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Invited Commentary
Oncology
August 24, 2021

Increased Access for Vulnerable Patient Populations to Promote Equity in Lung Cancer Screening—Clearing a Path

Author Affiliations
  • 1Department of Medicine, Harvard Medical School, Boston, Massachusetts
  • 2Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
  • 3Dana-Farber Cancer Institute at St Elizabeth’s Medical Center, Boston, Massachusetts
JAMA Netw Open. 2021;4(8):e2120699. doi:10.1001/jamanetworkopen.2021.20699

In their article, Prosper et al1 have utilized National Lung Screening Trial (NLST) data and a statistical method to extrapolate and measure how hypothetically increasing the percentage of Black participants in study populations (as well as varying the gender distribution and history of tobacco use) could potentially affect lung cancer mortality rates. They found that increasing the percentage of Black participants was associated with a greater relative reduction in lung cancer mortality. This pattern increased as they increased the percentage of hypothetical Black participants. The authors also found a greater relative reduction in lung cancer mortality if they increased the percentage of smokers and male participants. Their work is elegant and thought-provoking, and the authors should be commended for their approach. As a lung cancer clinician, I would hypothesize that enriching the population for other factors linked to poor outcomes (eg, lower socioeconomic position, Medicaid insurance) might show a similar pattern.

The authors go on to state that their work is in line with previous subgroup analyses using NLST data,2,3 and while this work can be helpful in estimating health outcomes in populations, it is not to be seen as a replacement for true efforts to recruit diverse patient populations to clinical trials. Indeed, it would be the height of folly for trialists to surmise that a statistical model can replace the hard work of truly involving historically excluded and marginalized communities in the planning, implementation, and recruitment for clinical trials. Our experience in health services research has shown that adjusting for race, class, and social status is helpful for hypothesis generation, but is not the same as an intervention.4 While statistical models can be idealized, actual interventions are messy affairs not always amenable to randomization. Indeed, interventions focused on access in vulnerable communities require investigators to engage with the community in a prospective manner.5

A great example of a lung cancer screening intervention is the work done by Cykert et al.6 This is a tremendous example of formulating an intervention after review of descriptive work and using those hypotheses to build an intervention with the community. The clinical trials for COVID-19 vaccines show us that when motivated, recruitment of participants from racial and ethnic groups historically excluded from such trials (eg, Black, Indigenous, and people of color) is possible.7

The events of the last 18 months have brought about an increased reckoning with the structural inequity that is embedded in our health care system. While the impact of race, class, and social status on health outcomes has been demonstrated time and again, the combined tipping points of horrific injustices committed against Black men and women witnessed while the world was on lockdown with the disproportionate impact of COVID-19 deaths on Black and Brown communities in the US has allowed for a more honest and urgent conversation about access, inclusion, and equity. The work of Prosper et al1 suggests that increasing the percentage of Black patients included in the NLST might have resulted in better outcomes for those participants. Now we just need the will to build our trials and interventions to include historically marginalized communities prospectively even when there is not a global pandemic and sustain this awareness of systemic inequity moving forwards. Lives depend on it.

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Article Information

Accepted for Publication: June 28, 2021.

Published: August 24, 2021. doi:10.1001/jamanetworkopen.2021.20699

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Lathan C. JAMA Network Open.

Corresponding Author: Christopher Lathan, MD, MS, MPH, Dana-Farber Harvard Cancer Center, 450 Brookline Ave, Boston, MA 02215 (christopher_lathan@dfci.harvard.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Prosper  A, Inoue  K, Brown  K, Bui  AAT, Aberle  D, Hsu  W.  Association of inclusion of more Black individuals in lung cancer screening with reduced mortality.   JAMA Netw Open. 2021;4(8):e2119629. doi:10.1001/jamanetworkopen.2021.19629Google Scholar
2.
Church  TR, Black  WC, Aberle  DR,  et al; National Lung Screening Trial Research Team.  Results of initial low-dose computed tomographic screening for lung cancer.   N Engl J Med. 2013;368(21):1980-1991. doi:10.1056/NEJMoa1209120PubMedGoogle Scholar
3.
Tanner  NT, Gebregziabher  M, Hughes Halbert  C, Payne  E, Egede  LE, Silvestri  GA.  Racial differences in outcomes within the National Lung Screening Trial—implications for widespread implementation.   Am J Respir Crit Care Med. 2015;192(2):200-208. doi:10.1164/rccm.201502-0259OCPubMedGoogle ScholarCrossref
4.
Williams  DR, Kontos  EZ, Viswanath  K,  et al.  Integrating multiple social statuses in health disparities research: the case of lung cancer.   Health Serv Res. 2012;47(3 Pt 2):1255-1277. doi:10.1111/j.1475-6773.2012.01404.xPubMedGoogle Scholar
5.
Agurs-Collins  T, Persky  S, Paskett  ED,  et al.  Designing and assessing multilevel interventions to improve minority health and reduce health disparities.   Am J Public Health. 2019;109(S1):S86-S93. doi:10.2105/AJPH.2018.304730Google ScholarCrossref
6.
Cykert  S, Eng  E, Walker  P,  et al.  A system-based intervention to reduce Black-White disparities in the treatment of early stage lung cancer: a pragmatic trial at five cancer centers.   Cancer Med. 2019;8(3):1095-1102. doi:10.1002/cam4.2005Google ScholarCrossref
7.
Baden  LR, El Sahly  HM, Essink  B,  et al.  Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine.   N Engl J Med. 2021;384(5):403-416. doi:10.1056/NEJMoa2035389Google ScholarCrossref
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