Safety-Net Burden and Likelihood of Curative-Intent Surgery for Non-Small Cell Lung Cancer

Background: Black patients are less likely to undergo surgery for early-stage non-small cell lung cancer (NSCLC) compared to whites and are more likely to undergo resection at low-volume hospitals. However, little is known about the relationship between hospital safety-net burden and the likelihood of curative-intent surgery for blacks and whites. This study analyzes whether hospital safety-net burden is associated with curative-intent surgery among all adult early-stage NSCLC patients treated at American College of Surgeons (ACoS) Commission on Cancer (CoC) accredited facilities. Study Design: Adult patients diagnosed with invasive initial primary early-stage (TNM I-II) NSCLC during 2003-2005 were selected from the National Cancer Data Base (NCDB). Curative-intent surgery was defined as anatomic resection. Hospital safety-net burden was defined as the percent of cancer patients per facility that were Medicaid-insured or uninsured. Generalized estimating equations and linear mixed models were used to control for clustering by facility. Results: Of 52,853 evaluable patients, patients treated at high safety-net burden facilities were significantly less likely (p < .0001) to undergo curative-intent surgery than patients treated at low safety-net burden facilities (57.2% and 66.0%, respectively). Controlling for patient and other facility characteristics, high safety-net burden remained significantly associated (p < .0001) with reduced likelihood of curative-intent surgery overall (OR=0.72, C.I. 0.65–0.79), and in black- and white-only models (OR=0.64, C.I. 0.52–0.77; OR = 0.74, C.I. 0.67–0.82, respectively). Conclusions: Both black and white adult patients treated for early-stage NSCLC at high safety-net burden facilities are less likely to undergo curative-intent surgery than those treated at low safety-net burden facilities. Innovative solutions are needed to ensure quality cancer care at high safety-net burden facilities.