Do Lung Cancer Eligibility Criteria Align with Risk among Blacks and Hispanics?

Virtual Health Care Encounters for Lung Cancer Screening in a Safety-Net Population: Observations From the COVID-19 Pandemic

PURPOSE

The COVID-19 pandemic disrupted normal mechanisms of health care delivery and facilitated the rapid and widespread implementation of telehealth technology. As a result, the effectiveness of virtual health care visits in diverse populations represents an important consideration. We used lung cancer screening as a prototype to determine whether subsequent adherence differs between virtual and in-person encounters in an urban, safety-net health care system.

METHODS

We conducted a retrospective analysis of initial low-dose computed tomography (LDCT) ordered for lung cancer screening from March 2020 through February 2023 within Parkland Health, the integrated safety-net provider for Dallas County, TX. We collected data on patient characteristics, visit type, and LDCT completion from the electronic medical record. Associations among these variables were assessed using the chi-square test. We also performed interaction analyses according to visit type.

RESULTS

Initial LDCT orders were placed for a total of 1,887 patients, of whom 43% were female, 45% were Black, and 17% were Hispanic. Among these orders, 343 (18%) were placed during virtual health care visits. From March to August 2020, 79 of 163 (48%) LDCT orders were placed during virtual visits; after that time, 264 of 1,724 (15%) LDCT orders were placed during virtual visits. No patient characteristics were significantly associated with visit type (in-person v virtual) or LDCT completion. Rates of LDCT completion were 95% after in-person visits and 97% after virtual visits (P = .13).

CONCLUSION

In a safety-net lung cancer screening population, patients were as likely to complete postvisit initial LDCT when ordered in a virtual encounter as in an in-person encounter.

Early Detection and Interception of Lung Cancer

Recent advances in lung cancer treatment have led to dramatic improvements in 5-year survival rates. And yet, lung cancer remains the leading cause of cancer-related mortality, in large part, because it is often diagnosed at an advanced stage, when cure is no longer possible. Lung cancer screening (LCS) is essential for intercepting the disease at an earlier stage. Unfortunately, LCS has been poorly adopted in the United States, with less than 5% of eligible patients being screened nationally. This article will describe the data supporting LCS, the obstacles to LCS implementation, and the promising opportunities that lie ahead.

Characteristics of lung cancer screening eligible population in the US and prediction of the eligibility with simplified criteria

Background

In 2021, updates to the lung cancer screening (LCS) guidelines extended the eligibility to include younger individuals and those with lower lifetime smoking intensity. A significant challenge in the LCS implementation is identifying eligible individuals because lifetime smoking intensity, a key criterion of current guidelines, is typically unavailable in electronic health records and difficult to assess accurately. This study aimed to (I) examine the characteristics of the eligible population in the US based on current guidelines and (II) evaluate the performance of five simplified criteria as alternative tools for predicting LCS eligibility.

Methods

National Health and Nutrition Examination Survey (NHANES) 2013-2018 data were used. Five simplified criteria were: (I) ever smoker, defined as an individual with any positive smoking history; (II) current or former smoker, an individual with any positive smoking history or who quit smoking within 15 years; (III) current smoker, an individual currently smoking; (IV) current smoker, an individual currently smoking >0.5 packs per day (ppd); (V) current smoker, a person currently smoking >1 ppd. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated. The complex survey design was considered.

Results

About 16.70 million individuals (representing 16.01% of population aged 50-80 years) were eligible for LCS in the US. The percentage of LCS eligibility was higher among people who were younger, male, non-Hispanic White, less educated, single, not insured, with poorer health status and lower socioeconomic status. Except for the criterion of current smoker with >1 ppd having low sensitivity (0.08), other criteria had sensitivity ranging between 0.45 and 1.00. The accuracy of the five criteria used ranged between 0.70 and 0.91.

Conclusions

Individuals with less favorable social and clinical characteristics have higher chances of being eligible for LCS, potentially amplifying disparities in LCS utilization. Simplified criteria can be used as prescreening tools to identify target populations, which could facilitate LCS implementation at the population level.

Promoting lung cancer screening of high-risk patients by primary care providers

BACKGROUND

Lung cancer screening (LCS) with low-dose computed tomography (LDCT) of the chest of eligible patients remains low. Accordingly, augmentation of appropriate LCS referrals by primary care providers (PCPs) was sought.

