Factors Associated With Decisions to Undergo Surge

Authors: Samuel Cykert Peggye DilworthAnderson Michael H Monroe Paul Walker Franklin R McGuire Giselle CorbieSmith Lloyd J Edwards Audrina Jones Bunton

Publish Date: 2010/06/16

Volume: 303, Issue: 23, Pages: 2368-2376

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Abstract

Context Lung cancer is the leading cause of cancer death in the United States Surgical resection for stage I or II non–small cell cancer remains the only reliable treatment for cure Patients who do not undergo surgery have a median survival of less than 1 year Despite the survival disadvantage many patients with earlystage disease do not receive surgical care and rates are even lower for black patientsDesign Setting and Patients Prospective cohort study with patients identified by pulmonary oncology thoracic surgery and generalist practices in 5 communities through study referral or computerized tomography review protocol A total of 437 patients with biopsyproven or probable earlystage lung cancer were enrolled between December 2005 and December 2008 Before establishment of treatment plans patients were administered a survey including questions about trust patientphysician communication attitudes toward cancer and functional status Information about comorbid illnesses was obtained through chart auditsResults A total of 386 patients met full eligibility criteria for lung resection surgery The median age was 66 years range 2690 years and 29 of patients were black The surgical rate was 66 for white patients n = 179/273 compared with 55 for black patients n = 62/113 P = 05 Negative perceptions of patientphysician communication manifested by a 5point decrement on a 25point communication scale odds ratio OR 042 95 confidence interval CI 032074 and negative perception of 1year prognosis postsurgery OR 027 95 CI 014050 absolute risk 34 were associated with decisions against surgery Surgical rates for blacks were particularly low when they had 2 or more comorbid illnesses 13 vs 62 for 2 comorbidities OR 004 95 CI 001025 absolute risk 49 and when blacks lacked a regular source of care 42 with no regular care vs 57 with regular care OR 020 95 CI 010043 absolute risk 15Conclusions A decision not to undergo surgery by patients with newly diagnosed lung cancer was independently associated with perceptions of communication and prognosis older age multiple comorbidities and black race Interventions to optimize surgery should consider these factorsLung cancer remains the leading cause of cancer death in the United States and proportionally this burden is greater for blacks1 Non–small cell histology represents more than 80 of cases23Surgical resection for stage I or II disease remains the only reliable cure4 Patients who do not undergo appropriate surgery face a median survival of less than 1 year and the sequelae of progressive cancer and then death while those who undergo appropriate surgery have a median survival of more than 4 years57 Despite patients fear of cancer8 and the dismal outcomes for those who do not proceed to surgery administrative data59 consistently show that almost onethird of patients with potentially curable disease do not undergo resection surgery A persistent surgical gap that disadvantages black patients has been reported for more than a decade1012Although administrative data underscore variations in medical care including racial disparities these data often lack the detail needed to identify modifiable factors effecting differences This limitation is particularly important with cancer because decisions against appropriate therapy whether caused by misperceptions poor communication or disorganized systems of care can jeopardize patients’ survival A prospective cohort study was performed of newly diagnosed patients with earlystage lung cancer to identify potentially modifiable factors regarding surgery and to explore why black patients undergo surgery even less than white patients

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