Socioeconomic Determinants of Guideline-Concordant Therapy for Early-Stage Non-Small Cell Lung Cancer: A Population-Based Analysis from Appalachian and Non-Appalachian Ohio, 2004-2015

Purpose: To examine the relative contributions of insurance, county-level poverty, and other socioeconomic factors, as compared with Appalachian geography, to receipt of guideline-concordant therapy for early-stage non-small cell lung cancer (NSCLC) in Appalachian and non-Appalachian Ohio. Methods: Retrospective population-based cohort study using the Ohio Cancer Incidence Surveillance System. We identified adults diagnosed with early-stage NSCLC between 2004 and 2015 (N=26,756). The primary outcome was receipt of guideline-concordant local therapy (surgery or definitive radiation). Rural-urban classification used USDA Rural-Urban Continuum Codes. Multivariable logistic regression and Cox proportional hazards models assessed predictors of treatment and survival, with E-values, race-stratified models, and propensity score weighting as sensitivity analyses. Findings: Median age was 71 years; 50.3% were male, 83.8% non-Hispanic White, and 20.4% Appalachian. Overall, 83.6% received guideline-concordant local therapy (59.6% surgery, 24.0% radiation). In adjusted analysis, Medicaid (adjusted odds ratio [OR] 0.53, 95% confidence interval [CI] 0.44-0.63; adjusted risk ratio [RR] 0.94, 0.91-0.96), county-level poverty >20% (OR 0.77, 95% CI 0.68-0.87; RR 0.96, 0.95-0.98), and unmarried status were independently associated with lower therapy receipt, whereas Appalachian residence was associated with modestly higher receipt (OR 1.17, 95% CI 1.06-1.29; RR 1.02, 1.01-1.04). Therapy rates converged across regions over the study period (year x Appalachian interaction p<0.001). Mortality was independently associated with lack of local therapy (adjusted hazard ratio [HR] 4.33, 95% CI 4.10-4.56), Medicaid (HR 1.25, 95% CI 1.14-1.37), and poverty >20% (HR 1.13, 95% CI 1.07-1.20). Conclusions: Socioeconomic factors, particularly Medicaid insurance and county-level poverty, were the patient characteristics most strongly associated with lower receipt of guideline-concordant therapy, whereas Appalachian residence was not a barrier. Findings support targeted interventions addressing insurance-related and poverty-related barriers to lung cancer care in high-poverty communities regardless of geographic designation.