Despite important improvements in mortality rates, more Black patients and Latinx in the United States die from lung cancer than from any other malignancy.¹ Although this is also true for White patients, minority populations suffer a higher burden of lung cancer and greater morbidity. For over 2 decades, multiple studies have consistently documented major disparities in diagnosis, staging, treatment, and end-of-life care among minority patients with lung cancer.^2–5 It is concerning that these care gaps are pervasive and even present among healthy minorities enrolled in a lung cancer screening trial.⁶

A major challenge in addressing lung cancer treatment disparities is that the underlying determinants are multilevel and multifactorial. Structural determinants of health, such as racism, discrimination, educational attainment, job opportunities, and housing environment, are major fundamental drivers of these inequalities.^7,8 At the patient level, cultural beliefs, mistrust, health literacy, and language barriers, among other factors are barriers to timely guideline concordant care.^9,10 Stereotyping, implicit biases, lack of cultural competency, and a limited number of minority lung cancer specialists are provider-level factors that may contribute to this problem. In addition, the organization of the health care system adds to the challenge. The relatively high complexity of lung cancer care requires that patients schedule, coordinate, and undergo multiple tests; interact with many specialists; and navigate the maze of tertiary care hospitals. Minority patients face geographic barriers to access lung cancer screening and care, may lack insurance or might have to cover substantial copayments, and might have difficulties in coordinating multiple appointments and tests. The cumulative effect of these factors may ultimately be unsurmountable for minority patients with lung cancer, leading to delayed treatment, suboptimal care, or no treatment at all.

Surgery is a critical component of the management of locoregional lung cancer and the only treatment associated with a meaningful long-term survival. Delays in surgical resection can lead to anxiety, increased suffering, and upstaging and worse lung cancer outcomes; however, the timeline for cancer spread remains unclear. Unfortunately, minority patients with lung cancer (including those who have been evaluated by a surgeon) are less likely to undergo full lobectomy for lung cancer and/or experience delays in care.^5,11,12 Thus, there is a critical need for interventions to eliminate these disparities in care.

Although the prevalence and the factors underlying racial and ethnic disparities in lung cancer treatment are well described, there are limited interventions to address these persistent care gaps. Most of the literature to date focuses on patient navigation, which aims to intervene primarily at the patient level. This approach is focused on providing assistance to patients and caregivers to help overcome system barriers and facilitate timely access to health care from screening through treatment, survivorship, and palliative and end-of-life care. Two studies conducted at a single institution used an advanced practice nurse as the navigator and demonstrated reduced time to lung cancer diagnosis and treatment.¹³ In one study, the proportion of patients diagnosed at early (ie, I and II) stages also increased. Additional interventions using lay health navigators to decrease disparities in lung cancer care are ongoing.¹⁴

The study by Charlot et al¹⁵ in the article that accompanies this editorial reports the impact of a multilevel intervention, the Accountability for Cancer Care through Undoing Racism (ACCURE), on surgical delays (defined as > 8 weeks from diagnosis) among Black versus White patients with stage I and II non–small-cell lung cancer. The study was conducted as a pragmatic trial at five cancer centers and consisted of a multilevel intervention including real-time warning systems for incomplete treatment milestones, feedback regarding lung cancer treatment rates according to race, and patient navigation. The investigators compared rates of timely surgery in Black and White patients who received the intervention versus historical and concurrent control groups. In adjusted analyses, Black patients who received the intervention (n = 85) had greater likelihood of undergoing timely surgery than Black patients in the historical (n = 271, relative risk [RR]: 1.43, 95% CI, 1.26 to 1.64) or concurrent (n = 37, RR: 1.30; 95% CI, 1.01 to 1.64) control group. However, the likelihood of timely resection also increased among White patients in the intervention compared with White patients in the historical or concurrent cohorts. Moreover, although the racial gap in timely surgery observed among historical controls (RR for timely surgery for Black patients v White patients: 0.76; 95% CI, 0.69 to 0.85) was no longer observed among patients who received the intervention (RR: 1.03; 95% CI, 0.93 to 1.14), there were no statistically significant differences in the rates of surgery within 8 weeks of diagnosis among Black versus White patients in the concurrent control group (RR: 0.91; 95% CI, 0.73 to 1.13). These findings point toward encouraging temporal improvements in the care received by minority patients with early-stage non–small-cell lung cancer that may be independent of the ACCURE intervention.

The study has strengths and limitations that are worth mentioning. First and foremost, the study is critically important in moving the field forward by unveiling possible interventions to mitigate inequities in lung cancer treatment. In addition, the relatively large sample of patients enrolled across five medical centers in different geographic areas adds to the generalizability of the study findings. However, the importance of the topic and the critical need for addressing disparities in care should not deter us from evaluating the potential limitations of the research. The lack of random assignment and the potential for selection bias and unmeasured confounders weakens the ability to establish strong causal conclusions on the basis of these results. Investigators excluded untreated patients or those who underwent stereotactic radiation therapy, a potentially less effective treatment. However, delays in care might have led some minority patients to receive radiation or not treatment at all rather than surgery. Thus, the studied sample may not provide a full picture of the problem. In addition, the number of Black patients in some of the comparison groups was low, limiting the power to identify racial disparities in care.

In summary, we applaud the work of this group of investigators and welcome their contributions to eliminating disparities in care. Although some of the results may not be conclusive, they clearly point to potential effective multilevel interventions that, if broadly implemented, may contribute to the efforts to eliminate this significant public health problem. Additional work in this area, with a strong focus on sustainable strategies to eliminate disparities, is highly needed.

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