Outcomes From a Minority-Based Lung Cancer Screening Program vs the National Lung Screening Trial

Understanding the Social Risk Factors That Avert Equitable Lung Cancer Care

BACKGROUND

Lung cancer remains the leading cause of cancer death in the United States. There is an association between certain social determinants of health (SDOH) and adverse cancer outcomes. These include Black race and low-income, which are associated with poorer adherence to lung cancer screening and presentation at a later stage of disease.

METHODS

We conducted a retrospective review of all patients with a diagnosis of lung cancer at a single urban, academic center from 2015 to 2021. Demographic data including race and clinical data including time taken to progress through various checkpoints (ie, concerning CT scan to diagnosis, diagnosis to treatment) were collected. Income data was approximated based on population medians at patient's home address zip code.

RESULTS

A total of 550 patients were included in the final analysis. The study population was 57.4% Black and 61.2% of patients presenting with a household income of $40,000 US Dollars or lower based on approximated median household income. The time from CT scan to first treatment for the entire cohort was 121.3 days with no statistically significant variance by race. However, among patients presenting at stage IV, 72.7% were black and 76.0% resided in a zip code with a median income < $40,000.

CONCLUSIONS

This study demonstrated no significant delays in progressing through checkpoints of lung cancer diagnosis and treatment on the basis of race or income approximation. Black patients and patients in low-income households were diagnosed with lung cancer at a more advanced stage. Efforts to close the gap in lung cancer disparities should be focused on targeting screening and early identification toward social groups that may be at highest risk of late presentation. Institutional focus on patient navigation through these stages should be paramount.

TWEETABLE ABSTRACT

There were no delays in progression to lung cancer diagnostic and therapeutic milestones based on race or income approximation. Black race and residing in a low-income area are predictors for presenting at stage IV.

Disruptions in Lung Cancer Detection During COVID-19

Objective: To quantify the extent of the disruption and recovery of lung cancer detection during the first two years of the pandemic, focusing on disparities across demographic and community factors. Methods: This retrospective cohort study used the SEER database to identify lung cancer cases from 2001 to 2021. Expected incidence rates for 2020 and 2021 were projected based on pre-pandemic trends (2000-2019) using the NCI's Joinpoint Regression program. Percent differences between expected and observed incidence rates were calculated. Multivariate and propensity score analyses were conducted to quantify changes in the odds of being diagnosed with metastatic disease during the pandemic. Results: Lung cancer incidence fell by 10% in 2020 compared to pre-pandemic projections, with rural populations, non-Hispanic Black and Asian patients, and females disproportionately affected. By 2021, detection rates partially recovered but remained 5% below expected levels. Localized disease detection improved significantly, while rural communities not adjacent to metropolitan areas faced further declines. Adjusted analyses showed that patients with small-cell lung cancer (SCLC) and those of Hispanic, non-Hispanic Black, or Asian/Pacific Islander ethnicity had persistently higher rates of distant disease presentation through 2021. Conclusions: The pandemic significantly reduced lung cancer detection, with only partial recovery by 2021. Persistent gaps, particularly in rural and minoritized populations, highlight the need for targeted interventions to reengage these communities.

Disparities in Lung Cancer: A Targeted Literature Review Examining Lung Cancer Screening, Diagnosis, Treatment, and Survival Outcomes in the United States

BACKGROUND

Although incidence and mortality of lung cancer have been decreasing, health disparities persist among historically marginalized Black, Hispanic, and Asian populations. A targeted literature review was performed to collate the evidence of health disparities among these historically marginalized patients with lung cancer in the U.S.

METHODS

Articles eligible for review included 1) indexed in PubMed®, 2) English language, 3) U.S. patients only, 4) real-world evidence studies, and 5) publications between January 1, 2018, and November 8, 2021.

