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

Patient Lung Cancer Screening Decisions and Environmental and Psychosocial Factors

Importance

Screening for lung cancer using low-dose computed tomography is associated with reduced lung cancer-specific mortality, but uptake is low in the US; understanding how patients make decisions to engage with lung cancer screening is critical for increasing uptake. Prior research has focused on individual-level psychosocial factors, but environmental factors (eg, historical contexts that include experiencing racism) and modifying factors-those that can be changed to make it easier or harder to undergo screening-also likely affect screening decisions.

Objective

To investigate environmental, psychosocial, and modifying factors influencing lung cancer screening decision-making and develop a conceptual framework depicting relationships between these factors.

Design, Setting, and Participants

This multimethod qualitative study was conducted from December 2021 to June 2022 using virtual semistructured interviews and 4 focus groups (3-4 participants per group). All participants met US Preventive Services Task Force eligibility criteria for lung cancer screening (ie, age 50-80 years, at least a 20 pack-year smoking history, and either currently smoke or quit within the past 15 years). Screening-eligible US participants were recruited using an online panel.

Main Outcomes and Measures

Key factors influencing screening decisions (eg, knowledge, beliefs, barriers, and facilitators) were the main outcome. A theory-informed, iterative inductive-deductive approach was applied to analyze data and develop a conceptual framework summarizing results.

Results

Among 34 total participants (interviews, 20 [59%]; focus groups, 14 [41%]), mean (SD) age was 59.1 (4.8) years and 20 (59%) identified as female. Half had a household income below $20 000 (17 [50%]). Participants emphasized historical and present-day racism as critical factors contributing to mistrust of health care practitioners and avoidance of medical procedures like screening. Participants reported that other factors, such as public transportation availability, also influenced decisions. Additionally, participants described psychosocial processes involved in decisions, such as perceived screening benefits, lung cancer risk appraisal, and fear of a cancer diagnosis or harmful encounters with practitioners. In addition, participants identified modifying factors (eg, insurance coverage) that could make receiving screening easier or harder.

Conclusions and Relevance

In this qualitative study of patient lung cancer screening decisions, environmental, psychosocial, and modifying factors influenced screening decisions. The findings suggest that systems-level interventions, such as those that help practitioners understand and discuss patients' prior negative health care experiences, are needed to promote effective screening decision-making.

The promise and challenges of multi-cancer early detection assays for reducing cancer disparities

Since improvements in cancer screening, diagnosis, and therapeutics, cancer disparities have existed. Marginalized populations (e.g., racial and ethnic minorities, sexual and gender minorities, lower-income individuals, those living in rural areas, and persons living with disabilities) have worse cancer-related outcomes. Early detection of cancer substantially improves outcomes, yet uptake of recommended cancer screenings varies widely. Multi-cancer early detection (MCED) tests use biomarkers in the blood to detect two or more cancers in a single assay. These assays show potential for population screening for some cancers-including those disproportionally affecting marginalized communities. MCEDs may also reduce access barriers to early detection, a primary factor in cancer-related outcome disparities. However, for the promise of MCEDs to be realized, during their development and testing, we are obligated to be cautious to design them in a way that reduces the myriad of structural, systematic, and personal barriers contributing to disparities. Further, they must not create new barriers. Population studies and clinical trials should include diverse populations, and tests must work equally well in all populations. The tests must be affordable. It is critical that we establish trust within marginalized communities, the healthcare system, and the MCED tests themselves. Tests should be expected to have high specificity, as a positive MCED finding will trigger additional, oftentimes invasive and expensive, imaging or other diagnosis tests and/or biopsies. Finally, there should be a way to help all individuals with a positive test to navigate the system for follow-up diagnostics and treatment, if warranted, that is accessible to all.

