The updated USPSTF 2021 lung cancer screening guidelines reduced racial disparities in access
USPSTF 2021 lung cancer screening updates take aim at racial disparities
January 20, 2022
by John R. Fischer, Senior Reporter
In addition to opening up eligibility, the USPSTF 2021 update for lung cancer screening decreased racial disparities in access to care.
The revised guidelines dropped the starting age to screen adults from 55 to 50 and redefined eligibility from a 30 pack-year smoking history to a 20 pack-year history. Adults who are either currently smoking or quit within the past 15 years are eligible. The changes were recommended last March, with CMS adopting them officially in November.
With the 2013 USPSTF criteria, a 10% higher number of white patients than African Americans were eligible to be screened. The 2021 update reduced this difference to 2%, wrote U.S. researchers in a retrospective analysis, according to Physician’s Weekly.
While African American patients often have a lower smoking pack-year history, they are at the same at higher risk for lung cancer compared to white people 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,” wrote the authors.
Participants were recruited from the Inflammation, Health, Ancestry, and Lung Epidemiology study and were from the Detroit metropolitan area. All were compared to volunteer controls and were between 21 and 89. Each had an interview and underwent low-dose chest CT and pulmonary function tests. A total of 912 had lung cancer, with 54% being women, and were compared to 1,457 controls without lung cancer at enrollment.
In addition to the 2013 recommendations, the authors compared the sensitivity and specificity of the 2021 USPSTF guidelines to that of the 2012 update for the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCOm2012) and the National Comprehensive Cancer Network (NCCN) group 2 criteria in a real-world setting.
Under the 2013 criteria, 324 of 625 (52%) white patients were eligible for screening versus 121 of 287 (42%) African American ones. Under 2021 recommendations, 408 of 625 (65%) white patients were able to get screened and 192 of 287 (63%) African American patients were able to as well. With the PLCOm2012 criteria, the disparity was even smaller, at 427 of 625 (68%) white patients versus 192 of 287 (67%) African American patients.
The 2013 guidelines were based on the National Lung Screening Trial. Racial disparities partially stemmed from 90% of participants in the trial being white, and its exclusion of fewer white control participants than African American control participants (514 of 838 [61%] versus 436 of 619 [70%]). Even within the control group, the racial disparity was absent when comparing the 2021 USPSTF criteria (401 of 838 [48%] white patients versus 308 of 619 [50%] African American patients) and the PLCOm2012 guidelines (475 of 838 [57%] white patients versus 368 of 619 [60%] African American patients).
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 than African Americans. At the same time, a higher proportion of African Americans patients were current smokers.
The researchers say lack of awareness, poor perception and limited access still need to be addressed, as does unfamiliarity among physicians with screening guidelines and challenges of shared decision-making. They recommend incorporating diverse populations into standard practice guideline designs to ensure equitable access among high-risk populations.
“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 Dr. Jonathan Nitz and Dr. Cherie Erkmen, in an accompanying commentary. “Lack of clarity in screening recommendations and payment likely impedes the uptake of lung cancer screening, especially among marginalized populations."
The revised guidelines dropped the starting age to screen adults from 55 to 50 and redefined eligibility from a 30 pack-year smoking history to a 20 pack-year history. Adults who are either currently smoking or quit within the past 15 years are eligible. The changes were recommended last March, with CMS adopting them officially in November.
With the 2013 USPSTF criteria, a 10% higher number of white patients than African Americans were eligible to be screened. The 2021 update reduced this difference to 2%, wrote U.S. researchers in a retrospective analysis, according to Physician’s Weekly.
While African American patients often have a lower smoking pack-year history, they are at the same at higher risk for lung cancer compared to white people 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,” wrote the authors.
Participants were recruited from the Inflammation, Health, Ancestry, and Lung Epidemiology study and were from the Detroit metropolitan area. All were compared to volunteer controls and were between 21 and 89. Each had an interview and underwent low-dose chest CT and pulmonary function tests. A total of 912 had lung cancer, with 54% being women, and were compared to 1,457 controls without lung cancer at enrollment.
In addition to the 2013 recommendations, the authors compared the sensitivity and specificity of the 2021 USPSTF guidelines to that of the 2012 update for the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCOm2012) and the National Comprehensive Cancer Network (NCCN) group 2 criteria in a real-world setting.
Under the 2013 criteria, 324 of 625 (52%) white patients were eligible for screening versus 121 of 287 (42%) African American ones. Under 2021 recommendations, 408 of 625 (65%) white patients were able to get screened and 192 of 287 (63%) African American patients were able to as well. With the PLCOm2012 criteria, the disparity was even smaller, at 427 of 625 (68%) white patients versus 192 of 287 (67%) African American patients.
The 2013 guidelines were based on the National Lung Screening Trial. Racial disparities partially stemmed from 90% of participants in the trial being white, and its exclusion of fewer white control participants than African American control participants (514 of 838 [61%] versus 436 of 619 [70%]). Even within the control group, the racial disparity was absent when comparing the 2021 USPSTF criteria (401 of 838 [48%] white patients versus 308 of 619 [50%] African American patients) and the PLCOm2012 guidelines (475 of 838 [57%] white patients versus 368 of 619 [60%] African American patients).
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 than African Americans. At the same time, a higher proportion of African Americans patients were current smokers.
The researchers say lack of awareness, poor perception and limited access still need to be addressed, as does unfamiliarity among physicians with screening guidelines and challenges of shared decision-making. They recommend incorporating diverse populations into standard practice guideline designs to ensure equitable access among high-risk populations.
“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 Dr. Jonathan Nitz and Dr. Cherie Erkmen, in an accompanying commentary. “Lack of clarity in screening recommendations and payment likely impedes the uptake of lung cancer screening, especially among marginalized populations."