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. 2025 Mar;14(5):e70757.
doi: 10.1002/cam4.70757.

Mediators of Racial Inequities in Non-Small Cell Lung Cancer Care

Safraz A Hamid  1   2 , Do H Lee  3 , Jeph Herrin  3   4 , James B Yu  3   5 , Craig E Pollack  6   7 , Lorraine T Dean  8 , Jacquelyne J Gaddy  3   4 , Carol R Oladele  9 , Shelli L Feder  10   11 , Maureen E Canavan  3   4 , Marcella Nunez-Smith  4   9 , Pamela R Soulos  3   4 , Cary P Gross  2   3   4
Affiliations

Mediators of Racial Inequities in Non-Small Cell Lung Cancer Care

Safraz A Hamid et al. Cancer Med. 2025 Mar.

Abstract

Background: Black patients with non-small cell lung cancer (NSCLC) are more often diagnosed at a later stage and receive inadequate evaluation and treatment compared to White patients. We aimed to identify factors representing exposure to structural racism that mediate the association between race and NSCLC care.

Methods: We queried Surveillance, Epidemiology, and End Results-Medicare for non-Hispanic Black and White patients ≥ 67 years diagnosed with NSCLC from 2013 to 2019. Our outcomes were localized diagnosis stage, receipt of stage-appropriate evaluation, receipt of stage-appropriate treatment, two-year survival, and receipt of "optimal" care, an aggregate metric comprising the first three listed outcomes. We estimated indirect effects of mediators on the association between race and outcomes.

Results: Of 69,130 patients, 8.2% were Black. Medicare-Medicaid dual eligibility, a marker of individual-level socioeconomic status (SES), accounted for the largest proportion of mediating effects for most outcomes, ranging from 13.6% (p < 0.001) for localized diagnosis stage to 25.0% (p < 0.001) for two-year survival. Receipt of an influenza vaccine, a marker of health care access, had the second largest mediating effects on the associations between race and diagnosis stage (9.5%, p < 0.001), treatment (15.3%, p < 0.001), and optimal care (11.4%, p < 0.001). Neighborhood-level SES accounted for the third largest proportion of the effects of race on each outcome, explaining between 9% and 16% of the racial inequities at each phase (all p < 0.001).

Conclusions: Individual- and neighborhood-level structural factors partly explain inequities in NSCLC care, and their effects vary based on the phase of care. Interventions should be adapted to the phase of care.

Keywords: mediation analysis; non‐small cell lung cancer; quality of care; racial inequities; structural racism.

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Conflict of interest statement

Jeph Herrin: Dr. Herrin receives funding from multiple institutes of the National Institutes of Health, from the Patient‐Centered Outcomes Research Institute, the American Heart Association, and the Agency for Healthcare Research and Quality for research projects; from the Centers for Medicare and Medicaid Services for development of quality measures; and from Pfizer. James B. Yu: Dr. Yu reports speaking fees and a research grant from Pfizer/Myovant, consulting fees from Boston Scientific, and stock in Modifi Bio. Craig E. Pollock: Dr. Pollack reports stock ownership in Gilead Pharmaceuticals outside the submitted work; he is a board member of the American Association of Service Coordinators; Johns Hopkins contracted with the US Department of Housing and Urban Development for him to assist the agency on housing and health issues from September 2019 to July 2022. Cary P. Gross: Dr. Gross has received research funding from the NCCN Foundation (with funds provided to NCCN by Astra‐Zeneca) and Genentech, as well as funding from Johnson and Johnson to help devise and implement new approaches to sharing clinical trial data. The other authors declare no conflicts of interest.

Figures

FIGURE 1
FIGURE 1
Sample construction.
FIGURE 2
FIGURE 2
Conceptual model for the effect of race on outcomes. The total effect of race on the five binary outcomes comprises the direct effect (C) and the indirect effects of the mediators (the product of A and B). Age, sex, marital status, and year of diagnosis are conceptualized as confounders in the model.
FIGURE 3
FIGURE 3
Association between race and each outcome. aStatistically significant multivariate association between race and outcome after adjusting for sex, age, and year of diagnosis. bStatistically significant bivariate association between race and outcome (Chi‐square Test).
FIGURE 4
FIGURE 4
Heat map of relative indirect effects of mediators. Darker tiles (green) indicate stronger relative indirect effects; lighter tiles (yellow) indicate weaker relative indirect effects. Gray tiles indicate no statistically significant mediation or inconsistent mediation. Inconsistent mediation occurs when the sign of the indirect effect in the model is different from the sign of the direct effect.
See this image and copyright information in PMC

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