RESULTS

Of 94 articles meeting selection criteria, 49 publications were selected, encompassing patient data predominantly between 2004 and 2016. Black patients were shown to develop lung cancer at an earlier age and were more likely to present with advanced-stage disease compared to White patients. Black patients were less likely to be eligible for/receive lung cancer screening, genetic testing for mutations, high-cost and systemic treatments, and surgical intervention compared to White patients. Disparities were also detected in survival, where Hispanic and Asian patients had lower mortality risks compared to White patients. Literature on survival outcomes between Black and White patients was inconclusive. Disparities related to sex, rurality, social support, socioeconomic status, education level, and insurance type were observed.

CONCLUSIONS

Health disparities within the lung cancer population begin with initial screening and continue through survival outcomes, with reports persisting well into the latter portion of the past decade. These findings should serve as a call to action, raising awareness of persistent and ongoing inequities, particularly for marginalized populations.

Racial/Ethnic disparities in exposure to neighborhood violence and lung cancer risk in Chicago

BACKGROUND

Despite the lower prevalence and frequency of smoking, Black adults are disproportionately affected by lung cancer. Exposure to chronic stress generates heightened immune responses, which creates a cell environment conducive to lung cancer development. Residents in poor and segregated neighborhoods are exposed to increased neighborhood violence, and chronic exposure to violence may have downstream physiological stress responses, which may explain racial disparities in lung cancer in predominantly Black urban communities.

METHODS

We utilized retrospective electronic medical records of patients who underwent a screening or diagnostic test for lung cancer at an academic medical center in Chicago to examine the associations between lung cancer diagnosis and individual characteristics (age, gender, race/ethnicity, and smoking status) and neighborhood-level homicide rate. We then used a synthetic population to estimate the neighborhood-level lung cancer risk to understand spatial clusters of increased homicide rates and lung cancer risk.

RESULTS

Older age and former/current smoking status were associated with increased odds of lung cancer diagnosis. Hispanic patients were more likely than White patients to be diagnosed with lung cancer, but there was no statistical difference between Black and White patients in lung cancer diagnosis. The odds of being diagnosed with lung cancer were significantly higher for patients living in areas with the third and fourth quartiles of homicide rates compared to the second quartile of homicide rates. Furthermore, significant spatial clusters of increased lung cancer risk and homicide rates were observed on Chicago's South and West sides.

CONCLUSIONS

Neighborhood violence was associated with an increased risk of lung cancer. Black residents in Chicago are disproportionately exposed to neighborhood violence, which may partially explain the existing racial disparity in lung cancer. Incorporating neighborhood violence exposure into lung cancer risk models may help identify high-risk individuals who could benefit from lung cancer screening.

Treatment of Stage I Lung Cancer Detected by Computed Tomography Screening

Introduction

Reducing lung cancer deaths through early detection by computed tomography (CT) screening requires delivery of effective treatment. We performed this retrospective study to determine the types of treatment used for screen-detected stage I lung cancer at our academic center and to compare the demographic and clinical characteristics of patients by type of treatment.

Methods

All persons screened in the lung cancer screening program at our institution through June 16, 2021, were included. Those with screening CT findings needing follow-up were managed through a thoracic surgery clinic. Demographic and clinical characteristics of patients diagnosed with having stage I lung cancer through June 16, 2021, were compared by type of treatment, with follow-up through December 31, 2021.

Results

Stage I NSCLC was diagnosed in 54 of 2203 persons screened (2.5%), on the basis of biopsy in 37 and on imaging findings in 17 patients in whom a tissue diagnosis could not be obtained. Treatment was by lobectomy in 18, sublobar resection in 14, and stereotactic body radiation therapy (SBRT) in 22. Patients treated with SBRT had lower forced expiratory volume in 1 second (p < 0.001) and diffusing capacity of the lung for carbon monoxide (p < 0.001) and more comorbidities (p = 0.003) than those treated with surgery. New or recurrent cancer developed in nine patients (three lobectomy, three sublobar resection, three SBRT).

Conclusions

Many patients with screen-detected stage I lung cancer are medically unfit for lobectomy, and a variety of treatments are being used. Assessment of treatment-based outcomes will be critical for ensuring an optimal balance of the risks and benefits of CT screening in a medically diverse population.

