intervention, or treatment of some kind, what’s the message?

Cykert: There are three situations where a patient has absolute contraindications for aggressive treatment. For instance, if someone has such bad lung disease that they’re on high-flow oxygen, in those situations, truly a patient should not undergo aggressive care. A lot of that is common sense. But when folks don’t have absolute contraindications, then both the patient and the physician should really be engaged in a discussion about what aggressive treatment should be, and should err on the side of giving full treatment. In lung cancer, almost every patient with early stage cancer who isn’t treated is going to be dead within 3 years. Half will be dead within a little over a year. You’re talking about a very aggressive disease. We ought to offer folks every opportunity to get the best treatment.

Falk: That really depends on a discussion between the patient and their doctor—“Hey doc, what would you suggest I should do? What kind of treatment should I get?” In reality, it’s almost, “Can I make it through the operation?” Because if I do, and the cancer is removed my longevity is markedly improved.”

Cykert: That’s right, that truly is it. Those discussions should have as much factual information as possible.

Falk: So you are engaged in two really important screening efforts. One, the screening tool that you’ve created for risk assessment for cardiovascular disease. The other, how to use the electronic health record to make sure that patients are getting the optimal treatment for lung cancer. Both unbelievably important prevention efforts. So congratulations for those endeavors.

Dr. Cykert, thank you so much for talking with us today.

Cykert: I enjoyed it.

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Read the referenced publication in the Journal of the American Medical Association.