Multilevel approaches to address disparities in lung cancer screening: a study protocol

BACKGROUND

Low-dose computed tomography (lung cancer screening) can reduce lung cancer-specific mortality by 20-24%. Based on this evidence, the United States Preventive Services Task Force recommends annual lung cancer screening for asymptomatic high-risk individuals. Despite this recommendation, utilization is low (3-20%). Lung cancer screening may be particularly beneficial for African American patients because they are more likely to have advanced disease, lower survival, and lower screening rates compared to White individuals. Evidence points to multilevel approaches that simultaneously address multiple determinants to increase screening rates and decrease lung cancer burden in minoritized populations. This study will test the effects of provider- and patient-level strategies for promoting equitable lung cancer screening utilization.

METHODS

Guided by the Health Disparities Research Framework and the Practical, Robust Implementation and Sustainability Model, we will conduct a quasi-experimental study with four primary care clinics within a large health system (MedStar Health). Individuals eligible for lung cancer screening, defined as 50-80 years old, ≥ 20 pack-years, currently smoking, or quit < 15 years, no history of lung cancer, who have an appointment scheduled with their provider, and who are non-adherent to screening will be identified via the EHR, contacted, and enrolled (N = 184 for implementation clinics, N = 184 for comparison clinics; total N = 368). Provider participants will include those practicing at the partner clinics (N = 26). To increase provider-prompted discussions about lung screening, an electronic health record (EHR) clinician reminder will be sent to providers prior to scheduled visits with the screening-eligible participants. To increase patient-level knowledge and patient activation about screening, an inreach specialist will conduct a pre-visit phone-based educational session with participants. Patient participants will be assessed at baseline and 1-week post-visit to measure provider-patient discussion, screening intentions, and knowledge. Screening referrals and screening completion rates will be assessed via the EHR at 6 months. We will use mixed methods and multilevel assessments of patients and providers to evaluate the implementation outcomes (adoption, feasibility, acceptability, and fidelity).

DISCUSSION

The study will inform future work designed to measure the independent and overlapping contributions of the multilevel implementation strategies to advance equity in lung screening rates.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04675476. Registered December 19, 2020.

Inadequate Uptake of USPSTF-Recommended Low Dose CT Lung Cancer Screening

In 2023, Journal of Primary Care and Community Health published the results of 4 outstanding studies in which investigators aimed to explore and improve clinician and eligible individuals' knowledge of the rationale for lung cancer screening (LCS). Their results highlighted the underutilization of LCS, particularly for certain high risk populations, and the continued disparities in screening seen between groups of eligible individuals. Here, key findings from those 2023 Journal of Primary Care and Community Health reports, along with salient findings of other recent LCS reports, are discussed. The bases for the United States Preventive Task Force (USPSTF) LCS recommendations, barriers primary care providers face, the perspective of eligible individuals, importance of shared decision-making (SDM) and disparities between groups in LCS are reviewed along with potential strategies to ensure that more eligible individuals are offered LCS.

Pain and Menthol Use Are Related to Greater Nicotine Dependence Among Black Adults Who Smoke Cigarettes at Wave 5 (2018-2019) of the Population Assessment of Tobacco and Health (PATH) Study

Burdens related to pain, smoking/nicotine dependence, and pain-smoking comorbidity disproportionately impact Black Americans, and menthol cigarette use is overrepresented among Black adults who smoke cigarettes. Menthol may increase nicotine exposure, potentially conferring enhanced acute analgesia and driving greater dependence. Therefore, the goal of the current study was to examine associations between pain, menthol cigarette use, and nicotine dependence. Data was drawn from Black adults who were current cigarette smokers (n = 1370) at Wave 5 (2018-2019) of the Population Assessment of Tobacco and Health Study. Nicotine dependence was assessed using the Wisconsin Inventory of Smoking Dependence Motives. ANCOVA revealed that moderate/severe pain (vs. no/low pain) was associated with greater overall nicotine dependence (p < .001) and greater negative reinforcement, cognitive enhancement, and affiliative attachment smoking motives (ps < .001). Menthol smokers with moderate/severe pain also endorsed greater cigarette craving and tolerance, compared to non-menthol smokers with no/low pain (ps < .05). Findings support the notion that among Black individuals who smoke cigarettes, the presence of moderate/severe pain (vs. no/low pain) and menthol use may engender greater physical indices of nicotine dependence relative to non-menthol use. Compared to no/low pain, moderate/severe pain was associated with greater emotional attachment to smoking and greater proclivity to smoke for reducing negative affect and enhancing cognitive function. Clinical implications include the need to address the role of pain and menthol cigarette use in the assessment and treatment of nicotine dependence, particularly among Black adults. These data may help to inform evolving tobacco control policies aimed at regulating or banning menthol tobacco additives.

