Did USPSTF’s Change in Lung Cancer Screening Recs Address Inequity?

The latest lung cancer screening guidelines from the U.S. Preventive Services Task Force (USPSTF) might have lowered eligibility thresholds for screening but they don’t appear to have addressed equity concerns.

An analysis of survey data from the 2019 Behavioral Risk Factor Surveillance System (BRFSS) showed that the proportion of individuals eligible for screening increased from 10.9% to 13.7% after revised guidelines were issued in March 2021, which lowered the threshold for lung cancer screening eligibility from age 55 to 50, and from 30 to 20 pack-years of smoking.

However, that increase had no effect on eligibility disparities affecting racial and ethnic minorities, reported Anand K. Narayan, MD, PhD, of the University of Wisconsin in Madison, and colleagues in Radiology.

Under the previous guidelines, screening eligibility was less likely for African-American respondents (adjusted OR 0.36, 95% CI 0.27-0.47) and Hispanic respondents (adjusted OR 0.15, 95% CI 0.09-0.24) than for white respondents.

However, the authors observed little change under the revised guidelines, as African-American respondents (adjusted OR 0.39, 95% CI 0.32-0.47) and Hispanic respondents (adjusted OR 0.15, 95% CI 0.10-0.23) remained less likely to be eligible after the revisions.

The study authors also found that among individuals who qualified for screening, there was little difference among the different racial/ethnic groups regarding the use of screening, “underscoring the importance of lung cancer screening eligibility criteria as a barrier to equitable access.”

“The net effect in practice is that the seemingly unbiased USPSTF eligibility criteria are markedly biased against two groups that are known to develop lung cancer at earlier ages and with less tobacco exposure because the models used to develop the USPSTF criteria were based only on age, total cumulative exposure to tobacco smoke, and years since quitting smoking,” wrote Paula Jacobs, PhD, and Sanya Springfield, PhD, both of the National Cancer Institute in Bethesda, Maryland, in an editorial accompanying the study. “Under these eligibility criteria, individuals who are in fact at high risk are routinely misclassified as being at lower risk and will not qualify for screening with insurance coverage.”

Yet, Narayan and his team noted that the USPSTF issued those revised recommendations partly in order to address equity concerns. Thus, in this study they wanted to evaluate the impact of revised guidelines on racial and ethnic disparities in screening eligibility using survey data from the 2019 BRFSS.

The primary outcome of the study was lung cancer screening eligibility under previous and revised USPSTF guidelines using responses to BRFSS questions to define eligibility. The primary exposure was self-reported race and ethnicity, while variables considered to be potential confounders included age, income, employment status, education level, marriage or domestic partnership, health insurance status, and established care with a physician.

The analysis of survey responses showed that under previous guidelines, 10.9% of 67,567 weighted survey respondents were eligible for lung cancer screening, including 12% of white respondents, 4% of Hispanic respondents, 7% of African-American respondents, 17% of American Indian respondents, 4% of Asian or Pacific Islander respondents, and 12% of other respondents.

Under revised guidelines, 13.7% of 77,689 weighted survey respondents were eligible for screening. However, while higher percentages of all racial and ethnic groups were eligible for screening, African Americans (9.1%), Hispanics (4.5%), and Asian/Pacific islanders (5.2%) remained much less likely to be eligible for screening compared with white respondents (14.7%).

Narayan and colleagues observed that vulnerable populations face numerous barriers to screening, such as racial and ethnic minority group biases, sexual orientation and gender minority group biases, and low socioeconomic status and lack of insurance. They suggested that creating screening eligibility criteria that accurately reflect cancer risk across different racial and ethnic groups “is paramount to reducing [lung cancer screening] disparities.”

In their editorial, Jacobs and Springfield argued that an approach that incorporates culturally tailored education and outreach efforts, as well as risk-based models for high-risk population groups, “would go a long way toward reducing screening disparities among racial, ethnic, and other underserved populations.”

Last Updated September 27, 2021