Benefits of CT lung cancer screening impacted by inequities

By Kate Madden Yee, staff writer

March 31, 2022 -- Are individuals who could most benefit from low-dose CT lung cancer screening getting it? Not necessarily, and the problem appears to be exacerbated by health and racial factors, according to a study published March 31 in JAMA Network Open.

Ironically, patients in poor health are more likely to undergo CT lung cancer screening, perhaps since they are interacting with the healthcare system more regularly. But having health complications reduces the mortality prevention benefits of lung cancer screening, and often the health of racial minorities is more compromised than their white counterparts, wrote a team led by Dr. Alison Rustagi, PhD, of the San Francisco Veterans Affairs Health Care System.

"Lung cancer screening in the U.S. is more common among those who may be less likely to benefit from screening because of poor underlying health," the group noted. "Furthermore, [our research showed that] 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 lung cancer screening despite the potential for greater benefit of screening this population."

Screening for lung cancer via low-dose CT can improve patient outcomes by catching cancers earlier, Rustagi and colleagues wrote. The question is whether patients eligible for screening who are in poor health actually benefit from screening, since early intervention typically involves surgery -- which may not be feasible for those with health challenges.

The team defined poor health as the presence of comorbidities such as diabetes, history of heart disease, chronic kidney disease, asthma, and functional challenges such as difficulty walking or climbing stairs, dressing or bathing, or attending to daily responsibilities.

"[Poor] self-rated health and all-cause mortality are still associated with race and ethnicity in the U.S., with non-Hispanic Black individuals experiencing a 20% higher all-cause mortality than non-Hispanic White individuals, in large part due to structural racism," the team explained. "If poor health is associated with increased screening, and individuals from historically minoritized racial and ethnic groups are more likely to be poor health, then racial and ethnic disparities could be obscured unless comparisons account for health status."

The investigators analyzed data from 14,550 patients taken from the Behavioral Risk Factor Surveillance System (2017 to 2020). Those included in the study were between 55 and 79 with a less than 30 pack-year smoking history and were either current smokers or had quit within 15 years. Of the study cohort, 17% had undergone low-dose CT lung cancer screening. Patient health status and race/ethnicity were self-reported.

Rustagi's group found that the prevalence of lung cancer screening was lower among Black individuals (12%) compared with whites (17.5%), but the difference was not statistically significant (p = 0.57). But the health status of patients was associated with lung cancer screening: More patients in poor health reported undergoing lung cancer screening than their healthy counterparts -- 25.2% compared with 7.6% -- and relatively healthy Black individuals were 53% less likely to have undergone lung cancer screening compared with healthy white counterparts.

"These findings suggest that individuals in poor health are more likely than those with good health status to undergo lung cancer screening, which can lessen its potential mortality

benefit, and non-Hispanic Black individuals are less likely to undergo lung cancer screening despite its likely greater benefit in this group," the investigators wrote.

The study findings underscore the distressing reality of healthcare inequity, according to Rustagi's group.

"These results are concerning, as the long-term benefits of screening those with frail health are unknown; these individuals were excluded from the randomized clinical trials that demonstrate a mortality benefit for lung cancer screening, and it is thought that surgical resection of early-stage cancers is associated with the demonstrated mortality benefit of screening," it concluded.

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