Racial Disparities in Lung Cancer Screening Among Veterans, 2013 to 2021

Importance

Racial disparities in lung cancer screening (LCS) are often ascribed to barriers such as cost, insurance status, access to care, and transportation. Because these barriers are minimized within the Veterans Affairs system, there is a question of whether similar racial disparities exist within a Veterans Affairs health care system in North Carolina.

Objectives

To examine whether racial disparities in completing LCS after referral exist at the Durham Veterans Affairs Health Care System (DVAHCS) and, if so, what factors are associated with screening completion.

Design, Setting, and Participants

This cross-sectional study assessed veterans referred to LCS between July 1, 2013, and August 31, 2021, at the DVAHCS. All included veterans self-identified as White or Black and met the US Preventive Services Task Force eligibility criteria as of January 1, 2021. Participants who died within 15 months of consultation or who were screened before consultation were excluded.

Exposures

Self-reported race.

Main Outcomes and Measures

Screening completion was defined as completing computed tomography for LCS. The associations among screening completion, race, and demographic and socioeconomic risk factors were assessed using logistic regression models.

Results

A total of 4562 veterans (mean [SD] age, 65.4 [5.7] years; 4296 [94.2%] male; 1766 [38.7%] Black and 2796 [61.3%] White) were referred for LCS. Of all veterans referred, 1692 (37.1%) ultimately completed screening; 2707 (59.3%) never connected with the LCS program after referral and an informational mailer or telephone call, indicating a critical point in the LCS process. Screening rates were substantially lower among Black compared with White veterans (538 [30.5%] vs 1154 [41.3%]), with Black veterans having 0.66 times lower odds (95% CI, 0.54-0.80) of screening completion after adjusting for demographic and socioeconomic factors.

Conclusions and Relevance

This cross-sectional study found that after referral for initial LCS via a centralized program, Black veterans had 34% lower odds of LCS screening completion compared with White veterans, a disparity that persisted even after accounting for numerous demographic and socioeconomic factors. A critical point in the screening process was when veterans must connect with the screening program after referral. These findings may be used to design, implement, and evaluate interventions to improve LCS rates among Black veterans.

Adapting Community Educational Programs During the COVID-19 Pandemic: Comparing the Feasibility and Efficacy of a Lung Cancer Screening Educational Intervention by Mode of Delivery

Few eligible patients receive lung cancer screening. We developed the Lung AIR (awareness, information, and resources) intervention to increase community education regarding lung cancer screening. The intervention was designed as an in-person group intervention; however, the COVID-19 pandemic necessitated adapting the mode of delivery. In this study we examined intervention feasibility and efficacy overall and by mode of delivery (in-person group vs. one-on-one phone) to understand the impact of adapting community outreach and engagement strategies. Feasibility was examined through participant demographics. Efficacy was measured through pre/post knowledge, attitudes, and beliefs about lung cancer screening, and intention to complete screening. We reached N = 292 participants. Forty percent had a household income below $35,000, 58% had a high school degree or less, 40% were Hispanic, 57% were Black, and 84% reported current or past smoking. One-on-one phone sessions reached participants who were older, had lower incomes, more current smoking, smoked for more years, more cigarettes per day, lower pre-intervention lung cancer screening knowledge, and higher pre-intervention fear and worry. Overall pre/post test scores show significant increases in knowledge, salience, and coherence, and reduced fear and worry. Participants in the one-on-one phone sessions had significantly higher increases in salience and coherence and intention to complete screening compared to participants in the in-person group sessions. The Lung AIR intervention is a feasible and effective community-based educational intervention for lung cancer screening. Findings point to differences in reach and efficacy of the community-based intervention by mode of delivery.

