Annals of Surgical Oncology

, Volume 19, Issue 3, pp 722–727 | Cite as

Race and Health Disparities in Patient Refusal of Surgery for Early-Stage Non-Small Cell Lung Cancer: A SEER Cohort Study

  • Rohtesh S. Mehta
  • Diana Lenzner
  • Athanassios Argiris
Healthcare Policy and Outcomes



Several factors, including race, age, stage, comorbid conditions, social support, and socioeconomic status, have been linked to the likelihood of a patient having surgery for early-stage non-small cell lung cancer (NSCLC). The aim of the present study is to determine the influence of race and health disparities on refusal of recommended potentially curative surgery.


The Surveillance, Epidemiology, and End Results (SEER) database was used to create a cohort of 62,514 patients diagnosed with stages I and II NSCLC between 1988 and 2002, of whom 51,938 were recommended for surgery. The outcome variable was refusal of recommended surgical treatment, while race was the key predictor variable. Potential confounders were adjusted for in the hierarchical generalized logistic regression analysis.


A majority was White (86%) and underwent surgery (81%). About 2% of Blacks (n = 109), 1.4% of Whites (n = 756), and 2.8% of “other” race individuals (n = 96) refused surgery. In the multivariable adjusted model, Blacks [odds ratio (OR) 1.95, 95% confidence interval (CI) 1.5, 2.3, P < 0.001] and those of “other” race (OR 2.03, 95% CI 1.5, 2.5, P < 0.001) had greater odds of refusing surgery than did Whites. Increasing age, male gender (OR 1.17, P = 0.031), and being unmarried (OR 2.1, P < 0.001) were other factors associated with higher odds of refusal. Significant county variations were also noted in refusal of surgery.


Blacks and “other” races are more likely to refuse recommended surgery for early-stage NSCLC compared with Whites. Future studies should focus on exploring potential reasons for refusal and developing communication interventions.


