Shrestha Pratibha, Liu Ying, Struthers James, Kozower Benjamin, Lian Min
Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri.
Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, Missouri.
JAMA Netw Open. 2025 Mar 3;8(3):e251061. doi: 10.1001/jamanetworkopen.2025.1061.
Data on the impact of geographic access to cancer care on early-stage non-small cell lung cancer (NSCLC) treatment and outcomes are limited.
To examine the associations of geographic access to cancer care with guideline-recommended treatment and outcomes in patients with early-stage NSCLC.
DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study included patients with early-stage NSCLC newly diagnosed between January 1, 2007, and December 31, 2015, followed up through December 31, 2016, and identified from the Surveillance, Epidemiology, and End Results dataset. Data analysis was performed from March to November 2024.
Geographic access to thoracic surgeons and radiation oncologists was quantified using the 2-step floating catchment area algorithm and categorized into quintile 1 (least access) through quintile 5 (greatest access).
Multilevel logistic regression was performed to estimate odds ratios (ORs) of receipt of surgery and radiotherapy. Hazard ratios (HRs) of lung cancer-specific mortality were estimated using Fine and Gray subdistribution hazard regression.
Among 65 259 patients, the mean (SD) age was 69.4 (10.1) years; 33 114 patients (50.7%) were female, 1071 (1.6%) were uninsured, and 7541 (11.6%) were enrolled in Medicaid. The least (vs greatest) geographic access to thoracic surgeons (HR, 1.10; 95% CI, 1.03-1.18; P < .001 for trend) and radiation oncologists (HR, 1.11; 95% CI, 1.04-1.18; P < .001 for trend) was associated with higher lung cancer mortality. Patients in counties with the least (vs greatest) access to thoracic surgeons were less likely to undergo surgery (OR, 0.80; 95% CI, 0.69-0.93; P < .001 for trend); this association was much stronger in Asian than non-Hispanic White patients and in Medicaid-insured than non-Medicaid-insured patients. Although there was no significant association overall, geographic access to radiation oncologists was significantly associated with radiotherapy use in older (OR, 0.85; 95% CI, 0.76-0.95), Hispanic (OR, 0.65; 95% CI, 0.49-0.86), and uninsured (OR, 0.63; 95% CI, 0.43-0.94) patients.
In this cohort study, geographic access to cancer care was associated with guideline-recommended treatment for early-stage NSCLC and outcomes, particularly in socially marginalized patients, underscoring the importance of ensuring appropriate geographic allocations of cancer care resources and addressing travel barriers to health care to improve NSCLC treatment, prognosis, and equity.
关于获得癌症治疗的地理途径对早期非小细胞肺癌（NSCLC）治疗及预后影响的数据有限。
探讨早期NSCLC患者获得癌症治疗的地理途径与指南推荐治疗及预后之间的关联。
设计、设置和参与者：这项基于人群的队列研究纳入了2007年1月1日至2015年12月31日新诊断的早期NSCLC患者，并随访至2016年12月31日，数据来自监测、流行病学和最终结果数据集。数据分析于2024年3月至11月进行。
使用两步浮动集水区算法对获得胸外科医生和放射肿瘤学家治疗的地理途径进行量化，并分为五分位数1（获得途径最少）至五分位数5（获得途径最多）。
采用多水平逻辑回归估计接受手术和放疗的比值比（OR）。使用Fine和Gray亚分布风险回归估计肺癌特异性死亡率的风险比（HR）。
在65259例患者中，平均（标准差）年龄为69.4（10.1）岁；33114例患者（50.7%）为女性，1071例（1.6%）未参保，7541例（11.6%）参加了医疗补助计划。获得胸外科医生治疗的地理途径最少（与最多相比）（HR，1.10；95%CI，1.03 - 1.18；趋势P < 0.001）和获得放射肿瘤学家治疗的地理途径最少（与最多相比）（HR，1.11；95%CI，1.04 - 1.18；趋势P < 0.001）与较高的肺癌死亡率相关。获得胸外科医生治疗途径最少（与最多相比）的县的患者接受手术的可能性较小（OR，0.80；95%CI，0.69 - 0.93；趋势P < 0.001）；这种关联在亚裔患者中比非西班牙裔白人患者更强，在参加医疗补助计划的患者中比未参加医疗补助计划的患者更强。尽管总体上没有显著关联，但获得放射肿瘤学家治疗的地理途径与年龄较大（OR，0.85；95%CI，0.76 - 0.95）、西班牙裔（OR，0.65；95%CI，0.49 - 0.86）和未参保（OR，0.63；95%CI，0.43 - 0.94）患者的放疗使用显著相关。
在这项队列研究中，获得癌症治疗的地理途径与早期NSCLC的指南推荐治疗及预后相关，特别是在社会边缘化患者中，这突出了确保癌症治疗资源进行适当地理分配以及解决医疗保健出行障碍以改善NSCLC治疗、预后和公平性的重要性。
