Study examines reasons patients with early stage lung cancer do not have surgery

Despite a greater likelihood of poorer outcomes, many patients newly-diagnosed with early-stage lung cancer do not undergo surgery. New research indicates that among the factors associated with this decision include misunderstandings of the prognosis, negative perceptions of patient-physician communication and older age, with black patients more likely to not have surgery, according to a study in the June 16 issue of JAMA.

Lung cancer is the leading cause of cancer death in the United States. "Surgical resection for stage I or II non-small cell cancer remains the only reliable treatment for cure. Patients who do not undergo surgery have a median [midpoint] survival of less than 1 year. Despite the survival disadvantage, many patients with early-stage disease do not receive surgical care and rates are even lower for black patients," the authors write.

Samuel Cykert, M.D., of the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, N.C., and colleagues conducted a study among newly diagnosed patients with early-stage lung cancer to identify potentially modifiable factors regarding undergoing surgery and to explore why black patients have this surgery less than white patients. The study included 437 patients with biopsy-proven or probable early-stage lung cancer, who were enrolled be­tween December 2005 and December 2008. Before determining treatment plans, patients were administered a survey including questions about trust, patient-physician communication, attitudes toward cancer and functional status. Informa­tion about co-existing illnesses was obtained through examination of charts. A total of 386 patients met eligibility criteria for lung resection surgery. The median age was 66 years and 29 percent of patients were black. Two hun­dred forty-one patients (62 percent) had lung cancer surgery within 4 months of diagnosis (179/273 white pa­tients [66 percent] vs. 62/113 black patients [55 percent]).

"Potentially reversible factors associ­ated with omitting cancer surgery in­cluded (1) a patient's belief that the lung cancer diagnosis was less than 90 percent cer­tain, (2) a feeling that over­all quality of life would be worse in 1 year because of lung cancer surgery, and (3) patients' per­ception of lower-quality cancer com­munication manifested by a 5-point decrement on a 25-point communication scale," the authors write.

The researchers also found that black patients with 2 or more co-existing illnesses had a lower likelihood of surgery, compared to those with less than 2 co-existing illnesses, 13 percent vs. 62 percent, respectively. Surgical rates were also low for black patients when they lacked a regular source of care (42 percent with no regular care vs. 57 percent with regular care), and lower in­come was associated with fewer surgeries for white patients.

"We found that patients' negative perceptions about the communication process and misperceptions of quality of life 1 year after lung cancer diagnosis were related to lower surgical rates in everyone. These re­sults suggest the need for preopera­tive discussions that pay close atten­tion to the prognosis for functional and pulmonary recovery after surgery com­pared with expected cancer progres­sion without intervention," the researchers write.

(JAMA. 2010;303[23]:2368-2376. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Racial Disparities in Lung Cancer Resection

In an accompanying editorial, Gene L. Colice, M.D., of the Washington Hospital Center and George Washington University, Washington, D.C., comments on the findings of this study.

"The report by Cykert et al reaf­firms the disturbing fact that blacks with stage I or II non-small cell lung cancer are less likely than whites to un­dergo potentially curative surgical resection, and also provides important and somewhat unsettling insights into how stage I or II non-small cell lung cancer is managed in a diverse U.S. community. Besides concentrating on ways to improve communication between clinicians and black patients, at­tention should be directed at establishing minimal commu­nity performance standards for managing non-small cell lung cancer. These essential steps should be in place if and when an effective lung cancer screening tool becomes available."

(JAMA. 2010;303[23]:2411-2412. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.