Prevention and treatment of early-stage non-small-cell lung cancer: the Value-Based Healthcare approach to address social disparities

Lung cancer & healthcare disparities access

Lung cancer is the second most common cancer and one of the leading causes of death globally [1]. Non-small-cell lung cancer (NSCLC) accounts for the 80–85% of lung cancer diagnoses, showing a 5-year survival rate of 26% – increasing to 63% when cancer has not spread outside the lung [2,3]. Lung cancer patients often experience significant emotional burden and distress, and ruminative thinking, which can adversely affect quality of life (QoL) and overall health outcomes [4–7]. The mortality rate is deeply affected by screening procedures that allow early detection, and lower cancer spread [8]. Notwithstanding the critical role of the lung cancer screening programs, several organizational, contextual and individual factors interfere in equally reaching patients on time. Among these, social and wealth disparities have been reported as one of the most important barriers in promoting prevention adherence [9]. People at equal risk – in terms of physical, environmental and lifestyle factors – of developing lung cancer could have different probabilities to access to the preventive programs based on their race, ethnicity and socioeconomic status [10]. Indeed, direct (e.g., treatment and exam costs) and indirect (e.g., cost for transportation and lodging, absence from work) expenses are often high and people may have trouble paying for their care. Furthermore, individuals from disadvantaged social groups may have limited access to financial resources, which can further exacerbate the financial toxicity associated with lung cancer and health-related QoL [11].

This scenario is extremely important when considering that social and wealth disparities are associated with a higher incidence of lung cancer and poorer clinical outcomes (survival rate and QoL) for patients. Consistently, Ebner and colleagues (2020) [12] have observed that socio-economic status is an important determinant of treatment differences in NSCLC patients (Stage I). In particular, data retrieved suggested that NSCLC patients having different socio-economic risk factors (e.g., age, ethnicity, income, education) had a higher probability of undergoing to non-standard therapy, or to not undergoing to a specific therapy with a critical impact on survivorship trajectory (surgery 71.8% vs nonstandard therapy 22.7% vs not therapy 21.8%) [12]. Accruing evidence highlighted that the increased attitude in engaging in risky behaviors (e.g., smoking) and the limited access to quality healthcare has led low-income individuals and those with lower educational skills to a higher risk of either developing lung cancer or receiving the diagnosis in advanced stages, when the disease is less treatable [13,14]. A cohort retrospective study on 32,711 NSCLC patients reported that individuals living in higher deprivation contexts (e.g., low sociodemographic and educational status) had lower survival rates [15]. Besides, racial and ethnic minorities, such as African–Americans, have a higher incidence of lung cancer and worse survival rates compared with non-Hispanic whites [16]. Geographic location, including living in urban or rural area, is also associated with disparities in lung cancer outcomes, with rural residents experiencing higher mortality rates [17]. In particular, rural communities often have higher rates of smoking and exposure to environmental toxins, which contribute to higher incidence rates of lung cancer [18]. Moreover, access to healthcare, particularly specialty care, can be limited in rural areas: individuals who lack health insurance or have limited access to healthcare are less likely to receive early diagnosis and treatment [19]. A recent qualitative study [20] investigating the challenges faced by individuals living in poverty in accessing lung cancer screening, reported that people often face financial and systemic barriers to accessing healthcare due to the high costs of screening treatments, as well as related costs such as transportation and time off work. Additionally, the lack of insurance coverage for screening and limited availability of screening facilities in low-income neighborhood constitute another important limit to cancer care [20]. Moreover, participants in the study reported limited access to information and a lack of awareness about the importance of early detection due to a variety of factors, including limited education and language barriers.

The Value-Based HealthCare Paradigm

The Value-Based HealthCare (VBHC) paradigm developed by Michael E Porter and Elizabeth Teisberg is a healthcare delivery model aimed at improving the quality of healthcare outcomes for patients while reducing overall healthcare costs [21,22]. This paradigm focuses on three fundamental principles declined as follows: the identification of the ‘Value for the Patient’, the implementation of a ‘Coordinated Care’ and a ‘cost–effectiveness’ approach along the care process.

