Study: USPSTF 2021 Lung Cancer Update Helped Mitigate Screening Racial Disparities

The United States Preventive Services Task Force (USPSTF) 2021 guideline changes that broadened its age and smoking pack-year requirement for lung cancer screening helped improve on early, fixed screening criteria for the disease, broadened eligibility, and reduced racial disparities in screening access, according to new research published in JAMA Oncology.¹

Last year, the USPSTF guideline was revised from its 2013 version to include adults aged 50 to 80 years with a 20 pack-year smoking history and who are either currently smoking or quit within the past 15 years, authors explained.

The 2013 recommendation, however, was based on data from the National Lung Screening Trial, of which 90% of participants were White. Although African American patients tend to have a lower smoking pack-year history, this population has the same or higher lung cancer risk compared with White individuals and are also at risk at a younger age.

“Broader fixed criteria and the use of predictive model risk-based criteria have been proposed as an approach to better include those at high risk and address racial disparities in eligibility,” the researchers wrote.

Apart from the 2013 USPSTF criteria, the 2012 modification of the model from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCOm2012) and the National Comprehensive Cancer Network (NCCN) group 2 criteria have been introduced as alternatives for lung cancer screening.

To better understand the 2021 USPSTF guideline sensitivity and specificity with regard to race, the investigators compared it with the PLCOm2012, NCCN group 2, and USPSTF 2013 criteria in a real-world setting.

The retrospective analysis included individuals originally recruited for the Inflammation, Health, Ancestry, and Lung Epidemiology study residing in the Detroit metropolitan area. All patients were enrolled in cancer centers between 2012 and 2018 and compared with volunteer controls. Participants were aged 21 to 89 years while “patients with lung cancer who were never smokers and controls who were never smokers were not included in these analyses.”

In addition to completing an interview, participants also underwent a low-dose chest CT and pulmonary function tests. A total of 912 individuals had lung cancer (54% women with a mean [SD] age of 63.7 [9.5] years) and were compared with 1457 controls without lung cancer at enrollment.

When testing whether patients and controls would have qualified for lung cancer screening using the different criteria, the researchers found the following:

• With the use of 2021 USPSTF criteria, 590 patients with lung cancer (65%) were eligible for screening compared with 619 patients (68%) per the PLCOm2012 criteria and 445 patients (49%) per the 2013 USPSTF criteria
• With the use of 2013 USPSTF criteria, significantly more White patients than African American patients with lung cancer (324 of 625 [52%] vs 121 of 287 [42%]) would have been eligible for screening
• This racial disparity was absent when using 2021 USPSTF criteria (408 of 625 [65%] White patients vs 182 of 287 [63%] African American patients) and PLCOm2012 criteria (427 of 625 [68%] White patients vs 192 of 287 [67%] African American patients)
• The 2013 USPSTF criteria excluded 950 control participants (65%), while the PLCOm2012 criteria excluded 843 control participants (58%) and the 2021 USPSTF criteria excluded 709 control participants (49%)
• The 2013 USPSTF criteria excluded fewer White control participants than African American control participants (514 of 838 [61%] vs 436 of 619 [70%])
• This racial disparity is again absent when using 2021 USPSTF criteria (401 of 838 [48%] White patients vs 308 of 619 [50%] African American patients) and PLCOm2012 guidelines (475 of 838 [57%] White patients vs 368 of 619 [60%] African American patients)

In this cohort, White patients with lung cancer had significantly higher mean pack-years and a higher proportion of White patients had 30 or more pack-years of exposure compared with African American patients. However, a significantly greater proportion of African American patients were current smokers.

“As expected, broader inclusion criteria increased sensitivity, but at the cost of decreased specificity,” the researchers wrote. “In our study, the sensitivity and specificity of the 2021 USPSTF guidelines are close to those of the predictive model–based PLCOm2012 criteria but are much more straightforward to use in a clinical setting.”

Lowering the age and smoking criteria successfully bridged the gap in racial disparity without the inclusion of other lung cancer risk factors, they added.

In 2018, lung cancer screening was measured at 5% despite the procedure being covered by private and Medicare insurance. Factors like lack of awareness, poor perception, and limited access to screening centers all hinder uptake of this preventive service, the authors noted. In addition, physician unfamiliarity with screening guidelines and challenges of sharing decision-making could also impact screening rates.

The retrospective nature of the study marks a limitation and future, prospective trials with good racial representation are warranted.

“According to the Patient Protection and Affordable Care Act, a grade B recommendation by the USPSTF automatically qualifies one for coverage by Medicare and Medicaid, but as of 2019, only 31 state Medicaid programs confirm coverage of screening for lung cancer,” wrote Jonathan A. Nitz, MD, and Cherie P. Erkmen, MD, in an accompanying commentary.²

“Lack of clarity in screening recommendations and payment likely impedes the uptake of lung cancer screening, especially among marginalized populations,” they said.

The authors stress that clinicians and investigators need to bring stability to the often complex topic of lung cancer screening recommendations. Standardized practice guidelines based on evidence from diverse populations will help ensure equitable access for high-risk populations, they concluded.

References

1. Pu CY, Lusk CM, Neslund-Dudas C, Gadgeel S, Soubani AO, Schwartz AG. Comparison between the 2021 USPSTF lung cancer screening criteria and other lung cancer screening criteria for racial disparity in eligibility. JAMA Oncol. Published online January 13, 2022. doi:10.1001/jamaoncol.2021.6720

2. Nitz JA, Erkmen CP. New 2021 USPSTF lung cancer screening criteria a—an opportunity to mitigate racial disparity. JAMA Oncol. Published online January 13, 2022. doi:10.1001/jamaoncol.2021.6708