Racial Disparities in Lung Cancer Screening: An Exploratory Investigation

doi:10.1016/j.jnma.2017.09.003

Journal of the National Medical Association

Volume 110, Issue 5, October 2018, Pages 424-427

https://doi.org/10.1016/j.jnma.2017.09.003 Get rights and content

Abstract

Background/Purpose

Lung cancer is the leading cause of cancer death in the United States. Black Americans have the highest rate of lung cancer mortality, due to being diagnosed at later stage. Lung Cancer Screening (LCS) facilitates earlier detection and has been associated with a reduction in cancer death. We investigated LCS utilization and explored racial disparities (Black vs. non-Black) in LCS among patients for whom LCS is clinically indicated.

Methods

Using electronic medical records from the Lifespan Medical System, we randomly selected 200 patients who were likely to meet U. S. Preventive Services Taskforce (USPSTF) guidelines for LCS and mailed each patient a survey to assess LCS eligibility and uptake.

Results

Nearly three-quarters (n = 146, 73%) completed the survey and, of survey respondents, 92% (n = 134) were eligible for the study. Among eligible patients, 35% met criteria for LCS; non-Black patients were 90% more likely to meet criteria for LCS than Black patients (44% vs. 27%). Of the patients meeting USPSTF criteria, only 21% reported being screened; eligible non-Black patients were 2.8 times more likely to have had LCS than eligible Black patients (30% vs. 12%).

Conclusions

LCS utilization is low despite coverage provided through the Affordable Care Act. Black patients are less likely to qualify for screening and disproportionately less likely to be screened for lung cancer compared with non-Black patients. Targeted intervention strategies are needed to increase referral for and uptake of LCS in patients who are at high risk for developing lung cancer, and for Black patients in particular.

Introduction

Lung cancer is the leading cause of cancer death in the United States, accounting for 13% of new cancer diagnoses and 27% of cancer deaths.¹ The disproportionate rate of cancer-related death is attributable to the majority (57%) of diagnoses made in late stage.¹ The National Lung Screening Trial (NLST) found that annual screening of long-term current and former smokers with low dose computerized tomography (LDCT) resulted in a 20% reduction in cancer deaths.² This reduction was attributed to diagnosis at earlier stage when treatment is curative. The United States Preventative Services Task Force (USPSTF) recommends annual lung cancer screening (LCS) with LDCT for current and recent (quit < 15 years) former smokers, aged 55–80 years, with a 30 pack year smoking history.

LCS has been underutilized. In 2011, 21% of current or former smokers over age 55 reported being screened.³ In 2015, the Affordable Care Act (ACA) began requiring coverage of LCS for those meeting USPSTF criteria. Research is needed to evaluate whether the ACA has improved rates of guideline-consistent LCS.

Black smokers should be screened for lung cancer, but, due to lower tobacco exposure,⁴ they are less likely to meet screening criteria. Black men have the highest rates of lung cancer, Black patients are diagnosed at later stage, and lung cancer is more fatal in Black men.¹ Health disparities in survival may be compounded by USPSTF criteria for LCS, which are largely based on tobacco exposure.

In the current exploratory study, we investigated USPSTF LCS eligibility and LCS utilization among Black and non-Black patients of an academic medical system. We hypothesized that (1) LCS utilization would be low, and (2) LCS eligibility and utilization would be disproportionately lower for Black patients.

Section snippets

Participants

Potential participants (n = 200) were randomly selected from the electronic medical record for a healthcare organization in Rhode Island. Black patients were oversampled, comprising 50% of the sample. Inclusion criteria were: current or former smoker, aged 55–80. Exclusion criteria were: history of lung cancer or cognitive impairment, deceased, and non-English speaking.

Procedures

Procedures were approved by the Institutional Review Board. In September, 2016, participants were mailed a study packet

Survey response

Of 200 potential participants, 143 returned the survey (10 opted out, 1 deceased, 43 unreachable, 3 returned to sender; response rate = 73%; 70 Black, 73 non-Black). Patients who reported never smoking regularly were excluded from analyses (n = 9; analytical sample n = 134 participants).

Sample characteristics

As displayed in Table 1, 52% of participants were female; mean age was 64.4 (SD = 8.5). Forty-nine percent were of Black race, 50% White, and 1% Other; 27% were daily smokers, 9% non-daily smokers, and 64%

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Patient willingness and barriers to receiving a CT scan for lung cancer screening
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: Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

: Conflict of Interest Statement: The authors have no conflicts of interest to report.

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ArticleRacial Disparities in Lung Cancer Screening: An Exploratory Investigation

Abstract

Background/Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Participants

Procedures

Survey response

Sample characteristics

Cancer statistics, 2015

CA Cancer J Clin

Reduced lung-cancer mortality with low-dose computed tomographic screening

NEJM

Patient willingness and barriers to receiving a CT scan for lung cancer screening

Lung Cancer

Differential eligibility of African American and European American lung cancer cases using LDCT screening guidelines

BMJ Open Respir Res

National Health and Nutrition Examination Survey Questionnaire

Article
Racial Disparities in Lung Cancer Screening: An Exploratory Investigation