The ‘first principle’ would prioritize the outcomes that matter most to patients. In this way, patients are placed at the center of the care process and their values, preferences and goals are considered when designing and delivering care. Indeed, the VBHC paradigm identifies a hierarchy of both clinical and patient-reported outcomes measures that would allow the assessment of different variables related to the patient's functional status, quality of life and symptom relief. In this perspective, the overall patients' experience would be considered, leading to a better comprehension of what matters the most to patients. Further, this approach emphasizes the significance of the definition of a personalized care pathway, as each patient has unique needs, preferences and values that should be taken into account when developing a screening program and treatment protocols [23–25]. The ‘second principle' highlights the importance of coordinating care across different healthcare providers (from the general practitioner to the specialists) and clinical settings (from the local ambulatory and to the hospital), to ensure that patients receive the right care at the right time. This would allow care continuity and encourage healthcare providers to work together, thus improving communication and collaboration among different specialists [26]. Finally, the cost–effectiveness ‘principle' aims to reduce healthcare costs by improving the efficiency of healthcare delivery. More specifically, the VBHC assets refers to reducing waste in healthcare delivery and costly interventions – such as unnecessary tests or procedures – while still maintaining high-quality outcomes for patients [27].

In summary, the VBHC model would shift from the volume of services provided to a healthcare system in which different stakeholders (e.g., general practitioners, nurses and different health specialists) deliver care that achieves the desired outcomes at the lowest possible cost and data are systematically collected, analyzed and used to continuously improve the quality and efficiency of care. Measuring value would also help to identify inefficiencies and areas for improving and optimizing resources to provide high-value care [26].

These principles constitute the basis for implementing a shared decision-making process by incorporating patient values and preferences in the choice of the right treatment, thus improving adherence to screening programs and treatment protocols [28,29].

The adoption of personalized treatment plans, the integration of patient-reported outcomes into clinical decision making, and the use of multidisciplinary teams would promote a better coordination in the care process.

What is value-based healthcare & how does it address healthcare disparities in the lung cancer pathway?

Concepts supported by the VBHC paradigm are becoming increasingly important in the cancer field and in the management of the lung cancer. Coherently with this assumption, we argue that the VBHC might offer a framework to address social disparities in lung cancer patients in several ways [30–32].

First, one of the key tenets of VBHC is ‘patient-centeredness', which involves understanding and addressing the unique needs, values and preferences of the patient [21]. In this way, disparities related to language and educational barriers, cultural differences and health literacy, as well as financial, informational and systemic barriers would be included and concretely addressed [33]. Along the patient's perspective, the evaluation of the financial burden would be also highlighted by considering both direct and indirect costs for lung cancer screening and treatments. Healthcare disparities that individuals living in poverty face when accessing lung cancer screening would be better arisen and patients' cultural beliefs, economic barriers and values related to healthcare may be reported accordingly to the specific backgrounds [34]. On the other hand, stakeholders may better understand these roadblocks and boundaries, developing new lung screening procedures and health policies able to address and overcome them. In particular, health policies should be designed ensuring the integration of the future patients' perspective and social and health needs. Second, VBHC promotes a robust data collection and analysis to accurately measure patient outcomes and healthcare costs and adopt a cost-effective care, which involves achieving the best possible outcomes at the lowest possible cost [35]. In the context of lung cancer screening, this means not only measuring screening rates, but also the impact of screening on overall health outcomes (physical and psychological) and health equity.

Finally, VBHC emphasizes continuous improvement and update, which involves using data and feedback that could be useful for both the patient and the stakeholder to adopt a shared decision-making process and improve care delivery. Indeed, the collected outcomes (physical, psychological and social) and costs could be used to develop predictive model of patients' trajectories of care and expenses to be incurred, thus providing more awareness on the own care pathway and on costs associated with their treatments. This condition can lead lung cancer patients to making more informed decisions about their care integrating their values and priorities [33]. Patients' feedback and outcomes may be also used to identify areas for improvement, such as increasing patient education, health literacy and awareness about the importance of the lung cancer screening as risk-reduction measure and improving the accessibility of screening facilities in underserved communities and area with poor medical recourses.

A new perspective to overcome social disparities in cancer care

Social disparities in lung cancer patients are a significant public health concern. Efforts to reduce disparities must address the root causes and target high-risk populations through prevention and early detection strategies. By addressing these disparities, all individuals may have favorable access to equitable healthcare and achieve better clinical outcomes and health-related QoL.

The value-based healthcare paradigm has emerged as a promising approach that could help healthcare systems, healthcare providers and other stakeholders involved in the care's system to address social inequalities and reduce financial toxicity.

Financial disclosure

The authors have no financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Competing interests disclosure

The authors have no competing interests or relevant affiliations with any organization or entity with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, stock ownership or options and expert testimony.

Writing disclosure

No writing assistance was utilized in the production of this manuscript.