If surgery for early non–small cell lung cancer (NSCLC) is not performed within 8 weeks of diagnosis, survival outcomes are not as good as they could be. Ensuring that patients undergo surgery within this period can be lifesaving.
A new system that was tried out at five cancer centers in North Carolina dramatically increased the number of patients who received surgery within the key 8-week window.
The first-of-its-kind audit and feedback system, known as ACCURE (Accountability for Cancer Care Through Undoing Racism and Equity), harnesses real-time data from electronic health records (EHRs) and alerts healthcare providers to patients who are at risk of “disappearing” from treatment.
The 2.5-year quality-improvement initiative was especially helpful for Black patients.
It resulted in 43% more Black patients undergoing surgery within 8 weeks of diagnosis compared to an historical control group (P < .01).
Overall, 87% of Black patients received surgery within 8 weeks, vs only 59% historically.
The results of a study of the new system were published online in the Journal of Clinical Oncology.
This study “is critically important in moving the field forward by unveiling possible interventions to mitigate inequities in lung cancer treatment,” comment the authors of an accompanying editorial.
“These results suggest that implementation of real-time notifications of incomplete treatment milestones, physician feedback about racial gaps in treatment rates, and patient navigation may improve lung cancer outcomes among minority patients with early-stage disease,” say editorialists Juan P. Wisnivesky, MD, DrPh, and Cardinale B. Smith, MD, PhD, both from the Icahn School of Medicine at Mount Sinai, New York City.
Importance of Prompt Surgery
Lung cancer is now the third most common cancer among Black people, after breast and prostate cancers, according to the Cancer Disparities Progress Report.
Around 25,690 cases of lung cancer among Black people are expected this year.
The need to carry out surgery promptly is especially important for patients with early-stage disease (ie, stage I and stage II NSCLC). Each week of treatment delay reduces survival by 3.2% for patients with stage I NSCLC and by 1.6% for those with stage II disease, according to a recent analysis of the US National Cancer Database. The same study found that Black patients waited 6.7 days longer than White patients for potentially curative treatment (P < .001).
ACCURE appeared to eliminate this racial gap in timely surgery across the five cancer centers. In the 5 years prior to the study, the median time to lung cancer surgery was 43 days for Black individuals and 32 days for their White counterparts (P < .01).
While ACCURE was running, Black patients underwent surgery within 28 days and White patients did so within 21 days, a statistically nonsignificant difference (P < .33).
The ACCURE intervention, the first of its kind, had three major components. Each day, a real-time EHR-based warning system flagged missed appointments and tardy clinical milestones. A dedicated nurse navigator who was trained in racial equity communication alerted the clinical team to care delays. The nurse also ironed out patient barriers, such as transportation problems or misconceptions about treatment, by building a relationship with each patient before problems arose. Finally, a physician champion reviewed race-specific data on treatment completion quarterly with surgical teams to uncover any biased decision-making.
“Having these milestones embedded into that system and being able to track them in real time for all the patients involved ― and react to any issues ― is the reason why we’re seeing benefits in both Black and White patients,” said first author Marjory Charlot, MD, an oncologist and assistant professor of medicine at the University of North Carolina at Chapel Hill (UNC).
There is also an extra layer of awareness. “Once providers and care teams are made aware of racial bias in their practice, and you can see it on paper, that also impacts care,” Charlot said.
The study by Charlot’s team was a secondary analysis of ACCURE. The system was launched in 2013 with funding from the National Cancer Institute (NCI) to tackle racial disparities in breast and lung cancer treatment. Results of the larger ACCURE trial were published in 2019.
ACCURE was the brainchild of the Greensboro Health Disparities Collaborative, an academic-community partnership that has a solid track record in community-based participatory research.
Samuel Cykert, MD, a professor of medicine at UNC and director of the UNC Program for Health and Clinical Informatics, headed up the original ACCURE team.
Cykert said that 20 years ago, he was struck by data that showed that Black women who began undergoing breast cancer chemotherapy were much less likely to complete therapy. “And so when we looked at [cancer registries], we found out that they only signal when chemotherapy got started ― they didn’t have any record of whether chemotherapy got finished,” he told Medscape Medical News.
Cykert’s team studied the phenomenon of “disappearing” patients ― people with cancer who are eligible for curative treatment but decide not to proceed. The results of their study were published in JAMA in 2010. The authors found, as expected, that rates of surgery were lower among Black patients with early-stage lung cancer. They also found out why some patients disappear from the care continuum when their lives are at stake.
“Black patients who felt that communication was poor between them and the physician were more likely to disappear from care,” said Cykert. In addition, “Black patients who did not have a regular source of care, like a primary care doctor, were more likely to disappear,” he said.
The ACCURE trial aimed to overcome such barriers. “We didn’t wait until the patient dropped out,” said Cykert.
Cykert would like to see a system similar to that of ACCURE across the board in healthcare.
“Now we all have live digital data, everybody ought to have a system that identifies patients that are outliers, regardless of what the cause is. And then every center ought to be building a system of engagement that brings people back into care,” he said.
Charlot and Cykert have disclosed no relevant financial relationships.
J Clin Oncol. Published online February 14, 2022. Abstract, Editorial
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