METHODS

The quality improvement (QI) project was performed between April 2021 and June 2022. It incorporated patient education, shared decision-making (SDM) with PCPs, and tracking of initial LDCT completion. In each case, lag time (LT) to LCS and pack-years (PYs) were calculated from initial LCS eligibility. The cohort's scores were compared to national scores. Patient zip codes were used to create a geographic map of our cohort for comparison with public health data.

RESULTS

An immediate and sustained increase in weekly LCS referrals from PCPs was recorded. Of 337 initial referrals, 95% were men, consisting of 66.2% Black, 28.4% White, and 5.4% other. Mean PY was less for minorities (45.3 vs. 37.3 years; p = .0002) but mean LT was greater for Whites (7.9 vs. 6.2 years; p = .03). Twenty-five percent of veterans failed to report to their scheduled screening, and two declined referrals. Notably, most no-show patients lived in transit deserts. Furthermore, Lung-RADS scores 4B/4X were more than double the expected prevalence (p = .008).

CONCLUSIONS

The PCPs in this study successfully augmented LCS referrals. A substantial proportion of these patients were no-shows, and our data suggest complex racial and socioeconomic factors as contributing variables. In addition, a higher-than-expected number of initial Lung-RADS scores 4B/4X were reported. A large, multisite QI project is warranted to address overcoming potential transportation barriers in high-risk patient populations.

How We Got Here: The Legacy of Anti-Black Discrimination in Radiology

Current disparities in the access to diagnostic imaging for Black patients and the underrepresentation of Black physicians in radiology, relative to their representation in the general U.S. population, reflect contemporary consequences of historical anti-Black discrimination. These disparities have existed within the field of radiology and professional medical organizations since their inception. Explicit and implicit racism against Black patients and physicians was institutional policy in the early 20th century when radiology was being developed as a clinical medical field. Early radiology organizations also embraced this structural discrimination, creating strong barriers to professional Black radiologist involvement. Nevertheless, there were numerous pioneering Black radiologists who advanced scholarship, patient care, and diversity within medicine and radiology during the early 20th century. This work remains important in the present day, as race-based health care disparities persist and continue to decrease the quality of radiology-delivered patient care. There are also structural barriers within radiology affecting workforce diversity that negatively impact marginalized groups. Multiple opportunities exist today for antiracism work to improve quality of care and to apply standards of social justice and health equity to the field of radiology. An initial step is to expand education on the disparities in access to imaging and health care among Black patients. Institutional interventions include implementing community-based outreach and applying antibias methodology in artificial intelligence algorithms, while systemic interventions include identifying national race-based quality measures and ensuring imaging guidelines properly address the unique cancer risks in the Black patient population. These approaches reflect some of the strategies that may mutually serve to address health care disparities in radiology. ^© RSNA, 2023 See the invited commentary by Scott in this issue. Quiz questions for this article are available in the supplemental material.

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.

Comparison Between the 2021 USPSTF Lung Cancer Screening Criteria and Other Lung Cancer Screening Criteria for Racial Disparity in Eligibility

IMPORTANCE

In 2021, the US Preventive Services Task Force (USPSTF) broadened its age and smoking pack-year requirement for lung cancer screening.

OBJECTIVES

To compare the 2021 USPSTF lung cancer screening criteria with other lung cancer screening criteria and evaluate whether the sensitivity and specificity of these criteria differ by race.

DESIGN, SETTING, AND PARTICIPANTS

This study included 912 patients with lung cancer and 1457 controls without lung cancer enrolled in an epidemiology study (INHALE [Inflammation, Health, Ancestry, and Lung Epidemiology]) in the Detroit metropolitan area between May 15, 2012, and March 31, 2018. Patients with lung cancer and controls were 21 to 89 years of age; patients with lung cancer who were never smokers and controls who were never smokers were not included in these analyses. Statistical analysis was performed from August 31, 2020, to April 13, 2021.

MAIN OUTCOMES AND MEASURES

The study assessed whether patients with lung cancer and controls would have qualified for lung cancer screening using the 2013 USPSTF, 2021 USPSTF, and 2012 modification of the model from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCOm2012) screening criteria. Sensitivity was defined as the percentage of patients with lung cancer who qualified for screening, while specificity was defined as the percentage of controls who did not qualify for lung cancer screening.