Lung cancer screening decisional needs among African American smokers of lower socioeconomic status

OBJECTIVES

Adherence to most evidence-based cancer screenings is lower among African Americans due to system- and individual-level factors that contribute to persistent disparities. Given the recommendation for low-dose computed tomography (LDCT) screening among individuals at high risk for lung cancer, we sought to describe aspects of decision-making for LDCT among African Americans and to examine associations between select components of decision-making and screening-related intentions.

DESIGN

African Americans (N = 119) with a long-term smoking history, aged 55-80 years, and without lung cancer were recruited to participate in a cross-sectional survey. We measured knowledge, awareness, decisional conflict, preferences, and values related to lung cancer screening.

RESULTS

The majority of the study population was of lower socioeconomic status (67.2% had an annual income of ≤$20,000) and long-term current (79%) smokers. Participants had a median 20 pack-years smoking history. Most participants (65.8%) had not heard of LDCT and the total lung cancer screening knowledge score was M = 7.1/15.0 (SD = 1.8). Participants with higher scores on the importance of the pros and cons of screening expressed greater likelihood of talking with a doctor, family, and friends about screening (p's < .10).

CONCLUSIONS

Findings have implications for addressing the decisional needs of lower socioeconomic African American current and former smokers to promote informed decision-making for LDCT.

Health Equity: What the Neuroradiologist Needs to Know

Health equity means that everyone has the opportunity to be as healthy as possible, but achieving health equity requires the removal of obstacles to health such as poverty, discrimination, unsafe environments, and lack of access to health care. The pandemic has highlighted the awareness and urgency of delivering patient-centered, high-value care. Disparities in care are antithetical to health equity and have been seen throughout medicine and radiology, including neuroradiology. Health disparities result in low value and costly care that is in conflict with evidence-based medicine, quality standards, and best practices. Although the subject of health equity is often framed as a moral or social justice issue, there are compelling economic arguments that also favor health equity. Not only can waste in health care expenditures be countered but more resources can be devoted to high-value care and other vital national economic interests, including sustainable support for our health system and health providers. There are many opportunities for neuroradiologists to engage in the advancement of health equity, while also advancing the interests of the profession and patient-centered high-value care. Although there is no universal consensus on a definition of health equity, a recent report seeking clarity on the lexicon offered the following conceptual framework: "Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care."¹ This definition contrasts with that of health disparities that contribute to inequitable care as a result of demographic differences among populations such as those attributable to race, sex, access, residence, socioeconomic status, insurance status, age, religion, and disability.^2,3 In effect, the greater the health disparities and negative social determinants of health, the greater the health inequities will be.

Lung cancer screening use and implications of varying eligibility criteria by race and ethnicity: 2019 Behavioral Risk Factor Surveillance System data

BACKGROUND

In 2021, the US Preventive Services Task Force (USPSTF) expanded the eligibility criteria for low-dose computed tomographic lung cancer screening (LCS) to reduce racial disparities that resulted from the 2013 USPSTF criteria. The annual LCS rate has risen slowly since the 2013 USPSTF screening recommendations. Using the 2019 Behavioral Risk Factor Surveillance System (BRFSS), this study 1) describes LCS use in 2019, 2) compares the percent eligible for LCS using the 2013 versus 2021 USPSTF criteria, and 3) determines the percent eligible using the more detailed PLCOm2012_Race3L risk-prediction model.

METHODS

The analysis included 41,544 individuals with a smoking history from states participating in the BRFSS LCS module who were ≥50 years old.

RESULTS

Using the 2013 USPSTF criteria, 20.7% (95% confidence interval [CI], 19.0-22.4) of eligible individuals underwent LCS in 2019. The 2013 USPSTF criteria was compared to the 2021 USPSTF criteria, and the overall proportion eligible increased from 21.0% (95% CI, 20.2-21.8) to 34.7% (95 CI, 33.8-35.6). Applying the 2021 criteria, the proportion eligible by race was 35.8% (95% CI, 34.8-36.7) among Whites, 28.5% (95% CI, 25.2-31.9) among Blacks, and 18.0% (95% CI, 12.4-23.7) among Hispanics. Using the 1.0% 6-year threshold that is comparable to the 2021 USPSTF criteria, the PLCOm2012_Race3L model selected more individuals overall and by race.

