Expert Assesses Challenges of Disparity in Lung Cancer

Loretta Erhunmwunsee, MD

With a rapidly evolving treatment paradigm such as non—small cell lung cancer, it is imperative that researchers and clinicians appropriately treat patients on an individualized basis—especially those who are considered to have racial and socioeconomic disparities.

Such patients are known to not only have differing prognostic factors and survival outcomes, but are also likely to respond differently to therapeutic modalities—whether they are systemic, surgical, or radiation based.

“As we push the envelope to make care for patients with lung cancer better, we need to also understand that we have to work hard to allow vulnerable patients to not be left behind,” explained Loretta Erhunmwunsee, MD.

OncLive: What are the disparities in lung cancer that you presented on?

What drives these disparities?

During the 2017 OncLive^® State of the Science Summit^TM on Advanced Non—Small Cell Lung Cancer, Erhunmwunsee, a thoracic surgeon and assistant professor of surgery at City of Hope, lectured on the racial and socioeconomic disparities in lung cancer trials. In an interview during the meeting, she detailed more of these differences, what drives them, and how personalized medicine impacts some of these patient populations.Erhunmwunsee: I reviewed the fact that there are racial and socioeconomic status disparities as it relates to every type of treatment, whether it be surgery, chemotherapy, or radiation therapy. We also discussed the fact that there are these same disparities in clinical trial participation. The reason this is important is that we sort of move the envelope toward more personalized medicine with checkpoint inhibition and other molecular strategies. It’s important to understand that our trials are underrepresented by certain groups; some of these groups are the most vulnerable.What is so interesting is that it’s multifactorial; there are so many different things that impact the fact that race and socioeconomic status are important. There are genomic and genetic differences, right? One of the slides [I presented] showed that EGFR mutations might be very different in African-American men than in Asian men. A MET mutation is certainly different.

The point is that genetic and genomic differences impact those racial and socioeconomic status differences—as does access and tobacco use—so there are a lot of things that impact some of the differences we see. However, I focused on the treatment differences.

Personalized medicine is extremely important. How does that impact these populations?

What advice can you give to community oncologists to better reach these disadvantaged patients?

Certain groups and, especially, disadvantaged groups, are less likely to get treatment; they are also the same folks who are less likely to survive.What is so awesome is that, when I started training, advanced lung cancer meant [likely] death. There was very little to offer, and now because of molecular strategies and these genetic and genomic differences, it is so different. Personalized medicine is, in essence, finding out which mutations a particular tumor has and treating it with medication that specifically targets that. We have just found that it is changing the paradigm; it is changing the way we see lung cancer, especially advanced lung cancer. In some patients, advanced lung cancer is almost like a chronic disease. You can see long-term survival [in some patients], and that is because of this new wave.As a person who is very interested and passionate about making sure that every patient gets good care, I would say to my fellow clinicians that we need to understand that certain groups are less likely to do well and certain groups are less likely to get treatment. Certain groups are more likely to have higher [rates of] mortality, and it is important for us to understand who those groups are and that they need more support.

If you see someone who has less education or has low income, they might be the person that you want to connect with your social workers, or you might want to [treat] them in a multidisciplinary fashion. The truth is, they have more hurdles to get over. It is part of our responsibility to understand that if you know a patient has more risk factors for death, you will acknowledge those risk factors.

In your lecture, you discussed “the Hispanic paradox.” Can you elaborate?

Sometimes, as clinicians, we forget low socioeconomic status within lung cancer; being an African-American male means that their survival is decreased. Even Hispanic patients are also less likely to get treatment. The point is, simply, our medical oncologists, surgical oncologists, and radiation oncologists need to understand that different patients have different hurdles.I love talking about that because it is so interesting, and it exposes the fact that we know so little. Here's the truth: there are risk factors and Hispanics are less likely to get treatment. They are more likely to have advanced stage lung cancer and they have higher rates of being disadvantaged. Those 3 things are powerful risk factors for poor health and poor survival.

However, lung cancer in Hispanic patients doesn’t reflect that. To me, that is just so interesting because it shows us that we don’t know everything. There certainly have been studies to try to understand “the Hispanic paradox” and some of the things that have come out. Hispanic patients smoke differently; there are lower rates of smoking in most Hispanic groups. Cubans smoke more than Mexicans, but Cubans have a much higher rate of lung cancer and mortality from lung cancer than Mexican because of that.

It is about the genetic differences, as well. Hispanic and Latino patients have a profile that appears to be more favorable. There have been some data that suggest that they frequently have adenocarcinoma and, sometimes, high rates of minimally invasive adenocarcinoma; we know that histology leads to longer survival. Also, I don’t know if this is as clear, but in many cohorts that have looked at Hispanic and Latino patients, many of those with lung cancer have been women—which is very different than in African Americans, Caucasian Americans, and other groups. We know that women live longer. When you have all of that [information], that at least, in part, explains the paradox.