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Key Studies in NSCLC: Independent Conference Coverage of the 2021 ASCO Scientific Meeting
  • CME

Zofia Piotrowska, MD, MHS
Karen L. Reckamp, MD, MS
Released: August 20, 2021

Equity

Racial Disparities in NSCLC: Study Design

Zofia Piotrowska, MD, MHS:
To close our discussion, let’s turn our attention to equity in the care we deliver to our patients, which was the official theme at ASCO 2021 and a thread seen throughout all of the sessions. To highlight the importance of this topic, let’s look at a standout retrospective cohort study that assessed racial disparities in biomarker testing and clinical trial enrollment in NSCLC. This study compared rates of biomarker testing, use of targeted therapies, and clinical trial enrollment in Black vs White patients within the Flatiron database who were diagnosed with advanced or metastatic NSCLC from January 1, 2017, to October 31, 2020, including for an overall NSCLC population (N = 14,768) and a subpopulation with nonsquamous histology (n = 10,333), where we all know biomarker testing is critical to guide optimal first-line treatment decisions.30

Racial Disparities in NSCLC: Rates of Biomarker Testing and Receipt of Targeted Therapies

Zofia Piotrowska, MD, MHS:
Rates of biomarker testing were poor across the board, with only approximately three quarters of patients having ever been tested regardless of race, but were particularly low among Black patients. The rate of NGS testing was approximately 50% in White patients and only 40% in Black patients, and that held up in both the overall population and the nonsquamous population (P <.0001). Overall rates of targeted therapy use were similar for White and Black patients, with a trend in the nonsquamous cohort toward inferior first-line use in Black patients.30

Racial Disparities in NSCLC: Clinical Trial Participation

Zofia Piotrowska, MD, MHS:
Not only do we see a difference in rates of biomarker testing between Black and White patients, but it also seems to have important implications for clinical trial enrollment. The rates of clinical trial participation by Black patients was half that of White patients (2.1% vs 3.9%, respectively), despite rates of mutations (ie, alteration in EGFR and ALK) not being significantly different between these 2 racial groups.30

Racial Disparities in NSCLC: Clinical Implications

Zofia Piotrowska, MD, MHS:
The disparities observed in this retrospective cohort analysis really highlight a need for us to focus on equity in care, which is something we’ll all need to work on as a community. Dr. Reckamp, what do you think about these data?

Karen L. Reckamp, MD, MS:
I agree. It is disappointing to see low overall rates of NGS testing, especially now that we have 9 oncogenic-driven targets with FDA-approved targeted therapies in advanced NSCLC. With so many biomarkers to guide optimal first-line treatment decisions, the use of comprehensive NGS testing has become essential. For example, we wouldn’t treat a patient with breast cancer without knowing ER, PR, and HER2 status, so not doing comprehensive testing in NSCLC is really not standard of care. It is doubly worrisome that rates were disproportionately worse in Black patients. This study was conducted in the Southern United States, where there is a significant Black population. I practice on the West Coast, where there is a significant Hispanic population, and would be interested to see if similar disparities exist for Latinos here.

We certainly need to find ways to overcome these disparities and make sure we are testing everyone, because we know that not doing so directly affects survival outcomes for these patients. Of importance, we saw last year with the Howlader article in the New England Journal of Medicine31 that we are improving survival for patients with metastatic NSCLC largely through giving them targeted therapies, and we know that biomarker testing guides the use of those therapies. One thought is that standards for insurance to cover comprehensive biomarker testing for everyone should be part of public policy.

Zofia Piotrowska, MD, MHS:
Absolutely. Black patients were 50% less likely to participate in clinical trials than White patients, and that speaks to the lack of equity in our healthcare system and disparities in access to care at large academic medical centers where clinical trials are being developed. It goes back to disparities in the rates of biomarker testing to identify patients for clinical trial participation. Another thing pointed out at many sessions at ASCO 2021 was that, when you look at the demographics of clinical trials, often the race breakdown is not representative of the US population or even the overall population of patients with lung cancer. That’s a really important point that we need to work together to correct going forward.

I can say that, at our institution and many others, this has become an area of focus, and I will repeat that we all need to work together, as a community, to try to develop better ways to capture patients of all ethnicities and backgrounds in our clinics, get biomarker testing for all of our patients, and enroll patients more representative of the overall US population onto clinical trials.

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