CONCLUSIONS

Using data from 20 states and using multiple imputation, higher LCS rates have been reported compared to prior BRFSS data. The 2021 expanded criteria will result in a greater number of screen-eligible individuals. However, risk-based screening that uses additional risk factors may be more inclusive overall and across subgroups.

LAY SUMMARY

In 2013, lung cancer screening (lung screening) was recommended for high risk individuals. The annual rate of lung screening has risen slowly, particularly among Black individuals. In part, this racial disparity resulted in expanded 2021 criteria. Survey data was used to: 1) describe the number of people screened in 2019, 2) compare the percent eligible for lung screening using the 2013 versus 2021 guidelines, and 3) determine the percent eligible using more detailed criteria. Lung screening rates increased in 2019, and the 2021 criteria will result in more individuals eligible for screening. Using additional criteria may identify more individuals eligible for lung screening.

Challenges in the Methodology for Health Disparities Research in Thoracic Surgery

Research on health disparities in thoracic surgery is based on large population-based studies, which is associated with certain biases. Several methodological challenges are associated with these biases and warrant review and attention. The lack of standardized definitions in health disparities research requires clarification for study design strategy. Further inconsistencies remain when considering data sources and collection methods. These inconsistencies pose challenges for accurate and standardized downstream data analysis and interpretation. These sources of bias should be considered when establishing the infrastructure of health disparities research in thoracic surgery, which is in its infancy and requires further development.

Social Disparities in Lung Cancer Risk and Screening

Significant disparities exist in lung cancer incidence and screening. Geographic, racial, gender, and socioeconomic disparities affect lung cancer incidence. As the leading cause of lung cancer, smoking varies among different racioethnic groups, genders, and socioeconomic statuses. In addition, environmental pollutants, such as radon, industrial toxins, and air pollution, are significant risk factors for lung cancer development that is disproportionately seen in working-class communities, as well as underserved and disabled populations. Lung cancer incidence depends on diagnosis. Literature examining lung cancer incidence and screening disparities have its limitations, as most studies are methodologically limited and do not adjust for important risk factors.

Plasma Based Protein Signatures Associated with Small Cell Lung Cancer

Small-cell-lung cancer (SCLC) is associated with overexpression of oncogenes including Myc family genes and YAP1 and inactivation of tumor suppressor genes. We performed in-depth proteomic profiling of plasmas collected from 15 individuals with newly diagnosed early stage SCLC and from 15 individuals before the diagnosis of SCLC and compared findings with plasma proteomic profiles of 30 matched controls to determine the occurrence of signatures that reflect disease pathogenesis. A total of 272 proteins were elevated (area under the receiver operating characteristic curve (AUC) ≥ 0.60) among newly diagnosed cases compared to matched controls of which 31 proteins were also elevated (AUC ≥ 0.60) in case plasmas collected within one year prior to diagnosis. Ingenuity Pathway analyses of SCLC-associated proteins revealed enrichment of signatures of oncogenic MYC and YAP1. Intersection of proteins elevated in case plasmas with proteomic profiles of conditioned medium from 17 SCLC cell lines yielded 52 overlapping proteins characterized by YAP1-associated signatures of cytoskeletal re-arrangement and epithelial-to-mesenchymal transition. Among samples collected more than one year prior to diagnosis there was a predominance of inflammatory markers. Our integrated analyses identified novel circulating protein features in early stage SCLC associated with oncogenic drivers.

