Cancer care disparities in Kentucky

Kentucky leads the nation in cases of lung cancer. Cancer patients in our region also experience barriers to care and racial disparities in care.

In a recent presentation on pursuing health equity in lung cancer care, Adam D. Lye, M.D., medical oncologist with Norton Cancer Institute, spoke about the severity of the issue and what providers can do to help.

“Cancer incidence in Kentucky is very high compared with other states, but lung cancer is far and away the most prevalent here,” Dr. Lye said. “We have a 55% higher rate than the U.S. average. Lung cancer is killing Kentuckians.”

Updated screening guidelines for African Americans

Some groups are at a higher risk for lung cancer for many reasons, including their living environment, social factors or genetics.

Smoking is still one of the most important risk factors for lung cancer. But providers should also consider the impacts of race and income level.

“In Kentucky, Black smokers and socioeconomically disadvantaged individuals have a higher incidence of non-small cell lung cancer, higher mortality from non-small cell lung cancer, lower rates of treatment and a greater chance of being diagnosed at an advanced stage,” Dr. Lye said during a recent continuing medical education opportunity, “Pursuing Health Equity in Lung Cancer Care: Addressing Prevention, Screening, Diagnosis & Barriers.”

When screening patients at higher risk for lung cancer, consider important statistical differences.

African Americans diagnosed with lung cancer are more likely to:

• Get lung cancer at a younger age, so providers should begin screening at age 50 and continue up to age 80
• Have a shorter smoking history and fewer cigarettes smoked than white smokers, so providers should screen beginning at 20 pack-years instead of 30
• Have a longer time since quitting
• Be diagnosed at an advanced stage, thus less likely to receive surgery

Socioeconomically disadvantaged individuals are statistically more likely to:

• Have fewer quit attempts at smoking than those with more resources

These factors also impact participation in screening. Patients are aware that smoking is risky, so some are embarrassed to talk to their provider about their smoking and quit attempts.

“A significant proportion of smokers expressed shame and stigma as being important barriers to screening,” Dr. Lye said. “They were embarrassed that they smoked … So they didn’t seek out the appropriate medical care.”

According to Dr. Lye, African Americans also have lower rates of screening participation for several reasons:

• Low referral rates from providers who aren’t aware of the guidelines
• Patients’ uncertainty about the benefits of lung cancer screening
• Lack of support or follow-up care
• Financial concerns

Health care disparities in Greater Louisville

A Norton Healthcare community health needs assessment highlighted common reasons people delay or do not seek care.

The most frequently cited reasons were:

• Confusion: The health care system can be difficult to navigate. Patients need information provided in a format that they can understand. Patient navigators are an important resource working to solve this problem at Norton Healthcare.
• Finances: Either their health insurance coverage is insufficient or they do not have health insurance.
• Access: There are areas with no clinics, hospitals or provider offices. Transportation may also be a barrier.
• Time: Many respondents reported issues taking time off work. Transportation time was also an issue, whether people drive or use other transportation.

Perhaps the most pernicious problem is distrust in the health care system and providers. Many studies illustrate the distrust people of color have of racism, history of racist encounters with medical personnel and deep-seated fear based on experiences of systemic racism and unconscious bias in health care overall.

What can providers do about racial disparities in health care?

Answers are not easy, clear or fast, but Dr. Lye suggested some places to start:

• We need to improve adherence to the lung cancer screening recommendations.
• We need to get rid of the stigma that goes along with being a smoker.
• Patients’ willingness or eagerness to be screened increased after they were educated on lung screening, what it is and how it would benefit them. Black individuals have a significantly greater reduction in lung cancer-specific and all-cause mortality after screening with low-dose CT.

“These individuals are really benefiting from lung cancer screening,” he said. “In fact, they may be the population that benefits the most. So it’s essential that, with our high-risk Black patients in particular, we give them this lifesaving examination.”