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New cohort analysis suggest updates to broaden the age and smoking-rate eligibility may have benefitted the historic disparity in low-dose CT screening practice.
Changes made to the United States Preventive Services Task Force (USPSTF) lung cancer screening guidelines last year have since resulted in decreased disparities in screening rates among Black and White adults, according to new study findings.
However, this new cohort analysis showed disparities among at-risk adults still persist, and that even more pertinent factors of lung cancer risk should be considered in clinician-guided screening strategies.
A New York-based investigative team led by Erica Phillips, MD, MS, of the department of medicine and Sandra and Edward Meyer Cancer Center at Weill Cornell Medicine, New York-Presbyterian Hospital, sought to interpret the effect of 2021 changes to the USPSTF low-dose computed tomography (CT) criteria for lung cancer screening eligibility.
Previous assessments such as the National Lung Screening Trial showed both Black adults were significantly underrepresented in lung cancer screening practices, and that low-dose CT scanning is associated with a 20% reduction in lung cancer-specific mortality versus chest radiography. To compensate for the burden of persistent screening disparity and promote the benefit of low-dose CT scanning, the USPSTF set a guideline update last year that reduced the minimum criteria age to 50 years, and smoking intensity to 20 pack-years.
“The recent changes have been met with enthusiasm in the hopes that they would improve screening rates among individuals, such as Black adults, who are less often eligible for lung cancer screening despite developing lung cancer at younger ages and after fewer pack-years of smoking,” Phillips and colleagues wrote. “Although the long-term consequences of the 2021 guidelines are not yet known, the fixed criteria based on smoking history and age alone have not accounted for additional risks from social factors associated with health.”
The team conducted a cohort analysis of data from the prospective longitudinal Reasons for Geographic and Racial Differences in Stroke trial, in which Black and White adults ≥45 years old were recruited from 2003 – 2007. They included the 14,285 trial participants who were eligible for lung cancer screening based on clinical and demographic characteristics aligning with the USPSTF 2021 guideline update.
Investigators sought a primary outcome of differences in proportion of Black adult participants versus White counterparts eligible for lung cancer screening based on the previous and current USPSTF guidelines. They also observed for key associations based on cohort demographics and social factors.
The assessments’ cohort had a mean age of 64.7 years old; 53.7% were men, while 40.5% identified as Black and 59.5% identified as White.
Fewer than 1 in 5 (19.2%) Black adults were eligible for lung cancer screening based on the previous 2013 USPSTF guidelines, versus 27.2% of White adults (-8.06 percentage points; 95% CI, -9.44 to -6.67). The disparity was lessened when investigators applied the 2021 updated criteria: 28.8% of Black adults were eligible for screening, versus 34.6% of White adults (-5.73 percentage points; 95% CI, -7.28 to -4.19).
Phillips and colleagues confirmed differences of -12.66 percentage points (95% CI, -14.71 to -10.61) and -12.15 percentage points (95% CI, -14.37 to -9.93) among Black versus White adults eligible for screening for the 2013 and 2021 guideline updates, respectively, once adjusting for patient demographics.
“Reasons for persistently disparate screening eligibility rates are multifactorial,” investigators wrote. “For example, Black adults are more likely to be current smokers and to have lower quit rates, in part because of targeted marketing by the tobacco industry, particularly with regard to mentholated products. Although moderation or discontinuation of the smoking cessation criterion has been reported to increase eligibility among Black adults, eliminating the criterion alone has not entirely mitigated the screening disparity.”
Investigators concluded that, though the assessment supported the benefit of the USPTSF guideline update in reducing lung cancer screening disparities, more work at the policy and political level must be done to achieve ideal equality in lung cancer screening and care access.
“Raising awareness and increasing knowledge about the benefits of lung cancer screening are also important elements in closing the disparity gap,” they wrote. “Lack of awareness of low-dose CT screening recommendations is still pervasive among physicians and patients and may be factors in the low levels of low-dose CT screening uptake. These points highlight the need for multilevel efforts to eliminate racial screening disparities.”
The study, “Analysis of Eligibility for Lung Cancer Screening by Race After 2021 Changes to US Preventive Services Task Force Screening Guidelines,” was published online in JAMA Network Open.