Background: In elderly patients with lung cancer, race/ethnicity is associated with not receiving treatment; however, little attention has been given to nonelderly patients (aged ≤65 years) with a range of disease stages and histologies. Nonelderly patients with lung cancer have superior survival at NCI-designated Comprehensive Cancer Centers (CCCs), although the reasons remain unknown. Patients and Methods: A retrospective cohort study was conducted in 9,877 patients newly diagnosed with small cell or non–small cell lung cancer (all stages) between ages 22 and 65 years and reported to the Los Angeles County Cancer Surveillance Program registry between 1998 and 2008. Multivariable logistic regression examined factors associated with nontreatment. Results: In multivariable analysis, race/ethnicity was associated with not receiving cancer treatment (black: odds ratio [OR], 1.22; P=.004; Hispanic: OR, 1.17; P=.04), adjusting for patient age, sex, disease stage, histology, diagnosis year, distance to treatment facility, type of facility (CCC vs non-CCC), and insurance status. With inclusion of socioeconomic status (SES) in the model, the effect of race/ethnicity was no longer significant (black: OR, 1.02; P=.80; Hispanic: OR, 1.00; P=1.00). Factors independently associated with nontreatment included low SES (OR range, 1.37–2.15; P<.001), lack of private insurance (public: OR, 1.71; P<.001; uninsured: OR, 1.30; P<.001), and treatment facility (non-CCC: OR, 3.22; P<.001). Conclusions: In nonelderly patients with lung cancer, SES was associated with nontreatment, mitigating the effect of race/ethnicity. Patients were also at higher odds of nontreatment if they did not have private insurance or received cancer care at a non-CCC facility. These findings highlight the importance of understanding how both patient-level factors (eg, SES, insurance status) and facility-level factors (eg, treatment facility) serve as barriers to treatment of nonelderly patients with lung cancer.
Submitted November 16, 2018; accepted for publication March 8, 2019.Author contributions:Study concept: Nardi, Wolfson. Study design: Nardi, Sun, Wolfson. Data analysis: Nardi, Sun, Wolfson. Data interpretation: All authors. Manuscript preparation: Nardi, Sun, Wolfson. Critical revision: All authors.Disclosures: The authors have disclosed that they have not received any financial considerations from any person or organization to support the preparation, analysis, results, or discussion of this article.Funding: This work was supported by the St. Baldrick’s Foundation, St. Baldrick’s Scholar Award (Wolfson), the NCCN Quality of Care Fellowship supported by a grant from Genentech (Nardi). Research reported in this article was supported by NCI of the National Institutes of Health under award number K12CA001727 (Wolfson).Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.Correspondence: Julie A. Wolfson, MD, MSHS, Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, O’Neal Comprehensive Cancer Center at UAB, 1600 7th Avenue South, Lowder 500, Birmingham, AL 35233. Email: firstname.lastname@example.org