RESULTS

Participants included 912 patients with a lung cancer diagnosis (493 women [54%]; mean [SD] age, 63.7 [9.5] years) and 1457 control participants without lung cancer at enrollment (795 women [55%]; mean [SD] age, 60.4 [9.6] years). With the use of 2021 USPSTF criteria, 590 patients with lung cancer (65%) were eligible for screening compared with 619 patients (68%) per the PLCOm2012 criteria and 445 patients (49%) per the 2013 USPSTF criteria. With the use of 2013 USPSTF criteria, significantly more White patients than African American patients with lung cancer (324 of 625 [52%] vs 121 of 287 [42%]) would have been eligible for screening. This racial disparity was absent when using 2021 USPSTF criteria (408 of 625 [65%] White patients vs 182 of 287 [63%] African American patients) and PLCOm2012 criteria (427 of 625 [68%] White patients vs 192 of 287 [67%] African American patients). The 2013 USPSTF criteria excluded 950 control participants (65%), while the PLCOm2012 criteria excluded 843 control participants (58%), and the 2021 USPSTF criteria excluded 709 control participants (49%). The 2013 USPSTF criteria excluded fewer White control participants than African American control participants (514 of 838 [61%] vs 436 of 619 [70%]). This racial disparity is again absent when using 2021 USPSTF criteria (401 of 838 [48%] White patients vs 308 of 619 [50%] African American patients) and PLCOm2012 guidelines (475 of 838 [57%] White patients vs 368 of 619 [60%] African American patients).

CONCLUSIONS AND RELEVANCE

This study suggests that the USPSTF 2021 guideline changes improve on earlier, fixed screening criteria for lung cancer, broadening eligibility and reducing the racial disparity in access to screening.

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.

Half of germline pathogenic and likely pathogenic variants found on panel tests do not fulfil NHS testing criteria

Genetic testing for cancer predisposition has been curtailed by the cost of sequencing, and testing has been restricted by eligibility criteria. As the cost of sequencing decreases, the question of expanding multi-gene cancer panels to a broader population arises. We evaluated how many additional actionable genetic variants are returned by unrestricted panel testing in the private sector compared to those which would be returned by adhering to current NHS eligibility criteria. We reviewed 152 patients referred for multi-gene cancer panels in the private sector between 2014 and 2016. Genetic counselling and disclosure of all results was standard of care provided by the Consultant. Every panel conducted was compared to current eligibility criteria. A germline pathogenic / likely pathogenic variant (P/LP), in a gene relevant to the personal or family history of cancer, was detected in 15 patients (detection rate of 10%). 46.7% of those found to have the P/LP variants (7 of 15), or 4.6% of the entire set (7 of 152), did not fulfil NHS eligibility criteria. 46.7% of P/LP variants in this study would have been missed by national testing guidelines, all of which were actionable. However, patients who do not fulfil eligibility criteria have a higher Variant of Uncertain Significance (VUS) burden. We demonstrated that the current England NHS threshold for genetic testing is missing pathogenic variants which would alter management in 4.6%, nearly 1 in 20 individuals. However, the clinical service burden that would ensue is a detection of VUS of 34%.

Evaluation of Population-Level Changes Associated With the 2021 US Preventive Services Task Force Lung Cancer Screening Recommendations in Community-Based Health Care Systems

IMPORTANCE

The US Preventive Services Task Force (USPSTF) released updated lung cancer screening recommendations in 2021, lowering the screening age from 55 to 50 years and smoking history from 30 to 20 pack-years. These changes are expected to expand screening access to women and racial and ethnic minority groups.

OBJECTIVE

To estimate the population-level changes associated with the 2021 USPSTF expansion of lung cancer screening eligibility by sex, race and ethnicity, sociodemographic factors, and comorbidities in 5 community-based health care systems.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed data of patients who received care from any of 5 community-based health care systems (which are members of the Population-based Research to Optimize the Screening Process Lung Consortium, a collaboration that conducts research to better understand how to improve the cancer screening processes in community health care settings) from January 1, 2010, through September 30, 2019. Individuals who had complete smoking history and were engaged with the health care system for 12 or more continuous months were included. Those who had never smoked or who had unknown smoking history were excluded.

EXPOSURES

Electronic health record-derived age, sex, race and ethnicity, socioeconomic status (SES), comorbidities, and smoking history.

