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Black patients now central to lung cancer screening guidelines



A 2021 update to the U.S. Preventive Services Task Force lung cancer screening guidelines eliminated racial disparities that were prevalent in the group’s 2013 guidance, according to a report in JAMA Oncology.

Fewer Black people qualified for screening in the earlier guideline of which the majority of its participants were White. In response, the group changed the screening eligibility age from 55 to 50 years and lowered the smoking pack by year requirement from 30 to 20 years.

The changes showed that Black smokers tend to develop lung cancer earlier and with fewer pack-years than White smokers.

The study details

To gauge the impact, investigators from Wayne State University, Detroit, reviewed 912 patients with lung cancer and 1,457 controls without lung cancer to see who would have qualified for screening under the 2013 and 2021 criteria.

They were participants in the Detroit-area INHALE (Inflammation, Health, Ancestry, and Lung Epidemiology) study from 2012 to 2018. Over 30% were Black.

“Lowering the age and smoking criteria successfully bridged the gap in racial disparity,” said investigators led by Chan Yeu Pu, MD, a lung cancer specialist at Wayne State University.

With the 2021 criteria, 65% of White patients and 63% of Black patients with lung cancer would have been eligible for screening. Under the 2013 guidance, 52% of White patients were eligible for screening, but only 42% of Black patients.

The update also eliminated racial disparities among controls. The new guidance excluded 48% of White controls without lung cancer from screening and 50% of Black controls. The 2013 criteria excluded fewer White controls (61%) than Black control subjects (70%).

“As expected, broader inclusion criteria increased sensitivity, but at the cost of decreased specificity,” the investigators wrote.

Why is screening important?

The hope of screening is to catch lung cancer early, when curative surgical resection is still possible, the team wrote, but although screening has increased over the years, uptake remains dismal, just 5% in 2018, for instance.

In an editorial, Philadelphia-area thoracic surgeons Jonathan Nitz, MD, and Cherie Erkmen, MD, wrote that “multiple and changing criteria” and “nebulous payment plans” have made “for a confusing message. ... We need standardized” guidelines to deliver “a clear message about lung cancer screening.”

The fact that nearly two-thirds of lung cancer patients wouldn’t have qualified for screening under current guidelines also needs to be addressed. “We need standardized practice guidelines based on evidence from diverse populations and policies to ensure equitable access for high-risk individuals. Although this study demonstrates improved, calculated sensitivity of the 2021 USPSTF guidelines to detect lung cancer, these refinements of criteria do not address the nearly two-thirds of patients with diagnosed lung cancer who are not eligible for screening. There is a pressing need to redefine screening criteria,” Dr. Nitz and Dr. Erkmen wrote.

Both the 2013 and 2021 guidelines were outperformed in the study by the 2012 modification of the model from the Prostate, Lung, Colorectal, and Ovarian Cancer (PLCOm2012 criteria), but only marginally so in the case of USPSTF’s 2021 guidance.

PLCOm2012 screening eligibility, however, are based on a complicated risk factor assessments that include race but also education level and other factors which might not be readily available in electronic records. USPSTF’s criteria “are much more straightforward to use in a clinical setting,” the investigators noted.

Study subjects were 21-89 years old and were in their early 60s, on average. Just over half were women. The analysis excluded lung cancer patients and controls who had never smoked.

The authors noted some limitations, including the retrospective nature of the study, plus, few lung cancers were diagnosed among the control group, which were not only small, but they did not include follow-ups with CT scans.

The work was funded by the National Institutes of Health and the Herrick Foundation. Dr. Pu didn’t have any commercial disclosures. One investigator disclosed personal fees from Takeda, AstraZeneca, Genentech/Roche, Pfizer, and other companies. Dr. Erkmen reported an American Cancer Society-Pfizer Award to address disparities.

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