National race and socioeconomic disparities in access to minimally invasive lung resection for early-stage lung cancer: Impact on mortality

Abstract

<h2>Abstract</h2><h3>Background</h3> Adoption of minimally invasive surgery (MIS) for early-stage non–small cell lung cancer (NSCLC) is increasing in the United States. We examined the relationship between sociodemographic factors and receipt of MIS among these patients. <h3>Methods</h3> Patients undergoing surgical resection for stage I and II NSCLC between 2010 and 2018 were identified in the National Cancer Database and stratified by surgical approach. Patients were excluded if they had nonanatomic or palliative resection, received neoadjuvant therapy, or lacked relevant clinical and demographic factors or follow-up. Multivariate analysis adjusted for baseline characteristics. The primary outcome was receipt of MIS; secondary outcomes were 30-and 90-day mortality. <h3>Results</h3> A total of 130,452 patients underwent open (n = 67,046; 51%), video-assisted thoracic surgery (VATS; n = 43,849; 34%), or robotic (n = 19,557; 15%) surgery. Non-Hispanic black patients were less likely than non-Hispanic white patients to undergo MIS (adjusted odds ratio [aOR], 0.895; 95% CI, 0.858-0.934; <i>P</i> < .001). This was not significant after adjusting for census-tract income (aOR, 0.967; 95% CI, 0.926-1.011; <i>P</i> = .1374). Non-Hispanic black patients were significantly more likely reside in lower income census-tracts and be underinsured; these factors were significantly associated with decreased access to MIS. Open surgery was associated with worse adjusted 30-day mortality (1.89% for open, 1.25% for VATS, 1.24% for robotic) and 90-day mortality (3.4% for open, 2.17% for VATS, 2.08% for robotic) compared to MIS (<i>P</i> < .001). Mortality was significantly associated with census-tract income level and insurance status (<i>P</i> < .001). <h3>Conclusions</h3> Racial disparities in receipt of MIS among early-stage NSCLC patients are mediated by census-tract income and insurance status. Access to MIS and insurance status are associated with improved 30- and 90-day mortality. Policy efforts are needed to improve access and outcomes for these patients.