Air quality, guideline-concordant care, and survival among patients with non-small cell lung cancer.

Abstract

697 Background: Air pollution is associated with lung cancer mortality and receipt of guideline-concordant care is associated with improved survival among patients diagnosed with non-small cell lung cancer (NSCLC). However, the contribution of air pollution exposure to survival among people receiving or not receiving guideline-concordant care has not been characterized. Methods: This retrospective cohort study used the National Cancer Database and included patients diagnosed with NSCLC from 2004—2021. Population-weighted yearly mean particulate matter <2.5µm (PM 2.5 ) concentrations at patients’ zip code of residence were estimated combining satellite, ground, and simulation datasets, dichotomized into ≤ or >9µg/m 3 —indicating areas that met the Environmental Protection Agency (EPA) air quality standard or not–and assigned to patients’ zip code of residence each year between date of diagnosis and date of death, last contact, or study end (12/31/2022). Guideline-concordant care was determined using the National Comprehensive Cancer Network Guidelines corresponding to patients’ diagnosis year and included eligibility and receipt of chemotherapy, radiotherapy, immunotherapy, and/or surgery based on stage. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using a Cox proportional hazard model controlled for age at diagnosis, comorbidity burden, insurance type, hospital type, sex, rurality, stage, and diagnosis year. Results: Among the 1,671,457 patients included, mean age was 68 years (standard deviation 11.1) and 77% received guideline-concordant care. Patients who did and did not receive guideline-concordant care had similar levels of air quality that met EPA air quality standard (PM 2.5 ≤9µg/m 3 ) at diagnosis (51% vs 46%). Compared to patients who resided in areas that met the EPA air quality standard and received guideline-concordant care, patients who received guideline-concordant care but lived in areas that did not meet the EPA air quality standard had 1.44 times the hazard of death (CI 1.43-1.45; Table). Moreover, patients who did not receive guideline-concordant care but lived in areas that met the EPA standard had 1.83 times the hazard of death (CI 1.82-1.84), and patients who did not receive guideline-concordant care and lived in areas that did not meet the EPA standard (i.e., worst-case scenario) had 2.80 times the hazard of death (CI 2.79-2.81). Conclusions: Survival following NSCLC diagnosis was influenced by receipt of guideline-concordant care and the air quality where patients lived. Findings support the importance of the EPA air quality standard and may help integrate consideration of environmental exposures alongside clinical factors into high-quality cancer care. Air quality, care, and survival HR (95% CI). Guideline-concordant care Air quality meets EPA standard Yes No Yes Reference 1.83 (1.82-1.84) No 1.44 (1.43-1.45) 2.80 (2.79-2.81)