USPSTF guideline revision could reduce racial disparity in lung cancer screening access
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The U.S. Preventive Services Task Force’s 2021 guideline for lung cancer screening improved upon previous fixed-screening criteria and may reduce racial disparities in access, according to a study published in JAMA Oncology.
The guideline changes broadened eligibility by lowering the smoking pack-years and age requirement for screening, compared with the 2013 USPSTF guidelines.
“Prior studies have already shown that African American individuals tend to have a lower smoking pack-year history but still have the same or higher lung cancer risk than white counterparts,” Chan Yeu Pu, MD, MS, assistant professor of medicine in the division of pulmonary, critical care and sleep medicine at Wayne State University School of Medicine, told Healio. “I wanted to see how much the 2021 UPSTF guidelines improved on the 2013 USPSTF guidelines, especially with the lowering of smoking pack-year requirement, which can mitigate the racial disparity above.”
Methodology
The analysis included 2,369 individuals aged between 21 and 89 years enrolled in the INHALE (Inflammation, Health, Ancestry, and Lung Epidemiology) study in the Detroit metropolitan area between May 15, 2012, and March 31, 2018. Of them, 912 had a lung cancer diagnosis (mean age, 63.7 years; 54% women; 69% white, 31% African American) and 1,457 served as lung cancer-free controls (mean age, 60.4 years; 55% women; 57% white, 43% African American).
Pu and colleagues assessed whether patients with lung cancer would have qualified for lung cancer screening using the 2013 and 2021 USPSTF guidelines, as well as the 2012 modification of the model from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCOm2012) screening criteria. Researchers defined sensitivity as percentage of patients with lung cancer who qualified for screening and specificity as the percentage of controls who did not qualify for screening.
Key findings
Results showed 590 patients with lung cancer (65%) as eligible for screening according to the 2021 USPSTF criteria, compared with 619 patients (68%) per the PLCOm2012 criteria and 445 patients (49%) per the 2013 USPSTF criteria. Additionally, the 2013 USPSTF criteria excluded 950 control participants (65%), whereas the PLCOm2012 criteria excluded 843 control participants (58%) and the 2021 USPSTF criteria excluded 709 control participants (49%).
In their comparison of racial subgroups, classified as white or African American, using 2013 USPSTF criteria, Pu and colleagues found significantly more white patients than African American patients with lung cancer (52% vs. 42%; P = .007) would have been eligible for screening. However, they reported no racial disparity when using 2021 USPSTF criteria (65% vs. 63%) and PLCOm2012 criteria (68% vs. 67%).
Further analyses revealed the 2013 USPSTF criteria excluded fewer white vs. African American control participants (61% vs. 70%). Again, researchers noted the absence of racial disparity when using 2021 USPSTF criteria (48% vs. 50%; P = .009) and the PLCOm2012 guidelines (57% vs. 60%).
Next steps
Study limitations included its retrospective nature, according to Pu and colleagues.
“Since my study was retrospective, I would like to see or take part in prospective studies evaluating racial disparities in lung cancer screening eligibility,” Pu told Healio.
A large, prospective trial with good racial representation would be a necessary next step to provide data on the benefits of screening African American individuals and to develop better guidelines, Pu and colleagues wrote.
Redefining screening criteria remains necessary and further research exploring all the risk factors for lung cancer — including genetic profiles, environmental exposures and vulnerable populations — is critical, Jonathan A. Nitz, MD, fellow at Fox Chase Cancer Center, and Cherie P. Erkmen, MD, professor of thoracic medicine and surgery at Lewis Katz School of Medicine at Temple University, wrote in a corresponding editorial.
"This study provides us with actionable information, affirming that adjustments to lung cancer screening criteria have the potential to mitigate disparity in screening and perhaps lung cancer outcomes. However, critical issues of low uptake of screening and inability to capture at-risk populations are unresolved and likely disproportionately affecting marginalized populations," they wrote.
References:
Pu CY, et al. JAMA Oncol. 2022;doi:10.1001/jamaoncol.2021.6720.
Nitz JA, et al. JAMA Oncol. 2022;doi:10.1001/jamaoncol.2021.6708.
For more information:
Chan Yeu Pu, MD, MS, can be reached at Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, 3990 John R St., Detroit, MI 48201; email: chanpu@med.wayne.edu.
Perspective
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Since the inception of lung cancer screening, ongoing studies have tried to address barriers and uptake of screening.
This study addresses an important question of racial disparities directly related to the eligibility criteria for screening. It has been observed that Black individuals who develop lung cancer are younger and have fewer pack-years of smoking exposure than white individuals. Hence, screening for a younger age group with less smoking exposure may be more inclusive of Black individuals.
In the current study’s cohort of patients with lung cancer, when applying the 2021 USPSTF criteria, 65% of white patients would have been selected vs. 63% of Black patients. This is a significant improvement compared with applying the 2013 criteria, through which 52% of white patients would be eligible vs. only 42% of Black patients.
The researchers also noted that the racial disparity is similarly mitigated even when using predictive models such as PLCOm2012; however, using the fixed-criteria model of the 2021 USPSTF guideline is perhaps more straightforward. It’s worth noting that although broadening the screening criteria will increase sensitivity of screening, it is likely to come at a cost of lower specificity, which means there are likely to be more individuals who would get unnecessary workup but may never develop lung cancer.
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