The impact of race on the association between structural racism and the quality of non-small cell lung cancer (NSCLC).

Abstract

1598 Background: Structural racism encompasses multiple intricate systems that generate and reinforce inequities amongst minoritized communities. Given the complexities associated with measuring structural racism, we sought to evaluate the relationship between structural racism and racial inequities amongst Black and White patients with NSCLC using an established structural racism index. Methods: We conducted a retrospective analysis using Surveillance, Epidemiology, and End Results -Medicare data. Outcomes were: localized stage at diagnosis, stage appropriate evaluation and treatment, and 2-year survival. We used the County Structural Racism (CSR) index, which assesses racial inequity within counties across various domains including criminal justice, education, employment, housing, and health care. We categorized counties into quintiles of the CSR index and estimated multivariable mixed effects logistic regression models to determine the adjusted association between structural racism and each outcome. We included interaction terms between patient race (Black versus White) and CSR to determine whether structural racism moderates the association between patient race and outcomes. We used the results of the regression models to calculate the adjusted predicted probabilities of each outcome across strata of patient race and CSR quintile. Results: The cohort included 54,344 individuals (10.3% Black, 89.7% White) diagnosed with NSCLC from 2013-2019. When compared to White patients, Black patients were less likely to be diagnosed at a localized stage (30.9% vs 38.4%), undergo stage appropriate evaluation and treatment (20.3% vs 28.0%), and survive two years after diagnosis (29.2% vs 37.3%) (all p < 0.001). Black patients were more likely to live in counties with higher structural racism (8.2% of the population in lowest quintile vs 19.2% in highest quintile). We did not find a clear association between structural racism and our outcomes. However, we did find that patient race moderated the association between structural racism and two-year survival. Specifically, Black patients in areas in the lowest quintile of structural racism had a predicted probability of two-year survival of 28.3% (95% CI, 25.2-31.4) compared to 31.1% (95% CI, 29.8-32.4) amongst White patients, a difference of 2.8% (p = 0.08). In areas with the highest structural racism, Black patients had an even more pronounced reduction in the probability of two-year survival (27.4%, 95% CI, 24.6-30.2 vs. 37.5, 95% CI, 34.9-40.1 for White patients), resulting in a disparity of 10.1% (p < 0.001). Conclusions: Increased structural racism exacerbates the racial disparity in two-year survival experienced by Black patients with NSCLC.