Tomi Akinyemiju, PhD smiles in front of a mural
Tomi Akinyemiju, PhD

STUDY: Lower Area-Level Income and Education Linked to Greater Likelihood of Advanced Lung Cancer Diagnosis

PRESS RELEASE by WILEY, Cancer News Room (6.20.22)

Lung cancer is the leading cause of cancer-related deaths in the United States, and early detection and treatment are key to prolonging survival in patients. A recent study published by Wiley online in CANCER, a peer-reviewed journal of the American Cancer Society, found that area-level education and income are associated with patients’ lung cancer stage at the time of diagnosis.

Research has shown that patients with lower income and education levels, and those living in more socioeconomically under-resourced regions, disproportionately experience poor lung cancer survival. Racial/ethnic minorities in the U.S. also face higher lung cancer-related mortality rates.

To understand the relationship between socioeconomic status and lung cancer stage at diagnosis, and how this association may vary by race/ethnicity and access to health care, a team led by Tomi F. Akinyemiju, PhD, MS, of Duke University School of Medicine, analyzed data from the 2004–2016 National Cancer Database of U.S. patients aged 18–89 years old who were diagnosed with any stage of non–small cell lung cancer. The investigators also collected information on the education and income levels of the areas in which patients resided, as well as details on patients’ health insurance status and where they received care.

Among 1,329,972 patients in the study, 17% of white patients were residents of areas in the lowest income quartile, compared with 50% of Black patients, and 18% of white patients resided in areas with the highest proportion of adults without a high school education, compared with 44% of Black patients.

Patients living in the lowest education areas and the lowest income areas had 12% and 13% higher odds, respectively, of having advanced-stage lung cancer at the time of diagnosis. These associations persisted among non-Hispanic white, non-Hispanic Black, Hispanic, and Asian patients; those with government and private insurance (but not no insurance); and those treated at any facility type (community, comprehensive community, academic/research, and integrated network facilities). However, Black patients residing in the highest education and income areas were more likely to have advanced-stage cancer than their white counterparts in the lowest education and income areas.

“Our findings support that poverty is a fundamental cause of poor lung cancer outcomes,” said Dr. Akinyemiju. “Strikingly, for Blacks, higher income did not necessarily translate to better outcomes compared with whites. This highlights the urgent need for targeted efforts to ensure equitable access to smoking cessation and lung cancer screening, and additional research into other factors that drive lung cancer aggressiveness in Blacks.”

An accompanying editorial by Erica T. Warner, ScD, MPH, of Massachusetts General Hospital, discusses the results and their implications. “Segregation and concentration of non-Hispanic Black and other individuals of color in areas with greater poverty and lower educational attainment is not coincidental,” wrote Dr. Warner. “As the authors acknowledge, these findings reflect the nature and impacts of structural racism.” She stressed the need for proactive, coordinated, community-engaged efforts to educate patients and clinicians, and to address patient and community barriers to improve screening, follow-up, and early recognition of lung cancer symptoms.

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In August 2023, a team of volunteers led by Trinitia Cannon, MD (third from left), Leda Scearce, CCC-SLP, MM, MS, and Dina Abouelella, MPH, which also included Tammara Watts, MD, PhD (center) and Katharine Ciarrocca, DMD, MSEd, partnered with North Raleigh International Baptist Church and Duke Raleigh Hospital to offer head and neck cancer screenings. Dozens of families from the Cedar Creek Apartment Complex community came out for the free screenings, education, and games, and Duke Raleigh Hospital donated backpacks full of school supplies.

