Cultural factors associated with racial disparities in lung cancer care.

RATIONALE: Minority patients with lung cancer are less likely to receive stage-appropriate treatment. Along with access to care and provider-related factors, cultural factors such as patients' lung cancer beliefs, fatalism, and medical mistrust may help explain this disparity. OBJECTIVES: To determine cultural factors associated with disparities in lung cancer treatment. METHODS: Patients with newly diagnosed lung cancer were recruited from four medical centers in New York City from 2008 to 2011. Using validated tools, we surveyed participants about their beliefs regarding lung cancer, fatalism, and medical mistrust. We compared rates of stage-appropriate treatment among blacks, Hispanics, and nonminority patients. Multiple regression analyses and structural equation modeling were used to assess whether cultural factors are associated with and/or mediate disparities in care. MEASUREMENTS AND MAIN RESULTS: Of the 352 patients with lung cancer in the study, 21% were black and 20% were Hispanic. Blacks were less likely to receive stage-appropriate treatment (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.27-0.93) compared with whites, even after adjusting for age, sex, marital status, insurance, income, comorbidities, and performance status. No differences in treatment rates were observed among Hispanics (OR, 1.05; 95% CI, 0.53-2.07). Structural equation modeling showed that cultural factors (negative surgical beliefs, fatalism, and medical mistrust) partially mediated the relationship between black race and lower rates of stage-appropriate treatment (total effect: -0.43, indirect effect: -0.13; 30% of total effect explained by cultural factors). CONCLUSIONS: Negative surgical beliefs, fatalism, and mistrust are more prevalent among minorities and appear to explain almost one-third of the observed disparities in lung cancer treatment among black patients. Interventions targeting cultural factors may help reduce undertreatment of minorities.

Metered dose inhaler technique among inner-city asthmatics and its association with asthma medication adherence.

INTRODUCTION: Inhaled medications, critical for asthma treatment, are self-administered through metered dose inhalers (MDI). Asthma self-management hinges on adherence to these medications and to proper MDI technique. OBJECTIVE: To assess predictors of proper MDI technique, and MDI technique as a tool to identify patients with low adherence to inhaled medications. METHODS: Prospective cohort of asthmatics from clinics in New York, NY and New Brunswick, NJ. MDI technique was assessed using a standardized checklist. Adherence to inhaled asthma controller medication was evaluated with the Medication Adherence Report Scale. Predictors of MDI technique were evaluated using regression analyses. The distribution of number of MDI technique steps missed was compared in adherent vs. non-adherent asthmatics. RESULTS: Overall, 326 patients were included (55% Hispanic, 27% Black). In adjusted analyses, age < 55 years was significantly associated with MDI technique (P = 0.03). Overall, 12%, 34%, 40% of asthmatics missed 5-6, 3-4, or 1-2 MDI steps; 16% received a perfect MDI technique score. Adherence rates were 20%, 39%, 48%, and 62% among those who missed 5-6, 3-4, 1-2, or none of the steps in the MDI technique checklist (P < 0.001). CONCLUSION: Poor MDI technique is common among inner-city patients with asthma and is associated with poor adherence to controller medications. Older patients with asthma are at higher risk of improper MDI technique. Assessment of MDI technique may be a simple clinical aid to identify patients with low adherence to controller medications.

Effectiveness of radiation therapy alone for elderly patients with unresected stage III non-small cell lung cancer.

PURPOSE: Chemoradiotherapy is the standard of care for unresectable stage III non-small cell lung cancer (NSCLC). Elderly patients, who are often considered unfit for combined chemoradiotherapy, frequently receive radiation therapy (RT) alone. Using population-based data, we evaluated the effectiveness and tolerability of lone RT in unresected elderly stage III NSCLC patients. METHODS AND MATERIALS: Using the Surveillance, Epidemiology and End Results (SEER) registry linked to Medicare records we identified 10,376 cases of unresected stage III NSCLC that were not treated with chemotherapy, diagnosed between 1992 and 2007. We used logistic regression to determine propensity scores for RT treatment using patients' pre-treatment characteristics. We then compared survival of patients who underwent lone RT vs. no treatment using a Cox regression model adjusting for propensity scores. The adjusted odds for toxicity among patients treated with and without RT were also estimated. RESULTS: Overall, 6468 (62%) patients received lone RT. Adjusted analyses showed that RT was associated with improved overall survival in unresected stage III NCSLC (hazard ratio [HR]: 0.76; 95% confidence interval [CI]: 0.74-0.79) after controlling for propensity scores. RT treated patients had an increased adjusted risk of hospitalization for pneumonitis (odds ratio [OR]: 89, 95% CI: 12-636), and esophagitis (OR: 8, 95% CI: 3-21). CONCLUSIONS: These data suggest that use of RT alone may improve the outcomes of elderly patients with unresected stage III NSCLC. Severe toxicity, however, was considerably higher in the RT treated group. The potential risks and benefits of RT should be carefully discussed with eligible elderly NSCLC patients.

