Race, Socioeconomic Status, and Survival: A Pathway Analysis in Metastatic Non-Small-Cell Lung Cancer

Purpose Black patients with advanced cancer experience persistent disparities in overall survival. We evaluated the sequential pathway linking race, neighborhood socioeconomic status (nSES), complexity of presentation at diagnosis, systemic treatment receipt, and survival. Methods We conducted a retrospective cohort analysis using the SEER-Medicare data (2016–2019) of Black and White patients aged ≥ 65 diagnosed with stage IV NSCLC. Pathway analysis was performed using a series of logistic, ordinal, and Cox proportional hazard models to assess how race interacts with nSES to influence comorbidity burden, stage at diagnosis, receipt of first-line systemic treatment, and mortality. Results Lower nSES was strongly associated with baseline comorbidity (low vs. high nSES: aOR = 1.59, 95% CI: 1.41–1.81). Non-receipt of systemic therapy was driven by low nSES (low nSES: aOR = 1.78, 95% CI: 1.55–2.05) and high comorbidity (NCI score \(\:>1\): aOR = 2.04, 95% CI: 1.79–2.33), rather than race independently (aOR = 1.11, p = 0.200). Non-treatment was the strongest predictor of overall mortality (aHR = 3.69, 95% CI: 3.46–3.92). In the fully adjusted model, the survival disparity for Black relative to White patients was attenuated (aHR = 0.95, 95% CI: 0.86–1.04, p = 0.300). Conclusion Observed survival disparities between Black and White patients were accounted for by sequential differences in nSES, complexity of presentation at diagnosis, and systemic treatment receipt. Policy interventions targeting upstream socioeconomic deprivations and supportive care models for complex patients are essential to achieve health equity.