A significant amount of progress has been made in improving the treatment of lung cancer and patient outcomes. However, a number of disparities that can have an impact on these persist, including those affecting lung cancer screening.
Lung cancer screening is an essential step toward effective treatment and improved survival, but its success depends on ensuring that it is available to all high-risk patients. The American Thoracic Society (ATS), in a statement published in October 2020, detailed their findings on the disparities in lung cancer screening eligibility as well as their suggested strategies for improving them.¹ What they found were gaps in, among other things, availability, education, and consistent insurance coverage, as well as some distrust in healthcare providers. These barriers, extending from providers to patients to the healthcare system, are what the ATS saw as factors that helped further the inequities in lung cancer screening.
The ATS identified room for improvement in identifying high-risk individuals in socioeconomically disadvantaged populations. Their research found that although African American individuals smoke less than White individuals, they have a higher smoking-adjusted risk for lung cancer. But because of the fewer pack-years smoked, African Americans were less likely to be eligible for lung cancer screening based on the US Preventive Services Task Force (USPSTF) guidelines from 2013. The USPSTF made changes to their guidelines in July 2020 that included lowering the recommended initial age for screening from 55 to 50 and the smoking history from 30 pack-years to 20.
The ATS also expressed concern that eligibility guidelines did not factor in research on sex-based differences; though studies have found that women tend to start smoking later in life and less intensively than men, they are more likely to be diagnosed with lung cancer at younger ages. Early detection is also important for people living with HIV, as the ATS points to past studies that have suggested an increased frequency of advanced-stage lung cancer in this group.
Individuals who smoke lightly and those who used to smoke heavily but quit many years ago are still at risk of developing lung cancer, and the ATS suggests that current guidelines for screening don’t reflect that enough (in tandem with previous findings in the statement, these groups of individuals include a large percentage of women and racial or ethnic minorities).
In addition to barriers relating to the individual smoker (fearing the stigma of smoking or a lung cancer diagnosis), the ATS found numerous systemic barriers that affected screening and eligibility. Although the US Centers for Medicare & Medicaid Services started providing coverage for screening in Medicare recipients who meet USPSTF criteria in 2015, Medicaid coverage for lung cancer screening is determined by each state (ATS proposes that healthcare providers and advocacy groups fight for mandating an expansion of Medicaid coverage of lung cancer screenings). Not every state provides coverage for lung cancer screenings, medical centers may not have the resources to implement it, and patients may simply be unable to cover the cost.
How does the ATS propose these disparities, as well as others addressed in the study, be remedied? In addition to their suggestion of lowering the criteria for age and smoking history (which the USPSTF has already begun doing), they also suggest using individualized risk calculators to determine eligibility for lung cancer screening. This has the potential to find high-risk candidates who may not have met the initial criteria, and they propose using these risk calculators in tandem with USPSTF guidelines.
The ATS provides other proposals for improving access to screening eligibility and lung health. These include research into efficient and effective tobacco-cessation services for patients and expanding insurance coverage for cessation treatments. At the healthcare level, the ATS recommends the integration of patient navigators into lung cancer screening programs to help increase education and use among more vulnerable populations. It is also pointed out that vulnerable and underserved populations have, in the past, been helped by mobile lung cancer screening units.
Ultimately, the ATS’ recommendations prioritize an increase in access, risk assessment, and education of lung cancer screenings.
- Rivera MP, Katki HA, Tanner NT, et al; on behalf of the American Thoracic Society Assembly on Thoracic Oncology. Addressing disparities in lung cancer screening eligibility and healthcare access. An official American Thoracic Society statement. Am J Respir Crit Care Med. 2020;202(7):e95-e112. doi:10.1164/rccm.202008-3053st