Sex-Based Disparities in Interval Time to Receipt of Surgical Treatment of Invasive Lung Cancer in Tennessee

Sex-Based Disparities in Interval Time to Receipt of Surgical Treatment of Invasive Lung Cancer in Tennessee | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sex-Based Disparities in Interval Time to Receipt of Surgical Treatment of Invasive Lung Cancer in Tennessee Lohuwa Mamudu, Nathan Ballew, Alberto Murguia, Erasmus Tetteh-Bator, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8735381/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background The time from diagnosis to the receipt of definitive surgical treatment can impact patients’ survival. This study examines the sex-based disparities in the interval time to receipt of surgical treatment (ITRST) of invasive lung cancer (LC). Method We analyzed retrospective Tennessee Cancer Registry data from 12,113 invasive LC patients aged 18 years or older who received surgical treatment within 52 weeks of diagnosis from 2005 to 2015. Kruskal-Wallis tests were conducted to determine the difference in ITRST within and between groups. Adjusted multivariable Cox regression analyses were conducted to examine the independent variables associated with delayed ITRST of LC among males and females. Results There was a significant difference in ITRST between males and females. Decreased risk of delay ITRST was associated with increasing age among females (adjusted hazard ratio [aHR] = 0.59–0.70; p = 0.001–0.006), but not among males. Black patients were less likely to delay surgical treatment compared to Whites (aHR = 0.76–0.81; P < 0.001). Married patients―overall (aHR = 1.23, p < 0.001), males (aHR = 1.26, p < 0.001), and females (aHR = 1.19, p = 0.008) were more likely to delay surgery than unmarried patients. Appalachian patients (overall aHR = 1.06; p = 0.026) were more likely to delay surgery compared to non-Appalachian patients. Patients with public insurance―overall (aHR = 1.30, p < 0.001), males (aHR = 1.30, p = 0.023), and females (aHR = 1.28, p = 0.025) had an increased risk of delayed surgery than those with private insurance, compared to self-pay/uninsured. Conclusion Delayed ITRST for invasive LC is more likely among males, married patients, residents of the Appalachian region, and those with public insurance. Health interventions aimed at minimizing delays should target these populations to reduce disparities. Invasive Lung Cancer Surgical Treatment Treatment Delay Treatment Disparities Appalachian and non-Appalachian Tennessee Cancer Epidemiology 1. Introduction Lung cancer (LC) exhibits pronounced disparities in disease burden and treatment across demographic and socioeconomic groups, contributing to significant inequities in health outcomes 1 – 3 . Although the survival rates of LC have improved in recent years, it remains the leading cause of cancer deaths in the United States (US) for both men and women 4 – 6 . In 2023, approximately 131,584 people died from LC (25.7 females and 34.0 males per 100,000 population) 7 . Early treatment of LC has been associated with improved survival and quality of life, particularly for patients with small, localized tumors 8 – 10 . Unfortunately, most LC cases are identified at the advanced stage when the disease has metastasized, 11 which makes treatment options difficult and reduces patients’ chances of survival 9 . The existing evidence suggests that surgical treatment is the most effective treatment for LC in terms of improved survival, with the timeliness of treatment after diagnosis as a key predictor of surgical success and the likelihood of survival of LC 10,12 . Studies have shown that early treatment has a favorable prognosis and a higher likelihood of survival 12 , 13 . Delay in LC treatment has resulted in the progression or metastasis of the disease to other organs 14 . A systematic review of 65 studies reported that the median time from diagnosis to treatment initiation ranged from 6 to 45 days 15 . Because timely treatment of LC is essential for improving survival and quality of life, it is imperative to understand and address factors that influence the time from diagnosis to surgical treatment, particularly given that surgery remains the most effective curative option for LC. This can be the initial step towards improving the quality of life and survival of LC patients. However, not every patient has equal timely receipt of surgical treatment. Lisa et al. (2009) found that women were 25% less likely than men, and the black race were associated with 66% lower likelihood (compared to the white race) to receive timely surgical treatment 16 . Despite the lower percentage of surgeries performed on women, they have demonstrated to have higher rates of survival after receiving surgical treatment 8 . A study on outcome disparities after ambulatory surgical procedures reported that unexpected hospital admission or death were less likely to occur among women after all treatment examinations 3 . LC death rates also differ between men and women, with mortality rates of 44.5 per 100,000 persons and 30.7 per 100,000, respectively 17 . Prior research has demonstrated sex-based disparities between men and women in cancer incidence, treatment, and outcomes 18 – 20 . Moreover, studies have shown sex disparities in cancer trials, denoting men as more likely to be chosen and participate in cancer trial treatments 21 . Factors other than race and sex may be important influences on the delayed or intervaltime to receipt of surgical treatment (ITRST). Regional factors may be particularly relevant, as lung cancer (LC) incidence is higher in U.S. states with greater tobacco use. Tennessee exemplifies these regional variations in the prevalence of tobacco use 22 . Tennessee ranks fourth among U.S. states for lung cancer incidence, with a rate of 73 cases per 100,000 compared with the national rate of 57. However, despite this high disease burden, Tennessee is ranked 31st out of 49 states with a significantly lower rate of LC cases treated with surgery as the first course of treatment than the national rate (i.e., 19% versus 21%) 23 . Tennessee also exemplifies additional within-state regional variations, divided into Appalachian and non-Appalachian regions, with the Appalachian region often predominantly known to be represented by underserved and economically disadvantaged communities 24 , 25 . This study investigated sex disparities in ITRST for invasive LC among Tennessee residents, adjusting for known independent variables. The specific objective included: (1) Examine the differences in ITRST of invasive LC within and between males and females. (2) Assess the likelihood of delay in ITRST of invasive LC among males and females. We hypothesize that disparity exists in the surgical treatment of LC by sex. This study is significant for addressing a critical gap in cancer care equity, clarifying sex-based differences, and identifying modifiable factors among LC patients in Tennessee, thereby enabling the redesign of effective sex-targeted treatment interventions, clinical guidelines, care pathways, and public awareness and education efforts. 2. Method and Materials 2.1 Data Source and Study Population Tennessee Cancer Registry (TCR) data were obtained from all Tennessee residents who were diagnosed with histologically confirmed LC as the primary site (C340-349) of diagnosis and histological type 8000–9053 codes by the international Classification of Diseases (ICD) for Oncology, Third Edition (ICD-O-3) from January 1, 2005 to December 31, 2015. TCR collects and uses these data for epidemiological research of cancer in Tennessee 26 . The data consisted of 13,189 LC patients who underwent surgical treatment after diagnosis. In this study, we included 12,113 (92%) individuals who received surgery after being diagnosed with invasive (malignant) LC at the localized, regional, or distant stage. We excluded 1,076 (8%) individuals with non-invasive LC, unknown LC stage, or having missing data of any variable of interest using the listwise deletion method. The proportion of excluded cases was relatively small (< 10%), reducing the likelihood of substantial selection bias due to listwise deletion. Data used in this study are restricted but available upon request to the Tennessee Department of Health- TCR 27 . All files are accessible with a reasonable request and approval from the department. The study protocol was approved by the Tennessee Department of Health Institutional Review Board (IRB) on February 1, 2018 (TDH-IRB 1057486) with continuation approval on August 8, 2021 (TDH-IRB 2020 − 0152). The National Institutes of Health (NIH) – Intramural Research Program IRB – Human Research Protections Program – Office of Human Subjects Research Protections determined that the research protocol for this study did not involve human subjects, and thus was exempt from IRB review (18-NIMHD-00722). 2.2 Measures 2.2.1 Outcome Variable The outcome variable for this study was the interval time to receipt of surgical treatment (ITRST) in weeks. The ITSRT, defined as the time from diagnosis to the receipt of definitive surgical treatment. The time from diagnosis to the receipt of surgical treatment was measured as the median time to definitive surgical treatment (in weeks) 28 ; with a surgical treatment delay defined as > 3.4 weeks (i.e., surgical treatment delay 15 ). This threshold aligns with prior studies evaluating the timeliness of lung cancer treatment and reflects clinically meaningful delays in initiating definitive surgical care 28 . 2.2.2 Exposure/Intervention (Surgical Treatment) Surgical treatment is the exposure or intervention given to the invasive LC patients in this study. The different surgical treatments included: Local tumor destruction or excision, NOS (not otherwise specified)”; Laser ablation or cryosurgery; Electrocautery, fulguration (includes use of hot forceps for tumor destruction) 1 ; Excision or resection of less than one lobe, NO 2 ; Excision, NOS 2 ; wedge resection 2 ; Laser excision 2 ; Segmental resection, including lingulentomy 2 ; Resection of [at least one] lobe or bilobectomy, but less than the whole lung (partial pneumonectomy, NOS); Lobectomy with mediastinal lymph node dissection; Lobe or bilobectomy extended NOS; Lobe or bilobectomy with chest wall; Lobe or bilobectomy with pericardium; Lobe or bilobectomy with diaphragm; Pneumonectomy, NOS; Pneumonectomy with mediastinal lymph node dissection (radical pneumonectomy); Extended pneumonectomy; Extended pneumonectomy plus pleura or diaphragm; Extended radical pneumonectomy; Resection of lung, NOS; and Surgery, NOS 9 , 23 . 2.2.3 Independent variables Covariates in this study included sex, age, race, marital status, region/country of residence, type of health insurance, and cancer stage. With reference to the National Institute of Health of Aging 29 , age was categorized into < 45; 45–54; 55–64; 65–74; and 75 + years; race was categorized as White, Black, and Other; marital status was categorized as single/never married; married/common law; divorced/separated; and widowed; the region of residence in Tennessee included non-Appalachian (has 43 counties) or Appalachian county (has 52 counties) 30 ; the health insurance status of the patient was classified into self-pay/uninsured, public insurance (i.e., Medicaid, Medicare, Indian Health Service, Veterans’ Affairs), or private insurance (i.e., fee for service, Health Maintenance Organization [HMO], Managed Care, and Preferred Provider Organization [PPO]); and the stages of cancer included the localized, regional, and distant stages. Ethical approval and consent to participate The research protocol was approved by the Tennessee Department of Health Institutional Review Board on February 1st, 2018 (TDH-IRB 1057486), with continuation approval on June 15, 2023 (TDH-IRB 2020 − 0152). The TDH IRB ensured that all human-related procedures were performed in accordance with relevant institutional guidelines and regulations. They obtained informed consent from all participants to participate in the data collection or, if participants were under 18, from a parent and/or legal guardian. The National Institutes of Health – Intramural Research Program IRB – Human Research Protections Program – Office of Human Subjects Research Protections determined that the research protocol for this study did not involve human subjects and was therefore exempt from IRB review (18-NIMHD-00722). The anonymized data was received from TDH on March 21, 2018. Thus, the data released by TDH for this study were de-identified. 