Guideline changes made by the United States Preventive Services Task Force (USPSTF) in 2021 that modify lung cancer screening criteria have improved on their earlier, fixed screening criteria, resulting in a broadening of eligibility for screening and reducing racial disparity in access to it, a retrospective analysis indicates.
In a comparison of the new lung cancer screening guidelines to the earlier 2013 USPSTF guidelines, the National Comprehensive Cancer Network high-risk group 2 (NCCN group 2) guidelines, and the Prostate Lung Colorectal and Ovarian Cancer Screening Trial (PLCOm2012) screening criteria, the sensitivity of the updated screening guidelines increased the percentage of patients with lung cancer who would qualify for screening but reduced the percentage of controls who would not qualify for lung cancer screening, Chan Yeu Pu, MD, Wayne State University School of Medicine, Detroit, Michigan, and colleagues reported in JAMA Oncology.
In addition and importantly, the updated USPSTF guidelines have eliminated the racial disparity in screening eligibility that the earlier guidelines had created simply by lowering the age and smoking criteria required for screening eligibility as set in the 2013 guidelines.
Black patients develop lung cancer at an earlier age and have fewer smoking pack-years than White patients; thus, lowering both age and smoking criteria for lung cancer screening eligibility helps to bridge the gap in racial disparity.
“Overall, this study provides us with actionable information, affirming that adjustments to lung cancer screening criteria have the potential to mitigate disparity in screening and perhaps lung cancer outcomes,” Cherie Erkman, MD, Temple University Health System, and Jonathan Nitz, MD, Fox Chase Cancer Center, Philadelphia, noted in an accompanying editorial. “However, critical issues of low uptake of screening and inability to capture at-risk populations are unresolved and likely disproportionately affecting marginalized populations.”
Commenting further on the study, the editorialists pointed out that while the new guidelines will increase the number of people who will now be eligible for lung cancer screening, actual screening rates remain very low.
For example, in 2018, only 5% of eligible patients underwent annual low-dose computed tomography as recommended by the USPSTF. They also noted that the updated recommendations do not address nearly two-thirds of patients with diagnosed lung cancer who are not eligible for screening.
The study authors also noted, “Because lung cancer screening has been covered by private and Medicare insurance, the uptake of screening has increased but was still only at 5% in 2018. Patient barriers to screening are mainly lack of awareness, poor perception, cost concerns, and limited access to screening centers.”
Pu and co-authors pointed out other barriers to screening—clinicians’ unfamiliarity with the screening guidelines, difficulty in determining patient eligibility, challenges of sharing decision-making, and skepticism regarding the evidence for screening…”
Erkman and Nitz agreed: “Lack of clarity in screening recommendations and payment likely impedes the uptake of lung cancer screening especially among marginalized populations….[W]e clinicians and investigators must bring stability to the turbulent sea of information regarding lung cancer screening.”
The study involved 912 participants with lung cancer and 1,457 controls without lung cancer.
Lung cancer patients were slightly older than controls — mean age of 63.7 years versus 60.4 years, respectively.
If patients with lung cancer were used to evaluate sensitivity, then 65% of them would have been eligible for screening based on the 2021 USPSTF guidelines, the authors reported, and under the PLCOm2012 criteria the number would be slightly higher at 68% (P=0.04) but was better than the 62% of patients who would be eligible for lung cancer screening based on the NCCN group 2 criteria and the 49% of patients who would be eligible for screening based on the 2013 USPSTF guidelines.
When racial subgroups were compared, 52% of White patients would have been eligible for screening according to the 2013 USPSTF criteria compared to 42% of Black patients (P=0.007).
This racial disparity is still present when using the NCCN group 2 criteria, where 67% of White patients would have been selected for screening versus only 51% of Black patients (P<0.001).
In contrast, “[t]he use of either the 2021 USPSTF criteria or the PLCOm2012 criteria mitigated this racial gap between White and African American patients,” the authors noted—at 65% for White patents and 63% Blacks based on the 2021 USPSTF criteria and 68% versus 67% for White and Black patients, respectively, using the PLCOm2012 criteria.
If the control group was used for specificity, then more individuals without lung cancer at 65% would not have been eligible for screening based on the 2013 USPSTF criteria.
This was followed by the NCCN group 2 guidelines where 59% of controls would be excluded from screening, as would 58% of controls if the PLCOm2021 model were used.
The 2021 USPSTF guidelines, in turn, would have excluded fewer fewer controls at 49%, the authors noted.
Racial disparity was again present when using either the 2013 USPSTF criteria or the NCCN group 2 criteria, with fewer White patients excluded from screening compared to Black patients (P=0.009 and P<0.001 respectively).
However, racial differences in eligibility were not seen when either the 2021 USPSTF criteria or the PLOCm2021 criteria were used with very similar percentages of White and Black patients being excluded from screening when both criteria were used to assess eligibility for it.
Interestingly, a very small percentage of controls developed lung cancer more than 12 months after study enrollment.
In this small group of patients, 75% of would have been eligible for screening based on the 2021 USPSTF recommendations as would 59% of them if the PLCOm2021 model was used.
The authors cautioned that the study was retrospective in nature and that a a large perspective trial with good racial representation is still needed to confirm the benefits of screening Black patients and allow for the development of better guidelines.
Disclosure:
The study was funded by the National Institutes of Health, the National Cancer Institute, and the Herrick Foundation.
The study authors and editorialists had no relevant relationships to disclose.
by
Pam Harrison, Contributing Writer, BreakingMED™
Kaiser Health News
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.
