Black-White NSCLC Survival Gap Widens in Counties With Greater Racial Inequity

Black patients with non–small cell lung cancer (NSCLC) had a 2-year survival rate that was 10 percentage points lower than that of White patients in counties with the highest levels of racial inequity, whereas the disparity was nearly nonexistent in the least segregated counties, according to a study recently published in JAMA Network Open.¹

Examining the Role of Structural Racism in NSCLC Outcomes

NSCLC, the most common form of lung cancer and the leading cause of cancer-related death in the US, continues to be marked by persistent racial disparities despite overall declines in incidence and mortality. Black patients are less likely than White patients to be diagnosed with localized disease and to receive guideline-concordant treatment, contributing to worse outcomes.² Although these inequities are well documented, the extent to which structural racism drives disparities in NSCLC care and survival remains poorly understood.¹

To better characterize this relationship, investigators examined 2 measures of structural racism: the Structural Racism Effect Index, which captures community-level deprivation across domains such as housing, education, employment, income, and transportation; and the County Structural Racism (CSR) index, which measures disparities between Black and White populations in housing, health care access, education, employment, and criminal justice. While deprivation-based measures reflect the cumulative effects of inequitable systems, they do not account for racial differences within communities, prompting the use of the CSR as a complementary metric.

The study evaluated whether these measures of structural racism were associated with the quality of NSCLC care and outcomes among Black and White patients, as well as whether they influenced racial disparities in treatment and survival. Focusing on Black-White differences, the researchers sought to determine whether the level of structural racism within a county modifies the relationship between race and NSCLC care, potentially helping explain persistent inequities in cancer outcomes.

The 3 primary outcomes were localized stage at diagnosis, stage-appropriate evaluation and treatment per National Comprehensive Cancer Network guidelines, and 2-year survival, assessed via multivariable mixed-effects logistic regression with interaction terms to test whether structural racism moderated the race-outcome association.

Survival Gap Widens in Counties With Greater Racial Inequity

The cross-sectional study used Surveillance, Epidemiology, and End Results Program data linked to Medicare claims for beneficiaries diagnosed with NSCLC between 2013 and 2019. Eligible patients were older than 67 years, enrolled in fee-for-service Medicare Parts A and B, non-Hispanic Black or White, and had confirmed NSCLC histology.

The sample included 54,344 patients, with a mean age of 77.7 years. Regarding race and ethnicity, 89.7% were non-Hispanic White and 10.3% were non-Hispanic Black. Black patients were more concentrated in higher-racism counties, with their share rising from 6.4% to 15.3% across deprivation quintiles and from 8.2% to 19.2% across dissimilarity quintiles.

Unadjusted disparities were significant across all 3 outcomes, all favoring White patients (P < .001): localized-stage diagnosis (30.9% vs 38.4%), stage-appropriate treatment (20.3% vs 28.0%), and 2-year survival (28.7% vs 36.6%).

County deprivation was associated with worse outcomes for both groups. Patients in the highest quintile had significantly lower odds of localized diagnosis (adjusted OR [AOR], 0.84; 95% CI, 0.74–0.94), guideline-concordant treatment (AOR, 0.69; 95% CI, 0.59–0.80), and 2-year survival (AOR, 0.66; 95% CI, 0.58–0.75). However, race-by-deprivation interaction terms were not significant, with deprivation penalizing Black and White patients similarly.

Conversely, a significant interaction emerged between the CSR dissimilarity index and patient race for both localized stage at diagnosis (P = .01) and 2-year survival (P = .002). In the lowest dissimilarity quintile, or the least segregated counties, there was no significant difference in 2-year survival between Black and White patients (−2.6%; 95% CI, −5.8% to 0.6%).

Meanwhile, in the highest dissimilarity quintile, White patients' 2-year survival was 36.8% compared with 26.8% among Black patients, a gap of 10.0 percentage points (95% CI, −12.2% to −7.7%; P < .001). The researchers highlighted a paradox: White patients actually had better survival in higher-dissimilarity counties, while Black patients saw no corresponding benefit.

Quantifying Structural Racism May Help Inform Equity-Focused Interventions

The researchers acknowledged several study limitations, including the study population excluding younger patients, Medicare Advantage enrollees, and uninsured individuals; these groups may also be affected by structural racism, in which case their exclusion limits generalizability. The study could also not incorporate smoking history, as Medicare claims do not reliably capture this information. The researchers noted that this is a meaningful gap given documented tobacco industry targeting of Black communities and inequitable retailer availability in marginalized neighborhoods.

Still, they highlighted the importance of their findings, especially that the amount of racial inequity within counties had a differential association with survival for Black vs White patients.

"This finding builds on prior work suggesting that increased structural racism most often correlates with heightened barriers for Black patients but not White patients,” the authors wrote. “These heightened barriers may reduce access to equitable health care and may ultimately lead to delayed diagnosis and poorer survival for Black patients. By quantifying structural racism and its association with cancer care delivery, we could identify targets that allow for the improvement of the quality of cancer care and mitigation of disparities.”

References

1. Gaddy JJ, Lee DH, Herrin J, et al. County-level structural racism indices and racial disparities in lung cancer care. JAMA Netw Open. 2026;9(5):e2613919. doi:10.1001/jamanetworkopen.2026.13919
2. Primm KM, Zhao H, Hernandez DC, Chang S. Racial and ethnic trends and disparities in NSCLC. JTO Clin Res Rep. 2022;3(8):100374. doi:10.1016/j.jtocrr.2022.100374