2.3 Statistical Analysis The statistical analyses conducted in this study involved investigating the ITRST among patients diagnosed with invasive LC in Tennessee. Firstly, we assessed the distribution of the ITRST, estimating the median, IQR, and SD (see Table 1 ). Second, we stratified the analyses by sex (i.e., males and females) and generated descriptive statistics using frequencies and percentages to assess the sample characteristics of the subgroups of covariates (see Table 1 ). Third, with a skewed ITRST, we conducted a nonparametric Kruskal-Wallis test to examine the statistical difference in ITRST for invasive LC among the levels of the covariates within and between male and female subsamples (see Table 1 ). Lastly, we conducted multivariable Cox regression analyses for the general sample of invasive LC patients and the stratified sample of males and females to investigate the likelihood risk of ITRST beyond the median time of 3.4 weeks (i.e., delayed surgical treatment) (see Table 2 ). Cox proportional hazards regression models were fitted after confirming that the proportional hazards assumptions were satisfied 28 . The results from the statistical analyses are reported using adjusted hazard ratios (aHR) with 95% confidence interval (CI) and statistical significance at p ≤ 0.05. All these analyses are performed by IBM SPSS Statistics 28 Premium. Table 1 Descriptive Characteristics and Kruskal-Wallis Tests of Difference in Interval Time to Receipt of Surgical Treatment within and Between Males and Females (N = 12,113) Outcome/Dependent Variable Median IQR SD ITRST in weeks 3.4 0–6.4 5.0 Independent Variables Overall Sample [N = 12,113; 100%] Males [n = 6,416; 53%] Females [n = 5,697; 47%] Males Vs Females n (%) p-value n (%) p-value n (%) p-value p-value Age 0.004** 0.280 < 0.001*** < 45 269 (2.2) 108 (1.7) 161 (2.8) 0.029* 45–54 1,322 (10.9) 576 (9.0) 746 (13.1) 0.219 55–64 3,179 (26.2) 1,690 (26.3) 1,489 (26.1) 0.963 65–74 4,885 (40.3) 2,669 (41.6) 2,216 (38.9) 0.685 75+ 2,458 (20.3) 1,373 (21.4) 1,085 (19.0) 0.014** Race < 0.001*** 0.072 < 0.001*** White 10,885 (89.9) 5,811(90.6) 5,074 (89.1) 0.663 Black 1,138 (9.4) 5,66 (8.8) 572 (10.0) 0.020* Other 90 (0.7) 39 (0.6) 51 (0.9) 0.986 Marital Status < 0.001*** < 0.001*** < 0.001*** Single/Never Married 1,175 (9.7) 596 (9.3) 579 (10.2) 0.179 Married/Common Law 7,427 (61.3) 4,646 (72.4) 2781 (48.8) 0.640 Divorced/Separated 1,627 (13.4) 713 (11.1) 914 (16.0) 0.701 Widow 1,884 (15.6) 461 (7.2) 1423 (25.0) 0.482 County of Residence 0.509 .988 0.363 non-Appalachia 5,869 (48.5) 3039 (47.4) 2830 (49.7) 0.378 Appalachia 6,244 (51.5) 3377 (52.6) 2867 (50.3) 0.990 Health Insurance Type < 0.001*** 0.001*** < 0.001*** Self-Pay/Uninsured 315 (2.6) 159 (2.5) 156 (2.7) 0.509 Private 3,443 (28.4) 1796 (28.0) 1647 (28.9) 0.817 Public 8,355 (69.0) 4461 (69.5) 3894 (68.4) 0.437 Cancer Stage < 0.001*** < 0.001*** < 0.001*** Local 6,092 (50.3) 3045 (47.5) 3047 (53.5) 0.552 Regional 4,825 (39.8) 2681 (41.8) 2144 (37.6) 0.314 Distant 1,196 (9.9) 690 (10.8) 506 (8.9) 0.482 Time to Treatment Initiation \(\:\le\:3.4\) median weeks 5,277 (43.6) - 2795 (43.6) - 2482 (43.6) - - > 3.4 median weeks 6,836 (56.4) - 3621 (56.4) - 3215 (56.4) - - Note : Tennessee Cancer Registry Data from 2005–2015 was analyzed. Frequencies and statistical differences/variation in ITRST within and between group variables from Kruskal-Wallis are estimated from a sample of 12,113. household. Bold values: Statistical significance with *p < 0.05, **p < 0.01, ***p < 0.001. Abbreviation: ITRST =Interval time to receipt of surgical treatment; IQR =Interquartile range; SD =Standard deviation Table 2 Adjusted Multivariable Cox Regression of the Likelihood Risk of Delay in Interval Time to Receipt of Surgical Treatment Beyond 3.4 Median Weeks Model I – Overall Sample (N = 12,113) Model II – Male Sample (n = 6,416) Model III – Female Sample (n = 5,697) Independent Variables aHR (95% CI) p-value aHR (95% CI) p-value aHR (95% CI) p-value Age 0.010** 0.284 < 0.001 < 45 [Ref] - - - - - 45–54 0.83 (0.69-1.00) 0.052 0.98 (0.74–1.31) 0.905 0.70 (0.55–0.90) 0.006** 55–64 0.82 (.68-0.98) 0.032* 1.03 (0.78–1.36) 0.852 0.66 (0.52–0.84) < 0.001*** 65–74 0.86 (0.72–1.04) 0.110 1.10 (0.83–1.46) 0.495 0.68 (0.53–0.86) 0.002** 75+ 0.78 (0.65–0.94) 0.010* 1.03 (0.77–1.37) 0.839 0.59 (0.46–0.76) < 0.001*** Race < 0.001*** 0.003** < 0.001*** White [Ref] - - - - - Black 0.79 (0.73–0.86) < 0.001*** 0.81 (0.72–0.91) < 0.001*** 0.76 (0.68–0.86) < 0.001*** Other 0.94 (0.72–1.24) 0.678 0.89 (0.58–1.35) 0.574 0.95 (0.66–1.37) 0.801 Marital Status < 0.001*** < 0.001*** 0.005** Single/Never Married [Ref] - - - - - - Married/Common Law 1.23 (1.13–1.34) < 0.001*** 1.26 (1.12–1.42) < 0.001*** 1.19 (1.05–1.35) 0.008*** Divorced/Separated 1.03 (0.93–1.13) 0.615 1.02 (0.88–1.17) 0.843 1.03 (0.89–1.18) 0.726 Widowed 1.10 (0.99–1.22) 0.071 1.13 (0.96–1.34) 0.141 1.09 (0.95–1.25) 0.247 County of Residence non-Appalachian [Ref] - - - - - Appalachian 1.06 (1.01–1.11) 0.026* 1.05 (0.98–1.12) 0.134 1.06 (0.99–1.14) 0.109 Health Insurance Type < 0.001 < 0.001*** 0.031* Self-Pay/Uninsured [Ref] - - - - - Public 1.30 (1.12–1.52) < 0.001*** 1.30 (1.04–1.62) 0.023* 1.28 (1.03–1.58) 0.025* Private 1.14 (0.98–1.33) 0.093 1.09 (0.87–1.37) 0.452 1.17 (0.95–1.45) 0.143 Cancer Stage 0.233 0.356 0.719 Distant [Ref] - - - - - - Local 0.97 (0.88–1.06) 0.455 0.96 (0.85–1.08) 0.473 0.97 (0.84–1.12) 0.884 Regional 1.01 (0.92–1.11) 0.864 1.01 (0.89–1.13) 0.939 1.01 (0.87–1.17) 0.596 Note: Tennessee Cancer Registry Data from 2005–2015 was analyzed. Multivariate Cox Regression of the likelihood risk of ITRST beyond 3.4 median weeks Bold values: Statistical significance with *p < 0.05, **p < 0.01, ***p < 0.001. Abbreviation: ITRST =Interval time to receipt of surgical treatment; aHR = Adjusted hazard ratio; CI =Confidence interval; Ref =Reference group 3. Results 3.1 Sample Characteristics and Variation in Interval Time to Receipt of Surgical Treatment Within and Between Males and Females Subsamples Out of the total of 12,113 individuals who received surgical treatment for invasive LC, 53% were males and 47% were females. The median ITRST was 3.4 weeks (IQR = 0-6.4 weeks) with SD of 5.0 weeks. The majority of 56.4% of both subgroups of males and females received surgery after 3.4 weeks. Among the subgroups of males and females, most patients who underwent surgical treatment for invasive LC were aged 65–74 (males = 41.6% vs female = 38.9%), White (males = 90.6% vs female = 89.1%), married (males = 72.4% vs female = 48.8%), lived in the Appalachian Tennessee (males = 52.6% vs female = 50.3%), had public health insurance (males = 69.5% vs female = 68.4%), and were diagnosed at the localized stage of the LC (males = 47.5.5% vs female = 53.5%). Also, there was a statistically significant difference in ITRST (p < 0.001) among the levels of marital status, health insurance, and stage of invasive in the overall sample and within the subsample of both males and females. Notably, Black patients demonstrated shorter ITRST compared to White patients in both the overall and sex-stratified analyses, an unexpected finding given prior literature and one that should be interpreted cautiously. While age and race showed significant differences in the overall sample and among female patients, these differences were not significant among male patients. In addition, there was a statistically significant difference in ITRST between the male and female subsamples of age 75 years (p = 0.014), as well as among Blacks (p = 0.020) ( see Table 1 ). [ Insert Table 1 ] 3.2 Likelihood Risk of Delay in Interval Time to Receipt of Surgical Treatment for Invasive Lung Cancer in Tennessee Table 2 examined the association between covariates and delayed ITRST beyond 3.4 weeks within the overall population and by sex. In the overall population of patients who underwent surgery for invasive LC, those aged 55–64 and 75 + years and Blacks were significantly less likely at risk to experience delayed ITRST, i.e., 18% (aHR = 0.82; CI = 0.68–0.98; p = 0.032) and 22% (aHR = 0.78; CI = 0.65–0.94; p = 0.010) and 21% (aHR = 0.79; CI = 0.73–0.86; p < 0.001), respectively. On the other hand, patients who are married compared to single/never married (aHR = 1.23; CI = 1.13–1.34; p < 0.001), those living in Appalachian compared with non-Appalachian Tennessee (aHR = 1.06; CI = 1.01–1.11; p = 0.026), and those with public insurance coverage compared to self-pay/uninsured (aHR = 1.30; CI = 1.12–1.52; p < 0.001) were significantly more likely of delayed ITRST. Further, there were some differences in the likelihood of delayed ITRST beyond 3.4 weeks within the subsample population of males and females. Within the male subgroup, all the age groups showed an increased risk of delayed ITRST, except those aged 45–54 years, although none was statistically significant. Contrary to the male subsample, all the age groups among females were significantly less likely to experience ITRST beyond 3.4 weeks compared with their counterparts aged less than 45 years (aHR = 0.59–0.70; CI = 0.46–0.90; p = 0.001–0.006). Interestingly, among females, the likelihood of delayed ITRST decreased with aging. This pattern suggests a monotonic decrease in the likelihood of delayed surgical treatment with increasing age among female patients. Also, Black patients among both males (aHR = 0.81; CI = 0.72–0.91; p < 0.001) and females (aHR = 0.76; CI = 0.68–0.86; p < 0.001) were significantly less likely to delay ITRST beyond 3.4 weeks. In addition, patients who are married [male= (aHR = 1.26; CI = 1.12–1.42; p < 0.001) vs female= (aHR = 1.19; CI = 1.05–1.35; p = 0.008)] and those covered by public insurance [male= (aHR = 1.30; CI = 1.04–1.62; p = 0.023) vs female= (aHR = 1.28; CI = 1.03–1.58; p = 0.025)] had an increased likelihood of delay ITRST among both sexes. Moreover, in the overall population and within the subpopulations of male and female patients, those diagnosed with localized stage invasive LC had a decreased likelihood of delayed ITRST compared to patients with distant stage LC, while patients with regional stage invasive LC had a slightly increased likelihood; however, neither category was statistically significant ( see Table 2 ). [ Insert Table 2 ] 4. Discussion Surgical treatment continues to be one of the most recommended and effective forms of treatment for LC, producing favorable survival rates 31 , 32 . However, ITRST of LC among males and females in Tennessee was associated with several factors. In the overall sample, there was a significant difference in ITRST among the subsamples of age, race, marital status, health insurance, and cancer stage, but not region within the state. Additionally, there were several notable differences by sex in ITRST. Among the male subgroup, age, race, and county of residence did not show a significant difference. Also, between males and females, there was significant variation in ITRST among patients aged < 45 years, ≥ 75 years, and Blacks. In addition, age, race, marital status, county of residence, and health insurance were significantly associated with ITRST beyond 3.4 weeks (i.e., delay surgical treatment) in the overall sample of invasive LC patients, which was the same for the female subgroup. But the male subgroup did not show significant association for age, county of residence, and cancer stage. Our findings showed a significant influence of age on ITRST in Tennessee, especially among females. Similar to our study, Cushman et al. (2021) determined age as a factor influencing delayed time to treatment among LC patients 33 . We found that LC patients aged ≥ 45 years had a decreased risk of delayed surgical treatment compared with those aged < 45 years in both the overall sample and the female subsample. This difference was not seen among the male subsample. The present finding about females contradicts the finding in a study by Shugarman et al.(2009), who reported a decreased likelihood of LC patients receiving appropriate and timely treatment as age increased 16 . But their finding is supported by our findings observed among the male patients. It is unclear why elderly females undergo timely surgical treatment for LC, but their male counterparts do not. Perhaps, this may explain why female LC patients often have better survival outcomes than males 34 . Raine et al (2010) found in a retrospective study that older females were more likely to be recommended for surgical resection than males 35 , which may explain why older females in this study are less likely to delay surgical treatment for invasive LC. Nevertheless, surgical resection for LC among elderly patients is associated with favorable survival, despite the increased operative risk 36 , and timely treatment further improves the survival rate 13 . Therefore, encouraging elderly men to receive timely surgical treatment for LC can improve their quality of life and survival. Additionally, we recommend further studies to understand why elderly males have an increased risk of late surgical treatment for invasive LC, even though they have a poorer prognosis effect 34 . Regarding race influence on ITRST, we found that Tennessee Black patients were 21% significantly less likely to receive surgical treatment beyond 3.4 weeks compared to Whites in the overall sample, 24% among Black females, and 19% among males. In addition, we found a significant difference in the ITRST between Black males and females, but not with Whites and other races. However, this finding differs from several prior studies reporting a lower likelihood of timely surgical treatment among Black patients 16 , 37 , 38 . The reasons for these contradictory findings among Tennessean LC patients are yet unknown. Nonetheless, multiple studies have demonstrated that Black patients are less likely to be recommended by a physician to undergo surgical treatment 39 – 42 , although they have a poorer prognosis of survival 43 . Racial disparities in treatment delay can be attributed to factors such as limited access to treatment or declining treatment due to personal beliefs or perceptions 44 , 45 . It is critical to address these issues to reduce treatment and survival disparities for invasive LC, especially among racial minorities. An intervention to