Neoadjuvant therapy with immunotherapy is revolutionizing the treatment landscape for patients with locally advanced lung cancer who require surgery. Its implementation has shown remarkable advancements in surgical outcomes and a reduction in cancer recurrence rates. However, it is crucial to ensure equitable access to neoadjuvant therapy protocols, mitigating any socioeconomic disparities that may hinder its widespread adoption. To delve deeper, we had the privilege of sitting down with Brendon M. Stiles, MD, an expert in the field, to gain further insights. Dr. Stiles is Professor and Chief, Thoracic Surgery and Surgical Oncology, Department of Cardiothoracic & Vascular Surgery at Montefiore Einstein, and the Associate Director for Surgical Services in the Montefiore Einstein Cancer Center.

► Q: Are there any specific barriers or challenges that patients from lower socioeconomic backgrounds or minority communities face when it comes to accessing neoadjuvant therapy?

Dr. Stiles: Neoadjuvant therapy can be challenging to deliver. As an example, less than 4% of patients enrolled in the seminal neoadjuvant therapy trial, CheckMate 816, were Black or Hispanic. Biopsies and multiple imaging studies are typically required before starting therapy. Visits are required with surgeons, medical oncologists, and sometimes radiation oncologists. This can sometimes require a lot of time and resources for patients. Patients may also worry about the costs of expensive medications. 

► Q: How does the lack of socioeconomic/minority access to neoadjuvant therapy impact care and outcomes? Have you observed any differences in outcomes or patient experiences? 

Dr. Stiles: We don't know for sure that outcomes are reproducible in minority patients, as minority patients and those of lower socioeconomic status are often underrepresented in clinical trials. Like the example above, we recently reviewed seminal neoadjuvant and adjuvant lung cancer clinical trials and found that less than 2% of the patients were Black and less than 1% were Hispanic. For neoadjuvant therapy in particular, these patients may be reluctant to go down the pathway of systemic treatment first and may instead pursue upfront surgery which they assume is faster and easier. However, we believe that our patients will experience the same benefits demonstrated in large clinical trials and are carefully following them to make sure that their experiences are similar.

► Q: How do you and your team ensure equitable access to neoadjuvant therapy for patients from different socioeconomic backgrounds or minority groups in your practice? 

Dr. Stiles: We have worked hard to guide our patients through the entire treatment journey, taking time to explain outcomes and our expectations in easily understandable terms. We have emphasized that receiving neoadjuvant therapy may actually decrease the total amount of chemotherapy and immunotherapy patients will ultimately need to receive while improving their survival. As an institution, we have established the 
BRONX-CAN project - Building Reliable Oncology Navigation Centered Around Neoadjuvant therapy - which has been funded by the American Cancer Society. Our objectives are to identify patients with cancer who need neoadjuvant therapy and help them navigate the system to facilitate timely cancer diagnosis and staging, rapid development of treatment plans, and early treatment initiation. Our goal is to minimize the need for multiple redundant appointments and procedures. A unique aspect about the project is that it relies upon Nurse and Peer Navigators to help people impacted by cancer along their treatment journeys. The Nurse Navigator will attend cancer clinics and tumor boards but will also be a direct link for individual patients. 

► Q: In your opinion, what additional steps can be taken at the healthcare system or policy level to ensure equitable access to neoadjuvant therapy for all patients, regardless of their socioeconomic or minority status? 

Dr. Stiles: In our own healthcare system, we need to use innovative technological and tracking approaches, such as our virtual cancer center dashboard, to monitor our results and to identify how we can improve on our already outstanding cancer outcomes. We must focus on improving timelines of care and minimizing redundant visits. While doing so, we need to take a patient-centric approach and optimize patient engagement and understand patient barriers and preferences during neoadjuvant therapy using focused patient assessments and surveys. On a national level, there needs to be more collaboration between surgeons, multidisciplinary clinical teams, and industry to actively recruit and retain diverse participants in clinical trials.