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Racial/Ethnic Disparities

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Distrust of diagnosis and belief in alternative cures may partly explain blacks' lower rate of lung cancer surgery

Patients who don't undergo surgery for stage I and II non-small cell lung cancer can expect to survive less than a year. In contrast, those who undergo surgery have a median survival of 4 years, and 5-year cure rates approach 40 percent. Yet, more blacks than whites (36 vs. 23 percent) who have been diagnosed with this disease elect not to have surgery.

In order to tease out the factors driving the apparent racial difference in lung cancer surgery, Samuel Cykert, M.D., and Nancy Phifer, M.D., of the University of North Carolina School of Medicine, surveyed 181 diverse individuals about how they valued conditions relevant to lung cancer surgery. Participants were age 50 and older, 113 were white, and 68 were black.

The researchers, who were supported in part by the Agency for Healthcare Research and Quality (HS10861), used a survey and the standard gamble approach to determine the health utility score (HUS) for progressive lung cancer. The patient was guaranteed an intermediate health state (progressive lung cancer), then offered an intervention that could convert this disease state to normal health (cure) or immediate death. The patient was asked to express the risk of death that he or she was willing to take to avoid progressive lung cancer and achieve normal health. After controlling for other demographic factors, the HUS (with 0 equaling death and 1 perfect health) for progressive lung cancer was nearly twice as high in blacks as whites (0.32 vs. 0.18), meaning that blacks did not consider living with the progressive disease as horrible as whites.

However, the model incorporating utility data for blacks did not show that this attitude changed the surgical decision from the perspective of quality-adjusted life years. Lung cancer surgery remained heavily favored over the non-surgery decision (2.32 vs. 0.48 quality-adjusted life years) in baseline decision analysis for both blacks and whites. Factors that did profoundly affect blacks' decisions against surgery included their distrust of diagnosis, belief in alternative cures, and religious beliefs that their cancer would spontaneously subside.

See "Surgical decisions for early stage, non-small cell lung cancer: Which racially sensitive perceptions of cancer are likely to explain racial variation in surgery," by Drs. Cykert and Phifer, in the March 2003 Medical Decision Making 23, pp. 167-176.

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