Black individuals may not benefit from wider lung screening guidance

By Kate Madden Yee, staff writer

October 20, 2021 -- Although recently updated CT lung cancer screening guidelines from the U.S. Preventive Services Task Force (USPSTF) expand the pool of people eligible for screening, the benefits may not reach Black individuals, according to a letter published October 20 in JAMA Network Open.

Why? Because even if the new recommendation encompasses more people, there's still the issue of insurance, wrote a team led by Dr. Jessica Lozier of the Medical University of South Carolina in Charleston.

"The new USPSTF recommendations will include screening eligibility for an additional seven million younger Americans and a higher proportion of Black adults within this group will be uninsured," the authors explained. "[Our findings] suggest that given the association insurance may have on the ability to be screened, disparities could paradoxically worsen rather than improve."

In March, the USPSTF released updated guidance that reduced the starting age for CT lung cancer screening from 55 to 50 and adjusted smoking history from 30 pack years to 20 pack years. In part, the impetus for this change was to boost the number of Black individuals who could be screened, since they tend to develop lung cancer at a younger age, have less of a pack-year history, and experience poorer outcomes than their white counterparts.

Since then, a lively debate has ensued as to whether the recommendation is effective in addressing this particular healthcare inequity. Lozier's team further explored the question using data on smoking history and lung cancer screening adherence from 2017, 2018, and 2019 Behavioral Risk Factor Surveillance System (BRFSS) surveys, including information from 12,879 white participants and 501 Black participants who met USPSTF lung cancer screening criteria.

Lozier and colleagues did not find significant differences according to race and ethnicity in terms of current or former smokers or clinician visits within the past year. But they did find that Black individuals were more likely to be screened at 65 or older compared with their white peers: In fact, almost 80% of Black adults who reported being screened for lung cancer were eligible for Medicare -- suggesting that insurance may be a factor for whether someone gets regular lung cancer screening.

Age characteristics of patients screened for lung cancer by race
Age range White individuals Black individuals
55-64 48.8% 21.1%
65-80 51.2% 79%

"Currently, Black adults are nearly twice as likely to be uninsured and more than twice as likely to have Medicaid, which may not cover lung cancer screening," the group wrote. "Of the eight million U.S. adults who currently qualify for screening, estimates suggest that more than half of those aged 50 years to 64 years have Medicaid or are uninsured."

So, are the updated USPSTF lung cancer screening guidelines effective in expanding the pool of eligible individuals -- and in a way that mitigates healthcare disparities between Black people and white individuals? Not exactly, unless factors such as insurance are taken into account, according to corresponding author Dr. Gerard Silvestri, also of the Medical University of South Carolina.

"Peeling back the onion of disparities is more complicated than just Black and White," he told "Access to services, having an identifiable primary care provider, and having screening services where you live are all important. [After all,] it doesn’t matter much if you are eligible if you can’t receive the service."

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