In patients with non–small cell lung cancer (NSCLC) where the cancer has spread to one or more lymph nodes close to the lungs—a condition known as pathologic N1 (pN1) disease—current guidelines recommend a two-part protocol: surgical resection, followed by chemotherapy.

However, a retrospective study published by Toubat et al in The Annals of Thoracic Surgery of almost 15,000 patients found that among those who underwent resection for pN1 disease, only slightly more than half (54.1%) received chemotherapy afterward. Patients were less likely to receive chemotherapy if they lived in rural areas or were on Medicaid or uninsured.

“This study shows that inequalities exist when it comes to getting the highest level of care,” said lead study author Elizabeth A. David, MD, MAS, a cardiothoracic surgeon at Keck Medicine of USC. “Previous studies have determined that socioeconomic status plays a role in the surgical management of patients with lung cancer, but we are the first to examine the relationship between socioeconomic status and access to chemotherapy in patients with pN1 disease.”

Study Design

Researchers collected data on patients with pN1 NSCLC from the National Cancer Database. They then split these patients into those who had received multiagent chemotherapy vs those who had received surgery alone.

The study authors examined multiple socioeconomic status variables of the patients—race/ethnicity, median household income, education level, urban/rural area of residence, and insurance status—to reach their conclusion of a disparity in treatment among those in rural areas or without insurance or on Medicaid.

Results

Patients were less likely to receive chemotherapy if they lived in a rural area (odds ratio [OR] = 1.23, 95% confidence interval [CI] = 1.11–1.37, P < .001), or were uninsured or on Medicaid (OR = 1.23, 95% CI = 1.07–1.41, P = .004).

Lower income and uninsured or Medicaid insurance status were also found to be independently associated with increased mortality.

The study also revealed that the benefit of receiving chemotherapy in this patient population is higher than generally thought. Previous research has shown that patients with pN1 disease treated with both surgery and chemotherapy may have increased 5-year survival—by around 5.4%—over those who receive only surgery. The current study found that the survival rate actually increases by 14%.

“While this is a significantly greater number than historically reported, due to the breadth of our study, we believe this new statistic is accurate, and we have other studies ongoing to provide more validation,” said Dr. David.

While it was beyond the scope of the study to determine why patients are not receiving chemotherapy, Dr. David believes that patients may be offered the treatment but turn it down. Those in rural areas may have to travel to an urban area far from home to receive surgery and may not have the resources, such as transportation, to commit to follow-up chemotherapy treatments. For those with no insurance or on Medicaid, the cost of the chemotherapy may be a barrier to follow-up treatment.

“It is clear that as medical professionals, we need to find creative solutions to help at-risk populations receive guideline-recommended care,” concluded Dr. David. “Lung cancer survival rates are improving and all patients, regardless of where they live or financial status, should be able to take advantage of the treatment that will give them the best chance of recovery and survival.”

Disclosure: For full disclosures of the study authors, visit annalsthoracicsurgery.org.