MAIN OUTCOMES AND MEASURES

Differences in the proportion of the newly eligible population by age, sex, race and ethnicity, Charlson Comorbidity Index, chronic obstructive pulmonary disease diagnosis, and SES as well as lung cancer diagnoses under the 2013 recommendations vs the expected cases under the 2021 recommendations were evaluated using χ2 tests.

RESULTS

As of September 2019, there were 341 163 individuals aged 50 to 80 years who currently or previously smoked. Among these, 34 528 had electronic health record data that captured pack-year and quit-date information and were eligible for lung cancer screening according to the 2013 USPSTF recommendations. The 2021 USPSTF recommendations expanded screening eligibility to 18 533 individuals, representing a 53.7% increase. Compared with the 2013 cohort, the newly eligible 2021 population included 5833 individuals (31.5%) aged 50 to 54 years, a larger proportion of women (52.0% [n = 9631]), and more racial or ethnic minority groups. The relative increases in the proportion of newly eligible individuals were 60.6% for Asian, Native Hawaiian, or Pacific Islander; 67.4% for Hispanic; 69.7% for non-Hispanic Black; and 49.0% for non-Hispanic White groups. The relative increase for women was 13.8% higher than for men (61.2% vs 47.4%), and those with a lower comorbidity burden and lower SES had higher relative increases (eg, 68.7% for a Charlson Comorbidity Index score of 0; 61.1% for lowest SES). The 2021 recommendations were associated with an estimated 30% increase in incident lung cancer diagnoses compared with the 2013 recommendations.

CONCLUSIONS AND RELEVANCE

This cohort study suggests that, in diverse health care systems, adopting the 2021 USPSTF recommendations will increase the number of women, racial and ethnic minority groups, and individuals with lower SES who are eligible for lung cancer screening, thus helping to minimize the barriers to screening access for individuals with high risk for lung cancer.

Racial Differences in Adherence to Lung Cancer Screening Follow-Up: A Systematic Review and Meta-Analysis

BACKGROUND

In 2013 the United States Preventive Services Taskforce (USPSTF) instituted recommendations for annual lung cancer screening (LCS) with low dose chest computed tomography for high-risk individuals. LCS reduces lung cancer mortality, with greater reduction observed in Black participants in clinical trials. While racial disparities in lung cancer mortality have been well documented, less is known about disparities in LCS participation and adherence to follow-up in clinical practice.

RESEARCH QUESTION

What is the association between race and adherence to LCS follow-up?

STUDY DESIGN & 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 adherence to LCS follow-up and compared rates by race. Studies were pooled using random-effects meta-analysis.

RESULTS

We screened 18,300 titles/abstracts and 229 studies were selected for full-text review. Nine studies met inclusion criteria; seven were included in the meta-analysis. Median adherent follow-up rate was 37% (range 16-82%). Notable differences among the studies included the proportion of the Black population (range 4-47%) and the structure of the LCS programs. The meta-analyses showed lower adherence to LCS follow-up in the Black population (Odds Ratio [OR]=0.67, [95% CI: 0.55, 0.80]). This disparity persisted across all malignancy risk levels determined by initial screening results.

INTERPRETATION

There is lower adherence to LCS follow-up in Black compared to White patients despite the higher potential lung cancer mortality benefit. Literature specifically addressing race-related barriers to LCS adherence is still limited. To ensure equity in LCS benefits, greater outreach to eligible Black patients should be implemented through increased physician education and utilization of screening program coordinators to focus on this patient population.

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.

Examining lung cancer screening utilization with public-use data: Opportunities and challenges

Lung cancer screening with low-dose computed tomography is recommended for high-risk smokers who meet specific eligibility criteria. Current guidelines suggest that eligible adults with a heavy smoking history will benefit from annual low dose computed tomography but due to several associated risks (e.g., false-positives, radiation exposure, overdiagnosis) a shared decision-making consultation is required by the Centers for Medicare & Medicaid Services, and endorsed by the United States Preventive Services Task Force. In order to examine potential for tracking LCS uptake, adherence, and patient-provider communication at a national level, we reviewed four regularly publicly available national surveys (National Health Interview Survey [NHIS], Behavioral Risk Factor Surveillance System [BRFSS], National Health and Nutrition Examination Survey [NHANES], and Health Information National Trends Survey [HINTS]) to assess available data; an overview of 37 publications using these sources is also provided. The results show that none of the surveys include items that fully assess current LCS guidelines. Implications for future research-including the potential to examine factors associated with LCS uptake and patient-provider communication-are addressed.

