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Table 1.  Demographic Characteristics, Smoking History, and Health Care Access of Respondents Who Were Eligible and Respondents Who Were Screened, BRFSS 2017-2019a
Demographic Characteristics, Smoking History, and Health Care Access of Respondents Who Were Eligible and Respondents Who Were Screened, BRFSS 2017-2019a
Table 2.  Demographic Characteristics of the US Population and States Participating in BRFSS Lung Cancer Screening Module, 2017-2019
Demographic Characteristics of the US Population and States Participating in BRFSS Lung Cancer Screening Module, 2017-2019
1.
de Koning  HJ, van der Aalst  CM, de Jong  PA,  et al.  Reduced lung cancer mortality with volume CT screening in a randomized trial.   N Engl J Med. 2020;382:503-513. doi:10.1056/NEJMoa1911793Google ScholarCrossref
2.
US Preventive Services Task Force.  Screening for lung cancer: recommendation statement.   JAMA. 2021;325(10):962-970. doi:10.1001/jama.2021.1117Google ScholarCrossref
3.
Haddad  DN, Sandler  KL, Henderson  LM, Rivera  MP, Aldrich  MC.  Disparities in lung cancer screening: a review.   Ann Am Thorac Soc. 2020;17(4):399-405. doi:10.1513/AnnalsATS.201907-556CMEPubMedGoogle ScholarCrossref
4.
Cohen  RA, Terlizzi  EP, Martinez  ME. Health insurance coverage: early release of estimates from the National Health Interview Survey 2018. National Center for Health Statistics. Published May 2019. Accessed September 15, 2021. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201905.pdf
5.
Zhao  G, Okoro  CA, Li  J, Town  M.  Health insurance status and clinical cancer screenings among U.S. adults.   Am J Prev Med. 2018;54(1):e11-e19. doi:10.1016/j.amepre.2017.08.024PubMedGoogle ScholarCrossref
6.
Jemal  A, Fedewa  SA.  Lung cancer screening with low-dose computed tomography in the United States—2010 to 2015.   JAMA Oncol. 2017;3(9):1278-1281. doi:10.1001/jamaoncol.2016.6416PubMedGoogle ScholarCrossref
Research Letter
Oncology
October 20, 2021

Lung Cancer Screening Eligibility and Screening Patterns Among Black and White Adults in the United States

Author Affiliations
  • 1Division of Pulmonary Medicine, Thoracic Oncology Research Group, Hollings Cancer Center, Medical University of South Carolina, Charleston
  • 2Surveillance and Health Equity Sciences, American Cancer Society, Atlanta, Georgia
  • 3Prevention and Early Detection, American Cancer Society, Atlanta, Georgia
JAMA Netw Open. 2021;4(10):e2130350. doi:10.1001/jamanetworkopen.2021.30350
Introduction

Lung cancer screening (LCS) with annual low radiation dose computed tomography (LDCT) for adults aged 55 years to 80 years with a 30 pack-year history of smoking was initially recommended by the United States Preventive Services Task Force (USPSTF) in 2013. In 2020, a large European trial demonstrated a mortality benefit from screening in persons aged 50 years with a 20 pack-year history of smoking.1 Based on these results and predictive modeling, the USPSTF recently updated their recommendations by lowering the age and pack-year requirements for screening from 55 years to 50 years and 30 pack-years to 20 pack-years, respectively.2

Reducing racial disparities in screening eligibility was an additional goal of the taskforce. Black individuals tend to develop lung cancer at a younger age with less pack-year history of smoking and have worse outcomes than White individuals.3 Thus, lowering the age and pack-year requirements will increase the number of Black persons eligible for LCS. We undertook this study to compare the demographics of US adults who are currently being screened for lung cancer to assess how the proposed changes might influence screening rates by race and age going forward.

Methods

This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. This study was deemed exempt from institutional review board approval at the Medical University of South Carolina, and informed consent was waived because patients were deidentified in the survey from which the data were extracted.

We used 2017, 2018, and 2019 Behavioral Risk Factor Surveillance System (BRFSS) surveys from 10 states, 8 states, and 20 states, respectively, collecting data on detailed smoking history and LCS. Characteristics of respondents in these states were compared with the US population. The main outcome was the proportion of respondents who were eligible for LCS according to USPSTF criteria and self-reported receipt of LDCT in the past year according to race and ethnicity (non-Hispanic White respondents vs non-Hispanic Black respondents).

Respondents self-identified their race and ethnicity, and those who answered no to identifying as Hispanic and reported their race as Black or White were included. Race was considered in this study because of the disparities in lung cancer mortality between Black and White people and the new USPSTF guidelines were aimed at reducing these disparities. There were too few respondents who identified as Asian or Hispanic to examine race-specific screening characteristics.

Respondents meeting USPSTF criteria for LCS were selected (non-Hispanic White respondents: n = 13 132; non-Hispanic Black respondents: n = 518) and those who were missing data on LDCT data were excluded (253 non-Hispanic White respondents; 17 non-Hispanic Black respondents). The proportion of eligible individuals and those reporting screening and their demographic characteristics were computed according to race and/or ethnicity, with 95% CIs and χ2 tests (α = .05). All statistical analyses accounted for complex sampling design and were conducted with SAS statistical software, version 9.4 (SAS Institute). Statistical tests were 2-tailed, and data were collected from January 2017 to December 2019 and analyzed between January and July 2021.