  1. 1.
    CDC Data & Statistics | Feature: Top 10 cancers among men. Accessed 3 Jan 2011.
  2. 2.
    CDC Data & Statistics | Feature: Top 10 cancers among women. Accessed 3 Jan 2011.
  3. 3.
    Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: Burdens upon an aging, changing nation. J Clin Oncol. 2009;27:2758–65.PubMedCrossRefGoogle Scholar
  4. 4.
    Surveillance, Epidemiology, and End Results (SEER) Program ( SEER*Stat database: Incidence—SEER 17 regs research data + hurricane Katrina impacted Louisiana cases, Nov 2009 sub (1973–2007 varying)—linked to county attributes—total U.S., 1969–2007 counties, national cancer institute, DCCPS, surveillance research program, cancer statistics branch, released April 2010, based on the November 2009 submission.
  5. 5.
    SEER Data, 1973–2007. Accessed 4 Jan 2011.
  6. 6.
    Farjah F, Wood DE, Yanez ND III, et al. Racial disparities among patients with lung cancer who were recommended operative therapy. Arch Surg. 2009;144:14–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Bach PB, Cramer LD, Warren JL, Begg CB. Racial differences in the treatment of early-stage lung cancer. N Engl J Med. 1999;341:1198–205.PubMedCrossRefGoogle Scholar
  8. 8.
    Hardy D, Liu CC, Xia R, et al. Racial disparities and treatment trends in a large cohort of elderly black and white patients with nonsmall cell lung cancer. Cancer. 2009;115:2199–211.PubMedCrossRefGoogle Scholar
  9. 9.
    Hardy D, Xia R, Liu CC, Cormier JN, Nurgalieva Z, Du XL. Racial disparities and survival for nonsmall-cell lung cancer in a large cohort of black and white elderly patients. Cancer. 2009;115:4807–18.PubMedCrossRefGoogle Scholar
  10. 10.
    Tammemagi CM, Neslund-Dudas C, Simoff M, Kvale P. In lung cancer patients, age, race-ethnicity, gender and smoking predict adverse comorbidity, which in turn predicts treatment and survival. J Clin Epidemiol. 2004;57:597–609.PubMedCrossRefGoogle Scholar
  11. 11.
    Smith CB, Bonomi M, Packer S, Wisnivesky JP. Disparities in lung cancer stage, treatment and survival among American Indians and Alaskan Natives. Lung Cancer. 2010;72:160–4.Google Scholar
  12. 12.
    Yang R, Cheung MC, Byrne MM, et al. Do racial or socioeconomic disparities exist in lung cancer treatment? Cancer. 2010;116:2437–47.PubMedGoogle Scholar
  13. 13.
    Du XL, Lin CC, Johnson NJ, Altekruse S. Effects of individual-level socioeconomic factors on racial disparities in cancer treatment and survival: findings from the national longitudinal mortality study, 1979–2003. Cancer. 2011;117:3242–51.Google Scholar
  14. 14.
    Blackstock AW, Herndon JE II, Paskett ED, et al. Outcomes among African-American/non-African-American patients with advanced non-small-cell lung carcinoma: report from the cancer and leukemia group B. J Natl Cancer Inst. 2002;94:284–90.PubMedCrossRefGoogle Scholar
  15. 15.
    Blackstock AW, Herndon JE II, Paskett ED, et al. Similar outcomes between African American and non-African American patients with extensive-stage small-cell lung carcinoma: report from the cancer and leukemia group B. J Clin Oncol. 2006;24:407–12.PubMedCrossRefGoogle Scholar
  16. 16.
    Smith TJ, Penberthy L, Desch CE, et al. Differences in initial treatment patterns and outcomes of lung cancer in the elderly. Lung Cancer. 1995;13:235–52.PubMedCrossRefGoogle Scholar
  17. 17.
    Cykert S, Dilworth-Anderson P, Monroe MH, et al. Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer. JAMA. 2010;303:2368–76.PubMedCrossRefGoogle Scholar
  18. 18.
    McCann J, Artinian V, Duhaime L, Lewis JW,Jr, Kvale PA, DiGiovine B. Evaluation of the causes for racial disparity in surgical treatment of early stage lung cancer. Chest. 2005;128:3440–6.PubMedCrossRefGoogle Scholar
  19. 19.
    About the SEER Program—SEER. Accessed 4 Jan 2011.
  20. 20.
    SEER*Stat Software. Accessed 4 Jan 2011.
  21. 21.
    Rural-Urban Continuum Code—SEER Datasets. Accessed 2 Feb 2011.
  22. 22.
    SAS Institute Inc. SAS 9.1.3 Help and Documentation. SAS Institute Inc., Cary, NC; 2000–2004.Google Scholar
  23. 23.
    Musa D, Schulz R, Harris R, Silverman M, Thomas SB. Trust in the health care system and the use of preventive health services by older black and white adults. Am J Public Health. 2009;99:1293–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Kennedy BR, Mathis CC, Woods AK. African Americans and their distrust of the health care system: healthcare for diverse populations. J Cult Divers. 2007;14:56–60.PubMedGoogle Scholar
  25. 25.
    Margolis ML, Christie JD, Silvestri GA, Kaiser L, Santiago S, Hansen-Flaschen J. Racial differences pertaining to a belief about lung cancer surgery: results of a multicenter survey. Ann Intern Med. 2003;139:558–63.PubMedGoogle Scholar
  26. 26.
    Gansler T, Henley SJ, Stein K, Nehl EJ, Smigal C, Slaughter E. Sociodemographic determinants of cancer treatment health literacy. Cancer. 2005;104:653–60.PubMedCrossRefGoogle Scholar
  27. 27.
    Cykert S, Phifer N. Surgical decisions for early stage, non-small cell lung cancer: which racially sensitive perceptions of cancer are likely to explain racial variation in surgery? Med Decis Making. 2003;23:167–76.PubMedCrossRefGoogle Scholar
  28. 28.
    Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient–physician relationship. JAMA. 1999;282:583–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Morse DS, Edwardsen EA, Gordon HS. Missed opportunities for interval empathy in lung cancer communication. Arch Intern Med. 2008;168:1853–58.PubMedCrossRefGoogle Scholar
  30. 30.
    Passik SD, Dugan W, McDonald MV, Rosenfeld B, Theobald DE, Edgerton S. Oncologists’ recognition of depression in their patients with cancer. J Clin Oncol. 1998;16:1594–600.PubMedGoogle Scholar
  31. 31.
    Gabrijel S, Grize L, Helfenstein E, et al. Receiving the diagnosis of lung cancer: Patient recall of information and satisfaction with physician communication. J Clin Oncol. 2008;26:297–302.PubMedCrossRefGoogle Scholar
  32. 32.
    Oncotalk. Improving oncologists’ communication skills. Accessed 23 Mar 2011.

Copyright information

© Society of Surgical Oncology 2011

Authors and Affiliations

  • Rohtesh S. Mehta
    • 1
  • Diana Lenzner
    • 2
  • Athanassios Argiris
    • 3
  1. 1.Division of General Internal Medicine, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghUSA
  2. 2.Biostatistics FacilityUniversity of Pittsburgh Cancer InstitutePittsburghUSA
  3. 3.Division of Hematology/Oncology, Department of Medicine, and Cancer Therapy & Research CenterUniversity of Texas Health Science CenterSan AntonioUSA

Personalised recommendations