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Correspondence |

Evaluation of the Causes of Racial Disparity in Surgical Treatment of Early-Stage Lung Cancer FREE TO VIEW

Daniel S. Dube, MD
Author and Funding Information

Affiliations: Stanford University, Stanford, CA,  Henry Ford Hospital, Detroit, MI

Correspondence to: Daniel S. Dube, MD, Stanford University, Pulmonary and Critical Care, 300 Pasteur Dr, Stanford University Medical Center, Stanford, CA 94305-5236; e-mail: ddube@stanford.edu



Chest. 2006;130(4):1281-1282. doi:10.1378/chest.130.4.1281
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To the Editor:

The idea reported in the article by McCann et al (November 2005)1that black patients decline surgical treatment for stage 1 and 2 cancers more frequently than their white counterparts requires careful scrutiny. This study should be assessed as an exploration of the ability of physicians to communicate their therapeutic objectives to black patients. Consequently, dynamic variables such as clarity of message, body language, and emphasis could not be captured by retrospective case record analysis. Furthermore, the authors neglected to evaluate the role of physician factors in their observations. This omission is surprising considering that many investigators have shown that physicians asymmetrically employ established standards when caring for black patients.2 McCann et al1 noted that all black patients who were offered surgery by black physicians accepted the procedure. However, this observation was not pursued further. Intriguingly, the authors also noted that elderly black patients declined surgery at an even greater frequency. It would have been interesting if the authors had explored whether this phenomenon correlated with the age, gender, or ethnicity of the advising physician. This line of thought would be in concordance with the notion that physician-patient differences are a causal factor in diverse cases of disparities in care.

The dynamic complexity of the sociocultural universe of modern metropolitan ethnic populations requires more complex communication skills than are required for situations in which the physician and patient are socioculturally more congruent. Uncovering the etiologies of racial disparities calls for innovative research in communication, including visual and audio record analysis as well as physician interviews, to explore the clinical logic behind discrepant care. These approaches would lead to practical solutions toward an important health-care delivery problem.

Dr. Dube has no conflict of interest to report.

Dr. DiGiovine has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

McCann, J, Artinian, V, Duhaime, L, et al (2005) Evaluation of the causes for racial disparity in surgical treatment of early stage lung cancer.Chest128,3440-3446. [CrossRef] [PubMed]
 
Krishnan, JA, Diette, GB, Skinner, EA, et al Race and sex differences in consistency of care with national asthma guidelines in managed care organizations.Arch Intern Med2001;161,1660-1668. [CrossRef] [PubMed]
 
To the Editor:

I thank Dr. Dube for his interesting comments about our article.1He points out that a more complete evaluation of the physician-patient interactions would allow for a better understanding of why black patients declined surgical interventions for lung cancer. I agree with him. In the “Discussion” section of our article, we discussed the fact that prior research2has shown that black patients seeing white physicians rated their physician’s decision-making style as less participatory. Since the publication of our article, research3 has shown that black patients with lung cancer have less trust in their physicians after the visit despite equivalent trust before the visit. As Dr. Dube points out, a better understanding of the dynamics of physician-patient communication and how they effect the development of trust will be a key factor in improving surgical rates.

Dr. Dube would have us further scrutinize physician demographic data to assess how it impacted decision making. As pointed out in the article,1 we only had three black patients offered surgery by black physicians. All three accepted. Given the small numbers, I am not sure how we could have pursued this further. He also wonders why we did not further evaluate the gender and age of the physician. We found no impact of patient gender on any of our outcomes, so we did not feel that physician gender would impact the offering or accepting of surgery. In terms of age, we did find that older patients were more likely to decline surgery. However, to evaluate the issue of concordance, we would want to ask the question of whether patients who met with physicians of similar age would be more likely to accept surgery. The average age of our patients was approximately 68 years. None of our physicians were > 60 years old, and the majority were < 40 years old. Thus, it would be hard to see how we could find concordance between patient age and physician age.

Our study was retrospective and meant to leverage the ability to review large numbers of cases to begin to evaluate the proximate causes of decreased surgical rates in black patients. We were thus unable to evaluate the physician patient interaction in depth. Nevertheless, we do feel that our research has provided the insight that we should focus efforts on physician-patient communication as a way to improve surgical rates in black patients with lung cancer. Such efforts would hopefully lead to increased surgical rates and thus decreased mortality from lung cancer in the African-American population.

References
McCann, J, Artinian, V, Duhaime, L, et al Evaluation of the causes for racial disparity in surgical treatment of early stage lung cancer.Chest2005;128,3440-3446. [CrossRef] [PubMed]
 
Cooper-Patrick, L, Gallo, JJ, Gonzales, JJ, et al Race, gender, and partnership in the patient-physician relationship.JAMA1999;282,583-589. [CrossRef] [PubMed]
 
Gordon, HS, Street, RL, Jr, Sharf, BF, et al Racial differences in trust and lung cancer patients’ perceptions of physician communication.J Clin Oncol2006;24,904-909. [CrossRef] [PubMed]
 

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References

McCann, J, Artinian, V, Duhaime, L, et al (2005) Evaluation of the causes for racial disparity in surgical treatment of early stage lung cancer.Chest128,3440-3446. [CrossRef] [PubMed]
 
Krishnan, JA, Diette, GB, Skinner, EA, et al Race and sex differences in consistency of care with national asthma guidelines in managed care organizations.Arch Intern Med2001;161,1660-1668. [CrossRef] [PubMed]
 
McCann, J, Artinian, V, Duhaime, L, et al Evaluation of the causes for racial disparity in surgical treatment of early stage lung cancer.Chest2005;128,3440-3446. [CrossRef] [PubMed]
 
Cooper-Patrick, L, Gallo, JJ, Gonzales, JJ, et al Race, gender, and partnership in the patient-physician relationship.JAMA1999;282,583-589. [CrossRef] [PubMed]
 
Gordon, HS, Street, RL, Jr, Sharf, BF, et al Racial differences in trust and lung cancer patients’ perceptions of physician communication.J Clin Oncol2006;24,904-909. [CrossRef] [PubMed]
 
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