combat these disparities would be to improve the healthcare workforce’s training on diversity and inclusion, enabling healthcare professionals to practice cultural humility/sensitivity to understand their patients’ cultures and values and work with them. Potential explanations for this finding may include differences in disease severity at presentation, referral urgency, provider decision-making, or unmeasured clinical factors not captured in registry data. Further investigation is needed to clarify these mechanisms. Our study also found that Tennessean LC patients who were married were more likely to be at risk for delayed ITRST after 3.4 weeks than unmarried LC patients, both in the overall sample and each of the stratified samples of males and females, with married men revealing a more increased risk of late surgical treatment. In contrast, previous studies found marriage to be a protective factor influencing treatment outcomes and survival rates for cancer patients 46 – 48 . A study by Wu et al. (2017) found that married cancer patients were more likely to receive surgical treatment compared to other marital status groups 47 , which may be explained by married couples having a more robust social support system, adhering to medical protocols, and other positive health behaviors 49 – 51 . Therefore, it would be fascinating to know in further research why married Tennessean invasive LC patients are more likely of delayed surgical treatment. Despite conflicting findings, several studies have reported marital status as an influential factor for lung cancer treatment and outcomes, with some disparities. Therefore, there is a need for interventions that focus on addressing these disparities. An intervention strategy focused on LC screening for all individuals regardless of marital status may improve the ITRST. Also, improving physicians’ understanding of varying social support systems outside of marriage can be a mitigating tool against delaying LC treatment. It has been suggested that physician bias towards unmarried patients could increase their likelihood of not receiving surgical treatment 50 . Hence, addressing this bias may lead to an improved ITRST and a favorable prognosis of LC survival for both sexes. Marriage may not uniformly translate into logistical or healthcare navigation support, particularly in rural or Appalachian settings where caregiving burden, transportation barriers, and healthcare access constraints may still contribute to treatment delays. Moreover, there was a significant association between ITRST and the Tennessee county/region of residence among the overall invasive LC patients, but not in the subgroup analysis of males and females. Our study revealed that LC patients living in Appalachian regions were 6% more likely to be at risk of delayed surgical treatment beyond 3.4 weeks after diagnosis. Although there are limited studies on surgical treatment for LC patients in the Appalachian regions, this finding in the present study is supported by Atkins et al. (2017), who reported region of residence as a contributing factor associated with LC treatment received 52 . Another study by Shugarman et al. (2011) did not find a link between the location of residence (urban vs. rural) and LC treatment and survival rates. However, it was found that rural residents were more likely to have lower socioeconomic status (SES), with limited access to healthcare services and resources 53 . Similarly, residents in Appalachian regions have also reported receiving less adequate healthcare and services compared to non-Appalachian residents 54 . This can probably cause a delay in the surgical treatment of LC patients in the Appalachian Tennessee. Therefore, improving the SES and health infrastructures of the Appalachian region can help improve the ITRST of LC in Tennessee. Another intervention is to maximize the utilization of telemedicine services when appropriate, which can be beneficial to speed up the timely receipt of LC surgical treatment. This can help improve the existing surgical treatment disparities affecting LC patients residing in Appalachian Tennessee. Additionally, health insurance had a significant influence on ITRST in the present study. There was a significantly higher risk of delayed surgical treatment beyond 3.4 median weeks among LC patients with public insurance in the overall sample. This was similar for the separate analysis of males and females, although males had a slightly higher risk of delayed surgical treatment compared to females. Patients with private insurance had a less increased risk of delayed treatment than those with public insurance, compared to self-pay/uninsured patients, but not statistically significant. Consistent with our findings, Sean et al. (2018), using the National Cancer Database, found that early-stage LC patients with Medicaid were more likely to receive delayed surgical therapy than privately insured patients 55 . This may explain why LC patients with private insurance are reported to have improved overall survival than those with public insurance or uninsured 56 . Previous studies have also reported that uninsured and publicly insured patients are less likely to be recommended for surgical procedures than those with private insurance 57 , 58 . Some suggested reasons for delay in surgical treatment among patients with public insurance have been associated with long waiting times due to inadequate providers and low reimbursement levels, and the high cost of pre- and post-surgery medications 59 , 60 . The reason why both public and private insurance LC patients have a higher risk of delayed surgical treatment among Tennesseans warrants further studies. Meanwhile, increasing the number of public insurance providers and speeding up funds disbursements may help reduce the time patients wait to receive surgical treatment for LC, which can result in improved quality of life and survival. Furthermore, cancer stage was not found to significantly influence delayed ITRST for invasive LC in the present study, which was consistent in the overall sample and the subsample of males and females. This finding mirrors that of Billings & Wells (1996), who found that treatment delay was not associated with tumor stage in a study on LC patients who underwent surgical resection 61 . Despite the lack of correlation between cancer stage and ITRST, a prior study has suggested that more advanced stages of LC were associated with shorter treatment delay due to the urgent state and progression of the disease 62 . Interestingly, several studies have also found a correlation between shorter time to treatment and poorer prognosis and survival rates 38 , 63 – 66 . Additionally, Bullard et al. (2017) reported that receiving timely treatment was not associated with increased survival time of LC at the local, regional, or distant stage 67 . The inconsistency in findings suggests that further research is needed to better understand the link between cancer stage and ITRST and how it impacts patients’ survival. Regardless, reducing the time to treatment can improve survival rates for LC patients, especially at the early stage of the disease 38 , 64 – 66 . Therefore, reducing delays in surgical treatment for LC can be crucial to eliminating the risk of disease recurrence and worse prognosis and survival. Our findings are corroborated by previous studies, demonstrating minimal to no difference in time to treatment between male and female cancer patients 68 , 69 . However, when there was a difference, males tend to be at a higher risk than females for delayed surgical treatment for invasive LC. Despite the findings of our study, sex has played a role in other aspects of lung cancer treatment and survival 70 , 71 . Past studies have demonstrated sex as a factor associated with disparities in LC surgical treatment survival rates, with females having a post-surgical survival rate advantage over males 48 , 72 – 74 , and treatment delay may play a vital role in this relationship. Further research should be conducted to gain a better understanding of what causes the delay in surgical treatment for invasive LC within the subgroup factors identified in this study among both males and females, which is important to aid a more strategic and effective policy intervention towards improving treatment outcomes and survivorship. These findings suggest that delayed surgical treatment may partially contribute to observed sex differences in lung cancer survival, representing a testable hypothesis for future longitudinal and survival-focused studies. 5. Limitation The present study has some limitations. Several important factors or variables could influence the ITRST for invasive LC, which were not captured in this study. This is because we were limited by the available data collected by the TCR. The TCR data collected from 2005-15 did not have variables such as SES. Also, the delay in a recommended surgical treatment from diagnosis can occur in different forms, i.e., either patient delay or system delay. The different delays may present different risk factors. TCR data does not differentiate the kind of delay encountered by patients from diagnosis to treatment. The inability to distinguish between referral delays, system-level delays, and patient-driven delays limits more precise identification of intervention points. Additionally, the type of cancer, either small cell LC or non-small cell LC, may influence the delay time to receipt of surgical procedure, which was not included in the data we investigated. The Tennessee Cancer Registry also does not capture comorbidity burden, which may influence surgical candidacy and timing and could partially explain observed differences in ITRST. Furthermore, because this study is observational, the associations identified should not be interpreted as causal relationships but rather as indicators of potential disparities in access to or timing of surgical care. Notwithstanding the outlined limitations, the present study offers essential findings and evidence of disparities in the subject area of delay time to surgical treatment for invasive LC among Tennessean males and females, and the overall population. This is important for further studies or investigation, and policy intervention towards improving the quality of life and survival of individuals diagnosed with LC. 6. Conclusion In summary, it was found that increased risk of delayed time to surgical treatment was significantly associated with patients who were married, resided in the Appalachian County/region, and had public insurance. Whereas decreased risk of delayed time to surgical treatment was significantly associated with Black patients and those aged 45 years and above among the females. Generally, males were more at risk of delayed LC surgical treatment than females. This study provides additional knowledge on the subject of delay time to LC treatment and contributes to the overall understanding of mechanisms that influence the likelihood and disparities in delay surgical treatment of invasive LC, identifying potential targets for intervention to minimize the treatment delays and disparities. Declarations Data Availability Statement The datasets generated and/or analyzed during the current study are restricted and are not publicly available. However, a formal request can be made to the State of Tennessee Department of Health Policy, Planning and Assessment, Office of Cancer Surveillance, Tennessee Cancer Registry, Email: [email protected] . Clinical trial number Not applicable Acknowledgements The authors present deep gratitude to Dr. Faustine Williams of the Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health (ZIA MD000015) for their voluntary contributions that facilitated the conduct of this study. Author Contributions L.M. contributed to the Conceptualization, Methodology, Data Curation, Formal Analysis, Visualization, Validation, Software, Writing – Original Draft Preparation, Writing − Review & Editing, Project Administration, and Supervision. N.B. and A.M. contributed to the Conceptualization, Methodology, Data Curation, Formal Analysis, Visualization, Software, Writing – Original Draft Preparation, and Writing − Review & Editing. E.T-B. and M.M. contributed to Methodology, Visualization, Validation, Writing − Review & Editing. F.J.D. contributed to the Conceptualization, Visualization, Validation, Writing − Review & Editing. M.W., H.M.M. , S.S. ,and T.Q.A contributed to Methodology, Visualization, Validation, Writing − Review & Editing. Corresponding author: Lohuwa Mamudu, [email protected] Ethical Approval The research protocol was approved by the Tennessee Department of Health Institutional Review Board on February 1st, 2018 (TDH-IRB 1057486), with continuation approval on June 15, 2023 (TDH-IRB 2020-0152). The TDH IRB ensured that all human-related procedures were performed in accordance with relevant institutional guidelines and regulations. They obtained informed consent from all participants to participate in the data collection or, if participants were under 18, from a parent and/or legal guardian. The National Institutes of Health – Intramural Research Program IRB – Human Research Protections Program – Office of Human Subjects Research Protections determined that the research protocol for this study did not involve human subjects and therefore was exempt from IRB review (18-NIMHD-00722). The anonymized data was received from TDH on March 21, 2018. Thus, the data released by TDH for this study were de-identified. Consent to Participate Not applicable Consent to Publish Not applicable Funding Declaration No funding was received for this work. Competing Interests The authors declare no competing interests. References Greenwald HP, Polissar NL, Borgatta EF, McCorkle R, Goodman G. Social factors, treatment, and survival in early-stage non-small cell lung cancer. Am J Public Health. 