Delays to surgery and worse outcomes: The compounding effects of social determinants of health in non–small cell lung cancer

OBJECTIVE: To quantify the compounding effects of social determinants of health on time to surgery (T2S) and clinical outcomes. METHODS: The National Cancer Database was queried for treatment-naïve patients with cT1-4N0-1M0 non–small cell lung cancer undergoing (bi)lobectomy or pneumonectomy between 2006 and 2016 with 1 to 180 days T2S, the number of days between diagnosis and surgery; surgical delays were defined as statistically significant increased T2S compared with a reference cohort. Social determinants of health factors prognostic for surgical delays were identified using multivariable regression. The 30-/90-day mortality and 5-year survival estimates were calculated using logistic and Cox regressions, respectively. RESULTS: In total, 110,005 patients met inclusionary criteria. Multivariable analysis identified race, insurance, and facility type as factors with significant 3-way interaction: T2S of one depended on the others. Income and education also contributed to delays. Privately insured (private) non-Hispanic White patients at academic medical centers (AMCs) were the reference with T2S of 44.1 days. At AMCs, private Black patients had significant delays to surgery (54.7 days; P < .0001), as did Medicaid and uninsured Black patients (58.5 days; P < .0001, 59.4 days; P < .0001, respectively). The 15-day surgical delays were associated with statistically significant 5% increased 30-day mortality odds (confidence interval [CI], 1.03-1.08), 6% increased 90-day mortality odds (CI, 1.04-1.08), and 4% decrease in hazard of death at 5 years (CI, 1.04-1.05). CONCLUSIONS: In treatment-naïve patients with cT1-4N0-1M0 non–small cell lung cancer, Black race, Medicaid, uninsured status, and AMCs generate compounding surgical delays with increased 30-/90-day mortality and decreased 5-year survival. Thoracic surgeons can leverage these facility and demographic-specific insights to standardize time to surgery and begin mitigating underlying disparities.