Evaluating beliefs associated with late-stage lung cancer presentation in minorities.

INTRODUCTION: Minority patients in the United States present with later stages of lung cancer and have poorer outcomes. Cultural factors, such as beliefs regarding lung cancer and discrimination experiences, may underlie this disparity. METHODS: Patients with a new diagnosis of lung cancer were recruited from four medical centers in New York City. A survey, using validated items, was conducted on the minority (black and Hispanic) and nonminority patients about their beliefs regarding lung cancer, fatalism, and medical mistrust. Univariate and logistic regression analyses were used to compare beliefs among minorities and nonminorities and to assess the association of these factors with late-stage (III and IV) presentation. RESULTS: Of the 357 lung cancer patients, 40% were black or Hispanic. Minorities were more likely to be diagnosed with advanced-stage lung cancer (53% versus 38%, p = 0.01). Although beliefs about lung cancer etiology, symptoms, and treatment were similar between groups (p > 0.05), fatalistic views and medical mistrust were more common among minorities and among late-stage lung cancer patients (p < 0.05, for all comparisons). Adjusting for age, sex, education, and insurance, minorities had increased odds of advanced-stage lung cancer (odds ratio: 1.79; 95% confidence interval, 1.04-3.08). After controlling for fatalism and medical mistrust, the association between minority status and advanced stage at diagnosis was attenuated and no longer statistically significant (odds ratio: 1.56; 95% confidence interval, 0.84-2.87). CONCLUSIONS: Fatalism and medical mistrust are more common among minorities and may partially explain the disparities in cancer stage at diagnosis. Addressing these factors may contribute to reducing disparities in lung cancer diagnosis and outcomes.

Beliefs and attitudes about lung cancer screening among smokers.

The National Lung Screening Trial (NLST) recently reported that annual computed tomography (CT) screening is associated with decreased lung cancer mortality in high-risk smokers. Beliefs about lung cancer and screening, particularly across race and ethnicity, and their influence on CT screening utilization are largely unexamined. Our study recruited asymptomatic, high-risk smokers, 55-74 years of age from primary care clinics in an academic urban hospital. Guided by the self-regulation theory, we evaluated cognitive and affective beliefs about lung cancer. Intention to screen for lung cancer with a CT scan was assessed by self-report. We used univariate and logistic regression analyses to compare beliefs about screening and intention to screen among minority (Blacks and Hispanics) and non-minority participants. Overall, we enrolled 108 participants, of which 40% were Black and 34% were Hispanic; the mean age was 62.3 years, and median pack-years of smoking was 26. We found that intention to screen was similar among minorities and non-minorities (p=0.19); however, Hispanics were less likely to report intention to screen if they had to pay for the test (p=0.02). Fatalistic beliefs, fear of radiation exposure, and anxiety related to CT scans were significantly associated with decreased intention to screen (p<0.05). Several differences were observed in minority versus non-minority participants' beliefs toward lung cancer and screening. In conclusion, we found that concerns about cost, which were particularly prominent among Hispanics, as well as fatalism and radiation exposure fears may constitute barriers to lung cancer screening. Lung cancer screening programs should address these factors to ensure broad participation, particularly among minorities.

Racial and ethnic differences in beliefs about lung cancer care.

BACKGROUND: Disparities in lung cancer treatment and palliative care are well documented. However,the mechanisms underlying these disparities are not fully understood. In this study, we evaluated racial and ethnic differences in beliefs and attitudes about lung cancer treatment and palliative care among patients receiving a new diagnosis of lung cancer. METHODS: Patients were recruited from four medical centers in New York City and surveyed about their beliefs regarding lung cancer care, including disease-directed treatments, palliative and end-of-life care, and fatalistic and spiritual beliefs. We used univariate and multiple regression analyses to compare the distribution of beliefs among minority (black and Hispanic) and nonminority patients. RESULTS: Of the 335 patients, 21% were black, 20% were Hispanic, and 59% were nonminority. Beliefs about chemotherapy and radiotherapy were similar across the three groups ( P > .05),whereas black patients were more likely to believe that surgery might cause lung cancer to spread( P =.008). Fatalistic beliefs potentially affecting cancer treatment were more common among both minority groups ( P ≤ .02). No signifi cant differences were found in attitudes toward clinician communication about cancer prognosis ( P > .05). However, both blacks and Hispanics were more likely to have misconceptions about advance directives and hospice care ( P ≤ .02). CONCLUSIONS: Similarities and differences in beliefs about disease-directed treatment were observed between minority and nonminority patients with lung cancer. Minority patients hold more fatalistic views about the disease and misperceptions about advance care planning and hospice care. Further research is needed to assess the impact of these beliefs on decisions about lung cancer care and patient outcomes.