Evidence of Racial Disparities in the Lung Cancer Screening Process: a Systematic Review and Meta-Analysis

BACKGROUND

Annual lung cancer screening (LCS) with low-dose chest computed tomography for high-risk individuals reduces lung cancer mortality, with greater reduction observed in Black participants in clinical trials. While racial disparities in lung cancer mortality exist, less is known about disparities in LCS participation. We conducted a systematic review to explore LCS participation in Black compared with White patients in the USA.

METHODS

A systematic review was conducted through a search of published studies in MEDLINE, PubMed, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied-Health Literature Database, from database inception through October 2020. We included studies that examined rates of LCS participation and compared rates by race. Studies were pooled using random-effects meta-analysis.

RESULTS

We screened 18,300 titles/abstracts; 229 studies were selected for full-text review, of which nine studies met inclusion criteria. Studies were categorized into 2 groups: studies that reported the screening rate among an LCS-eligible patient population, and studies that reported the screening rate among a patient population referred for LCS. Median LCS participation rates were 14.4% (range 1.7 to 62.6%) for eligible patient studies and 68.5% (range 62.6 to 88.8%) for referred patient studies. The meta-analyses showed screening rates were lower in the Black compared to White population among the LCS-eligible patient studies ([OR]=0.43, [95% CI: 0.25, 0.74]). However, screening rates were the same between Black and White patients in the referred patient studies (OR=0.94, [95% CI: 0.74, 1.19]).

DISCUSSION

Black LCS-eligible patients are being screened at a lower rate than White patients but have similar rates of participation once referred. Differences in referrals by providers may contribute to the racial disparity in LCS participation. More studies are needed to identify barriers to LCS referral and develop interventions to increase provider awareness of the importance of LCS in Black patients. Trial Registry PROSPERO; No.: CRD42020214213; URL: http://www.crd.york.ac.uk/PROSPERO.

Likelihood of Lung Cancer Screening by Poor Health Status and Race and Ethnicity in US Adults, 2017 to 2020

IMPORTANCE

Lung cancer screening (LCS) via low-dose chest computed tomography can prevent mortality through surgical resection of early-stage cancers, but it is unknown whether poor health is associated with screening. Though LCS may be associated with better outcomes for non-Hispanic Black individuals, it is unknown whether racial or ethnic disparities exist in LCS use.

OBJECTIVE

To determine whether health status is associated with LCS and whether racial or ethnic disparities are associated with LCS independently of health status.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, population-based study of community-dwelling US adults used data from Behavioral Risk Factor Surveillance System annual surveys, 2017 to 2020. Participants were aged 55 to 79 years, with a less than 30 pack-year smoking history, and were current smokers or those who quit within 15 years. Data were analyzed from August to November 2021.

EXPOSURES

Self-reported health status and race and ethnicity.

MAIN OUTCOMES AND MEASURES

Self-reported LCS in the last 12 months.

RESULTS

Of 14 550 individuals (7802 men [55.5%]; 7527 [55.0%] aged 65-79 years [percentages are weighted]), representing 3.68 million US residents, 17.0% (95% CI, 15.1%-18.9%) reported undergoing LCS. The prevalence of LCS was lower among non-Hispanic Black than non-Hispanic White individuals but not to a significant degree (12.0% [95% CI, 4.3%-19.7%] vs 17.5% [95% CI, 15.6%-19.5%]; P = .57). Health status was associated with LCS: 468 individuals in poor health vs 96 individuals in excellent health reported LCS (25.2% [95% CI, 20.6%-29.9%] vs 7.6% [95% CI, 5.0%-10.3%]; P < .001), and those with difficulty climbing stairs were more likely to report LCS than those without this functional limitation. Adjusting for sociodemographic factors, functional status, and comorbidities, self-rated health status remained associated with LCS (adjusted odds ratio, 1.19 per each 1-step decline in health; 95% CI, 1.03-1.38), and non-Hispanic Black individuals were 53% less likely to report LCS than non-Hispanic White individuals (adjusted odds ratio, 0.47; 95% CI, 0.24-0.90). Results were robust in sensitivity analyses in which health was alternatively quantified as number of comorbidities.