1998;88(11):1681–4. Lathan CS, Neville BA, Earle CC. The effect of race on invasive staging and surgery in non–small-cell lung cancer. J Clin Oncol. 2006;24(3):413–8. Menachemi N, Chukmaitov A, Brown LS, Saunders C, Brooks RG. Quality of care differs by patient characteristics: outcome disparities after ambulatory surgical procedures. Am J Med Qual. 2007;22(6):395–401. Xia W, Yu X, Mao Q, et al. Improvement of survival for non-small cell lung cancer over time. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8735381","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":609065075,"identity":"d608ebcf-3caa-47c9-89f2-a9da2ae2a2af","order_by":0,"name":"Lohuwa Mamudu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYBACPgYeMC3H3sDceAAmKoFPCxtUizHPAcYGoBYD4rUk9hCvhb33mDRPzbb0HonEhgMf9/yRM2dgPnibB58WnnNp0jzHbueCtByc8czA2LKBLdkarxaJHDPpHLbbufuBWg7zHDBI3HCAx0yasJZ/t9N5QFr+gLXwfyOsJbftdgJYCwPEFjb8WnjOGFv/7btt2MPzsOFgzwFjY4PDbMaWc/Bo4WfvMbw549tteR725IMPfhyQkzM43vzwxhs8WrAAZtKUj4JRMApGwSjAAgCtm0wRA/dybwAAAABJRU5ErkJggg==","orcid":"","institution":"California State University, Fullerton","correspondingAuthor":true,"prefix":"","firstName":"Lohuwa","middleName":"","lastName":"Mamudu","suffix":""},{"id":609065076,"identity":"4a98da33-6169-4d2e-9510-a5f435059ed4","order_by":1,"name":"Nathan Ballew","email":"","orcid":"","institution":"California State University, Fullerton","correspondingAuthor":false,"prefix":"","firstName":"Nathan","middleName":"","lastName":"Ballew","suffix":""},{"id":609065077,"identity":"36182fe9-6ec6-417f-8af2-0e8c3c8e5587","order_by":2,"name":"Alberto Murguia","email":"","orcid":"","institution":"California State University, Fullerton","correspondingAuthor":false,"prefix":"","firstName":"Alberto","middleName":"","lastName":"Murguia","suffix":""},{"id":609065078,"identity":"d787de3a-b6d2-4132-869b-816205498e17","order_by":3,"name":"Erasmus Tetteh-Bator","email":"","orcid":"","institution":"Jackson State University","correspondingAuthor":false,"prefix":"","firstName":"Erasmus","middleName":"","lastName":"Tetteh-Bator","suffix":""},{"id":609065079,"identity":"6db786df-278d-40b6-8c2b-b8072b8cc1f2","order_by":4,"name":"Mohammad Masum","email":"","orcid":"","institution":"San Jose State University","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"","lastName":"Masum","suffix":""},{"id":609065080,"identity":"8909c690-db3e-4bf5-b283-691944f22816","order_by":5,"name":"Fortenberry J. Dennis","email":"","orcid":"","institution":"Indiana University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Fortenberry","middleName":"J.","lastName":"Dennis","suffix":""},{"id":609065081,"identity":"05fc2432-1dc4-495c-864c-b75b69ca8c59","order_by":6,"name":"Martin Whiteside","email":"","orcid":"","institution":"Tennessee Cancer Registry","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Whiteside","suffix":""},{"id":609065082,"identity":"ee94d8fa-0083-47be-a4f5-39ed954e9c00","order_by":7,"name":"Hadii M. Mamudu","email":"","orcid":"","institution":"East Tennessee State University","correspondingAuthor":false,"prefix":"","firstName":"Hadii","middleName":"M.","lastName":"Mamudu","suffix":""},{"id":609065083,"identity":"90939911-9287-4b0f-a492-440dc973b377","order_by":8,"name":"Saanie Sulley","email":"","orcid":"","institution":"National Healthy Start Association","correspondingAuthor":false,"prefix":"","firstName":"Saanie","middleName":"","lastName":"Sulley","suffix":""},{"id":609065084,"identity":"20d7ee61-87b7-47a3-ad84-c98a81b29fe5","order_by":9,"name":"Theophilus Q. Asenso","email":"","orcid":"","institution":"Oslo University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Theophilus","middleName":"Q.","lastName":"Asenso","suffix":""}],"badges":[],"createdAt":"2026-01-29 22:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8735381/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8735381/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105562713,"identity":"aed36264-239c-4518-ab6d-3dc1c03a5520","added_by":"auto","created_at":"2026-03-27 12:44:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1455129,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8735381/v1/039b2f55-b893-4744-acc0-839afe867ae0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sex-Based Disparities in Interval Time to Receipt of Surgical Treatment of Invasive Lung Cancer in Tennessee","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eLung cancer (LC) exhibits pronounced disparities in disease burden and treatment across demographic and socioeconomic groups, contributing to significant inequities in health outcomes\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Although the survival rates of LC have improved in recent years, it remains the leading cause of cancer deaths in the United States (US) for both men and women\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. In 2023, approximately 131,584 people died from LC (25.7 females and 34.0 males per 100,000 population)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Early treatment of LC has been associated with improved survival and quality of life, particularly for patients with small, localized tumors\u003csup\u003e\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Unfortunately, most LC cases are identified at the advanced stage when the disease has metastasized,\u003csup\u003e11\u003c/sup\u003e which makes treatment options difficult and reduces patients\u0026rsquo; chances of survival\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe existing evidence suggests that surgical treatment is the most effective treatment for LC in terms of improved survival, with the timeliness of treatment after diagnosis as a key predictor of surgical success and the likelihood of survival of LC\u003csup\u003e10,12\u003c/sup\u003e. Studies have shown that early treatment has a favorable prognosis and a higher likelihood of survival\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Delay in LC treatment has resulted in the progression or metastasis of the disease to other organs\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. A systematic review of 65 studies reported that the median time from diagnosis to treatment initiation ranged from 6 to 45 days\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Because timely treatment of LC is essential for improving survival and quality of life, it is imperative to understand and address factors that influence the time from diagnosis to surgical treatment, particularly given that surgery remains the most effective curative option for LC. This can be the initial step towards improving the quality of life and survival of LC patients.\u003c/p\u003e \u003cp\u003eHowever, not every patient has equal timely receipt of surgical treatment. Lisa et al. (2009) found that women were 25% less likely than men, and the black race were associated with 66% lower likelihood (compared to the white race) to receive timely surgical treatment \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Despite the lower percentage of surgeries performed on women, they have demonstrated to have higher rates of survival after receiving surgical treatment\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. A study on outcome disparities after ambulatory surgical procedures reported that unexpected hospital admission or death were less likely to occur among women after all treatment examinations\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. LC death rates also differ between men and women, with mortality rates of 44.5 per 100,000 persons and 30.7 per 100,000, respectively\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Prior research has demonstrated sex-based disparities between men and women in cancer incidence, treatment, and outcomes\u003csup\u003e\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Moreover, studies have shown sex disparities in cancer trials, denoting men as more likely to be chosen and participate in cancer trial treatments\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFactors other than race and sex may be important influences on the delayed or intervaltime to receipt of surgical treatment (ITRST). Regional factors may be particularly relevant, as lung cancer (LC) incidence is higher in U.S. states with greater tobacco use. Tennessee exemplifies these regional variations in the prevalence of tobacco use\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Tennessee ranks fourth among U.S. states for lung cancer incidence, with a rate of 73 cases per 100,000 compared with the national rate of 57. However, despite this high disease burden, Tennessee is ranked 31st out of 49 states with a significantly lower rate of LC cases treated with surgery as the first course of treatment than the national rate (i.e., 19% versus 21%)\u003csup\u003e23\u003c/sup\u003e. Tennessee also exemplifies additional within-state regional variations, divided into Appalachian and non-Appalachian regions, with the Appalachian region often predominantly known to be represented by underserved and economically disadvantaged communities\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. This study investigated sex disparities in ITRST for invasive LC among Tennessee residents, adjusting for known independent variables. The specific objective included: (1) Examine the differences in ITRST of invasive LC within and between males and females. (2) Assess the likelihood of delay in ITRST of invasive LC among males and females. We hypothesize that disparity exists in the surgical treatment of LC by sex. This study is significant for addressing a critical gap in cancer care equity, clarifying sex-based differences, and identifying modifiable factors among LC patients in Tennessee, thereby enabling the redesign of effective sex-targeted treatment interventions, clinical guidelines, care pathways, and public awareness and education efforts.\u003c/p\u003e"},{"header":"2. Method and Materials","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Data Source and Study Population\u003c/h2\u003e \u003cp\u003eTennessee Cancer Registry (TCR) data were obtained from all Tennessee residents who were diagnosed with histologically confirmed LC as the primary site (C340-349) of diagnosis and histological type 8000\u0026ndash;9053 codes by the international Classification of Diseases (ICD) for Oncology, Third Edition (ICD-O-3) from January 1, 2005 to December 31, 2015. TCR collects and uses these data for epidemiological research of cancer in Tennessee\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. The data consisted of 13,189 LC patients who underwent surgical treatment after diagnosis. In this study, we included 12,113 (92%) individuals who received surgery after being diagnosed with invasive (malignant) LC at the localized, regional, or distant stage. We excluded 1,076 (8%) individuals with non-invasive LC, unknown LC stage, or having missing data of any variable of interest using the listwise deletion method. The proportion of excluded cases was relatively small (\u0026lt;\u0026thinsp;10%), reducing the likelihood of substantial selection bias due to listwise deletion. Data used in this study are restricted but available upon request to the Tennessee Department of Health- TCR\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. All files are accessible with a reasonable request and approval from the department. The study protocol was approved by the Tennessee Department of Health Institutional Review Board (IRB) on February 1, 2018 (TDH-IRB 1057486) with continuation approval on August 8, 2021 (TDH-IRB 2020\u0026thinsp;\u0026minus;\u0026thinsp;0152). The National Institutes of Health (NIH) \u0026ndash; Intramural Research Program IRB \u0026ndash; Human Research Protections Program \u0026ndash; Office of Human Subjects Research Protections determined that the research protocol for this study did not involve human subjects, and thus was exempt from IRB review (18-NIMHD-00722).