Abstract Background Adherence to National Comprehensive Cancer Network (NCCN) guidelines for pre-treatment workup is critical for accurate staging and treatment planning in non-small cell lung cancer (NSCLC). However, national patterns of adherence and the influence of sociodemographic characteristics remain poorly characterized. We evaluated patient-level factors associated with guideline-concordant pre-treatment evaluation, emphasizing the interaction between race and socioeconomic status (SES). Methods We analyzed 67,032 patients aged ≥67 years with NSCLC in the SEER-Medicare Fee-for-Service database diagnosed between 2015 and 2021. For each stage, we used a claims-based approach to determine completion of NCCN-recommended diagnostic workup. Variables associated with workup completion in bivariate analyses (p 0.10) were included in multivariable logistic regression models adjusted for demographic and clinical covariates. Socioeconomic status (SES), represented by area-level median household income quantiles, was included in the model with race and their interaction. Adjusted predicted probabilities of workup completion were estimated by race and SES combinations. Results Overall, 82.8% (N = 55,521) of patients were White, followed by Black patients (7%, N = 4,689). The median age at diagnosis was 76.6. The cohort was slightly more female (50.6%, N = 33, 919). The distribution across stages included Stage I (28.1%, N = 18,812), Stage II (9%, N = 6,002), Stage III (17.7%, N = 11, 857;), and Stage IV (45.3%, N = 30, 361) of 919). Adherence to stage-specific recommended workup occurred less frequently with increasing Stage; Stage I, 31.8%, Stage II, 28.9%, Stage III 1 9.4%, and Stage IV 21.9% (P 0.001). Stage IV patients had significantly lower odds of completing required workup compared to Stage I (OR 0.60; 95% CI: 0.58-0.63; P 0.001). The final multivariable model demonstrated a statistically significant interaction between race and income (P 0.001). The lowest predicted probability of stage-specific completion occurred among Black patients in the lowest income quintile (0.16; 95% CI: 0.14-0.17), whereas the highest occurred among White patients in the highest income quintile (0.28; 95% CI: 0.29-0.30). Across all race groups, stage-specific recommended workup completion rose progressively with increasing income, but the income gradient was steepest among Black patients. Discussion Adherence to stage-specific NCCN recommended workup is suboptimal across all stages of NSCLC, and decreases with advancing stage. Disparities in stage-specific work up reflects both socioeconomic and racial mechanisms; SES was a major driver of lower completion and racial inequities were most pronounced at the lowest SES level, consistent with effect modification by income. Targeted interventions are needed to address these disparities and improve equity in lung cancer care. This abstract is funded by: NCCN
Bischin et al. (Fri,) studied this question.