CONCLUSIONS AND RELEVANCE

LCS in the US is more common among those who may be less likely to benefit from screening because of poor underlying health. Furthermore, racial or ethnic disparities were evident after accounting for health status, with non-Hispanic Black individuals nearly half as likely as non-Hispanic White individuals to report LCS despite the potential for greater benefit of screening this population.

Cancer prevention, risk reduction, and control: opportunities for the next decade of health care delivery research

In this commentary, we discuss opportunities to optimize cancer care delivery in the next decade building from evidence and advancements in the conceptualization and implementation of multi-level translational behavioral interventions. We summarize critical issues and discoveries describing new directions for translational behavioral research in the coming decade based on the promise of the accelerated application of this evidence within learning health systems. To illustrate these advances, we discuss cancer prevention, risk reduction (particularly precision prevention and early detection), and cancer treatment and survivorship (particularly risk- and need-stratified comprehensive care) and propose opportunities to equitably improve outcomes while addressing clinician shortages and cross-system coordination. We also discuss the impacts of COVID-19 and potential advances of scientific knowledge in the context of existing evidence, the need for adaptation, and potential areas of innovation to meet the needs of converging crises (e.g., fragmented care, workforce shortages, ongoing pandemic) in cancer health care delivery. Finally, we discuss new areas for exploration by applying key lessons gleaned from implementation efforts guided by advances in behavioral health.

Increased Disparities in Patients Diagnosed with Metastatic Lung Cancer Following Lung CT Screening in the United States

OBJECTIVES

We sought to determine if implementation of low dose computed tomography (LDCT) screening for lung cancer in the United States had led to changes in patients being diagnosed with metastatic lung cancer over time.

MATERIALS AND METHODS

The Surveillance, Epidemiology, and End Result (SEER) database was utilized to determine the proportion of lung cancers diagnosed as stage I to III and stage IV from 2009-2018. Changes in lung cancer stage distribution were compared in the overall population and by race.

RESULTS

From 2009 to 2018, the proportion of stage I to III lung cancers increased from 52% (51.3%-53.2%) in 2009 to 56% (54.0%-55.8%) in 2018 (P < .001). Correspondingly, the proportion of lung cancers diagnosed in stage IV decreased from 48% (46.8%-48.7%) in 2009 to 45% (44.2%-46.0%) (P < .001) in 2018. For white patients, the proportion increased from 53% (51.6%-53.7%) to 56% (55.1%-57.1%) (P < .001). However, for black patients, no trend was present, with the proportion being 51% (47.9%-53.4%) in 2009 and 52% (49.0%-54.2%) in 2018 (P = .303).

CONCLUSION

Since the implementation of LDCT screening, the proportion of early-stage lung cancers increased in the general population. These changes in stage distribution were not present in black patients.

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.

