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The likelihood that patients with early-stage non-small cell lung cancer (NSCLC) will receive curative-intent surgery varies substantially from state to state, according to data presented at the American Association for Cancer Research Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved.

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"We do not have a uniform quality of health care in this country," Helmneh M. Sineshaw, MD, MPH, Senior Epidemiologist and Health Services Researcher with the American Cancer Society, said in a news release. "Curative surgery for NSCLC is one example, with disparities in health care across population subgroups."


Previous studies have shown significant racial and socioeconomic disparities in the receipt of curative surgery for early-stage NSCLC, but this is the first to show that there are also statewide differences. The researchers sought to examine the extent of, and factors associated with, variations in receiving curative surgery for early-stage NSCLC across states in the United States and determine whether the racial disparity varies by state.


For the study, which was supported by the ACS, the team assessed data from patients who were diagnosed with stages 1 or 2 NSCLC between 2007 and 2011 in 38 states and the District of Columbia, from population-based cancer registries compiled by the North American Association of Central Cancer Registries.


The results showed that Massachusetts, New Jersey, and Utah had the highest rates of receipt of curative surgery-about 75 percent in each state-and the researchers then chose Massachusetts as the standard of comparison for all states.


The lowest likelihood of receipt of the surgery was in Wyoming, where patients with early-stage NSCLC were 25 percent less likely than those in Massachusetts to receive the surgery. The next largest gaps were in Oklahoma (20% less likely), New Mexico (19% less likely), Colorado (17% less likely), Louisiana (also 17% less likely), and Texas (16% less likely).


Sineshaw said some of the disparity could be explained by geography, since states with major medical centers generally had higher rates. Also, insurance coverage could be a factor, although adjusting for insurance resulted in only minor statistical differences.


"From state to state, the quality of insurance coverage may be different, even as we move toward universal health care," he continued. "Varying standards for copays, for example, can all add up and make a difference in the cost of treatment."


Sineshaw said one potential way to narrow the disparity would be to further standardize health care coverage. Also, he suggested, doctors across the nation could be encouraged to share information on their practices.

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The team also evaluated data on race to see whether disparities persisted. Non-Hispanic blacks were found to be less likely than non-Hispanic whites to receive the surgery in all states/registries, although the disparities were significant in only two states-Florida and Texas-after adjusting for socioeconomic factors and clinical characteristics.


In Florida, non-Hispanic black patients had a 12 percent lower chance of receiving curative surgery, and in Texas, non-Hispanic black patients had an 11 percent lower chance of receiving curative surgery than non-Hispanic white patients did.


Sineshaw said a limitation of the study is that it did not examine patient/physician communication, which could influence a patient's willingness to undergo curative surgery. Also, the study did not control for comorbidity, so some patients may have been ruled ineligible for the surgery due to outstanding health issues. However, accounting for state-level chronic obstructive lung disease prevalence did not change the results.