影响晚期NSCLC患者接受手术的社会经济与系统层面因素

Background: Lung cancer is a major contributor to cancer-related morbidity and mortality in the United States. Although advances in medical and surgical treatment have improved outcomes, economically disadvantaged patients, particularly those living in rural areas or lacking health insurance, continue to experience substantial treatment disparities. These disparities are exacerbated by the introduction of newer surgical technologies, as underserved patients often have limited access to these modern treatments. Objective: To evaluate the association between area-level socioeconomic status (SES) and type of surgery received, robotic-assisted thoracic surgery (RATS), video-assisted thoracic surgery (VATS), and open lobectomy among patients with non-small-cell lung cancer (NSCLC). Methods: Data were drawn from the 2015-2022 National Cancer Database and included patients diagnosed with Stage 0-IIIa NSCLC. The primary exposure was area-level income, defined by quartiles of median household income in the patient's zip code. Multinomial logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the association between income quartiles and surgical approach, using open surgery as the reference group. Models were adjusted for patient, clinical, hospital, and socioeconomic characteristics. All comparisons were considered statistically significant with p <.05. Results: The study included 84,931 patients with NSCLC, with a mean age of 67.8 ±8.5 years. Patients were identified as having undergone either an open lobectomy (38.4%), VATS (33.3%), or RATS (28.2%) during the study period. Most patients were older, White, and Medicare-insured, with care predominantly at academic metropolitan centers. In the adjusted models, low-income (<$46,277) patients were less likely to undergo RATS (aOR: 0.81, 95% CI: 0.76-0.87) or VATS (aOR: 0.82, 95% CI: 0.77-0.87) versus open lobectomy compared to patients from high-income (≥$74,063) areas. Compared to academic hospitals, community centers were 67% less likely to receive RATS (aOR: 0.33, 95% CI: 0.30-0.37) and 39% less likely to receive VATS (aOR: 0.61, 95% CI: 0.57-0.67). Additionally, males were less likely than females to receive RATS or VATS. Conclusions: The findings indicate that patients with NSCLC from low SES areas have reduced access to advanced, minimally invasive surgical techniques (RATS and VATS). Targeted efforts to ensure access to modern surgical care are warranted to reduce and mitigate treatment disparities and improve patient outcomes.