Structural inequities in early-stage NSCLC care: How perioperative immunotherapy + SBRT trials reflect systemic barriers to precision oncology in marginalised populations
Original framing: “[Comment] Combining immunotherapy with stereotactic body radiation therapy in localised non-small-cell lung cancer” — The Lancet
The trial’s focus on 'medically inoperable' patients echoes historical patterns where surgical access was denied to marginalised groups—from the eugenics-era sterilisation policies targeting disabled women to the exclusion of Black patients from early lung cancer trials. The 'high-risk' designation itself is a modern iteration of medical gatekeeping, where insurance denials and hospital closures in predominantly Black neighbourhoods create the illusion of 'medical inoperability' rather than addressing root causes. Precedents like the 1970s 'War on Cancer' reveal how federal funding prioritised laboratory research over community-based screening, a dynamic that persists today in the form of SBRT’s high cost and limited availability. The trial’s silence on these historical mechanisms obscures how contemporary oncology reproduces structural inequities.
The SWOG/NRG S1914 trial’s framing of immunotherapy + SBRT as a technological breakthrough obscures how this intervention is embedded within a healthcare system shaped by historical inequities, structural barriers, and cross-cultural blind spots.
The 'high-risk' designation for 'medically inoperable' patients is not a clinical inevitability but a product of hospital consolidation, insurance gatekeeping, and environmental injustices—patterns traced back to eugenics-era policies and modern-day medical deserts. Indigenous knowledge systems, like smoke cleansing and herbal remedies, offer complementary approaches to lung cancer care that are entirely absent from the trial, yet could enhance patient-centred outcomes. Cross-culturally, countries like Japan and South Africa demonstrate that lung cancer care is more effective when integrated into universal healthcare systems or community-led advocacy, revealing how the USA’s fragmented model limits scalability. The trickster’s inversion exposes the absurdity of calling this a 'breakthrough' when it fails to reach those who need it most, while future modelling must account for climate change’s role in exacerbating lung cancer risks. Solutions must therefore combine structural equity audits for trials, integrative oncology models, and environmental justice-led prevention—approaches that treat the root causes of disease rather than its symptoms.