The impact of income and education on lung cancer screening utilization, eligibility, and outcomes: a narrative review of socioeconomic disparities in lung cancer screening

Non-small cell lung cancer (NSCLC) is the leading cause of cancer deaths in the US and worldwide. In particular, vulnerable populations such as those of low socioeconomic status (SES) are at the highest risk for and suffer the highest mortality from NSCLC. Although lung cancer screening (LCS) has been demonstrated to be a powerful tool to lower NSCLC mortality, it is underutilized by eligible smokers, and disparities in screening are likely to contribute to inequities in NSCLC outcomes. It is imperative that we collect and analyze LCS data focused on individuals of low socioeconomic position to identify and address barriers to LCS utilization and help close the gaps in NSCLC mortality along socioeconomic lines. Toward this end, this review aims to examine published studies that have evaluated the impact of income and education on LCS utilization, eligibility, and outcomes. We searched the PubMed, Ovid MEDLINE, and CINAHL Plus databases for all studies published from January 1, 2010, to October 21, 2020, that discussed socioeconomic-based LCS outcomes. The review reveals that income and education have impact on LCS utilization, eligibility, false positive rates and smoking cessation attempts; however, there is a lack of studies evaluating the impact of SES on LCS follow-up, stage at diagnosis, and treatment. We recommend the intentional inclusion of lower SES participants in LCS studies in order to clarify appropriate eligibility criteria, risk-based metrics and outcomes in this high-risk group. We also anticipate that low SES smokers and their providers will require increased support and education regarding smoking cessation and shared decision-making efforts.

Personalising lung cancer screening: An overview of risk-stratification opportunities and challenges

Randomised clinical trials have shown the efficacy of computed tomography lung cancer screening, initiating discussions on whether and how to implement population‐based screening programs. Due to smoking behaviour being the primary risk‐factor for lung cancer and part of the criteria for determining screening eligibility, lung cancer screening is inherently risk‐based. In fact, the selection of high‐risk individuals has been shown to be essential in implementing lung cancer screening in a cost‐effective manner. Furthermore, studies have shown that further risk‐stratification may improve screening efficiency, allow personalisation of the screening interval and reduce health disparities. However, implementing risk‐based lung cancer screening programs also requires overcoming a number of challenges. There are indications that risk‐based approaches can negatively influence the trade‐off between individual benefits and harms if not applied thoughtfully. Large‐scale implementation of targeted, risk‐based screening programs has been limited thus far. Consequently, questions remain on how to efficiently identify and invite high‐risk individuals from the general population. Finally, while risk‐based approaches may increase screening program efficiency, efficiency should be balanced with the overall impact of the screening program. In this review, we will address the opportunities and challenges in applying risk‐stratification in different aspects of lung cancer screening programs, as well as the balance between screening program efficiency and impact.

Addressing Disparities in Lung Cancer Screening Eligibility and Healthcare Access. An Official American Thoracic Society Statement

Background: There are well-documented disparities in lung cancer outcomes across populations. Lung cancer screening (LCS) has the potential to reduce lung cancer mortality, but for this benefit to be realized by all high-risk groups, there must be careful attention to ensuring equitable access to this lifesaving preventive health measure.Objectives: To outline current knowledge on disparities in eligibility criteria for, access to, and implementation of LCS, and to develop an official American Thoracic Society statement to propose strategies to optimize current screening guidelines and resource allocation for equitable LCS implementation and dissemination.Methods: A multidisciplinary panel with expertise in LCS, implementation science, primary care, pulmonology, health behavior, smoking cessation, epidemiology, and disparities research was convened. Participants reviewed available literature on historical disparities in cancer screening and emerging evidence of disparities in LCS.Results: Existing LCS guidelines do not consider racial, ethnic, socioeconomic, and sex-based differences in smoking behaviors or lung cancer risk. Multiple barriers, including access to screening and cost, further contribute to the inequities in implementation and dissemination of LCS.Conclusions: This statement identifies the impact of LCS eligibility criteria on vulnerable populations who are at increased risk of lung cancer but do not meet eligibility criteria for screening, as well as multiple barriers that contribute to disparities in LCS implementation. Strategies to improve the selection and dissemination of LCS in vulnerable groups are described.