Racial and socioeconomic disparities in lung cancer screening in the United States: A systematic review

Nonsmall cell lung cancer (NSCLC) is the leading cause of cancer deaths. Lung cancer screening (LCS) reduces NSCLC mortality; however, a lack of diversity in LCS studies may limit the generalizability of the results to marginalized groups who face higher risk for and worse outcomes from NSCLC. Identifying sources of inequity in the LCS pipeline is essential to reduce disparities in NSCLC outcomes. The authors searched 3 major databases for studies published from January 1, 2010 to February 27, 2020 that met the following criteria: 1) included screenees between ages 45 and 80 years who were current or former smokers, 2) written in English, 3) conducted in the United States, and 4) discussed socioeconomic and race-based LCS outcomes. Eligible studies were assessed for risk of bias. Of 3721 studies screened, 21 were eligible. Eligible studies were evaluated, and their findings were categorized into 3 themes related to LCS disparities faced by Black and socioeconomically disadvantaged individuals: 1) eligibility; 2) utilization, perception, and utility; and 3) postscreening behavior and care. Disparities in LCS exist along racial and socioeconomic lines. There are several steps along the LCS pipeline in which Black and socioeconomically disadvantaged individuals miss the potential benefits of LCS, resulting in increased mortality. This study identified potential sources of inequity that require further investigation. The authors recommend the implementation of prospective trials that evaluate eligibility criteria for underserved groups and the creation of interventions focused on improving utilization and follow-up care to decrease LCS disparities.

Artificial Intelligence and Machine Learning in Radiology: Current State and Considerations for Routine Clinical Implementation

Although artificial intelligence (AI) has been a focus of medical research for decades, in the last decade, the field of radiology has seen tremendous innovation and also public focus due to development and application of machine-learning techniques to develop new algorithms. Interestingly, this innovation is driven simultaneously by academia, existing global medical device vendors, and-fueled by venture capital-recently founded startups. Radiologists find themselves once again in the position to lead this innovation to improve clinical workflows and ultimately patient outcome. However, although the end of today's radiologists' profession has been proclaimed multiple times, routine clinical application of such AI algorithms in 2020 remains rare. The goal of this review article is to describe in detail the relevance of appropriate imaging data as a bottleneck for innovation, provide insights into the many obstacles for technical implementation, and give additional perspectives to radiologists who often view AI solely from their clinical role. As regulatory approval processes for such medical devices are currently under public discussion and the relevance of imaging data is transforming, radiologists need to establish themselves as the leading gatekeepers for evolution of their field and be aware of the many stakeholders and sometimes conflicting interests.

Disparities in Lung Cancer Screening: A Review

Lung cancer is the leading cause of cancer mortality in the United States. Certain groups are at increased risk of developing lung cancer and experience greater morbidity and mortality than the general population. Lung cancer screening provides an opportunity to detect lung cancer at an early stage when surgical intervention can be curative; however, current screening guidelines may overlook vulnerable populations with disproportionate lung cancer burden. This review aims to characterize disparities in lung cancer screening eligibility, as well as access to lung cancer screening, focusing on underrepresented racial/ethnic minorities and high-risk populations, such as individuals with human immunodeficiency virus. We also explore potential system- and patient-level barriers that may influence smoking patterns and healthcare access. Improving access to high-quality health care with a focus on smoking cessation is essential to reduce the burden of lung cancer experienced by vulnerable populations.

Public Health Foundations for Radiology Resident Education: Healthcare Disparities in Radiology

Increasing recognition within the medical literature and by the Accreditation Council for Graduate Medical Education has been attributed to the need for enhanced resident education on concepts related to public health and health equity. Despite increasing documentation of pervasive inequalities within the scope of radiology, dedicated curricula designed to improve cultural competency and understanding of healthcare disparities among radiology trainees remains sparse. With relatively fewer patient interactions, radiology trainees are particularly susceptible to insufficient contextual awareness of how socioeconomic factors influence patient health and behaviors, physician recommendations, and ultimately clinical outcomes. The purpose of this article is to provide a high-yield background of foundational health equity and disparity concepts for radiology trainees, from which additional educational curricula may be derived. Specifically, this article will discuss the fundamental socioeconomic factors known to contribute to discrepant access and use of imaging services, followed by areas in radiology with well-documented disparities of which trainees should be aware. Lastly, previous and current strategies for addressing disparities in radiology will be discussed with the ultimate goal of stimulating trainee participation and the development of novel approaches.

Analysis of the 30-Pack-Year Smoking Threshold in African Americans From an Underserved Lung Cancer Screening Program

PURPOSE

African Americans were underrepresented in lung cancer screening (LCS) trials, despite having higher lung cancer incidence and worse outcomes compared with Caucasians. There is concern that the 30-pack-year threshold excludes some African Americans who may benefit from LCS.

