Racial and ethnic variation in referral times for thoracic oncologic surgery in a major metropolitan area



      The study objective was to understand the impact of race/ethnicity on access to thoracic surgical care for patients undergoing lung resection for cancer.


      We performed a retrospective analysis on 206 consecutive patients who underwent lung resection for cancer (120 female, 86 male; median age 66 years), with respect to how race and ethnicity impact time to referral for thoracic surgery to a major healthcare center. Time between initial radiographic appearance of a lung nodule/mass 1 cm or greater to surgical referral and time from surgical referral to operation were evaluated for 121 White, 30 Asian, 26 Hispanic, 12 African American, and 17 mixed or other race patients. The impact of age, sex, median income of patient's household, national and state Area Deprivation Indices, insurance type, and distance between the patient's domicile and our hospital was evaluated. The influence of the referring physician's practice (hospital-based, hospital-affiliated, or private), internal or external referral, race/ethnicity, and level of specialization was also studied.


      African American, Asian, Hispanic, and mixed/other race patients had significantly longer wait times between initial radiographic finding of a lung nodule/mass 1 cm or greater and surgical referral compared with White individuals (median days: African American, 78; Asian, 95; Hispanic, 92; mixed or other, 65; White, 35). Multiple linear regression analysis demonstrated that race/ethnicity was the only significant predictor of prolonged time to surgical referral when adjusted for age, sex, median household income level, national and state Area Deprivation Indices, insurance type, and distance between patient's home and our hospital. The referring physician's type of practice and internal versus external referral were not significant. However, the physician's race/ethnicity and level of specialization had an impact on referral times, with nonspecialists referring patients sooner to thoracic surgery compared with specialists who ordered more workup tests. For all patient races/ethnicities, there was no difference in time between surgical referral and day of operation.


      Race and ethnicity have a major impact on the time from initial radiographic appearance of a lung nodule/mass 1 cm or greater to referral for surgical resection for cancer. This study suggests the need to develop strategies to reduce minority wait times and improve timely access to surgery for patients with thoracic malignancies.

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      Abbreviations and Acronyms:

      CT (computed tomography), IQR (interquartile range), ROC (receiver operating characteristic), UCSD (University of California, San Diego)
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        • American Cancer Society
        Key statistics for lung cancer, volume 5.
        Date: 2017
        Date accessed: August 15, 2021
        • Abidoye O.
        • Ferguson M.K.
        • Salgia R.
        Lung carcinoma in African Americans.
        Nat Clin Pract Oncol. 2007; 4: 118-129
        • O'Brien K.
        • Cokkinides V.
        • Jemal A.
        • Cardinez C.
        • Murray T.
        • Samuels A.
        • et al.
        Cancer statistics for Hispanics, 2003.
        CA Cancer J Clin. 2003; 53: 208-226
        • Jonnalagadda S.
        • Lin J.
        • Nelson E.
        • Powell A.
        • Salazar-Schicchi J.
        • Berman R.
        • et al.
        Racial and ethnic differences in beliefs about lung cancer care.
        Chest. 2012; 142: 1251-1258
        • Balsa A.I.
        • McGuire T.G.
        Prejudice, clinical uncertainty and stereotyping as sources of health disparities.
        J Health Econ. 2003; 22: 89-116
        • Lathan C.S.
        • Neville B.A.
        • Earle C.C.
        The effect of race on invasive staging and surgery in non-small-cell lung cancer.
        J Clin Oncol. 2006; 24: 413-418
        • U.S. Census Bureau
        Mean household income in the United States by county, 2019 version.
        • University of Wisconsin School of Medicine and Public Health
        Area Deprivation Index Calculator. 2015.
        • Amin M.B.
        • Greene F.L.
        • Edge S.B.
        • Compton C.C.
        • Gershenwald J.E.
        • Brookland R.K.
        • et al.
        The Eighth Edition AJCC Cancer Staging Manual: continuing to build a bridge from a population-based to a more “personalized” approach to cancer staging.
        CA Cancer J Clin. 2017; 67: 93-99
        • International Agency for Research on Cancer
        Agents classified by the IARC monographs, volumes 1-129, 2021.
        • US Census Bureau
        2020 US census data.
        Date accessed: August 20, 2021
        • Patrick W.L.
        • Bojko M.
        • Han J.J.
        • Kelly J.J.
        • Iyengar A.
        • Helmers M.
        • et al.
        Neighborhood socioeconomic status is associated with differences in operative management and long-term survival after coronary artery bypass grafting.
        J Thorac Cardiovasc Surg. August 19, 2020; ([Epub ahead of print])
        • Williams C.D.
        • Salama J.K.
        • Moghanaki D.
        • Karas T.Z.
        • Kelley M.J.
        Impact of race on treatment and survival among U.S. veterans with early-stage lung cancer.
        J Thorac Oncol. 2016; 11: 1672-1681
        • Grumbach K.
        • Hart L.G.
        • Mertz E.
        • Coffman J.
        • Palazzo L.
        Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington.
        Am Fam Med. 2003; 1: 97-104
        • Scheffler R.M.
        • Kessell E.
        • Brandt M.
        Covered California: the impact of provider and health plan market power on premiums.
        J Health Polit Pol Law. 2015; 40: 1179-1202
        • Bala M.M.
        • Strzeszynski L.
        • Topor-Madry R.
        Mass media interventions for smoking cessation in adults.
        Cochrane Database Syst Rev. 2017; 11: CD004704
        • Patil R.
        • Shrivastava R.
        • Juvekar S.
        • McKinstry B.
        • Fairhurst K.
        Specialist to non-specialist teleconsultations in chronic respiratory disease management: a systematic review.
        J Glob Health. 2021; 11: 04019
        • Takeshita J.
        • Wang S.
        • Loren A.W.
        • Mitra N.
        • Shults J.
        • Shin D.B.
        Association of racial/ethnic and gender concordance between patients and physicians with patient experience ratings.
        JAMA Netw Open. 2020; 3: e2024583
        • Ricks T.N.
        • Abbyad C.
        • Polinard E.
        Undoing racism and mitigating bias among healthcare professionals: lessons learned during a systematic review.
        J Racial Ethnic Health Dispar. Available online September 3, 2021; (
        • Jones J.W.
        The question of racial bias in thoracic surgery: appearances and realities.
        Ann Thorac Surg. 2001; 72: 6-8
        • Schulson L.B.
        • Paasche-Orlow M.K.
        • Xuan Z.
        • Fernandez A.
        Changes in perceptions of discrimination in health care in California, 2003 to 2017.
        JAMA Netw Open. 2019; 2: e196665
        • Vimalananda V.G.
        • Meterko M.
        • Waring M.E.
        • Qian S.
        • Solch A.
        • Wormwood J.B.
        • et al.
        Tools to improve referrals from primary care to specialty care.
        Am J Manag Care. 2019; 25: e237-e242
        • American Cancer Society
        Facts & figures 2021. American Cancer Society. Atlanta, Ga. 2021.