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Measures\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 Outcome Variable\u003c/h2\u003e \u003cp\u003eThe outcome variable for this study was the interval time to receipt of surgical treatment (ITRST) in weeks. The ITSRT, defined as the time from diagnosis to the receipt of definitive surgical treatment. The time from diagnosis to the receipt of surgical treatment was measured as the median time to definitive surgical treatment (in weeks)\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e; with a surgical treatment delay defined as \u0026gt;\u0026thinsp;3.4 weeks (i.e., surgical treatment delay\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e). This threshold aligns with prior studies evaluating the timeliness of lung cancer treatment and reflects clinically meaningful delays in initiating definitive surgical care\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Exposure/Intervention (Surgical Treatment)\u003c/h2\u003e \u003cp\u003eSurgical treatment is the exposure or intervention given to the invasive LC patients in this study. The different surgical treatments included: Local tumor destruction or excision, NOS (not otherwise specified)\u0026rdquo;; Laser ablation or cryosurgery; Electrocautery, fulguration (includes use of hot forceps for tumor destruction)\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e; Excision or resection of less than one lobe, NO\u003csup\u003e2\u003c/sup\u003e; Excision, NOS\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e; wedge resection\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e; Laser excision\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e; Segmental resection, including lingulentomy\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e; Resection of [at least one] lobe or bilobectomy, but less than the whole lung (partial pneumonectomy, NOS); Lobectomy with mediastinal lymph node dissection; Lobe or bilobectomy extended NOS; Lobe or bilobectomy with chest wall; Lobe or bilobectomy with pericardium; Lobe or bilobectomy with diaphragm; Pneumonectomy, NOS; Pneumonectomy with mediastinal lymph node dissection (radical pneumonectomy); Extended pneumonectomy; Extended pneumonectomy plus pleura or diaphragm; Extended radical pneumonectomy; Resection of lung, NOS; and Surgery, NOS \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.2.3 Independent variables\u003c/h2\u003e \u003cp\u003eCovariates in this study included sex, age, race, marital status, region/country of residence, type of health insurance, and cancer stage. With reference to the National Institute of Health of Aging\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, age was categorized into \u0026lt;\u0026thinsp;45; 45\u0026ndash;54; 55\u0026ndash;64; 65\u0026ndash;74; and 75\u0026thinsp;+\u0026thinsp;years; race was categorized as White, Black, and Other; marital status was categorized as single/never married; married/common law; divorced/separated; and widowed; the region of residence in Tennessee included non-Appalachian (has 43 counties) or Appalachian county (has 52 counties)\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e; the health insurance status of the patient was classified into self-pay/uninsured, public insurance (i.e., Medicaid, Medicare, Indian Health Service, Veterans\u0026rsquo; Affairs), or private insurance (i.e., fee for service, Health Maintenance Organization [HMO], Managed Care, and Preferred Provider Organization [PPO]); and the stages of cancer included the localized, regional, and distant stages.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e \u003cp\u003eThe research protocol was approved by the Tennessee Department of Health Institutional Review Board on February 1st, 2018 (TDH-IRB 1057486), with continuation approval on June 15, 2023 (TDH-IRB 2020\u0026thinsp;\u0026minus;\u0026thinsp;0152). The TDH IRB ensured that all human-related procedures were performed in accordance with relevant institutional guidelines and regulations. They obtained informed consent from all participants to participate in the data collection or, if participants were under 18, from a parent and/or legal guardian. The National Institutes of Health \u0026ndash; Intramural Research Program IRB \u0026ndash; Human Research Protections Program \u0026ndash; Office of Human Subjects Research Protections determined that the research protocol for this study did not involve human subjects and was therefore exempt from IRB review (18-NIMHD-00722). The anonymized data was received from TDH on March 21, 2018. Thus, the data released by TDH for this study were de-identified. \u003cp\u003e2.3 Statistical Analysis\u003c/b\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe statistical analyses conducted in this study involved investigating the ITRST among patients diagnosed with invasive LC in Tennessee. Firstly, we assessed the distribution of the ITRST, estimating the median, IQR, and SD (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Second, we stratified the analyses by sex (i.e., males and females) and generated descriptive statistics using frequencies and percentages to assess the sample characteristics of the subgroups of covariates (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Third, with a skewed ITRST, we conducted a nonparametric Kruskal-Wallis test to examine the statistical difference in ITRST for invasive LC among the levels of the covariates within and between male and female subsamples (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Lastly, we conducted multivariable Cox regression analyses for the general sample of invasive LC patients and the stratified sample of males and females to investigate the likelihood risk of ITRST beyond the median time of 3.4 weeks (i.e., delayed surgical treatment) (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Cox proportional hazards regression models were fitted after confirming that the proportional hazards assumptions were satisfied\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. The results from the statistical analyses are reported using adjusted hazard ratios (aHR) with 95% confidence interval (CI) and statistical significance at p\u0026thinsp;\u0026le;\u0026thinsp;0.05. All these analyses are performed by IBM SPSS Statistics 28 Premium.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Characteristics and Kruskal-Wallis Tests of Difference in Interval Time to Receipt of Surgical Treatment within and Between Males and Females (N\u0026thinsp;=\u0026thinsp;12,113)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome/Dependent Variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eIQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eITRST in weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0\u0026ndash;6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIndependent Variables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOverall Sample\u003c/b\u003e\u003c/p\u003e \u003cp\u003e[N\u0026thinsp;=\u0026thinsp;12,113; 100%]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMales\u003c/b\u003e\u003c/p\u003e \u003cp\u003e[n\u0026thinsp;=\u0026thinsp;6,416; 53%]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003eFemales\u003c/b\u003e\u003c/p\u003e \u003cp\u003e[n\u0026thinsp;=\u0026thinsp;5,697; 47%]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eMales Vs Females\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.004**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e269 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e108 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e161 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.029*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u0026ndash;54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,322 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e576 (9.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e746 (13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.219\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e55\u0026ndash;64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,179 (26.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,690 (26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1,489 (26.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.963\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e65\u0026ndash;74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,885 (40.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,669 (41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2,216 (38.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.685\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e75+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,458 (20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,373 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1,085 (19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.014**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10,885 (89.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5,811(90.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5,074 (89.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.663\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,138 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5,66 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e572 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.020*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e51 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.986\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle/Never Married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,175 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e596 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e579 (10.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.179\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried/Common Law\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7,427 (61.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,646 (72.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2781 (48.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.640\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced/Separated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,627 (13.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e713 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e914 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.701\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,884 (15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e461 (7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1423 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.482\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCounty of Residence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.509\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.988\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.363\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enon-Appalachia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5,869 (48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3039 (47.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2830 (49.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.378\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppalachia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6,244 (51.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3377 (52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2867 (50.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.990\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth Insurance Type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-Pay/Uninsured\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e315 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e159 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e156 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.509\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,443 (28.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1796 (28.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1647 (28.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.817\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8,355 (69.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4461 (69.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3894 (68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.437\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCancer Stage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6,092 (50.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3045 (47.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3047 (53.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.552\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,825 (39.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2681 (41.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2144 (37.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.314\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,196 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e690 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e506 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.482\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime to Treatment Initiation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\le\\:3.4\\)\u003c/span\u003e\u003c/span\u003e median weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5,277 (43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2795 (43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2482 (43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; 3.4 median weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6,836 (56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3621 (56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3215 (56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNote\u003c/b\u003e: Tennessee Cancer Registry Data from 2005\u0026ndash;2015 was analyzed. Frequencies and statistical differences/variation in ITRST within and between group variables from Kruskal-Wallis are estimated from a sample of 12,113. household.