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.

The Patient Perspective on Lung Cancer Screening and Health Disparities

Lung cancer screening is just starting to be implemented across the United States. Challenges to screening include access to care, awareness of the option for screening, stigma and implicit bias that are due to stigmatization of smoking, stigma of race, nihilism with lung cancer diagnosis viewed as a "death sentence," shared decision making, and underestimation of lung cancer risk. African Americans (AA) have the highest lung cancer mortality rate in the United States despite similar smoking rates as whites. AAs are diagnosed at a later stage, and there is a greater likelihood they will refuse treatment options when diagnosed. Additionally, fewer AAs were found to meet lung cancer screening eligibility criteria compared with whites because of lower tobacco exposure and younger age at time of diagnosis. Outreach and access for lung cancer screening in the AA community and other subpopulations at risk are critical to avoid further increasing disparities in lung cancer morbidity and mortality as lung cancer screening is implemented across the United States. The path forward requires implementing outreach programs and providing lung cancer screening in underserved communities at high risk for lung cancer; consideration of using National Comprehensive Cancer Network guidelines for screening selection criteria, including risk model screening selection; and developing interventions to address stigma, clinician implicit bias, and nihilism.

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.

Knowledge and attitudes towards low dose computed tomography lung cancer screening and smoking among African Americans-a mixed method study

BACKGROUND

The purpose of this study is to investigate knowledge, attitudes, and smoking cessation needs for African Americans who receive low dose computed tomography (LDCT) in an effort to reduce the health burden of lung cancer.

METHODS

A mixed method study was conducted among African Americans who received LDCT. Data were gathered using a self-administered questionnaire and structured in-depth interview. Descriptive statistics were used to provide summary information on knowledge, attitude and smoking behaviors. Thematic analysis was used to analyze interview data. The sample size for both the quantitative and qualitative approach was fifteen.

RESULTS

The results showed that 73% of participants were male, the mean age was 61.8 (SD =4.6) years old, and 66.7% of participants had an income less than $20,000. Eighty percent had an education level of high school or below and 73.3% were overweight or obese. Smoking history was long (mean years =39 SD =14.9), but the number of cigarettes smoked per day was low (mean =9.2 SD =7.3), and 64% of the patients had a low nicotine dependence. Assessment of knowledge and attitudes towards LDCT revealed that participants had a moderate/lower knowledge score (mean =4.3 SD =2.6), and most had a positive attitude. All participants planned to quit smoking, with 73% planning to quit within the next 6 months. Similar findings were also observed in the qualitative analysis.

CONCLUSIONS

African Americans who receive LDCT lung cancer screening in this study have a moderate/lower knowledge score and positive attitude towards LDCT. Most were not heavy smokers and had a lower nicotine dependence. Understanding the factors associated with smoking cessation among at-risk African American smokers will help reduce disparities in lung cancer burden, and is important to improve health for medically underserved minority populations.

The Casualties Left Behind in Tobacco's Cinders of Combustion

Purpose

This paper 1) defines the scope of tobacco-related health disparities; 2) reviews population-based approaches aimed to eliminate disparities- Medicaid, the U.S. Preventive Health Service Task Force, and the Family Smoking Prevention and Tobacco Control Act; and 3) discusses their potential role in reducing tobacco use and lung cancer disparities.

Recent findings

The implementation of population-based approaches aimed to reduce tobacco use and chronic diseases has been inequitable. The poor are predominately affected by limited access to comprehensive tobacco cessation coverage. Moreover, lung cancer screenings reveal that those disproportionately excluded are African Americans who have the highest lung cancer incidence and mortality in the United States. The potential impact of the Family Smoking Prevention and Tobacco Control Act is unclear, but the proposed rule to ban menthol combustible and not non-combustible tobacco products could potentially contribute to a cycle of addiction in disadvantaged communities. Alternative solutions, including civil rights litigation, should be investigated.

Summary

Eliminating tobacco-related health disparities is a health, social justice, civil rights, and ethical issue that deserves immediate attention and equitable policy solutions.

Disparities in the Treatment and Outcome of Stage I Non-Small-Cell Lung Cancer in the 21st Century

BACKGROUND

African American (AA) individuals are less likely to receive treatment and more likely to die from cancer compared with Caucasian (C) individuals. Recent advancements in surgery and radiation have improved outcomes in early stage non-small-cell lung cancer (ESNSCLC). We studied racial disparities in ESNSCLC in the past decade.

