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Original Investigation
June 27, 2019

Evaluation of USPSTF Lung Cancer Screening Guidelines Among African American Adult Smokers

Author Affiliations
  • 1Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
  • 2Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
  • 3Department of Radiology, Massachusetts General Hospital, Boston
  • 4Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
  • 5Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
JAMA Oncol. Published online June 27, 2019. doi:10.1001/jamaoncol.2019.1402
Key Points

Question  Can US Preventive Services Task Force (USPSTF) lung cancer screening guidelines be modified in order that screening eligibility and clinical validity are equitable for African American individuals?

Findings  In this cohort study of 48 364 adult smokers who were observed for up to 12 years, significantly fewer African American smokers with lung cancer met the USPSTF screening guidelines compared with white smokers. Large racial disparities in sensitivity and specificity were observed.

Meaning  The findings suggest that current lung cancer screening guidelines may be too conservative for African American smokers and that race-specific smoking pack-year eligibility should be considered to make screening operationally equitable.


Importance  The United States Preventive Services Task Force (USPSTF) recommends low-dose computed tomography screening for lung cancer. However, USPSTF screening guidelines were derived from a study population including only 4% African American smokers, and racial differences in smoking patterns were not considered.

Objective  To evaluate the diagnostic accuracy of USPSTF lung cancer screening eligibility criteria in a predominantly African American and low-income cohort.

Design, Setting, and Participants  The Southern Community Cohort Study prospectively enrolled adults visiting community health centers across 12 southern US states from March 25, 2002, through September 24, 2009, and followed up for cancer incidence through December 31, 2014. Participants included African American and white current and former smokers aged 40 through 79 years. Statistical analysis was performed from May 11, 2016, to December 6, 2018.

Exposures  Self-reported race, age, and smoking history. Cumulative exposure smoking histories encompassed most recent follow-up questionnaires.

Main Outcomes and Measures  Incident lung cancer cases assessed for eligibility for lung cancer screening using USPSTF criteria.

Results  Among 48 364 ever smokers, 32 463 (67%) were African American and 15 901 (33%) were white, with 1269 incident lung cancers identified. Among all 48 364 Southern Community Cohort Study participants, 5654 of 32 463 African American smokers (17%) were eligible for USPSTF screening compared with 4992 of 15 901 white smokers (31%) (P < .001). Among persons diagnosed with lung cancer, a significantly lower percentage of African American smokers (255 of 791; 32%) was eligible for screening compared with white smokers (270 of 478; 56%) (P < .001). The lower percentage of eligible lung cancer cases in African American smokers was primarily associated with fewer smoking pack-years among African American vs white smokers (median pack-years: 25.8 [interquartile range, 16.9-42.0] vs 48.0 [interquartile range, 30.2-70.5]; P < .001). Racial disparity was observed in the sensitivity and specificity of USPSTF guidelines between African American and white smokers for all ages. Lowering the smoking pack-year eligibility criteria to a minimum 20-pack-year history was associated with an increased percentage of screening eligibility of African American smokers and with equitable performance of sensitivity and specificity compared with white smokers across all ages (for a 55-year-old current African American smoker, sensitivity increased from 32.2% to 49.0% vs 56.5% for a 55-year-old white current smoker; specificity decreased from 83.0% to 71.6% vs 69.4%; P < .001).

Conclusions and Relevance  Current USPSTF lung cancer screening guidelines may be too conservative for African American smokers. The findings suggest that race-specific adjustment of pack-year criteria in lung cancer screening guidelines would result in more equitable screening for African American smokers at high risk for lung cancer.