\u003c/p\u003e \u003cp\u003eBold values: Statistical significance with *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003cp\u003eAbbreviation: ITRST =Interval time to receipt of surgical treatment; IQR =Interquartile range; SD =Standard deviation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdjusted Multivariable Cox Regression of the Likelihood Risk of Delay in Interval Time to Receipt of Surgical Treatment Beyond 3.4 Median Weeks\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eModel I \u0026ndash; Overall Sample (N\u0026thinsp;=\u0026thinsp;12,113)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eModel II \u0026ndash; Male Sample (n\u0026thinsp;=\u0026thinsp;6,416)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eModel III \u0026ndash; Female Sample (n\u0026thinsp;=\u0026thinsp;5,697)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndependent Variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaHR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eaHR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eaHR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.010**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 45 \u003cb\u003e[Ref]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u0026ndash;54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.83 (0.69-1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.98 (0.74\u0026ndash;1.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.905\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.70 (0.55\u0026ndash;0.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.006**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e55\u0026ndash;64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.82 (.68-0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.032*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.03 (0.78\u0026ndash;1.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.852\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.66 (0.52\u0026ndash;0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e65\u0026ndash;74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.86 (0.72\u0026ndash;1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.10 (0.83\u0026ndash;1.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.495\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.68 (0.53\u0026ndash;0.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.002**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e75+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.78 (0.65\u0026ndash;0.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.010*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.03 (0.77\u0026ndash;1.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.839\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.59 (0.46\u0026ndash;0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.003**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite \u003cb\u003e[Ref]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.79 (0.73\u0026ndash;0.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.81 (0.72\u0026ndash;0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.76 (0.68\u0026ndash;0.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.94 (0.72\u0026ndash;1.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.678\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.89 (0.58\u0026ndash;1.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.574\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.95 (0.66\u0026ndash;1.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.801\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.005**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle/Never Married \u003cb\u003e[Ref]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried/Common Law\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.23 (1.13\u0026ndash;1.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.26 (1.12\u0026ndash;1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.19 (1.05\u0026ndash;1.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.008***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced/Separated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.03 (0.93\u0026ndash;1.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.615\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.02 (0.88\u0026ndash;1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.843\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.03 (0.89\u0026ndash;1.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.726\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.10 (0.99\u0026ndash;1.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.13 (0.96\u0026ndash;1.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.09 (0.95\u0026ndash;1.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.247\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCounty of Residence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enon-Appalachian \u003cb\u003e[Ref]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppalachian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.06 (1.01\u0026ndash;1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.026*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.05 (0.98\u0026ndash;1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.06 (0.99\u0026ndash;1.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.109\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth Insurance Type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.031*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-Pay/Uninsured \u003cb\u003e[Ref]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.30 (1.12\u0026ndash;1.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.30 (1.04\u0026ndash;1.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.023*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.28 (1.03\u0026ndash;1.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.025*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.14 (0.98\u0026ndash;1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.09 (0.87\u0026ndash;1.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.17 (0.95\u0026ndash;1.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.143\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCancer Stage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.233\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.719\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistant \u003cb\u003e[Ref]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.97 (0.88\u0026ndash;1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.455\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.96 (0.85\u0026ndash;1.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.97 (0.84\u0026ndash;1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.884\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.01 (0.92\u0026ndash;1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.864\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.01 (0.89\u0026ndash;1.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.01 (0.87\u0026ndash;1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.596\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eNote: Tennessee Cancer Registry Data from 2005\u0026ndash;2015 was analyzed. Multivariate Cox Regression of the likelihood risk of ITRST beyond 3.4 median weeks\u003c/p\u003e \u003cp\u003eBold values: Statistical significance with *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003cp\u003eAbbreviation: ITRST =Interval time to receipt of surgical treatment; aHR\u0026thinsp;=\u0026thinsp;Adjusted hazard ratio; CI =Confidence interval; Ref =Reference group\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e \u003cb\u003e3.1 Sample Characteristics and Variation in Interval Time to Receipt of Surgical Treatment Within and Between Males and Females Subsamples\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOut of the total of 12,113 individuals who received surgical treatment for invasive LC, 53% were males and 47% were females. The median ITRST was 3.4 weeks (IQR\u0026thinsp;=\u0026thinsp;0-6.4 weeks) with SD of 5.0 weeks. The majority of 56.4% of both subgroups of males and females received surgery after 3.4 weeks. Among the subgroups of males and females, most patients who underwent surgical treatment for invasive LC were aged 65\u0026ndash;74 (males\u0026thinsp;=\u0026thinsp;41.6% vs female\u0026thinsp;=\u0026thinsp;38.9%), White (males\u0026thinsp;=\u0026thinsp;90.6% vs female\u0026thinsp;=\u0026thinsp;89.1%), married (males\u0026thinsp;=\u0026thinsp;72.4% vs female\u0026thinsp;=\u0026thinsp;48.8%), lived in the Appalachian Tennessee (males\u0026thinsp;=\u0026thinsp;52.6% vs female\u0026thinsp;=\u0026thinsp;50.3%), had public health insurance (males\u0026thinsp;=\u0026thinsp;69.5% vs female\u0026thinsp;=\u0026thinsp;68.4%), and were diagnosed at the localized stage of the LC (males\u0026thinsp;=\u0026thinsp;47.5.5% vs female\u0026thinsp;=\u0026thinsp;53.5%).\u003c/p\u003e \u003cp\u003eAlso, there was a statistically significant difference in ITRST (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) among the levels of marital status, health insurance, and stage of invasive in the overall sample and within the subsample of both males and females. Notably, Black patients demonstrated shorter ITRST compared to White patients in both the overall and sex-stratified analyses, an unexpected finding given prior literature and one that should be interpreted cautiously. While age and race showed significant differences in the overall sample and among female patients, these differences were not significant among male patients. In addition, there was a statistically significant difference in ITRST between the male and female subsamples of age\u0026thinsp;\u0026lt;\u0026thinsp;45 years (p\u0026thinsp;=\u0026thinsp;0.029) and \u0026gt;\u0026thinsp;75 years (p\u0026thinsp;=\u0026thinsp;0.014), as well as among Blacks (p\u0026thinsp;=\u0026thinsp;0.020) (\u003cb\u003esee\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e[\u003cb\u003eInsert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cb\u003e3.2 Likelihood Risk of Delay in Interval Time to Receipt of Surgical Treatment for Invasive Lung Cancer in Tennessee\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e examined the association between covariates and delayed ITRST beyond 3.4 weeks within the overall population and by sex. In the overall population of patients who underwent surgery for invasive LC, those aged 55\u0026ndash;64 and 75\u0026thinsp;+\u0026thinsp;years and Blacks were significantly less likely at risk to experience delayed ITRST, i.e., 18% (aHR\u0026thinsp;=\u0026thinsp;0.82; CI\u0026thinsp;=\u0026thinsp;0.68\u0026ndash;0.98; p\u0026thinsp;=\u0026thinsp;0.032) and 22% (aHR\u0026thinsp;=\u0026thinsp;0.78; CI\u0026thinsp;=\u0026thinsp;0.65\u0026ndash;0.94; p\u0026thinsp;=\u0026thinsp;0.010) and 21% (aHR\u0026thinsp;=\u0026thinsp;0.79; CI\u0026thinsp;=\u0026thinsp;0.73\u0026ndash;0.86; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), respectively. On the other hand, patients who are married compared to single/never married (aHR\u0026thinsp;=\u0026thinsp;1.23; CI\u0026thinsp;=\u0026thinsp;1.13\u0026ndash;1.34; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), those living in Appalachian compared with non-Appalachian Tennessee (aHR\u0026thinsp;=\u0026thinsp;1.06; CI\u0026thinsp;=\u0026thinsp;1.01\u0026ndash;1.11; p\u0026thinsp;=\u0026thinsp;0.026), and those with public insurance coverage compared to self-pay/uninsured (aHR\u0026thinsp;=\u0026thinsp;1.30; CI\u0026thinsp;=\u0026thinsp;1.12\u0026ndash;1.52; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significantly more likely of delayed ITRST.\u003c/p\u003e \u003cp\u003eFurther, there were some differences in the likelihood of delayed ITRST beyond 3.4 weeks within the subsample population of males and females. Within the male subgroup, all the age groups showed an increased risk of delayed ITRST, except those aged 45\u0026ndash;54 years, although none was statistically significant. Contrary to the male subsample, all the age groups among females were significantly less likely to experience ITRST beyond 3.4 weeks compared with their counterparts aged less than 45 years (aHR\u0026thinsp;=\u0026thinsp;0.59\u0026ndash;0.70; CI\u0026thinsp;=\u0026thinsp;0.46\u0026ndash;0.90; p\u0026thinsp;=\u0026thinsp;0.001\u0026ndash;0.006). Interestingly, among females, the likelihood of delayed ITRST decreased with aging. This pattern suggests a monotonic decrease in the likelihood of delayed surgical treatment with increasing age among female patients. Also, Black patients among both males (aHR\u0026thinsp;=\u0026thinsp;0.81; CI\u0026thinsp;=\u0026thinsp;0.72\u0026ndash;0.91; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and females (aHR\u0026thinsp;=\u0026thinsp;0.76; CI\u0026thinsp;=\u0026thinsp;0.68\u0026ndash;0.86; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significantly less likely to delay ITRST beyond 3.4 weeks. In addition, patients who are married [male= (aHR\u0026thinsp;=\u0026thinsp;1.26; CI\u0026thinsp;=\u0026thinsp;1.12\u0026ndash;1.42; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) vs female= (aHR\u0026thinsp;=\u0026thinsp;1.19; CI\u0026thinsp;=\u0026thinsp;1.05\u0026ndash;1.35; p\u0026thinsp;=\u0026thinsp;0.008)] and those covered by public insurance [male= (aHR\u0026thinsp;=\u0026thinsp;1.30; CI\u0026thinsp;=\u0026thinsp;1.04\u0026ndash;1.62; p\u0026thinsp;=\u0026thinsp;0.023) vs female= (aHR\u0026thinsp;=\u0026thinsp;1.28; CI\u0026thinsp;=\u0026thinsp;1.03\u0026ndash;1.58; p\u0026thinsp;=\u0026thinsp;0.025)] had an increased likelihood of delay ITRST among both sexes. Moreover, in the overall population and within the subpopulations of male and female patients, those diagnosed with localized stage invasive LC had a decreased likelihood of delayed ITRST compared to patients with distant stage LC, while patients with regional stage invasive LC had a slightly increased likelihood; however, neither category was statistically significant (\u003cb\u003esee\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e[\u003cb\u003eInsert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eSurgical treatment continues to be one of the most recommended and effective forms of treatment for LC, producing favorable survival rates\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. However, ITRST of LC among males and females in Tennessee was associated with several factors. In the overall sample, there was a significant difference in ITRST among the subsamples of age, race, marital status, health insurance, and cancer stage, but not region within the state. Additionally, there were several notable differences by sex in ITRST. Among the male subgroup, age, race, and county of residence did not show a significant difference. Also, between males and females, there was significant variation in ITRST among patients aged\u0026thinsp;\u0026lt;\u0026thinsp;45 years, \u0026ge;\u0026thinsp;75 years, and Blacks. In addition, age, race, marital status, county of residence, and health insurance were significantly associated with ITRST beyond 3.4 weeks (i.e., delay surgical treatment) in the overall sample of invasive LC patients, which was the same for the female subgroup. But the male subgroup did not show significant association for age, county of residence, and cancer stage.