PATIENTS AND METHODS

The Surveillance, Epidemiology, and End Results database was used to retrieve data of 62,312 ESNSCLC patients age 60 years and older diagnosed between 2004 and 2012. Patients were divided into racial cohorts: C, AA, American Indian (AI), Asian/Pacific Islander (API), or unknown. Demographics characteristics, therapy, and survival were compared using χ² test, Kaplan-Meier method, and Cox multivariate analysis.

RESULTS

AA and AI individuals were less likely to receive surgery than typical ESNSCLC patients (55.9% and 57.6% vs. 66.7%; P < .0001). Two-year overall survival (OS) for C individuals was 70%, for AA 65%, AI 60%, and API 76% (P < .0001). Two-year cancer-specific survival (CSS) for C individuals was 79%, AA 76%, AI 73%, and API 84% (P < .0001). Median CSS for AI and AA individuals was less than that of typical ESNSCLC patients (49 and 80 months vs. 107 months; P < .0001). This difference disappeared in multivariate analysis, accounted by sex, age, treatment, histology, and T stage (all P < .0001).

CONCLUSION

Despite treatment advancements in the past decade, AA and AI individuals continue to have worse OS and CSS from ESNSCLC. This might be because of the association with more adverse risk factors, including older age, squamous histology, male sex, T2 stage, and tendency to forgo treatment.

Racial disparities in eligibility for low-dose computed tomography lung cancer screening among older adults with a history of smoking

PURPOSE

Lung cancer early detection screening has been demonstrated to decrease lung cancer mortality among high-risk smokers. This study aimed to examine whether current screening guidelines may disproportionately exclude African American smokers who are at higher overall risk for lung cancer.

METHODS

Data from the 2014 Health and Retirement Study were analyzed. Older African Americans and Whites with a history of smoking were included in the analyses (n = 7,348). Eligibility criteria established by the U.S. Preventive Services Task Force (USPSTF) for LDCT lung cancer screening were used. Multivariate logistic regression analyses were conducted to examine racial differences in eligibility for LDCT lung cancer screening.

RESULTS

Overall, 21.1% of current and 10.5% of former smokers met USPSTF's eligibility criteria for LDCT screening. In multivariate logistic regression analyses, African American smokers were less likely to be eligible for LDCT lung cancer screening compared to Whites (odds ratio = 0.5; p < 0.001).

CONCLUSION

African American smokers were less likely to meet established lung cancer screening eligibility criteria compared to Whites. Current lung cancer screening criteria may not adequately capture African Americans at risk and may widen the health disparities in African Americans. Further longitudinal studies are needed to evaluate the efficacy of current lung cancer screening guideline.

Low-dose computed tomography lung cancer screening as a teachable moment for smoking cessation among African American smokers: A feasibility study

Low-dose computed tomography (LDCT) screening may be a teachable moment for smoking cessation among African Americans. African Americans have been understudied within the context of LDCT and smoking cessation. The study objective was to evaluate the feasibility of recruiting African Americans to a future longitudinal trial and to obtain sample size estimates for that trial. Participants (N = 18) were African Americans eligible for LDCT screening who completed a questionnaire at three time points. Self-efficacy and intention to quit smoking were compared. The results of the current study show that it is feasible to recruit African Americans eligible for LDCT.

The association between HOTAIR polymorphisms and cancer susceptibility: an updated systemic review and meta-analysis

OBJECTIVES

This work aims to explore whether HOX transcript antisense intergenic RNA (HOTAIR) polymorphisms are associated with cancer susceptibility.

MATERIALS AND METHODS

A comprehensive search was conducted for literature published from January 2007 to July 2017. The pooled odds ratios (ORs) and the corresponding 95% CIs were calculated using the Revman 5.2 software. Eighteen articles of 36 case-control studies were enrolled including six HOTAIR polymorphisms and 10 cancer types.

