From ASCO Daily News

Address disparities in lung cancer screening – a focus of several abstracts presented at ASCO’s 2021 annual meeting.

Lung cancer remains the leading cause of cancer death worldwide.¹ It carries a 5-year overall survival rate of less than 20%, mainly resulting from the often advanced stage at diagnosis.² Lung cancer screening guidelines were implemented by the National Comprehensive Cancer Network (NCCN) and the U.S. Preventive Services Task Force (USPSTF) in 2011 and 2013, respectively, after landmark clinical trials, such as the National Lung Screening Trial and The Dutch–Belgian Randomized Lung Cancer Screening Trial, showed earlier diagnosis and decreased mortality rates with low-dose CT (LDCT) as a screening modality.^3-6 Despite these recommendations, lung cancer screening remains vastly underused to date, with less than 20% of the high-risk eligible population undergoing lung cancer screening. Low rates of lung cancer screening are even more noticeable among underserved populations. Herein, we discuss three abstracts from the 2021 ASCO Annual Meeting that address disparities in lung cancer screening, including an abstract we coauthored (Table).

Address Disparities in Lung Cancer Screening Completions

Abstract 10506 aimed to determine (1) the uptake of baseline lung cancer screening among patients who received a referral for LDCT and (2) if there were individual or socioeconomic factors associated with LDCT compliance after a referral was placed. This retrospective population-based study was conducted within the five health systems of the Lung Population-Based Research to Optimize the Screening Process Consortium from January 2014 through June 2019. A total of 13,920 patients were referred for baseline lung cancer screening, of whom 70.3% were non-Hispanic White, 14.1% were non-Hispanic Black, and 15.7% were of other or unknown race/ethnicity. Of the patients who were referred for screening, 62% received LDCT. Patients who were male (63.6%), former smokers (65.9%), and older (64.2% age 65-69 and 64.1% older than age 70) had higher rates of LDCT screening after receiving a referral. Differences in screening completion were observed by race/ethnicity, with 81.8% of Asian/Pacific Islander, 63.3% of Hispanic, 56.1% of non-Hispanic Black, 61.8% of non-Hispanic White, and 55.2% of other-race patients undergoing LDCT after referral (p < 0.001). Additionally, the study found that non-Hispanic Black men were significantly less likely to undergo a baseline LDCT than non-Hispanic White men (odds ratio [OR] 0.87, 95% CI [0.84, 0.94]; p = 0.59), whereas non-Hispanic Black women had a higher tendency toward screening completion than non-Hispanic White women (OR 1.13, 95% CI [0.93, 1.38]).

This study highlights the need to further investigate the factors that may impact lung cancer screening uptake in different subgroups of individuals, which, in turn, could help physicians tailor population-specific interventions to promote adherence and decrease disparities.

This study highlights the need to further investigate the factors that may impact lung cancer screening uptake in different subgroups of individuals, which, in turn, could help physicians tailor population-specific interventions to promote adherence and decrease disparities.

Address Disparities in Lung Cancer Screening for Uninsured, High-Risk Populations

Abstract 6507 highlights the use of practical LDCT technology in attempting to increase lung cancer screening rates for uninsured, high-risk populations. The study authors hypothesized that access to lung cancer screening among underserved populations would improve with a mobile screening unit that could be brought into each community. Thirty-two portable LDCT scanners were installed in a coach bus and brought to underserved and predominantly rural (78%) populations in North Carolina. The Lung-RADS classification was used to evaluate the findings. As part of this initiative, 1,200 individuals (64% uninsured, 4% underinsured) were screened. The median age was 61 and individuals had a 47.1 average pack-year history of smoking. Of the individuals screened, 51.5% were male, 17.8% were Black, 2.3% were Hispanic/Latino, and 0.5% were Native American. The study found 97 individuals with Lung-RADS 4 lesions, and 30 of these patients (23 White patients and 7 Black patients) were diagnosed with lung cancer. Forty-three percent were diagnosed with stage I, 7% with stage II, 20% with stage III, and 27% with stage IV disease. Twenty-one patients were treated with curative intent. Five patients were found to have incidental cancer at other sites; two instances of pancreatic, two instances of renal cell carcinoma, and one instance of head and neck cancer were found.
This study addressed a major unmet need, access to LDCT, by bringing the intervention directly to underserved communities. Potentially, these efforts led to early detection of lung cancer in these high-risk, vulnerable populations.

Table. Summary of ASCO Annual Meeting Research Addressing Disparities in Lung Cancer Screening

Abbreviations: LDCT, low-dose CT; NCCN, National Comprehensive Cancer Network; USPSTF, U.S. Preventive Services Task Force; vs. versus.View larger
Lung Cancer Screening Eligibility Among Hispanic/Latino and African American Populations
Lastly, Abstract 6538, which was coauthored by the authors of this editorial, was a retrospective study that assessed NCCN and USPSTF screening eligibility among Hispanic/Latino and African American patients prior to lung cancer diagnosis. A total of 36% and 57% of the 428 patients included in the analysis were ineligible for screening prior to their lung cancer diagnosis according to the NCCN and USPSTF criteria, respectively. Among the NCCN screening–ineligible patients, 18% identified as African American and 8% as Hispanic/Latino. Among the USPSTF screening–ineligible patients, 16% and 8% identified as Africa American and Hispanic/Latino, respectively. The study found that Hispanic/Latino patients had significantly higher USPSTF ineligibility rates than non-Hispanic/Latino patients (80% vs. 56%; p = 0.027). Additionally, both African American and Hispanic/Latino patients had higher tendencies toward NCCN than USPSTF eligibility criteria, as 52% and 20% of Hispanic/Latino patients met NCCN and USPSTF eligibility criteria, respectively (p = 0.001). Similarly, 57% and 39% of African American patients were NCCN and USPSTF screening–eligible prior to lung cancer diagnosis (p = 0.0029).
We and our colleagues concluded that disparities in race, ethnicity, and screening criteria exist, and these disparities highlight how lung cancer can be overlooked in ethnic minority patients who are high-risk, especially if current USPSTF criteria are applied.

Concluding Thoughts:

As physicians, it is imperative that we continue promoting and enforcing lung cancer screening in an attempt to improve the mortality rate of such malignancies. Special attention should be given to underserved populations who fall victim to historical disadvantages in their access to care. Ongoing efforts to re-evaluate and broaden the screening criteria are necessary to ensure that every high-risk individual is included. It is of paramount importance that we continue the fight toward health equity and close the gap in health disparities for our most vulnerable populations.

References

American Cancer Society. Key Statistics for Lung Cancer. Updated January 12, 2021. Accessed June 16, 2021.
Noone AM, Howlader N, Krapcho M, et al. SEER Cancer Statistics Review (CSR), 1975–2015. National Cancer Institute. Updated September 10, 2018. Accessed June 16, 2021.
Aberle DR, Adams AM, Berg CD, et al.; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409
Ru Zhao Y, Xie X, de Koning HJ, et al. NELSON lung cancer screening study. Cancer Imaging. 2011;11 Spec No A(1A):S79-S84.
Moyer VA; U.S. Preventive Services Task Force. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160:330-338.
Wood DE, Kazerooni EA, Baum SL, et al. Lung Cancer Screening, Version 3.2018, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2018;16:412-441