Addressing Disparities in Lung Cancer Begins With Accountability

Individual and institutional accountability will create lasting foundations for systemic change against deeply rooted disparities in lung cancer care, according to Narjust Florez (Duma), MD.

“The single thing that investigators can do is ask patients to participate in clinical trials. Data suggest that 30% of physicians have bias against minority patients participating in clinical trials,” Florez, who is a medical oncologist and associate director of the Cancer Equity Program at Dana-Farber Cancer Institute, said. “They feel like the patient will not understand, that the patient will not comply, or that the patient will not want to participate in a clinical trial. Data have eliminated that myth. At the institutional level, we need to bring the clinical trials to the community.”

In an interview with OncLive^® during the 23rd Annual International Lung Cancer Congress^®, Florez, who is also an assistant professor of medicine at Harvard Medical School, discussed the alarming regularity of disparities in lung cancer care, the elements that perpetuate them, and ways to address them on an individual and institutional level.

OncLive^®: How prevalent are disparities in lung cancer?

Florez: In lung cancer, we have defined disparities since the moment of screening. There are significant disparities in screening, racial and socioeconomic disparities. There also disparities at the time of diagnosis. Vulnerable populations are facing significant delays in diagnosis. We also have a lack of inclusion of women and minorities in clinical trials. We have documented cancer health disparities in lung cancer from the moment of screening to the moment of death.

Which populations are most likely to experience decreased access to screenings and adequate lung cancer care?

Before we talk about the populations that are at higher risk, we must talk about the concept of intersectionality. Humans are not the result of 1 experience: we are the result of the interactions of several identities. How do these identities interact negatively? An example would be a woman of color who lives in a low socioeconomic status. She faces a gender bias because people do not think that lung cancer can happen to women. She also has the racial challenges of being a Black woman; living in low socioeconomic status reduces access to health care. All those identities multiply, and they produce more cancer health disparities.

Vulnerable populations [include] ethnic and racial minorities: Black individuals and African Americans, Hispanic, Latinx, and Native Americans. Other vulnerable populations include immigrants, patients who do not feel comfortable talking about health care in English because they speak other languages, uninsured patients, patients who identify as members of the LGBTQ community, incarcerated patients, and finally, older adults. All those groups are vulnerable populations. When you put them together, that is most of the population.

How might more inclusive clinical trial enrollment help to reduce some of these disparities?

This is an issue that has been documented for a long time. I published a landmark paper in 2018 that reviewed the latest 12 years of recruitment in clinical trials for minority patients, women, and older adults. We are doing worse now than we were before. We are not including these populations in clinical trials; that is a problem. Giving the opportunity to a patient to be in a clinical trial allows them to get access to drugs or combinations of drugs early, prior to FDA approval. Despite the changes the FDA has made, we still face significant delays for approvals. It takes years for a drug to be approved.

Because we do not include the population that represents the United States, we are using data that have been collected in a majority White male population to treat the rest of the population. I am going to give you an example [why this does not work]. Would you be okay wearing a wedding dress that was never tailored to you? Most brides would say, ‘No, I am not going to wear a wedding dress that is not tailored to me.’ That is what happens with cancer drugs that were tested in a majority White male population to treat the rest of the world. Then we are learning about adverse effects and lack of efficacy after the drugs are approved.

What can investigators do? How can more inclusive clinical trial enrollment be achieved?

If you ask a Black Latinx patient to participate in a clinical trial, there is a high likelihood that they will participate. We need to eliminate that myth that people like me will not want to participate in a clinical trial. At the individual level, we need to ask our patients.

I am part of an ivory tower institution. Most patients are seen in the community, but most trials take place in large academic institutions. It is financially difficult for a patient who lives in the community to come and pay Boston parking prices, for example. We need to bring the trials to our patients.

Where else do disparities persist that should be addressed?

Something that really motivates me is that we are developing more and more treatments for our patients with lung cancer, but we are still failing to do biomarker testing. All these drugs are very exciting. We are making our patients live longer, but that is only possible if our patients undergo biomarker testing. Only around 50% to 60% of patients are getting biomarker testing today in the United States, and if you’re [considering] a patient of color, that rate [ranges from] 35% to 40%. My point is that we can talk about the mutations and all the exciting data, but we cannot forget the importance of biomarker testing.

What other ongoing efforts are being made to address disparities in lung cancer care, and how can they be applied in clinical practice?

Something that was published recently is an anti-racist intervention for lung cancer surgery. Black men are less likely to receive curative lung cancer surgery; the only factor that data have shown affects this is the race. The most accurate way to cure lung cancer is surgery, but these Black men are not being offered that opportunity.

Marjory Charlot, MD, MPH, MSc, from UNC, developed an anti-racist intervention in which people are being held accountable all the time between diagnosis and surgery, and if the patient is a minority patient, they receive reminders and information through the medical record to help get that patient to surgery on time. That intervention to the electronic medical record and navigation significantly improved some of the disparities that existed in the institution. We can learn from that intervention and apply it to institutions across the country.

How can privilege be used to create equity?

The most important thing is that we all have privilege. We need to understand that. We are highly educated, we have electricity, we have internet. We are not worried about where our next meal is coming from. We need to use that privilege to create equity. Although systemic change is needed, we cannot wait until that happens to create equity. To all my colleagues, you, as an individual, have the power to create equity for all patients with cancer.