Radiotherapy and chemotherapy for elderly patients with stage I-II unresected lung cancer.

Radiotherapy (RT) is the standard therapy for unresected stage I-II nonsmall cell lung cancer (NSCLC). Using population-based data, we compared survival and toxicity among unresected elderly patients treated with combined chemoradiotherapy (CRT) or RT alone. Using the Surveillance, Epidemiology and End Results (SEER) registry (National Cancer Institute, Bethesda, MD, USA) we identified 3,006 cases of unresected stage I-II NSCLC. We used propensity score methods to compare survival and rates of toxicity of patients treated with RT versus CRT. Overall, 844 (28%) patients received CRT. Adjusted analyses showed that CRT was associated with improved survival (hazard ratio 0.85, 95% CI 0.78-0.94). Combination therapy was also associated with better survival among stage I patients treated with intermediate complexity RT (HR 0.80, 95% CI 0.70-0.90); however, no difference in survival was observed among patients treated with complex RT. In stage II patients, CRT was associated with improved survival regardless of the RT technique (HR 0.61-0.72). CRT was associated with increased odds of toxicity. Despite increased toxicity, CRT may improve survival of elderly unresected patients with stage II disease as well as stage I NSCLC treated with intermediate RT complexity. Randomised trials are needed to clarify the balance of benefits and risk of CRT in unresected patients.

Barriers to adherence to COPD guidelines among primary care providers.

BACKGROUND: Despite efforts to disseminate guidelines for managing chronic obstructive pulmonary disease (COPD), adherence to COPD guidelines remains suboptimal. Barriers to adhering to guidelines remain poorly understood. METHODS: Clinicians from two general medicine practices in New York City were surveyed to identify barriers to implementing seven recommendations from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Barriers assessed included unfamiliarity, disagreement, low perceived benefit, low self-efficacy, and time constraints. Exact conditional regression was used to identify barriers independently associated with non-adherence. RESULTS: The survey was completed by 154 clinicians. Adherence was lowest to referring patients with a forced expiratory volume in 1 s (FEV(1)) <80% predicted to pulmonary rehabilitation (5%); using FEV(1) to guide management (12%); and ordering pulmonary function tests (PFTs) in smokers (17%). Adherence was intermediate to prescribing inhaled corticosteroids when FEV(1) <50% predicted (41%) and long-acting bronchodilators when FEV(1) <80% predicted (54%). Adherence was highest for influenza vaccination (90%) and smoking cessation counseling (91%). In unadjusted analyses, low familiarity with the guidelines, low self-efficacy, and time constraints were significantly associated with non-adherence to ≥2 recommendations. In adjusted analyses, low self-efficacy was associated with less adherence to prescribing inhaled corticosteroids (OR: 0.28; 95% CI: 0.10, 0.74) and time constraints were associated with less adherence to ordering PFTs in smokers (OR: 0.31; 95% CI: 0.08, 0.99). CONCLUSIONS: Poor familiarity with recommendations, low self-efficacy, and time constraints are important barriers to adherence to COPD guidelines. This information can be used to develop tailored interventions to improve guideline adherence.

Survival and risk of adverse events in older patients receiving postoperative adjuvant chemotherapy for resected stages II-IIIA lung cancer: observational cohort study.

OBJECTIVE: To compare the survival and risk of serious adverse events in older patients with stages II-IIIA non-small cell lung cancer treated with or without postoperative platinum based chemotherapy. DESIGN: Observational cohort study. SETTING: Cases of lung cancer in Surveillance Epidemiology and End Results registry linked to Medicare files, 1992-2005, and follow-up data to December 2007. PARTICIPANTS: 3324 patients aged more than 65 years with resected stages II-IIIA lung cancer. MAIN OUTCOME MEASURES: Primary outcome was overall survival and secondary outcome was the rate of serious adverse events among older patients treated with or without adjuvant chemotherapy. RESULTS: Overall, 21% (n = 684) of patients received platinum based chemotherapy. Analyses adjusted, stratified, or matched by propensity scores showed that chemotherapy was associated with improved survival (hazard ratio range 0.78-0.81). The beneficial effect of chemotherapy was also observed among patients treated with radiation therapy (0.75-0.77) or without radiation therapy (0.74-0.77); however, chemotherapy was not beneficial for patients aged 80 or more (1.32-1.46). Adjuvant chemotherapy was associated with an increased odds of serious adverse events (odds ratio 2.0, 95% confidence interval 1.5 to 2.6). CONCLUSIONS: Platinum based adjuvant chemotherapy is associated with reduced mortality and increased risk of serious adverse events in older patients with stages II-IIIA lung cancer. The magnitude of the benefit is similar to that observed in randomised controlled trials carried out among selected patients.

