Where Access Breaks Down: Uncovering Persistent Disparities in Early-Stage Lung Cancer Treatment

Olivia Lynch, MD, MPH: My name is Olivia Lynch. I’m a postdoctoral research fellow in the National Clinician Scholars Program at Yale University, and I’m also a general surgery resident at Brigham and Women’s Hospital. My research focuses on disparities in surgical and cancer care, particularly those related to race, socioeconomic status, and language barriers. Broadly, I’m interested in understanding how patients move through the health care system and identifying where inequities arise in access to high-quality care.

Please share a brief overview of your research and key findings.

Dr Lynch: In this study, we examined treatment patterns among more than 28 000 Medicare beneficiaries with NSCLC using SEER–Medicare data from 2005 through 2019. Early-stage lung cancer is potentially curable, typically with surgery or radiation therapy. Overall, we found that about 82% of patients received curative treatment, but significant racial disparities persisted. Even after adjusting for factors like age, comorbidities, and frailty, Black patients were consistently about 8 to 9 percentage points less likely than White patients to receive curative therapy, and this gap remained stable across the time periods we studied. Importantly, these differences were primarily driven by disparities in surgery. Despite major advances in lung cancer treatment over the past 2 decades, the overall disparity in access to curative care has changed very little since it was first documented in the 1990s. Taken together, the findings suggest that structural barriers in the health care system continue to affect access to potentially life-saving treatment.

From a clinical pathways perspective, at what point in the care continuum do you think disparities in early-stage NSCLC treatment most often emerge—initial evaluation, surgical candidacy assessment, referral patterns, or treatment decision-making?

Dr Lynch: Our findings suggest that disparities likely emerge earlier in the care pathway, before patients even reach definitive treatment. Interestingly, among patients who underwent surgery, we did not observe racial differences in the likelihood of receiving the preferred surgical procedure, such as lobectomy. That suggests the gap may occur before patients get to the operating room, potentially during stages like referral to thoracic surgeons, evaluation at specialized cancer centers, or the process of determining surgical candidacy. In other words, the disparity may not be primarily about the treatment choice itself, but rather whether patients are able to access the specialists and systems that deliver those treatments.

Beyond patient comorbidity, what systemic factors—such as surgeon availability, institutional resources, or implicit bias—may be influencing surgical access?

Dr Lynch: As a surgery resident, surgical access is a topic I care about deeply. If we’ve developed a life-saving surgical procedure but it’s not accessible to the patients who need it, then our job isn’t done. Unfortunately, as we see in our study, disparities in access to surgery persist—even for procedures that have been standard of care for decades. This is likely multifactorial. Studies have shown that in areas with fewer surgeons, people receive less surgery overall, suggesting that workforce distribution and access to specialists may play a role. In addition, surgery—like many areas of medicine—has become increasingly specialized, which may further narrow the pool of surgeons performing complex thoracic procedures. Implicit bias is also an important factor to consider. Undergoing major surgery is physically demanding, and not every patient has the physiologic reserve to tolerate it — there are certainly valid patient-level factors we cannot capture in administrative data, such as social support, transportation access, or functional capacity, which may affect surgical candidacy. At the same time, unconscious bias in clinical decision-making may also influence which patients are ultimately offered surgery, and that’s an area that deserves continued attention.

You observed that disparities in Stereotactic Body Radiation Therapy (SBRT) use were most pronounced during its early adoption but narrowed over time. What does this tell us about how innovative therapies are integrated into practice, and how can pathway-driven implementation reduce inequities when new standards of care emerge?

Dr Lynch: During the early adoption of SBRT, we observed significant racial disparities in its use that improved over time. This suggests that when new and innovative treatments are first introduced, they may not initially reach all patient populations equally. As technology becomes more widely adopted and incorporated into clinical guidelines, access tends to become more equitable. Similar patterns have been observed with other medical innovations - in cancer and elsewhere. Disparities during early adoption likely operate at multiple levels, including which hospitals have access to new technology, provider awareness and training, implicit bias, and patient-level barriers. Standardizing care through evidence-based clinical pathways is certainly a strategy that may help reduce these inequities, as long as those pathways remain flexible, integrated into clinical workflows, and able to adapt quickly as new treatments emerge.

For oncology programs seeking to operationalize equity, what specific metrics should be tracked to detect and address disparities in real time?

Dr Lynch: Health systems seeking to operationalize equity should track metrics across the entire care pathway, not just final treatment decisions or clinical outcomes. Important metrics may include rates of referral to thoracic surgery and radiation oncology, time from diagnosis to evaluation by a specialist, time to treatment initiation, receipt of guideline-concordant curative treatment, and treatment modality by patient population. Stratifying these metrics by factors such as race, socioeconomic status, insurance type, and geography could help centers identify specific disparities early and intervene. Ultimately, improving equity will require real-time monitoring of treatment pathways so health systems can detect and address disparities as they emerge.