METHODS

LCS in an underserved health care system was reviewed. Providers attested that patients met LCS criteria, including 30-pack-year history, but patients also self-reported smoking histories. Self-reported data were used to identify patients with <30-pack-year histories.

RESULTS

Over 2 years, 784 patients self-reported sufficient data to calculate pack-years. The majority were men (57.5%), and 66.2% were African Americans. Median total years smoked was 40 (interquartile range, 30-45 years), and median pack-years was 25 (interquartile range, 15-40 pack-years). African Americans were more likely to report <30 pack-years compared with other races (P < .001). The overall incidence of lung cancer was 2.0%, and incidence was similar for those with ≥30 or <30 pack-years (2.1% versus 2.0%; odds ratio, 0.94; 95% confidence interval, 0.35-2.53; P = .902). Race was not associated with lung cancer diagnosis, but African Americans were the only race to have lung cancer if pack-years were <30. The incidence of cancer in African Americans was similar in those who reported ≥30 or <30 pack-years (2.2% versus 2.7%; odds ratio, 1.21; 95% confidence interval, 0.39-3.75; P = .740), and the 30-pack-year threshold was not associated with lung cancer diagnosis.

CONCLUSIONS

This is the first review of LCS in African Americans who self-reported <30 pack-years. Although retrospective, these data raise concern that the 30-pack-year threshold may not be an appropriate LCS criterion in African Americans.

Risk Prediction Model Versus United States Preventive Services Task Force Lung Cancer Screening Eligibility Criteria: Reducing Race Disparities

INTRODUCTION

Disparities exist in lung cancer outcomes between African American and white people. The current United States Preventive Services Task Force (USPSTF) lung cancer screening eligibility criteria, which is based solely on age and smoking history, may exacerbate racial disparities. We evaluated whether the PLCOm2012 risk prediction model more effectively selects African American ever-smokers for screening.

METHODS

Lung cancer cases diagnosed between 2010 and 2019 at an urban medical center serving a racially and ethnically diverse population were retrospectively reviewed for lung cancer screening eligibility based on the USPSTF criteria versus the PLCOm2012 model.

RESULTS

This cohort of 883 ever-smokers comprised the following racial and ethnic makeup: 258 white (29.2%), 497 African American (56.3%), 69 Hispanic (7.8%), 24 Asian (2.7%), and 35 other (4.0%). Compared with the USPSTF criteria, the PLCOm2012 model increased the sensitivity for the African American cohort at lung cancer risk thresholds of 1.51%, 1.70%, and 2.00% per 6 years (p < 0.0001). For example, at the 1.70% risk threshold, the PLCOm2012 model identified 71.3% African American cases, whereas the USPSTF criteria only identified 50.3% (p < 0.0001). In contrast, in case of whites there was no difference (66.0% versus 62.4%, respectively [p = 0.203]). Of the African American ever-smokers who were PLCO1.7%-positive and USPSTF-negative, the criteria missed from the USPSTF were those with pack-years less than 30 (67.7%), quit time of greater than 15 years (22.5%), and age less than 55 years (13.0%).

CONCLUSIONS

The PLCOm2012 model was found to be preferable over the USPSTF criteria at identifying African American ever-smokers for lung cancer screening. The broader use of this model in racially diverse populations may help overcome disparities in lung cancer screening and outcomes.

Rates of positive lung cancer screening examinations in academic versus community practice

