Study Suggests Reviewing Lung Cancer Screening Criteria for African Americans
African Americans have the highest mortality rate and shortest survival of any racial/ethnic group in the US for most cancers.1 A variety of factors are associated with this, including issues of healthcare access, socioeconomic disparities, structural racism, cultural differences, and a lack of research.1 Overall, African Americans have a higher baseline chance of developing lung cancer when compared to whites.2 Racial disparities exist in current research and guidelines, and steps can be taken to help rectify this through changing criteria and recommendations for screening and treatment.
Racial differences in smoking
Racial differences in smoking habits have been found, and these can affect smoking’s impact on health. By not taking these into account when developing screening guidelines, a large at-risk population is ignored. African American smokers are diagnosed with lung cancer at earlier ages and also have a higher risk of developing lung cancer with fewer pack-years of smoking than white smokers, and have more difficulties quitting.2 They also tend to smoke each cigarette longer, which increases the risk of exposure to the carcinogens in the cigarette.2 It has been hypothesized that there may be differences in how African Americans metabolize these carcinogens, but more research needs to be done.2
Current screening guidelines
Screening guidelines for lung cancer are largely based on whether a person smokes, how long they’ve smoked, and the number of cigarettes smoked; however, this will need to be reviewed because these guidelines aren’t applicable to everyone, particularly African Americans who smoke. A new study found that only one-third of African American smokers diagnosed with lung cancer over a 12-year period would have met criteria for annual lung cancer screening with low-dose computed tomography (CT), per the current guidelines by the US Preventive Services Task Force (USPSTF), compared to more than half of white smokers.2 That being said, the USPSTF guidelines were derived from a study population that included only 4% African American smokers.2 None of the risks and smoking behaviors were taken into consideration when developing the current screening guidelines, which state that screening is appropriate for patients age 55-80 with a 30 pack-year smoking history who are either still smoking or who have quit in the last 15 years.2
New findings and suggestions
The Southern Community Cohort Study had a study population that was predominantly African American and low income, with participants ranging in age from 40 to 79.3 It was found that reducing the number of pack-years in the existing guidelines to 20 for African American smokers would help reduce lung cancer screening disparities in this population and bring it closer to that of white smokers.2,3 If the age criterion was lowered to 50, it would reduce the disparity even more.2 The aim of the SCCS was not to look at whether this reduced deaths from lung cancer, or even to examine the cost-benefits of screening in this population, but merely to see what would help reduce the disparities between whites and African Americans in meeting criteria to get screened at all. This begs the larger question of whether lung cancer screening is being used in the optimal and most equitable way.2
Changes to screening guidelines, while important, is still only one factor in reducing disparities in lung cancer screening and diagnosis. Screening centers and facilities are sparse in low-income areas, or they may be too far away and patients cannot afford to get to the facility. Patients may not be aware of whether the screening is covered by insurance and may opt not to go for fear of not being able to afford the screening or any associated or incurred costs. Doctors may not always know how to calculate pack-years and there may be differing or incomplete information in patient records, which may also contribute to patients not being screened.
Talk to your doctor
African Americans who smoke or who have smoked in the past should speak with their doctor about their smoking habits, and whether screening is available to them. They can go over your medical and family history, along with your lifestyle behaviors, and provide you with information and resources that can help you make a decision about lung cancer screening.
Have you had biomarker testing done?