Novel Community Engagement/Research Effort in Head & Neck Cancer Launches

TheDuke University School of Medicine Department of Head and Neck Surgery & Communication Sciences (HNS&CS) recently launched Project CHECKERS (Community Head and NEck Cancer Knowledge, Engagement, Research and Screening) a Duke Cancer Institute-funded pilot project to bring head and neck cancer resources and education to the broader Durham community. Led by DCI head and neck surgeon Trinitia Cannon, MD, an associate professor in the Department, the project will be the Department’s first community-based participatory research project and the first such head and neck cancer screening and cancer prevention education project in North Carolina. Evolving Community Research The Project CHECKERS team will use a mixed methodology, which includes traditional surveys and screenings as well as interviews and focus groups. One of their community partners will be the Cedar Creek Apartment Complex community in North Raleigh. Many of these families are refugees — from at least seven different countries in Africa, Asia, and the Middle East — who speak Farsi, French, Swahili, Arabic, and other languages. They are building new lives in North Carolina, in a culture and language that is new to many of them. As is the case with many similar communities, their healthcare needs often go unmet. The investigators believe that, compared to traditional methods, mixed-method research is an improved way to establish a community partnership, highlight gaps in the community’s knowledge and risk perception, and pave the way for successful future health interventions. According to co-PI Nosayaba (Nosa) Osazuwa-Peters, BDS, MPH, PhD, an associate professor in the Department of Head and Neck Surgery & Communication Sciences, Project CHECKERS takes an important step in improving community engagement. “Traditional research is very systematic, very top-down. The researchers have knowledge and decide what they believe the community needs. But these outside scientific experts do not know the values, the culture, the knowledge, or the risks inherent in that community,” he explained. For example, traditional surveys restrict participants to answering either yes or no; for many people, that binary does not tell a complete story. “Project CHECKERS will help us understand the lived experiences of people in these communities,” added Osazuwa-Peters. “We’ll learn about context, and we’ll learn to ask questions that allow community members to express themselves. We’ll get responses we would never get based on yes or no.” Building a Partnership Project CHECKERS kicked off this fall with focus groups and interviews with community members facilitated by Laura Fish, PhD, MPH, assistant professor in Family Medicine and Community Health, Duke University School of Medicine, and program director for the Behavioral Health and Survey Research Core (a DCI shared resource). An advisory board will provide feedback from both clinical and community perspectives. Lessons learned from these conversations will help the team develop a knowledge and risk factor survey that will be administered during two head and neck cancer screening events with the community in 2024. The CHECKERS team will also recruit providers outside the department to participate in these events to address other health concerns in the community such as primary care, mental health, and women’s health. 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Noted Osazuwa-Peters, “The mixed-methods framework helps us understand not just whether an intervention works, but how, why, and for whom.” Community Partners Another plus to mixed-methods research is its appeal to community partners who might otherwise be hesitant to work with researchers. “The design places a high value on the stories behind the numbers,” explained Cannon, “so these projects are especially attractive to community partners such as faith-based organizations, whose priority is improving practice and outcomes, more so than research and advancing knowledge.” Project CHECKERS will provide a valuable bridge between Duke and the North Raleigh International Baptist Church (NRIBC), which ministers to a large immigrant community. NRIBC’s Pastor, Patrick Warutere, invited Duke to participate in the church’s inaugural Health and Dignity for All Fair in Raleigh in 2022. Cannon and CHECKERS co-PI Leda Searce,CCC-SLP, MM, MS, a Duke speech pathologist, recruited nurses, medical students, and resident volunteers to provide HNC screenings for the event. “We immediately felt a kinship with NRIBC’s Pastor Patrick Warutere and his leadership team,” shared Searce. “By the end of the day, we knew we wanted to continue to work together and set up a meeting the following week.” Duke HNS&CS and the NRIBC team worked closely to develop the research plan and ensure that the goals and expectations of each group were aligned and transparent. “That relationship with NRIBC has enabled us to incorporate the community’s perspectives into the development of Project CHECKERS,” said Searce. “Our aim was to amplify the assets and expertise of the community members themselves.” Cannon anticipates that Project CHECKERS will become a framework for future projects. “We are looking forward to similar initiatives in hearing health for older adults, right-hemisphere stroke awareness, and more.”