The benefits and harms of lung cancer screening reported in the National Lung Screening Trial (NLST) likely differ from those observed in academic and community settings. High rates of positive screening findings in the NLST led to the development of the Lung CT Screening Reporting and Data System (Lung-RADS) to standardize interpretation and reporting. We conducted a prospective observational study of lung cancer screening data from four lung cancer screening sites in North Carolina to compare prospective use of Lung-RADS in a real-world screened population versus Lung-RADS retrospectively applied to the NLST, and to determine if Lung-RADS assessment use differs in academic versus community settings. We included 4,037 screening examinations from 11/2014 to 12/2018 in academic and community sites and 75,126 NLST LDCT screening exams. On baseline screening exams, the proportion of positive LDCT exams was higher in community versus academic sites or the NLST (17.7% vs. 11.4% and 13.6%, P value <0.01). On subsequent screens, the proportion of positive exams was lowest in the NLST and higher in community and academic sites (5.9% vs. 12.7% and 11.6%, P value <0.01). After adjusting for age, race, sex, and smoking status, patients screened at academic versus community sites were 34% less likely to have a positive screen at baseline [adjusted odds ratio (aOR) =0.66; 95% confidence interval (95% CI): 0.51-0.86] but on subsequent examinations, there was no difference in academic versus community sites (aOR =0.91; 95% CI: 0.58-1.43). Our findings may be due to differences in radiologists' training or experiences or the availability of prior images for comparison.

Black patients referred to a lung cancer screening program experience lower rates of screening and longer time to follow-up

BACKGROUND

Racial disparities are well-documented in preventive cancer care, but they have not been fully explored in the context of lung cancer screening. We sought to explore racial differences in lung cancer screening outcomes within a lung cancer screening program (LCSP) at our urban academic medical center including differences in baseline low-dose computed tomography (LDCT) results, time to follow-up, adherence, as well as return to annual screening after additional imaging, loss to follow-up, and cancer diagnoses in patients with positive baseline scans.

METHODS

A historical cohort study of patients referred to our LCSP was conducted to extract demographic and clinical characteristics, smoking history, and lung cancer screening outcomes.

RESULTS

After referral to the LCSP, blacks had significantly lower odds of receiving LDCT compared to whites, even while controlling for individual lung cancer risk factors and neighborhood-level factors. Blacks also demonstrated a trend toward delayed follow-up, decreased adherence, and loss to follow-up across all Lung-RADS categories.

CONCLUSIONS

Overall, lung cancer screening annual adherence rates were low, regardless of race, highlighting the need for increased patient education and outreach. Furthermore, the disparities in race we identified encourage further research with the purpose of creating culturally competent and inclusive LCSPs.

Real-world Clinical Implementation of Lung Cancer Screening-Evaluating Processes to Improve Screening Guidelines-Concordance

BACKGROUND

Lung cancer screening (LCS) requires complex processes to identify eligible patients, provide appropriate follow-up, and manage findings. It is unclear whether LCS in real-world clinical settings will realize the same benefits as the National Lung Screening Trial (NLST).

OBJECTIVE

To evaluate the impact of process modifications on compliance with LCS guidelines during LCS program implementation, and to compare patient characteristics and outcomes with those in NLST.

DESIGN

Retrospective cohort study.

SETTING

Kaiser Permanente Colorado (KPCO), a non-profit integrated healthcare system.

PATIENTS

A total of 3375 patients who underwent a baseline lung cancer screening low-dose computed tomography (S-LDCT) scan between May 2014 and June 2017.

MEASUREMENTS

Among those receiving an S-LDCT, proportion who met guidelines-based LCS eligibility criteria before and after LCS process modifications, differences in patient characteristics and outcomes between KPCO LCS patients and the NLST cohort, and factors associated with a positive screen.

RESULTS

After modifying LCS eligibility confirmation processes, patients receiving S-LDCT who met guidelines-based LCS eligibility criteria increased from 45.6 to 92.7% (P < 0.001). Prior to changes, patients were older (68 vs. 67 years; P = 0.001), less likely to be current smokers (51.3% vs. 52.5%; P < 0.001), and less likely to have a ≥ 30-pack-year smoking history (50.0% vs. 95.3%; P < 0.001). Compared with NLST participants, KPCO LCS patients were older (67 vs. 60 years; P < 0.001), more likely to currently smoke (52.3% vs. 48.1%; P < 0.001), and more likely to have pulmonary disease. Among those with a positive baseline S-LDCT, the lung cancer detection rate was higher at KPCO (9.4% vs. 3.8%; P < 0.001) and was positively associated with prior pulmonary disease.

