Rural Patient Populations at Higher Risk of Lung Cancer Mortality


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Logan Roof, MD, discusses the importance of investigating demographic disparities that exist in lung cancer mortality, expands on the results of the population-based CDC database analysis, and discusses potential next steps to address these disparities in the future.

Logan Roof, MD

Logan Roof, MD

Although the incidence of lung cancer mortality has decreased in the United States Since 1999, men, Non-Hispanic Black individuals, rural populations, and individuals in Southern States have been subject to disproportionate disparities in disease-related outcomes, according to findings from a population-based CDC database analysis presented at the 2023 ASCO Annual Meeting.

In this analysis, investigators found that lung cancer age-adjusted mortality rates (AAMR) decreased by 42% between 1999 and 2020, with an average annual percent change of –2.6% (P <.001). However, rural patient populations experienced the highest AAMR and slowest rate of decrease at –1.7% annually (P < .001) compared with urban patient populations who experienced the lowest AAMR and fastest decrease at –3.1% (P< .001). Moreover, Non-Hispanic Black men from rural patient populations had the highest risk for mortality, with a decrease of –2.9% annually (P < .001) in subgroup analysis.

“The take-home message is that it is great that lung cancer incidence and mortality is declining overall. Unfortunately, that rate of decline is not the same for all patients and all populations,” study author Logan Roof, MD, said.

In an interview OncLive, Roof discussed the importance of investigating demographic disparities that exist in lung cancer mortality, expanded on the results of the population-based CDC database analysis, and discussed potential next steps to address these disparities in the future. Roof is a third-year hematology/oncology fellow and chief fellow of the Hematology/Oncology Fellowship Program at Cleveland Clinic Taussig Cancer Institute in Ohio.

OncLive: What was the importance of conducting this analysis?

Roof: The reason that we wanted to look at this [topic] is that we know that lung cancer is the leading cause of cancer-related mortality in the United States. There's also been a lot of studies that have shown that the incidence of mortality rates [associated with] lung cancer have been decreasing over the past few decades. However, there are also implications that the rate of decline has not been the same across all populations.

We wanted to first capture some of the data in a larger database to determine the cancer-related mortality in the United States specific to lung cancer, and how those demographic trends have [played out]. [We looked] at demographic factors such as geographic location, age, sex, and race. From here, we can also investigate concerted efforts to help mitigate some of those differences.

Could you expand on the patient population that was observed in this analysis?

We looked at the CDC WONDER database. This is a very large database of all patients in the United States, and you can look at it by mortality codes. We looked at any cause of mortality related to lung or bronchus cancer between 1999 and 2020. This is a very large population that we looked at, [because] we wanted to see the demographic trends.

What methods were implemented throughout this investigation?

We retrospectively queried the database to see the cause of death for lung and bronchus cancer in the United States between these 2 decades. We then looked at age-adjusted mortality rates and how those changed over time.

What findings from this analysis were presented at the 2023 ASCO Annual Meeting?

We found that the mortality rate for lung cancer rate declined by 2.6% overall in the United States. We then looked at [the results] by group, and we found some differences. In 1999, men had a very high mortality rate compared with women with lung cancer. However, closer to 2020, those differences had decreased. The rate of mortality for men has been declining, but for women, it looks like it may be increasing; this is a concern.

We also found that different geographic locations had different rates of decline. It looked like lung cancer was declining more rapidly in areas like the West, and it was declining the least rapidly in the Midwest. We found that different age ranges had different results [as well]. Different backgrounds, in terms of race and ethnicity, had different rates of lung cancer [mortality], and we also found geographic location disparities.

We found that rural populations had the worst mortality rates in the United States and that the rates of lung cancer mortality declined less rapidly in the rural population. Therefore, we want to identify targeted areas for improvement in certain populations.

What interventions or initiatives may help to decrease some of these disparities?

We want to not only identify these disparities. There's a lot of research out there that is helping identify disparities, which is the first step. We do want to know what disparities exist and how to best tackle them. However, we want this work to highlight the disparities, as well as key next steps on what we can do to help mitigate those disparities.

Some of the things that we're thinking about are increasing targeted interventions to certain vulnerable populations to help with efforts like smoking cessation, community outreach, and CT screening. Increasing pneumocystis pneumonia awareness of the lung cancer screening methodology, and doing mobile lung cancer screening initiatives, getting out into the community, and helping to get resources to where people need them the most [will be important]. Also working [to improve] access to care is very important, as well. Some rural populations had worse mortality, and their mortality is not declining at the same rate as some other more urban populations because of access to primary care, oncologists, and guideline-directed care.

We want to make sure to enroll patients in clinical trials, and it's been a national initiative to ensure that we enroll populations that are more representative of the populations that are affected by lung cancer. This way, we'll know that certain interventions may be beneficial for them, and they can see that full benefit. Another thing that we have been doing at the Cleveland Clinic is working with regional cancer sites to help get that care to patients in the community.

Lastly, throughout the COVID-19 pandemic, we have seen that telehealth is feasible; it can be utilized as a platform for a lot of vulnerable populations, including some areas that are geographically underrepresented and harder to reach. A lot of patients do still have access to some sort of telehealth platform, whether it be internet-based or if they have a cell phone, we can really reach people. Those are some of the initiatives that we want to see moving forward to try to help mitigate some of these disparities.

What would you like treating oncologists to know regarding implementing these next steps into practice?

The next steps, as providers, are to reach out to the community to figure out where we're missing people who could benefit from interventions, specifically focusing on community outreach, the affiliation of academic centers with community centers, targeted interventions for smoking cessation efforts, CT screening efforts, getting patients on clinical trials, and ensuring that everyone has access to the same high-quality care.


Didier AJ, Roof L, Stevenson J, et al. Demographic disparities in lung cancer mortality and trends in the United States between 1999 and 2020: a population-based CDC database analysis J Clin Oncol. 2023;41(suppl 16):6603. doi:10.1200/JCO.2023.41.16_suppl.6603

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