1. May, Brandon

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In the U.S. and around the globe, lung cancer is the leading cancer-related cause of death. Across the board, the disease contributes most to new cancer diagnoses, including 12.4 percent of total new cancer cases (Clin Chest Med 2011;32(4):605-644).

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Minorities and underserved populations tend to have the greatest mortality burden associated with lung carcinoma. While the barriers of care that result in the socioeconomic and racial disparities in lung carcinoma remain an important clinical challenge, many specialists are hopeful that these barriers can be overcome.


Researchers at Johns Hopkins Medicine have led the way in ascertaining a more in-depth understanding of lung cancer, including the lifestyle and socioeconomic factors that contribute to its high morbidity and mortality.


According to Dina George Lansey, MS, oncology researcher and instructor at Johns Hopkins Medicine, perhaps the most significant challenge for managing minorities with lung cancer is access to routine care. The hurdle, she told Oncology Times, is determining whether these patients have a primary care physician and, if so, whether they see their doctor at regular intervals.


Also, many underserved populations present at later stages of disease either because they are unaware of various screening guidelines or do not adhere to them. "At certain ages, those folks who are seeing a primary care physician are more likely to adhere to screening recommendations," Lansey commented. "For example, if you're a 40-year-old woman and you're seeing a primary care physician, then you would be encouraged to get a mammogram and subsequently every year you see that physician. You will know you need to take care of that screening."


Urban & Rural Communities

Community education regarding health care coverage options, as well as programs that increase patients' awareness of healthy living practices and regular cancer screenings, are crucial for underserved populations, whether they reside in rural or urban settings.


Lansey believes that the care access challenges faced by cancer patients are fairly similar to patients who live in rural and city environments; however, the means by which these challenges manifest can be sharply different.


"Minorities and underserved populations in rural communities have become a more important topic in discussions around health care disparities as they often have similar challenges to care access as those in urban populations," she stated. "In rural communities, you're not necessarily close to a cancer center that offers clinical trials or that sees lots of cancer patients. I think many of the barriers to care are similar for patients in both urban and rural areas, but how we go about addressing those barriers needs to be tailored."


For rural communities, she added, the challenge could be the number of providers available to patients, whereas those in an urban setting may not have transportation or insurance coverage.


Barriers to Clinical Trials

Clinical trials may be another missing piece to cancer care that is generally not investigated too deeply by patients. One of Lansey's roles at Johns Hopkins is to look at the barriers in cancer care and find ways to address them, whether that's conducting a research study to gain understanding of a specific barrier or interviewing patients to find out why they decide not to enroll in clinical trials.


"We want to know why people are declining clinical trials," she said. "If their physician talks to them about a clinical trial that could be appropriate for their diagnosis and isn't an available treatment option for them and they say no, then I would like to know why."


Generally, patients with cancer may decline a clinical trial because they prefer standard of care or because they're uncomfortable with the randomization process. "Some of those reasons are related to not being aware of how clinical trials are set up, how participants are protected, and how those clinical trials must be run in an interest to patient safety," Lansey added. "At Johns Hopkins, we have numerous education materials for patients, and we also educate our faculty and staff about why patients decline so they can be more mindful when having these discussions with their patients."


Currently, Johns Hopkins researcher Patrick Forde, MD, is actively recruiting for trials investigating neoadjuvant nivolumab monotherapy or in combination with ipilimumab in resectable non-small cell lung cancer (NCT02259621).


Clinician-Patient Communication

For underrepresented patients with lung cancer, access to checkups, trial sites, and pharmacies aren't always ideal. "If I talk to a patient about a clinical trial or a treatment option," Lansey stated, "it might be a good idea to follow-up with asking the patient how they'll get there."


Patients who reside in rural communities as well as those with lower socioeconomic status may not have feasible or reliable means of transportation to receive their care. "If we catch a barrier to access early on, then we can connect that patient to support services to make sure that they get to those visits," she said.


"At Johns Hopkins and elsewhere, I encourage clinicians to ask patients about potential barriers around education and awareness, as well as support services like transportation or the patient's work hours, so we can make sure that the care we're providing fits within their everyday life."


Brandon May is a contributing writer.


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