\u003c/p\u003e \u003cp\u003eOur findings showed a significant influence of age on ITRST in Tennessee, especially among females. Similar to our study, Cushman et al. (2021) determined age as a factor influencing delayed time to treatment among LC patients\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. We found that LC patients aged\u0026thinsp;\u0026ge;\u0026thinsp;45 years had a decreased risk of delayed surgical treatment compared with those aged\u0026thinsp;\u0026lt;\u0026thinsp;45 years in both the overall sample and the female subsample. This difference was not seen among the male subsample. The present finding about females contradicts the finding in a study by Shugarman et al.(2009), who reported a decreased likelihood of LC patients receiving appropriate and timely treatment as age increased\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. But their finding is supported by our findings observed among the male patients. It is unclear why elderly females undergo timely surgical treatment for LC, but their male counterparts do not. Perhaps, this may explain why female LC patients often have better survival outcomes than males\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. Raine et al (2010) found in a retrospective study that older females were more likely to be recommended for surgical resection than males\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e, which may explain why older females in this study are less likely to delay surgical treatment for invasive LC. Nevertheless, surgical resection for LC among elderly patients is associated with favorable survival, despite the increased operative risk\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e, and timely treatment further improves the survival rate\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Therefore, encouraging elderly men to receive timely surgical treatment for LC can improve their quality of life and survival. Additionally, we recommend further studies to understand why elderly males have an increased risk of late surgical treatment for invasive LC, even though they have a poorer prognosis effect\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRegarding race influence on ITRST, we found that Tennessee Black patients were 21% significantly less likely to receive surgical treatment beyond 3.4 weeks compared to Whites in the overall sample, 24% among Black females, and 19% among males. In addition, we found a significant difference in the ITRST between Black males and females, but not with Whites and other races. However, this finding differs from several prior studies reporting a lower likelihood of timely surgical treatment among Black patients\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. The reasons for these contradictory findings among Tennessean LC patients are yet unknown. Nonetheless, multiple studies have demonstrated that Black patients are less likely to be recommended by a physician to undergo surgical treatment\u003csup\u003e\u003cspan additionalcitationids=\"CR40 CR41\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e, although they have a poorer prognosis of survival\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. Racial disparities in treatment delay can be attributed to factors such as limited access to treatment or declining treatment due to personal beliefs or perceptions\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e,\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e. It is critical to address these issues to reduce treatment and survival disparities for invasive LC, especially among racial minorities. An intervention to combat these disparities would be to improve the healthcare workforce\u0026rsquo;s training on diversity and inclusion, enabling healthcare professionals to practice cultural humility/sensitivity to understand their patients\u0026rsquo; cultures and values and work with them. Potential explanations for this finding may include differences in disease severity at presentation, referral urgency, provider decision-making, or unmeasured clinical factors not captured in registry data. Further investigation is needed to clarify these mechanisms.\u003c/p\u003e \u003cp\u003eOur study also found that Tennessean LC patients who were married were more likely to be at risk for delayed ITRST after 3.4 weeks than unmarried LC patients, both in the overall sample and each of the stratified samples of males and females, with married men revealing a more increased risk of late surgical treatment. In contrast, previous studies found marriage to be a protective factor influencing treatment outcomes and survival rates for cancer patients\u003csup\u003e\u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e. A study by Wu et al. (2017) found that married cancer patients were more likely to receive surgical treatment compared to other marital status groups\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e, which may be explained by married couples having a more robust social support system, adhering to medical protocols, and other positive health behaviors\u003csup\u003e\u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e. Therefore, it would be fascinating to know in further research why married Tennessean invasive LC patients are more likely of delayed surgical treatment. Despite conflicting findings, several studies have reported marital status as an influential factor for lung cancer treatment and outcomes, with some disparities. Therefore, there is a need for interventions that focus on addressing these disparities. An intervention strategy focused on LC screening for all individuals regardless of marital status may improve the ITRST. Also, improving physicians\u0026rsquo; understanding of varying social support systems outside of marriage can be a mitigating tool against delaying LC treatment. It has been suggested that physician bias towards unmarried patients could increase their likelihood of not receiving surgical treatment\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e. Hence, addressing this bias may lead to an improved ITRST and a favorable prognosis of LC survival for both sexes. Marriage may not uniformly translate into logistical or healthcare navigation support, particularly in rural or Appalachian settings where caregiving burden, transportation barriers, and healthcare access constraints may still contribute to treatment delays.\u003c/p\u003e \u003cp\u003eMoreover, there was a significant association between ITRST and the Tennessee county/region of residence among the overall invasive LC patients, but not in the subgroup analysis of males and females. Our study revealed that LC patients living in Appalachian regions were 6% more likely to be at risk of delayed surgical treatment beyond 3.4 weeks after diagnosis. Although there are limited studies on surgical treatment for LC patients in the Appalachian regions, this finding in the present study is supported by Atkins et al. (2017), who reported region of residence as a contributing factor associated with LC treatment received\u003csup\u003e\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u003c/sup\u003e. Another study by Shugarman et al. (2011) did not find a link between the location of residence (urban vs. rural) and LC treatment and survival rates. However, it was found that rural residents were more likely to have lower socioeconomic status (SES), with limited access to healthcare services and resources\u003csup\u003e\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e. Similarly, residents in Appalachian regions have also reported receiving less adequate healthcare and services compared to non-Appalachian residents\u003csup\u003e\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e. This can probably cause a delay in the surgical treatment of LC patients in the Appalachian Tennessee. Therefore, improving the SES and health infrastructures of the Appalachian region can help improve the ITRST of LC in Tennessee. Another intervention is to maximize the utilization of telemedicine services when appropriate, which can be beneficial to speed up the timely receipt of LC surgical treatment. This can help improve the existing surgical treatment disparities affecting LC patients residing in Appalachian Tennessee.\u003c/p\u003e \u003cp\u003eAdditionally, health insurance had a significant influence on ITRST in the present study. There was a significantly higher risk of delayed surgical treatment beyond 3.4 median weeks among LC patients with public insurance in the overall sample. This was similar for the separate analysis of males and females, although males had a slightly higher risk of delayed surgical treatment compared to females. Patients with private insurance had a less increased risk of delayed treatment than those with public insurance, compared to self-pay/uninsured patients, but not statistically significant. Consistent with our findings, Sean et al. (2018), using the National Cancer Database, found that early-stage LC patients with Medicaid were more likely to receive delayed surgical therapy than privately insured patients\u003csup\u003e\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e. This may explain why LC patients with private insurance are reported to have improved overall survival than those with public insurance or uninsured\u003csup\u003e\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e. Previous studies have also reported that uninsured and publicly insured patients are less likely to be recommended for surgical procedures than those with private insurance\u003csup\u003e\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e,\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e. Some suggested reasons for delay in surgical treatment among patients with public insurance have been associated with long waiting times due to inadequate providers and low reimbursement levels, and the high cost of pre- and post-surgery medications\u003csup\u003e\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e,\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e. The reason why both public and private insurance LC patients have a higher risk of delayed surgical treatment among Tennesseans warrants further studies. Meanwhile, increasing the number of public insurance providers and speeding up funds disbursements may help reduce the time patients wait to receive surgical treatment for LC, which can result in improved quality of life and survival.\u003c/p\u003e \u003cp\u003eFurthermore, cancer stage was not found to significantly influence delayed ITRST for invasive LC in the present study, which was consistent in the overall sample and the subsample of males and females. This finding mirrors that of Billings \u0026amp; Wells (1996), who found that treatment delay was not associated with tumor stage in a study on LC patients who underwent surgical resection\u003csup\u003e\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u003c/sup\u003e. Despite the lack of correlation between cancer stage and ITRST, a prior study has suggested that more advanced stages of LC were associated with shorter treatment delay due to the urgent state and progression of the disease\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e. Interestingly, several studies have also found a correlation between shorter time to treatment and poorer prognosis and survival rates\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan additionalcitationids=\"CR64 CR65\" citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e. Additionally, Bullard et al. (2017) reported that receiving timely treatment was not associated with increased survival time of LC at the local, regional, or distant stage\u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e. The inconsistency in findings suggests that further research is needed to better understand the link between cancer stage and ITRST and how it impacts patients\u0026rsquo; survival. Regardless, reducing the time to treatment can improve survival rates for LC patients, especially at the early stage of the disease\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan additionalcitationids=\"CR65\" citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e. Therefore, reducing delays in surgical treatment for LC can be crucial to eliminating the risk of disease recurrence and worse prognosis and survival.