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November 2016 VOL 7, NO 10
Closing the Racial Divide for Curative Lung Cancer
Racial inequality in healthcare is a long-standing problem that has been studied for decades. The Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) trial, one of the first prospective trials to address racial disparities in access to care, shows that it is possible to improve access to potentially curative care for African American (AA) patients so that they are on a level playing field with white patients. In this multi-institutional trial sponsored by the National Institutes of Health, the ACCURE intervention improved curative treatment rates for uptake of surgical resection and stereotactic body radiation therapy (SBRT) to 96% for both AA and white patients with early-stage lung cancer. Specially trained nurse navigators were essential to the success of this intervention.
“We saw that the ACCURE intervention—an evidence-based strategic intervention—essentially eliminated racial disparity while improving rates of treatment completion for all races,” said Matthew A. Manning, MD, radiation oncologist at Cone Health Cancer Center in Greensboro, NC, in a presentation at the 2016 Annual Meeting of the American Society for Radiation Oncology. “The results also showed a spillover effect of ACCURE at all participating cancer centers,” he added, meaning that patients not enrolled in the trial may have benefited from staff training and educational sessions cultivating racial sensitivity.
The ACCURE intervention consists of multiple layers of patient support, including an electronic health record system that alerts clinicians and nurse navigators when a patient misses an appointment or other important milestones in care, such as a biopsy or scan. The staff then contacts the patient to help overcome barriers, for example, the need for a ride or not being available on the day of the appointment due to family factors, Dr Manning explained.
ACCURE utilizes nurse navigators trained about race-related barriers to care, with special training regarding trust and culturally appropriate communication.
The healthcare team is given race-specific feedback on patients’ perceptions of care derived from community-based research. The feedback is given in quarterly focus groups offered by Healthcare Equity Education and Training.
The intervention group (ACCURE) included 100 patients with stage I or II lung cancer enrolled in the trial between 2013 and 2015, 25% of whom were AA, compared with 13% in the local population. The primary outcome was rates of receiving surgical resection or SBRT within 4 months of diagnosis.
Baseline data were derived from 2044 patients treated at the cancer center from 2007 to 2011. The control group included 393 patients treated between 2014 and 2015 during the study to assess a spillover effect.
In the baseline group, 64% of AA patients and 76% of white patients received both resection and SBRT between 2007 and 2011. By contrast, in the ACCURE intervention group, 96% of both racial groups received this potentially curative treatment. Rates of treatment also rose in controls: 85% of AA patients and 87% of white patients received both surgery and SBRT from 2014 to 2015.
“Surgical resection was the vehicle of improvement within the ACCURE intervention cohort,” Dr Manning said.
Resection alone was received by 55% of AA patients and 61% of white patients in the baseline group, compared with 80% and 79%, respectively, in the ACCURE group and 57% and 55%, respectively, in controls.
Age and disease stage had an impact on treatment rates for both surgical resection and SBRT, but comorbidity affected surgical resection only. Patients younger than 70 years and those with earlier-stage disease were significantly more likely to receive either treatment (P <.05 for both comparisons). Patients with higher comorbidity scores were significantly less likely to receive surgery (P <.05).
“This study suggests that health systems can eliminate racial disparity with systems change through engagement with community organizations,” Dr Manning said. He explained that ACCURE was “the brainchild of community organizations that provided antiracism workshops and developed tools for institutions.”
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