Study Finds That Socioeconomic Factors can Affect Outcomes after Surgery for Lung Cancer

May 2015

"Nonclinical Factors Associated with 30-Day Mortality after Lung Cancer Resection: An Analysis of 215,000 Patients Using the National Cancer Data Base," published by the Journal of the American College of Surgeons, found that residents of low-income neighborhoods with lesser numbers of high school graduates may be more likely to die after lung cancer surgery than more affluent patients.

The Emory University authors had expected that outcomes would be linked with social and economic factors, said senior author and cardiothoracic surgeon Felix Fernandez, MD. "The clinical variables for short-term survival after lung cancer surgery are well known," he said. "The effects of non-clinical factors are less appreciated. We hope studies like ours will focus attention on access and quality initiatives in those groups at risk for poor outcomes."

Dr. Fernandez and his Emory team, which included fellow cardiothoracic surgeon Manu Sancheti, MD; research oncologist Theresa Gillespie, PhD; cardiothoracic surgery resident John Melvan, MD, PhD; biostaticians Dana Nickleach, MA, and Yuan Liu, PhD; radiation oncologist Kristin Higgins, MD; hematologist and medical oncologist Suresh Ramalingam, MD; and cancer outcomes researcher Joseph Lipscomb, PhD; reviewed records for more than 200,000 patients who had lung cancer surgery from 2003 to 2011. The study was the largest analysis to date of 30-day mortality in patients undergoing surgical resection for lung cancer derived from a nationally generalizable database.

The majority of patients in the study were white and approximately 65 years old, with roughly equal numbers of men and women. Most didn't have radiation before surgery. The most common procedure performed was lobectomy, an operation to remove the lobe of the lung with diseased tissue. Most patients had Medicare or another government insurance program, and half of them had a household income of more than $46,000. Most of them also received treatment at a university hospital or a comprehensive cancer center.

The researchers found that the standard clinical variables that influenced survival, such as age, gender, and other medical conditions, were joined by non-clinical variables like the neighborhoods where patients lived and the type of hospital where they were treated. Patients had poorer odds of surviving 30 days after surgery if they were older, had other complex medical conditions, or more advanced tumors. The likelihood of 30-day survival was also worse for patients that lived in lower income households, resided in less-educated communities, and that had received treatment at non-academic medical centers.

Patients from communities with a median household income of less than $30,000 were 25 percent more likely to die within 30 days of surgery than those living in neighborhoods with a median household income higher than $46,000. Similarly, patients from less-educated communities were 16 percent more likely to die within 30 days of their operation than those from better educated communities. Possible reasons for these stats include poorer access to cancer screening and other preventive health care for these patients.

The finding that community hospitals yielded poorer outcomes builds on earlier research showing that patients have better outcomes when both hospitals and surgeons do high volumes of the procedure. The study also notes that, ideally, cancer treatment centers encompass a specialized environment with the proper infrastructure and precise observation of quality improvement protocols designed for continual evaluation and enhancement. High volume hospitals are also often better equipped to provide team-based expertise for complex cases, have physicians that specialize in the diagnosis and treatment of rare cancer types, and use a centralized method for delivering complex medical and surgical care.

"The quality of care needs to be uniform across the country for high risk procedures, so that regardless of the treatment center, whether it is a community hospital or big academic tertiary care center, the results are going to be similar," Dr. Fernandez says.

One limitation of the study was its reliance on a large U.S. cancer registry, which only covers about 70 percent of cases, the researchers note. The researchers also relied on 2000 census data for socioeconomic analysis, which might have overlooked changes in demographics during the study period.

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