Intervention Removes Black-White Gaps in Survival From Early Stage Breast, Lung Cancer

A new study shows that system-level changes to the way cancer care is delivered can also eliminate Black-White disparities in survival from early stage lung and breast cancer. By identifying and addressing obstacles that kept patients from finishing radiation treatments for cancer, the intervention improved five-year survival rates for all patients and erased the survival gap between Black and White patients. Findings were presented October 25 at the American Society for Radiation Oncology (ASTRO) Annual Meeting in Chicago.

The Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) clinical trial is the first prospective study designed to erase gaps in cancer treatment completion and survival among Black and White patient populations. "Thousands of studies have looked at racial disparities in health care, but until recently, very few studies have implemented interventions to eliminate those disparities," said lead author Matthew A. Manning, MD, a radiation oncologist and Chief of Oncology at Cone Health in Greensboro, North Carolina. "This study shows that it can be done."

The ACCURE approach involved multiple changes to the way patients were supported while receiving cancer treatment. The process had four components: (1) an electronic health record with automatic alerts to flag missed appointments or unmet milestones in expected care; (2) a nurse navigator trained in race-specific barriers to help patients overcome obstacles to care when alerts are flagged; (3) a physician champion, to engage health care teams with race-related feedback on treatment completion; and (4) regular health equity education training sessions for staff.

Previously published results showed the ACCURE intervention greatly reduced disparities in treatment completion rates for Black and White patients receiving curative radiation therapy or surgery for early-stage breast or lung cancer. In the new study, researchers examined whether the increased completion rates led to improved outcomes, with specific attention to whether the intervention reduced racial disparities in cancer survival. They compared five-year survival rates for 1,413 patients with stages 0, I and II lung and breast cancer who were treated after the intervention began with 2,016 patients treated prior to the system changes.

Prior to the intervention, the five-year survival rate for Black patients with breast cancer was 89%, compared to 91% for White patients. After the system-level changes were initiated, five-year survival rates for both groups rose to 94%. Among those treated for early-stage lung cancer, survival rates increased from 37% to 54% for Black patients and from 43% to 56% for White patients.

"Historically, Black and White patients had different survival rates after treatment, but that difference disappeared," said Dr. Manning. "We are now able to say that this intervention eliminated disparities in overall survival."

Black people face the highest cancer death rate and shortest cancer survival rate of any racial/ethnic group in the U.S. According to the American Cancer Society, Black populations also encounter "greater obstacles to cancer prevention, detection, treatment and survival." By identifying and addressing the specific obstacles facing their patient populations—like limited access to transportation or difficulty taking time off work without penalty—and intentionally examining how obstacles varied by race, the ACCURE team was able to curb the negative impact of these barriers, said Dr. Manning.

"The bottom line is, unless we ask what happens when an appointment or milestone is missed, we just don't know what's going on, and the patient may never come back to us. If we do ask, we often have systems in place that can address those barriers. We can provide transportation or provide a letter for the patient for work. We can overcome many barriers, both internal and external to our health care institutions, but only if we know what they are."

Dr. Manning's hospital previously led a pilot study that found providing a free rideshare program to transport patients to radiation therapy sessions reduced no-show rates among vulnerable populations.

An emphasis on structural, institutional change rather than individual change to combat disparities was key to the ACCURE trial's success, said Samuel Cykert, MD, professor of medicine at the University of North Carolina School of Medicine and principal investigator for the trial. "The onus for change is on the system, not the individual patient. People can't help it if they miss a treatment day because they have a child to take care of, for example. The intervention also flags delays in care within the health system itself that occur even when patients don't miss appointments."

"The clinic can provide safety nets by instituting a method to flag these obstacles and delays, and by having steps in place to help the patient return to and complete treatment. That made all the difference with this trial," said Dr. Cykert.