\u003c/p\u003e \u003cp\u003eOur findings are corroborated by previous studies, demonstrating minimal to no difference in time to treatment between male and female cancer patients\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e. However, when there was a difference, males tend to be at a higher risk than females for delayed surgical treatment for invasive LC. Despite the findings of our study, sex has played a role in other aspects of lung cancer treatment and survival\u003csup\u003e\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e,\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e\u003c/sup\u003e. Past studies have demonstrated sex as a factor associated with disparities in LC surgical treatment survival rates, with females having a post-surgical survival rate advantage over males\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e,\u003cspan additionalcitationids=\"CR73\" citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e\u003c/sup\u003e, and treatment delay may play a vital role in this relationship. Further research should be conducted to gain a better understanding of what causes the delay in surgical treatment for invasive LC within the subgroup factors identified in this study among both males and females, which is important to aid a more strategic and effective policy intervention towards improving treatment outcomes and survivorship. These findings suggest that delayed surgical treatment may partially contribute to observed sex differences in lung cancer survival, representing a testable hypothesis for future longitudinal and survival-focused studies.\u003c/p\u003e"},{"header":"5. Limitation","content":"\u003cp\u003eThe present study has some limitations. Several important factors or variables could influence the ITRST for invasive LC, which were not captured in this study. This is because we were limited by the available data collected by the TCR. The TCR data collected from 2005-15 did not have variables such as SES. Also, the delay in a recommended surgical treatment from diagnosis can occur in different forms, i.e., either patient delay or system delay. The different delays may present different risk factors. TCR data does not differentiate the kind of delay encountered by patients from diagnosis to treatment. The inability to distinguish between referral delays, system-level delays, and patient-driven delays limits more precise identification of intervention points. Additionally, the type of cancer, either small cell LC or non-small cell LC, may influence the delay time to receipt of surgical procedure, which was not included in the data we investigated. The Tennessee Cancer Registry also does not capture comorbidity burden, which may influence surgical candidacy and timing and could partially explain observed differences in ITRST. Furthermore, because this study is observational, the associations identified should not be interpreted as causal relationships but rather as indicators of potential disparities in access to or timing of surgical care. Notwithstanding the outlined limitations, the present study offers essential findings and evidence of disparities in the subject area of delay time to surgical treatment for invasive LC among Tennessean males and females, and the overall population. This is important for further studies or investigation, and policy intervention towards improving the quality of life and survival of individuals diagnosed with LC.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eIn summary, it was found that increased risk of delayed time to surgical treatment was significantly associated with patients who were married, resided in the Appalachian County/region, and had public insurance. Whereas decreased risk of delayed time to surgical treatment was significantly associated with Black patients and those aged 45 years and above among the females. Generally, males were more at risk of delayed LC surgical treatment than females. This study provides additional knowledge on the subject of delay time to LC treatment and contributes to the overall understanding of mechanisms that influence the likelihood and disparities in delay surgical treatment of invasive LC, identifying potential targets for intervention to minimize the treatment delays and disparities.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are restricted and are not publicly available. However, a formal request can be made to the State of Tennessee Department of Health Policy, Planning and Assessment, Office of Cancer Surveillance, Tennessee Cancer Registry, Email: [email protected]. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAcknowledgements \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors present deep gratitude to Dr. Faustine Williams of the Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health (ZIA MD000015) for their voluntary contributions that facilitated the conduct of this study.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eL.M. \u003c/strong\u003econtributed to the Conceptualization, Methodology, Data Curation, Formal Analysis, Visualization, Validation, Software, Writing \u0026ndash; Original Draft Preparation, Writing \u0026minus; Review \u0026amp; Editing, Project Administration, and Supervision. \u003cstrong\u003eN.B. \u003c/strong\u003eand\u003cstrong\u003e A.M. \u003c/strong\u003econtributed to the Conceptualization, Methodology, Data Curation, Formal Analysis, Visualization, Software, Writing \u0026ndash; Original Draft Preparation, and Writing \u0026minus; Review \u0026amp; Editing. \u003cstrong\u003eE.T-B. \u003c/strong\u003eand \u003cstrong\u003eM.M. \u003c/strong\u003econtributed to Methodology, Visualization, Validation, Writing \u0026minus; Review \u0026amp; Editing. \u003cstrong\u003eF.J.D. \u003c/strong\u003econtributed to the Conceptualization, Visualization, Validation, Writing \u0026minus; Review \u0026amp; Editing. \u003cstrong\u003eM.W., H.M.M.\u003c/strong\u003e,\u003cstrong\u003e S.S.\u003c/strong\u003e,and\u003cstrong\u003e T.Q.A \u003c/strong\u003econtributed to Methodology, Visualization, Validation, Writing \u0026minus; Review \u0026amp; Editing.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCorresponding author: \u003c/strong\u003e\u003c/p\u003e\n\n\u003cp\u003eLohuwa Mamudu, [email protected] \u003c/p\u003e\n\n\n\u003cp\u003e\u003cstrong\u003eEthical Approval \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research protocol was approved by the Tennessee Department of Health Institutional Review Board on February 1st, 2018 (TDH-IRB 1057486), with continuation approval on June 15, 2023 (TDH-IRB 2020-0152). The TDH IRB ensured that all human-related procedures were performed in accordance with relevant institutional guidelines and regulations. They obtained informed consent from all participants to participate in the data collection or, if participants were under 18, from a parent and/or legal guardian. The National Institutes of Health \u0026ndash; Intramural Research Program IRB \u0026ndash; Human Research Protections Program \u0026ndash; Office of Human Subjects Research Protections determined that the research protocol for this study did not involve human subjects and therefore was exempt from IRB review (18-NIMHD-00722). The anonymized data was received from TDH on March 21, 2018. Thus, the data released by TDH for this study were de-identified. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\n\u003cp\u003eNot applicable\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent to Publish\u003c/strong\u003e\u003c/p\u003e\n\n\u003cp\u003eNot applicable\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\n\u003cp\u003eNo funding was received for this work.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGreenwald HP, Polissar NL, Borgatta EF, McCorkle R, Goodman G. Social factors, treatment, and survival in early-stage non-small cell lung cancer. 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Women With Pathologic Stage I, II, and III Non-small Cell Lung Cancer Have Better Survival Than Men. \u003cem\u003eChest\u003c/em\u003e. 2006/12/01/ 2006;130(6):1796\u0026ndash;1802. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1378/chest.130.6.1796\u003c/span\u003e\u003cspan address=\"10.1378/chest.130.6.1796\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Invasive Lung Cancer, Surgical Treatment, Treatment Delay, Treatment Disparities, Appalachian and non-Appalachian Tennessee, Cancer Epidemiology","lastPublishedDoi":"10.21203/rs.3.rs-8735381/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8735381/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe time from diagnosis to the receipt of definitive surgical treatment can impact patients\u0026rsquo; survival. This study examines the sex-based disparities in the interval time to receipt of surgical treatment (ITRST) of invasive lung cancer (LC).\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eWe analyzed retrospective Tennessee Cancer Registry data from 12,113 invasive LC patients aged 18 years or older who received surgical treatment within 52 weeks of diagnosis from 2005 to 2015. Kruskal-Wallis tests were conducted to determine the difference in ITRST within and between groups. Adjusted multivariable Cox regression analyses were conducted to examine the independent variables associated with delayed ITRST of LC among males and females.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThere was a significant difference in ITRST between males and females. Decreased risk of delay ITRST was associated with increasing age among females (adjusted hazard ratio [aHR]\u0026thinsp;=\u0026thinsp;0.59\u0026ndash;0.70; p\u0026thinsp;=\u0026thinsp;0.001\u0026ndash;0.006), but not among males. Black patients were less likely to delay surgical treatment compared to Whites (aHR\u0026thinsp;=\u0026thinsp;0.76\u0026ndash;0.81; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Married patients―overall (aHR\u0026thinsp;=\u0026thinsp;1.23, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), males (aHR\u0026thinsp;=\u0026thinsp;1.26, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and females (aHR\u0026thinsp;=\u0026thinsp;1.19, p\u0026thinsp;=\u0026thinsp;0.008) were more likely to delay surgery than unmarried patients. Appalachian patients (overall aHR\u0026thinsp;=\u0026thinsp;1.06; p\u0026thinsp;=\u0026thinsp;0.026) were more likely to delay surgery compared to non-Appalachian patients. Patients with public insurance―overall (aHR\u0026thinsp;=\u0026thinsp;1.30, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), males (aHR\u0026thinsp;=\u0026thinsp;1.30, p\u0026thinsp;=\u0026thinsp;0.023), and females (aHR\u0026thinsp;=\u0026thinsp;1.28, p\u0026thinsp;=\u0026thinsp;0.025) had an increased risk of delayed surgery than those with private insurance, compared to self-pay/uninsured.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDelayed ITRST for invasive LC is more likely among males, married patients, residents of the Appalachian region, and those with public insurance. Health interventions aimed at minimizing delays should target these populations to reduce disparities.\u003c/p\u003e","manuscriptTitle":"Sex-Based Disparities in Interval Time to Receipt of Surgical Treatment of Invasive Lung Cancer in Tennessee","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-20 15:15:38","doi":"10.21203/rs.3.rs-8735381/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-24T18:18:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-03T23:47:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-02T18:22:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"110123715547411549350029284177261669372","date":"2026-03-29T16:01:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"302412102431127577352919794819282302280","date":"2026-03-27T12:00:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"63564790443118308883927781277581991797","date":"2026-03-24T00:48:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-19T18:06:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186047727739671909019953588801310378299","date":"2026-03-18T15:31:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-18T10:34:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-26T05:19:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-25T07:06:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-21T18:29:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-02-21T18:13:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1a024562-73d7-42b5-8d44-491894f7f57b","owner":[],"postedDate":"March 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T14:08:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-20 15:15:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8735381","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8735381","identity":"rs-8735381","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}