Do CT lung cancer screening rules promote healthcare disparities?

2021 05 18 18 24 0040 Nurse Doctor Patient Black Woman 400

Does the current guidance from the U.S. Preventive Services Task Force (USPSTF) on CT lung cancer screening perpetuate healthcare disparities for minority groups? It appears so, according to a study published September 21 in Radiology.

Why? Because the measures used to establish screening eligibility don't take into account factors that contribute to a higher lung cancer burden among people of color, wrote a team led by Dr. Anand Narayan, PhD, of the University of Wisconsin in Madison.

"Racial and ethnic minority groups face higher lung cancer morbidity and mortality, reflecting occupational and environmental exposures, socioeconomic status, neighborhood characteristics, and health behaviors," the group wrote. "[Lung cancer screening] eligibility using age and pack-year criteria may exacerbate lung cancer disparities by limiting referral and access to lung cancer screening facilities among higher-risk underserved populations."

This past March, the USPSTF released updated CT lung cancer screening guidelines that expanded the pool of eligible individuals lowering the starting age from 55 to 50 and reducing the smoking history from 30 to 20 pack-years of smoking. The updated recommendation was an improvement on the 2014 version, which included study data in which only 4% of participants were Black.

But the framework of establishing screening eligibility by age and pack years remained, and it isn't comprehensive enough, Narayan said in a statement released by the RSNA.

"It was great to expand eligibility, but to just change the age and the pack-years doesn't fully address lung cancer risk," Narayan said. "We've long known that some racial/ethnic minorities face a higher risk of lung cancer, and that level of risk is not adequately reflected in the new guidelines."

Black and people of color face patient- and provider-level barriers that white people may not, from medical mistrust, cancer fatalism, and financial concerns to providers' lack of cultural awareness and implicit bias, the group noted.

Narayan and colleagues sought to assess the impact that the proposed USPSTF guideline change would have on healthcare disparities among people of color using data from the 2019 Behavioral Risk Factor Surveillance System Survey, which included more than 77,000 people.

The team found that overall, the proportion of individuals eligible for CT lung cancer screening increased with the guidance revision, from 10.9% in 2014 to 13.7% in 2021. But Black, Latino, and Asian/Pacific Islander people continue to be less eligible for screening than their white counterparts.

Eligibility for CT lung cancer screening by ethnic group
Race/ethnicity 2014 USPSTF guidance 2021 USPSTF guidance
White 12% 15%
American Indian or Alaska Native 17% 21%
Asian or Pacific Islander 4% 5%
Black 7% 9%
Latino 4% 5%
Other 12% 18%

How can these disparities be mitigated? By incorporating other factors such as body mass index, education level, race and ethnicity, family and personal history of cancer, and the presence of chronic obstructive pulmonary disease, the team suggested.

The guidelines could also address barriers with strategies like establishing outreach programs, using interpreters/translators/patient navigators/social workers, offering provider training on implicit bias, and providing transportation vouchers.

"If we put social determinants of health into our model, then we can more accurately reflect risk," Narayan said.

In an accompanying editorial, Paula Jacobs, PhD, and Sanya Springfield, PhD, both of the U.S. National Institutes of Health in Bethesda, MD, wrote that the study findings highlight how much more work there is to be done to reduce healthcare inequity.

"Addressing cancer disparities, such as those within cancer screening, is particularly timely," they wrote. "[The] National Cancer Institute recognizes that racism persists within biomedical research and that to make the progress needed to end cancer as we know it, all segments of the population must be included."

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