Investigators took direction from the foundational work of the Greensboro Health Disparities Collaborative – a longstanding, community-initiated partnership between medical, academic and community representatives – when designing the intervention, said Christina Yongue, MPH, MCHES, an assistant professor of public health education at the University of North Carolina at Greensboro and project manager for the ACCURE trial.

"The main concepts driving ACCURE – transparency, accountability and enhanced communication – came out of this collaborative and workshops on racial equity that were required for providers and staff," said Ms. Yongue. "These pillars were essential to building trust with our research participants, especially with Black patients who are historically marginalized in health care. The clinical results would not have been possible without this trust."

Moving forward, the ACCURE team is considering other applications for the intervention, such as addressing disparities in pregnancy/maternal care. "We've shown it's possible to eliminate disparities in cancer treatment completion and that this change has the potential to close cancer survival gaps downstream," said Dr. Manning. "But we think the application can be much broader."

ACCURE is an NIH-funded, five-year collaboration between the University of North Carolina at Chapel Hill (UNC), The Partnership Project, Inc., Cone Health and the University of Pittsburgh Medical Center (UPMC).

Abstract 53, American Society for Radiation Oncology (ASTRO) 2021 Annual Meeting

Overall Survival from a Prospective Multi-Institutional Trial to Resolve Black- White Disparities in the Treatment of Early Stage Breast and Lung Cancer

Manning1, C. Yongue2, A. Garikipati3, S. Cykert4, E. Eng4, J. Schaal5, A. Lightfoot6, N. Jones5, and L. Robertson7; 1Cone Health Cancer Center, Greensboro, NC, 2UNCG, Greensboro, NC, 3Duke University, Durham, NC, 4University of North Carolina, Chapel Hill, NC, 5The Partnership Project, Greensboro, NC, 6UNC Health, Chapel Hill, NC, 7UPMC Hillman Cancer Center, Pittsburgh, PA

Purpose/Objective(s): Black patients with curable lung or breast cancer complete treatment less often than similar White patients contributing to worse survival. ACCURE was a system-based intervention trial shown to eliminate black- White disparities in treatment completion and improved completion for all. The current study investigates how the ACCURE intervention influenced survival disparity.

Materials/Methods: We previously reported a prospective multi-institutional trial using a system-based intervention. Patients diagnosed with early-stage breast and lung cancer, aged 18 to 85 were eligible. Enrollment spanned from 2013 until 2015. Intervention components included: (1) a real time warning system derived from electronic health records, (2) feedback to clinical teams on cancer treatment according to race, and (3) a nurse navigator. Consented patients were compared to retrospective and concurrent controls. The primary study outcome was receipt of curative treatment. The current study compares 5-year survival according to race for eligible patients from the tumor registry during the study period with comparison to historical controls. The ACCURE study treatment for early stage lung cancer included resection or stereotactic body radiotherapy (SBRT) and survivals are now reported separately.

Results: 1,413 patients with stages 0, I & II lung and breast cancer diagnosed in 2013-2015 were compared to 2,016 treated in 2007-2011. The table shows statistically significant improved survival for black and White breast cancer patients and White lung cancer patients over time, while the racial gap in survival was reduced for lung and breast cancer. The 5-year observed survivals for White (2150) versus

Black (644) breast patients increased from 91% vs. 89% (p=NS) to 94% for both. The 5-year observed survival for White (510) and black (125) lung narrowed from 43% and 37% (p=NS) to 56% and 54%. Subgroup analysis of lung cancer patients showed 5 year survival for surgery was 78.5% and 70.1% for White and black patients (p=NS) while survival for SBRT was 41.9% and 50% for White and black patients (p=NS).

Conclusion: A systems-based intervention reduced racial gaps in treatment completion and improved care for all. This study suggests that equity in treatment may be associated with elimination of survival disparities during the ACCURE study. In the lung cancer sub-group, the higher survival of White lung cancer patients undergoing surgery and black patients undergoing SBRT may suggest some continued disparity in patient selection for lung resection. Further analysis of comorbid conditions and other important factors will shed light on the full survival impact of the intervention.