Intervention Clears Survival Gaps between Blacks and Whites in Patients with Early-Stage Lung and Breast Cancer
A new study shows that system-level changes in the way cancer care is delivered can also eliminate black-white disparities in early-stage lung and breast cancer survival. By identifying and removing barriers that prevented patients from completing radiation therapy for cancer, the intervention improved five-year survival rates for all patients and closed the survival gap between black and black patients. white. The results will be presented today at the annual meeting of the American Society for Radiation Oncology (ASTRO).
The Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) clinical trial is the first prospective study designed to address gaps in cancer treatment completion and survival among black and white patient populations. “Thousands of studies have looked at racial disparities in health care, but until recently very few studies have implemented interventions to eliminate these disparities,” said senior author Matthew A Manning, MD, radiation oncologist and chief of oncology at Cone Health in Greensboro, NC. “This study shows that it can be done.”
The ACCURE approach involved multiple changes in the way patients were supported while receiving cancer treatment. The process consisted of four components: (1) an electronic health record with automatic alerts to report missed appointments or unfulfilled milestones in expected care; (2) a nurse navigator trained in race-specific barriers to help patients overcome barriers to care when alerts are reported; (3) a champion physician, to engage healthcare teams with race-related feedback on treatment completion; and (4) regular training sessions on health equity for staff.
Previously published results showed that the ACCURE intervention significantly reduced disparities in treatment completion rates for black and white patients receiving curative radiation therapy or surgery for early-stage breast or lung cancer. In the new study, researchers examined whether increasing completion rates led to improved outcomes, paying particular attention to whether the intervention reduced racial disparities in cancer survival. They compared the five-year survival rates for 1,413 patients with stage 0, I and II lung and breast cancer who were treated after the start of the procedure with 2,016 patients treated before the changes. of the system.
Before the procedure, the five-year survival rate for black patients with breast cancer was 89%, compared to 91% for white patients. After the start of the system-level changes, the five-year survival rates for both groups rose to 94%. Among those treated for early-stage lung cancer, survival rates fell from 37% to 54% for black patients and from 43% to 56% for white patients.
Historically, black and white patients had different survival rates after treatment, but that difference disappeared. We are now in a position to say that this intervention eliminated the disparities in overall survival. “
Dr. Matthew A. Manning, MD, chief of oncology at Cone Health in Greensboro, NC
Blacks face the highest cancer death rate and the shortest cancer survival rate of any racial / ethnic group in the United States. According to the American Cancer Society, black populations also face “greater barriers to cancer prevention, detection, treatment and survival.” By identifying and addressing the specific barriers their patient populations face, such as limited access to transportation or difficulty in taking time off work without penalty, and intentionally examining how the barriers varied by race, the team ACCURE was able to limit the negative impact of these obstacles, said Dr Manning.
“At the end of the day, unless we ask what happens when an appointment or milestone is missed, we just don’t know what’s going on, and the patient may never come back to us. If we ask, we often have systems in place that can overcome these barriers. We can provide transportation or provide a letter to the patient for work. We can overcome many barriers, both internal and external to our healthcare facilities , but only if we know what they are.
Dr Manning’s Hospital previously conducted a pilot study which found that providing a free carpooling program to transport patients to radiation therapy sessions reduced no-show rates among vulnerable populations.
The focus on structural and institutional change rather than individual change to address disparities has been key to the success of the ACCURE trial, said Samuel Cykert, MD, professor of medicine at the Faculty of Medicine of the ‘University of North Carolina and principal investigator of the trial. “The responsibility for change lies with the system, not the individual patient. People can’t help themselves if they ever miss treatment because they have a child to care for, for example. The intervention signals also delays in care within the health care system itself that occur even when patients do not miss their appointments. “
“The clinic can provide safety nets by instituting a method to report these barriers and delays, and by putting in place measures to help the patient resume and complete treatment. It made all the difference with this trial, ”said Dr Cykert.
Investigators drew on the foundational work of the Greensboro Health Disparities Collaborative – a long-standing community-initiated partnership of medical, academic and community representatives – when designing the intervention, said Christina Yongue, MPH, MCHES, Assistant Professor of Public Health Education at the University of North Carolina at Greensboro and Project Leader for the ACCURE trial.
“The main concepts behind ACCURE – transparency, accountability and improved communication – emerged from this collaboration and the racial equity workshops that were required for providers and staff,” said Ms. Yongue. “These pillars were essential in building trust with our research participants, especially with black patients who are historically marginalized in healthcare. Clinical results would not have been possible without this trust.”
In the future, the ACCURE team is considering other applications for the intervention, such as addressing disparities in pregnancy / maternal care. “We have shown that it is possible to eliminate the disparities in the completion of cancer treatment and that this change has the potential to close the downstream cancer survival gaps,” said Dr. Manning. “But we think the application can be much broader.”
American Society of Radiation Oncology