Quantifying Benefits and Harms of Lung Cancer Screening in an Underserved Population: Results From a Prospective Study

Lung cancer screening with annual low-dose computed tomography reduces lung cancer death by 20-26%. However, potential harms of screening include false-positive results, procedures from false positives, procedural complications and failure to adhere to follow-up recommendations. In diverse, underserved populations, it is unknown if benefits of early lung cancer detection outweigh harms. We conducted a prospective observational study of lung cancer screening participants in an urban, safety-net institution from September 2014 to June 2020. We measured benefits of screening in terms of cancer diagnosis, stage, and treatment. We measured harms of screening by calculating false-positive rate, procedures as a result of false positive screens, procedural complications, and failure to follow-up with recommended care. Of patients with 3-year follow up, we measured these same outcomes in addition to compliance with annual screening. Of 1509 participants, 55.6% were African American, 35.2% White, 8.1% Hispanic, and 0.5% Asian. Screening resulted in cancer detection and treatment in 2.8%. False positive and procedure as a result of a false positive occurred in 9.2% and 0.8% of participants, respectively with no major complications from diagnostic procedures or treatment. Adherence to annual screening was low, 18.7%, 3.7%, and 0.4% at 1, 2, and 3 years after baseline screening respectively. Multidisciplinary lung cancer screening in a safety-net institution can successfully detect and treat lung cancer with few harms of false-positive screens, procedure after false-positive screens and major complications. However, adherence to annual screening is poor.

Does Race or Ethnicity Impact Complications After Pulmonary Lobectomy for Patients With Lung Cancer?

BACKGROUND

Racial disparity in surgical access and postoperative outcomes after pulmonary lobectomy continues to be a concern and target for improvement; however, evidence of independent impact of race on complications is lacking. The objective of this study was to investigate the impact of race/ethnicity on surgical outcomes after lobectomy for lung cancer and estimate the distribution of racial/ethnic groups among expected resectable lung cancer cases using a large national database.

METHODS

Patients who underwent lobectomy for lung cancer between 2005 and 2016 were identified in the American College of Surgeon National Surgical Quality Improvement Program. Preoperative characteristics and postoperative outcomes were compared between race/ethnicity groups in all patients and in propensity-matched cohorts, controlling for pertinent risk factors. Distribution of each race/ethnicity in the database was calculated relative to estimated numbers of patients with resectable lung cancer in the United States.

RESULTS

A total of 10,202 patients (age 67.6 ± 9.7, 46.7% male, 86.4% white) underwent nonemergent lobectomy (46.8% thoracoscopic). Blacks had higher rates of baseline risk factors. In propensity score-matched cohorts of whites, blacks, and Hispanics/Asians (n = 498 each), postoperatively, blacks had higher rates of prolonged intubation and longer hospital stay while whites had a higher rate of pneumonia. Race was independently associated with these adverse outcomes on multivariate analysis. Proportion of blacks and Hispanics in the American College of Surgeon National Surgical Quality Improvement Program was lower than their respective proportion of resectable lung cancer in the United States.

CONCLUSIONS

In a large national-level surgical database, there was lower than expected representation of black and Hispanic patients. Black race was independently associated with extended length of stay and prolonged intubation, whereas white was independently associated with postoperative pneumonia.

The SHARED Project: A Novel Approach to Engaging African American Men to Address Lung Cancer Disparities

Black men are disproportionately impacted by lung cancer morbidity and mortality. Low-dose helical computed tomography (LDCT) lung cancer screening has demonstrated benefits for reducing lung cancer deaths by identifying cancers at earlier, more treatable stages. Despite the known benefits, LDCT screening is underutilized in black men. Studies in racially heterogeneous populations have found correlations between screening behaviors and factors such as physician trust, physician referral, and a desire to reduce the uncertainty of not knowing if they had lung cancer; yet little is known about the factors that specifically contribute to screening behaviors in black men. Community engagement strategies are beneficial for understanding barriers to health-care engagement. One community engagement approach is the citizen scientist model. Citizen scientists are lay people who are trained in research methods; they have proven valuable in increasing communities' knowledge of the importance of healthy behaviors such as screening, awareness of research, building trust in research, and improving study design and ethics. This paper proposes an intervention, grounded in community-based participatory research approaches and social network theory, to engage black men as citizen scientists in an effort to increase lung cancer screening in black men. This mixed-methods intervention will examine the attitudes, behaviors, and beliefs of black men related to uptake of evidence-based lung cancer screening.