Results

This study included data from 13 380 US adults (non-Hispanic Black adults: 501 [3.7%]; non-Hispanic White adults: 12 879 [96.3%]). Among those eligible for screening, half currently smoked (non-Hispanic Black respondents: 51.1% [95% CI, 42.0%-60.1%]; non-Hispanic White respondents 50.9% [95% CI, 48.8%-53.0%]) and were aged 55 years to 64 years (non-Hispanic Black respondents: 50.4% [95% CI, 41.3%-59.4%]; non-Hispanic White respondents: 52.4% [95% CI 50.3%-54.5%]), and there were no significant differences according to race and ethnicity (Table 1). However, among those screened, more non-Hispanic Black respondents who were screened were aged 65 years to 80 years than non-Hispanic White respondents (47 of 66 [79.0%; 95% CI, 56.4%-91.6%] vs 1225 of 1988 [51.2%; 95% CI, 45.4%-57.0%]; P = 0.09). Of eligible non-Hispanic Black adults, 236 of 501 (34.2%; 95% CI, 26.9%-42.3%) were women, but women represented 35 of 66 (51.7%; 95% CI, 27.3%-75.1%) non-Hispanic Black adults who were screened. Conversely, the proportions of non-Hispanic White women who were eligible vs screened were similar (6055 of 12 879 [46.0%; 95% CI, 43.9%-48.2%] vs 957 of 1988 [46.3%; 95% CI, 40.6%-52.2%]). The rate of eligible adults reporting being screened was similar between racial groups (non-Hispanic Black adults: 16.5% [95% CI, 14.9%-18.2%]; non-Hispanic White adults: 14.0% [95% CI, 8.6%-21.9%,] P = 0.16). Most adults eligible for screening had a recent clinician visit (non-Hispanic Black respondents: 91.5% [95% CI, 86.1%-95.0%; non-Hispanic White respondents: 84.0% [95% CI, 82.5%-85.4%]).

Discussion

The new USPSTF recommendations to screen younger patients with less smoking history will increase the number of Black persons who are eligible and should, in theory, decrease racial disparities in screening eligibility. However, the findings of this study suggest this may not be the case. While screening rates were similar between Black adults and White adults, nearly 80% of Black adults who reported being screened were of Medicare age, which suggests that access to care plays a significant role in whether someone is screened. While, screening data were only available in a limited number of states, however, respondent characteristics and smoking status in these states were similar to the US population (Table 2). Currently, Black adults are nearly twice as likely to be uninsured and more than twice as likely to have Medicaid, which may not cover LCS.4 Furthermore, studies show that screening rates for breast, cervical, and colorectal cancer are 41% to 47% lower among the individuals who are uninsured.5 Of the 8 million US adults who currently qualify for screening, estimates suggest that more than half those aged 50 years to 64 years have Medicaid or are uninsured.6 Limitations of this study included the small sample size, data were based on self-reports, and screening rates were higher than that reported nationally.

The new USPSTF recommendations will include screening eligibility for an additional 7 million younger Americans and a higher proportion of Black adults within this group will be uninsured. The findings here suggest that given the association insurance may have on the ability to be screened, disparities could paradoxically worsen rather than improve. Recognizing the role that social determinants of health care, including insurance, play in accessing screening services is essential to ameliorating disparities.

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Article Information

Accepted for Publication: August 17, 2021.

Published: October 20, 2021. doi:10.1001/jamanetworkopen.2021.30350

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Lozier JW et al. JAMA Network Open.

Corresponding Author: Gerard A. Silvestri, MD, MS, Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, 69 Jonathon Lucas Dr, Charleston, SC 29425 (silvestr@musc.edu).

Author Contributions: Drs Fedewa and Silvestri had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Lozier, Fedewa, Silvestri.

Acquisition, analysis, or interpretation of data: Lozier, Fedewa, Smith.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Lozier, Smith, Silvestri.

Statistical analysis: Fedewa.

Obtained funding: Smith.

Administrative, technical, or material support: Lozier, Smith.

Conflict of Interest Disclosures: Drs Fedewa and Smith reported being employed by the American Cancer Society, which receives grants from private and corporate foundations, including foundations associated with companies in the health sector for research outside of the submitted work. Drs Fedewa and Smith reported that their salary is solely funded through American Cancer Society funds. No other disclosures were reported.

References
1.
de Koning  HJ, van der Aalst  CM, de Jong  PA,  et al.  Reduced lung cancer mortality with volume CT screening in a randomized trial.   N Engl J Med. 2020;382:503-513. doi:10.1056/NEJMoa1911793Google ScholarCrossref
2.
US Preventive Services Task Force.  Screening for lung cancer: recommendation statement.   JAMA. 2021;325(10):962-970. doi:10.1001/jama.2021.1117Google ScholarCrossref
3.
Haddad  DN, Sandler  KL, Henderson  LM, Rivera  MP, Aldrich  MC.  Disparities in lung cancer screening: a review.   Ann Am Thorac Soc. 2020;17(4):399-405. doi:10.1513/AnnalsATS.201907-556CMEPubMedGoogle ScholarCrossref
4.
Cohen  RA, Terlizzi  EP, Martinez  ME. Health insurance coverage: early release of estimates from the National Health Interview Survey 2018. National Center for Health Statistics. Published May 2019. Accessed September 15, 2021. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201905.pdf
5.
Zhao  G, Okoro  CA, Li  J, Town  M.  Health insurance status and clinical cancer screenings among U.S. adults.   Am J Prev Med. 2018;54(1):e11-e19. doi:10.1016/j.amepre.2017.08.024PubMedGoogle ScholarCrossref
6.
Jemal  A, Fedewa  SA.  Lung cancer screening with low-dose computed tomography in the United States—2010 to 2015.   JAMA Oncol. 2017;3(9):1278-1281. doi:10.1001/jamaoncol.2016.6416PubMedGoogle ScholarCrossref
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