Inhaler device, administration technique, and adherence to inhaled corticosteroids in patients with asthma.

AIM: To compare inhaled corticosteroid (ICS) inhaler type with user technique and ICS medication adherence among adults with asthma. METHODS: We classified 270 adults into two groups by ICS device type: metered-dose inhaler (MDI) or dry powder inhaler (DPI). Inhaler technique was assessed using standardised checklists. Medication adherence was evaluated using the Medication Adherence Report Scale (MARS). Differences in inhaler technique and MARS score among patients using MDIs versus DPIs were evaluated. RESULTS: Univariate analysis showed no difference in technique scores between the groups (p=0.46), but better ICS adherence among DPI users (p=0.001). In multivariable analysis, DPI use remained significantly associated with higher rates of adherence (OR 2.2; 95% CI 1.2 to 3.8) but not with inhaler technique (-0.2; 95% CI -0.5 to 0.1) after adjusting for potential confounders. CONCLUSIONS: Type of inhaler device appears to be associated with adherence to asthma controller medications. Prospective studies are needed to elucidate further the potential effect of the type of ICS delivery device on asthma self-management.

Perennial allergen-specific immunoglobulin E levels among inner-city elderly asthmatics.

BACKGROUND: The role of allergen sensitization has been well established among children and young adults with asthma. Some studies have suggested that allergens play a less important role among older patients with asthma. However, whether older asthmatics have a lower prevalence of allergen sensitization than younger adults remains controversial. The aim of this study was to access the prevalence of sensitization to indoor allergens in older compared to younger inner-city adults with persistent asthma. METHODS: The authors used data collected as part of a cohort study of inner-city adults with persistent asthma. Sensitization to indoor allergens (specifically Dermatophagoides pteronyssinus, D. farinae, cat, mouse, Aspergillus fumigates, Alternaria, German and American cockroaches) was evaluated by specific immunoglobulin E (IgE) antibodies measured from peripheral blood. Univariate and multiple regression analyses were used to compare ratios of sensitization according to age (≤ 35, 36-59, ≥ 60 years of age). RESULTS: Of the 245 patients in the study, 19% were over the age of 60 years. Overall 73%, 61%, and 41% of patients ≤ 35, 36-59, and ≥ 60 years old, respectively were sensitized to at least one indoor allergen (p = .01). Multivariate analysis showed that patients ≥ 60 years of age were significantly less likely to be sensitized (odds ratio 0.32, 95% confidence interval 0.11 to 0.89) compared to younger adults after controlling for potential confounders. CONCLUSIONS: Allergen sensitization is less common in older patients with persistent asthma. However, sensitization to any indoor allergen is relatively frequent in the elderly. Physicians should consider routinely accessing exposure and sensitization to these allergens as part of the evaluation of older inner-city patients with persistent asthma.

Use of herbal remedies and adherence to inhaled corticosteroids among inner-city asthmatic patients.

BACKGROUND: Complementary and alternative medicines (CAM), such as herbal remedies, are widely used by patients with chronic diseases, such as asthma. However, it is unclear whether use of the herbal remedies is associated with decreased adherence to inhaled corticosteroids (ICSs), a key component of asthma management. OBJECTIVE: To examine the association among use of herbal remedies, adherence to prescribed ICSs, and medication and disease beliefs. METHODS: We surveyed 326 adults with persistent asthma who received care at 2 inner-city outpatient clinics. Patients were asked about CAM use (teas, herbs, and rubs) for the treatment of asthma in the prior 6 months. Medication adherence was assessed using the Medication Adherence Report Scale, a validated self-report measure. Univariate and multiple regression analyses were used to assess the relationship among herbal remedy use, adherence to ICSs, and medication and disease beliefs. RESULTS: Overall, 25.4% (95% confidence interval, 20%-30%) of patients reported herbal remedy use. Univariate analyses showed that herbal remedy use was associated with decreased ICS adherence and increased asthma morbidity. In multivariable analysis, herbal remedy use was associated with lower ICS adherence (odds ratio, 0.4; 95% confidence interval, 0.2-0.8) after adjusting for confounders. Herbal remedy users were also more likely to worry about the adverse effects of ICSs (P = .01). CONCLUSIONS: The use of herbal remedies was associated with lower adherence to ICSs and worse outcomes among inner-city asthmatic patients. Medication beliefs, such as worry about ICS adverse effects, may in part mediate this relationship. Physicians should routinely ask patients with asthma about CAM use, especially those whose asthma is poorly controlled.