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Potter AL, Yang CJ, Woolpert KM, Puttaraju T, Suzuki K, Palmer JR. Evaluating Eligibility of US Black Women Under USPSTF Lung Cancer Screening Guidelines. JAMA Oncol. 2022;8(1):163–164. doi:10.1001/jamaoncol.2021.5790
The 2021 US Preventive Services Task Force (USPSTF) lung cancer screening guidelines1 have increased the number of smokers eligible for screening by lowering the age eligibility from 55 to 50 years and reducing the requisite pack-years of smoking from 30 to 20. While these changes should increase the proportion of Black individuals eligible for screening,2 it is possible that many high-risk Black women will continue to be ineligible.3,4 In this quality improvement study, we evaluate lung cancer screening eligibility among US Black women under the 2013 and 2021 USPSTF guidelines.
Participants of the Black Women’s Health Study (BWHS), which includes self-identified Black women from across the US (n = 58 973), were enrolled in 1995 by completing a health questionnaire with detailed information on cigarette smoking and other exposures; information was updated by biennial questionnaires.5 The study was approved by the Boston University Medical Campus Institutional Review Board. Incident lung cancers were identified by self-report and annual linkages with state cancer registries and the National Death Index. We evaluated the proportion of women diagnosed with lung cancer who would have been eligible under the 2013 vs 2021 USPSTF lung cancer screening guidelines. We also estimated the sensitivity and specificity of the USPSTF guidelines and alternative guidelines based on different criteria for pack-year smoking history and years since quitting (YSQ). Analyses were conducted using SAS, version 9.4 (SAS Institute).
During follow-up of 58 973 BWHS participants from July 1995 through December 2017, 559 women were diagnosed with lung cancer, with mean (SD) age at diagnosis of 64.0 (10.9) years (median [IQR], 65.0 [57.0-72.0] years); 43% were current smokers, 42% were former smokers, and 15% were never smokers. Mean (SD) number of pack-years were 27.6 (15.7) (median [IQR], 18.3 [11.0-32.0]) and 23.0 (17.3) (median [IQR], 17.0 [11.0-32.0]) among current and former smokers, respectively; among former smokers, mean (SD) YSQ was 22.4 (9.7) years (median [IQR], 25.5 [14.0-32.0] years).
Under 2013 USPSTF guidelines, 28.4% of BWHS participants with lung cancer who had a smoking history would have been eligible for lung cancer screening. Under the new 2021 guidelines, the proportion of women eligible for screening increased to 40.2%, representing a 41.5% increase in eligibility (McNemar test, P < .001). Among the 284 smokers who would not have been eligible for screening under the 2021 guidelines, 75.0% were ineligible because they had fewer than 20 pack-years smoking history, and 29.6% were ineligible because they quit smoking more than 15 years ago (Table 1).
Sensitivity and specificity of the 2021 guidelines among the 21 604 BWHS participants who were ever smokers were 40.2% and 86.5%, respectively (Table 2). Removing the requirement that former smokers must have quit smoking within the past 15 years was associated with an increase in sensitivity, to 48.2%, and a decrease in specificity, to 78.9%. Reducing the required number of pack-years to 15 or 10 years was associated with further increased sensitivity and decreased specificity.
In the present analysis, the proportion of Black women diagnosed with lung cancer who would have been eligible for screening increased by 41.5% under 2021 USPSTF screening guidelines compared with 2013 guidelines, yet 60% of the patients with lung cancer still would have been ineligible for screening. We found that revising the new USPSTF guidelines by removing the 15 YSQ requirement for former smokers would increase the proportion of Black women eligible for screening from 40.2% to 48.2%, with a small reduction in specificity. The 2021 USPSTF relaxation of age and pack-years requirements was prompted in part by the need to increase the proportion of Black individuals eligible for screening given their younger age at diagnosis of lung cancer and higher risk of lung cancer associated with fewer smoking pack-years compared with White individuals.2,6
Our findings suggest that removing the 15 YSQ criteria in the current USPSTF guidelines may be beneficial for Black women. Further research should be prioritized to determine if there is a need for sex and/or race and ethnicity differentiation in future revisions to the guidelines. A limitation of the current study was the lack of data on the use of lung cancer screening by eligible individuals in our cohort during the study period. Such information may be available in future studies.
Accepted for Publication: September 2, 2021.
Published Online: November 24, 2021. doi:10.1001/jamaoncol.2021.5790
Correction: This article was corrected on August 31, 2023, to fix data errors in the Results, Discussion, and Tables 1 and 2.
Corresponding Author: Julie R. Palmer, ScD, Slone Epidemiology Center at Boston University, 72 E Concord St, L-7, Boston, MA 02118 (firstname.lastname@example.org).
Author Contributions: Dr Palmer 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. Ms Potter and Dr Yang contributed equally to this work as co–first authors.
Concept and design: Potter, Yang, Puttaraju, Suzuki, Palmer.
Acquisition, analysis, or interpretation of data: Potter, Yang, Woolpert, Puttaraju, Palmer.
Drafting of the manuscript: Potter, Yang, Puttaraju, Palmer.
Critical revision of the manuscript for important intellectual content: Potter, Yang, Woolpert, Puttaraju, Suzuki.
Statistical analysis: Woolpert, Puttaraju.
Obtained funding: Palmer.
Administrative, technical, or material support: Puttaraju, Suzuki.
Supervision: Suzuki, Palmer.
Conflict of Interest Disclosures: Dr Palmer reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Palmer also receives funding from the Karin Grunebaum Cancer Research Foundation. No other disclosures were reported.
Funding/Support: This work was supported by the National Institutes of Health (U01CA164974, Dr Palmer). Lung cancer data were obtained in part from state cancer registries (Arizona, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, New Jersey, New York, North Carolina, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington, DC).
Role of the Funder/Sponsor: The National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the state cancer registries.