Disparities in lung cancer screening may persist despite revisions to USPSTF guideline
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A revised U.S. Preventive Services Task Force guideline could lead to increased lung cancer screening rates among women and racial and ethnic minority populations, according to a study published in JAMA Network Open.
However, without tailored criteria, the odds of eligibility for screening may remain low for women, as well as for Black or Hispanic individuals, researchers wrote.
“Lung cancer incidence and mortality disproportionately affect women and racial and ethnic minority populations, yet screening guidelines for the past several years were derived from clinical trials of predominately white men,” Thomas J. Reese, PharmD, PhD, researcher in the department of biomedical informatics at The University of Utah, and colleagues wrote. “To reflect current evidence, the USPSTF has revised the eligibility criteria, which may help to ameliorate sex- and race/ethnicity-related disparities in lung cancer screening.”
The draft USPSTF criteria, issued last year, lowered the age for individuals with a smoking history to begin annual screening — from age 55 years to 50 years — and reduced smoking pack-year eligibility from 30 pack-years to 20 pack-years.
For the cross-sectional study, researchers used data from the CDC’s Behavioral Risk Factor Surveillance System for 2017 and 2018 on 40,869 individuals (mean age, 64.6 years; 52% women) with a smoking history. The majority (81.5%) were white, followed by Black (8.4%) and Hispanic (3%).
Researchers compared the original USPSTF guideline criteria with the revised criteria and found that the proportion of individuals eligible for screening increased by 30.3% for men (29.4% to 38.3%), 40.5% for women (25.9% to 36.4%), 31.9% for white individuals (31.1% to 40.9%), 76.7% for Black individuals (16.3% to 28.8%) and 78.1% for Hispanic individuals (10.5% to 18.7%; P < .001 for all).
However, women had lower odds of screening eligibility than men (adjusted OR [aOR] = 0.88; 95% CI, 0.79-0.99). In addition, the odds of eligibility were lower for Black individuals (aOR = 0.43; 95% CI, 0.33-0.56) and Hispanic individuals (aOR = 0.7; 95% CI, 0.62-0.8) than white individuals.
“Results from the present investigation suggest that Black and Hispanic smokers are likely to continue to be underrepresented among individuals eligible for lung cancer screening, despite data suggesting that the risk for lung cancer is equivalent to or greater than that of white smokers,” Reese and colleagues wrote. “Data indicate that Black smokers are at significantly higher risk for lung cancer at all levels of smoking to up to 30 cigarettes per day, at which point the difference is no longer significant.”
The researchers suggested potential explanations for the disparity, including that Black smokers may take in more nicotine and carcinogens per cigarette compared with white smokers. Moreover, the nicotine and carcinogen exposure may be greater for smokers of menthol cigarettes, which Black smokers are more likely to use than white smokers, they wrote.
“Our results suggest that lung cancer screening inequity may persist or worsen for Hispanic individuals compared with white individuals,” Reese and colleagues wrote. “As such, simply raising or lowering the criteria based on age and smoking history are unlikely to have a meaningful effect on reducing inequities across racial/ethnic groups, and lung cancer screening criteria are likely to remain biased against Black and Hispanic smokers unless the criteria are adapted for different racial/ethnic groups.”
Perspective
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Rohit Kumar, MD
Although backed by good data for a decade now, screening for lung cancer continues to struggle with decreased implementation and widespread disparities, particularly based on sex and race. Over the last few years, many studies have shown disparities in screening among African Americans, other minorities and women, although these populations remain at higher risk for cancer with the same amount of smoking. Such evidence — along with newer data from European trials, NELSON in particular — has led the USPSTF to consider upgrading its recommendations to allow screening for individuals aged 50 years or older (previously 55) with a 20 pack-year tobacco exposure (previously 30).
The current JAMA study is among the first to provide evidence that adopting this strategy may reduce some of these disparities. In their cross-sectional survey study, Reese and colleagues showed that relaxing age and tobacco limits will increase the screen-eligible population of women, Black individuals and Hispanic individuals. However, compared with men and white individuals, the odds of eligibility for women and Black or Hispanic individuals remains low. The future will likely see tailored eligibility criteria using lung cancer risk-prediction models.
Reference:
De Koning HJ, et al. N Engl J Med. 2020;doi:10.1056/NEJMoa1911793.
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