RESULTS

The results showed that cancer risk was elevated in recessive mutation of rs12826786 (TT vs CC+CT: OR =1.55, 95% CI =1.19, 2.03; TT+CT vs CC: OR =1.23, 95% CI =1.04, 1.46; TT vs CC: OR =1.67, 95% CI =1.24, 2.24; T vs C: OR =1.24, 95% CI =1.09, 1.40) and rs920778 (TT vs CC+CT: OR =1.73, 95% CI =1.30, 2.30; TT+CT vs CC: OR =1.40, 95% CI =1.16, 1.70; TT vs CC: OR =1.83, 95% CI =1.25, 2.68; T vs C: OR =1.37, 95% CI =1.18, 1.59), while the results for polymorphisms of rs7958904, rs4759314, rs874945, and rs1899663 were insignificant. The stratified results for Chinese population were consistent with the overall group analysis.

CONCLUSION

Our meta-analysis showed that HOTAIR polymorphisms of rs12826786 and rs920778 were correlated with increased cancer risk, while rs7958904, rs4759314, rs874945, and rs1899663 were not. More studies with different types of cancer are needed to confirm the findings.

Lung Cancer Screening Update

Since the release of the US Preventive Services Task Force and Centers for Medicare and Medicaid Services recommendations for lung cancer screening, low-dose chest computed tomography screening has moved from the research arena to clinical practice. Lung cancer screening programs must reach beyond image acquisition and interpretation and engage in a multidisciplinary effort of clinical shared decision-making, standardization of imaging and nodule management, smoking cessation, and patient follow-up. Standardization of radiologic reports and nodule management will systematize patient care, provide quality assurance, further reduce harm, and contain health care costs. Although the National Lung Screening Trial results and eligibility criteria of a heavy smoking history are the foundation for the standard guidelines for low-dose chest computed tomography screening in the United States, currently only 27% of patients diagnosed with lung cancer would meet US lung cancer screening recommendations. Current and future efforts must be directed to better delineate those patients who would most benefit from screening and to ensure that the benefits of screening reach all socioeconomic strata and racial and ethnic minorities. Further optimization of lung cancer screening program design and patient eligibility will assure that lung cancer screening benefits will outweigh the potential risks to our patients.

Evaluating efficacy of current lung cancer screening guidelines

Objective

Current lung cancer screening criteria based primarily on outcomes from the National Lung Screening Trial may not adequately capture all subgroups of the population at risk. We aimed to evaluate the efficacy of lung cancer screening criteria recommended by the United States Preventive Services Task Force, Centers for Medicare and Medicaid Services, and the National Comprehensive Cancer Network in identifying known cases of lung cancer.

Methods

An investigation of the Stony Brook Cancer Center Lung Cancer Evaluation Center's database identified 1207 eligible, biopsy-proven lung cancer cases diagnosed between January 1996 and March 2016. Age at diagnosis, smoking history, and other known risk factors for lung cancer were used to determine the proportion of cases that would have met current United States Preventive Services Task Force, Centers for Medicare and Medicaid Services, and National Comprehensive Cancer Network eligibility requirements for lung cancer screening.

Results

Of the 1046 ever smokers in the study, 40% did not meet the National Lung Screening Trial age requirements, 20% did not have a ≥30 pack year smoking history, and approximately one-third quit smoking >15 years before diagnosis, thus deeming them ineligible for screening. Applying the United States Preventive Services Task Force, Centers for Medicare and Medicaid Services, and National Comprehensive Cancer Network eligibility criteria to the Stony Brook Cancer Center's Lung Cancer Evaluation Center cases, 49.2, 46.3, and 69.8%, respectively, would have met the current lung cancer screening guidelines.

Conclusions

The United States Preventive Services Task Force and Centers for Medicare and Medicaid Services eligibility criteria for lung cancer screening captured less than 50% of lung cancer cases in this investigation. These findings highlight the need to reevaluate the efficacy of current guidelines and may have major public health implications.

Risk factors assessment and risk prediction models in lung cancer screening candidates

From February 2015, low-dose computed tomography (LDCT) screening entered the armamentarium of diagnostic tools broadly available to individuals at high-risk of developing lung cancer. While a huge number of pulmonary nodules are identified, only a small fraction turns out to be early lung cancers. The majority of them constitute a variety of benign lesions. Although it entails a burden of the diagnostic work-up, the undisputable benefit emerges from: (I) lung cancer diagnosis at earlier stages (stage shift); (II) additional findings enabling the implementation of a preventive action beyond the realm of thoracic oncology. This review presents how to utilize the risk factors from distinct categories such as epidemiology, radiology and biomarkers to target the fraction of population, which may benefit most from the introduced screening modality.