CONCLUSION

Adherence to LCS guidelines requires eligibility confirmation procedures. Among those with a positive baseline S-LDCT, comorbidity burden and lung cancer detection rates were notably higher than in NLST, suggesting that the study of long-term outcomes in patients undergoing LCS in real-world clinical settings is warranted.

Evaluating Potential Racial Inequities in Low-dose Computed Tomography Screening for Lung Cancer

BACKGROUND

Lung cancer is the leading cause of cancer death in the US, and significant racial disparities exist in lung cancer outcomes. For example, Black men experience higher lung cancer incidence and mortality rates than their White counterparts. New screening recommendations for low-dose computed tomography (LDCT) promote earlier detection of lung cancer in at-risk populations and can potentially help mitigate racial disparities in lung cancer mortality if administered equitably. Yet, little is known about the extent of racial differences in uptake of LDCT.

OBJECTIVE

To evaluate potential racial disparities in LDCT screening in a large community-based cancer center in central North Carolina.

METHODS

We conducted a retrospective study of the initial patients undergoing LDCT in a community-based cancer center (n = 262). We used the Pearson chi-squared test to assess potential racial disparities in LDCT screening.

RESULTS

Study results suggest that Black patients may be less likely than White patients to receive LDCT screening when eligible (χ2 = 51.41, p < 0.0001).

CONCLUSION

Collaboration among healthcare providers, researchers, and decision makers is needed to promote LDCT equity.

Evaluation of USPSTF Lung Cancer Screening Guidelines Among African American Adult Smokers

Importance

The United States Preventive Services Task Force (USPSTF) recommends low-dose computed tomography screening for lung cancer. However, USPSTF screening guidelines were derived from a study population including only 4% African American smokers, and racial differences in smoking patterns were not considered.

Objective

To evaluate the diagnostic accuracy of USPSTF lung cancer screening eligibility criteria in a predominantly African American and low-income cohort.

Design, Setting, and Participants

The Southern Community Cohort Study prospectively enrolled adults visiting community health centers across 12 southern US states from March 25, 2002, through September 24, 2009, and followed up for cancer incidence through December 31, 2014. Participants included African American and white current and former smokers aged 40 through 79 years. Statistical analysis was performed from May 11, 2016, to December 6, 2018.

Exposures

Self-reported race, age, and smoking history. Cumulative exposure smoking histories encompassed most recent follow-up questionnaires.

Main Outcomes and Measures

Incident lung cancer cases assessed for eligibility for lung cancer screening using USPSTF criteria.

Results

Among 48 364 ever smokers, 32 463 (67%) were African American and 15 901 (33%) were white, with 1269 incident lung cancers identified. Among all 48 364 Southern Community Cohort Study participants, 5654 of 32 463 African American smokers (17%) were eligible for USPSTF screening compared with 4992 of 15 901 white smokers (31%) (P < .001). Among persons diagnosed with lung cancer, a significantly lower percentage of African American smokers (255 of 791; 32%) was eligible for screening compared with white smokers (270 of 478; 56%) (P < .001). The lower percentage of eligible lung cancer cases in African American smokers was primarily associated with fewer smoking pack-years among African American vs white smokers (median pack-years: 25.8 [interquartile range, 16.9-42.0] vs 48.0 [interquartile range, 30.2-70.5]; P < .001). Racial disparity was observed in the sensitivity and specificity of USPSTF guidelines between African American and white smokers for all ages. Lowering the smoking pack-year eligibility criteria to a minimum 20-pack-year history was associated with an increased percentage of screening eligibility of African American smokers and with equitable performance of sensitivity and specificity compared with white smokers across all ages (for a 55-year-old current African American smoker, sensitivity increased from 32.2% to 49.0% vs 56.5% for a 55-year-old white current smoker; specificity decreased from 83.0% to 71.6% vs 69.4%; P < .001).

Conclusions and Relevance

Current USPSTF lung cancer screening guidelines may be too conservative for African American smokers. The findings suggest that race-specific adjustment of pack-year criteria in lung cancer screening guidelines would result in more equitable screening for African American smokers at high risk for lung cancer.