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Abstract
This doctoral dissertation evaluated racial lung cancer (LC) inequities in the state of North Carolina and across the US and simulated the potential economic and equity impacts of interventions aiming to reduce inequities at different steps along the lung cancer screening, diagnosis, and treatment continuum.
The first aim of this dissertation leveraged 2004-2020 data from the North Carolina Central Cancer Registry (NCCCR) to pinpoint the counties with the largest Black/White inequities in stage at lung cancer diagnosis, receipt of any surgery and timely surgery receipt. This Aim also assessed the associations between county-level structural racism and inequities in these three outcomes.
In the second aim, we estimated the relative impact of lung cancer screening (LCS) guideline design, LCS uptake, and surgical equity on Black/White LC mortality inequities. We leveraged Surveillance, Epidemiology and End-Results program (SEER) data to build a natural history Markov- based model of Black and White individuals diagnosed with LC in 2014 (70% of whom belonged to the 1930-1950 birth cohorts). We simulated how race-stratified mortality would have changed under the US Preventive Services Task Force (USPSTF) 2013 and 2021 LCS recommendations – with and without surgical equity and at different levels of LCS uptake.
In the third and final Aim, we evaluated efficiency/equity tradeoffs across different LCS guidelines. We linked the LC natural history model built in Aim 2 to a previously calibrated and validated smoking history simulation model. Using this linked model, we aged a nationally representative cohort of individuals born in 1973 under three scenarios: no screening, and perfect uptake of the USPSTF 2013 and 2021 screening guidelines. We then employed cost-effectiveness analytical (DCEA) techniques to compare the impact of both guidelines on cost-effectiveness and racial equity.
The three studies presented here identified geographic targets for inequity-reduction interventions, assessed the relative impact of intervening at different steps along the LC screening, diagnosis, and treatment continuum, and demonstrated how to assess cost-effectiveness/equity trade-offs in LCS guideline design. In doing so, we provide decision makers with actionable insights to inform policy in North Carolina and across the US.
