Disparities of National Lung Cancer Screening Guidelines in the US Population

Abstract

Background: Current US Preventive Services Task Force (USPSTF) lung cancer screening guidelines are based on smoking history and age (55-80 years). These guidelines may miss those at higher risk, even at lower exposures of smoking or younger ages, because of other risk factors such as race, family history, or comorbidity. In this study, we characterized the demographic and clinical profiles of those selected by risk-based screening criteria but were missed by USPSTF guidelines in younger (50-54 years) and older (71-80 years) age groups.

Methods: We used data from the National Health Interview Survey, the CISNET Smoking History Generator, and results of logistic prediction models to simulate lifetime lung cancer risk-factor data for 100 000 individuals in the 1950-1960 birth cohorts. We calculated age-specific 6-year lung cancer risk for each individual from ages 50 to 90 years using the PLCOm2012 model and evaluated age-specific screening eligibility by USPSTF guidelines and by risk-based criteria (varying thresholds between 1.3% and 2.5%).

Results: In the 1950 birth cohort, 5.4% would have been ineligible for screening by USPSTF criteria in their younger ages but eligible based on risk-based criteria. Similarly, 10.4% of the cohort would be ineligible for screening by USPSTF in older ages. Notably, high proportions of blacks were ineligible for screening by USPSTF criteria at younger (15.6%) and older (14.2%) ages, which were statistically significantly greater than those of whites (4.8% and 10.8%, respectively; P < .001). Similar results were observed with other risk thresholds and for the 1960 cohort.

Conclusions: Further consideration is needed to incorporate comprehensive risk factors, including race and ethnicity, into lung cancer screening to reduce potential racial disparities.

Figure 1.

Model-based vs observed distributions of race, education, FHLC, and COPD for the 1950 birth cohort (male and female combined). The distributions of the remaining risk factors and the bivariate distributions of risk factors are shown in Supplementary Figures 4 and 5 (available online). Data sources: Race and education data from US Census Bureau; FHLC and COPD from the 2000 NHIS. We note that the risk factor simulator algorithm was calibrated to these reference data (see Supplementary Methods, available online). COPD = chronic obstructive pulmonary disease; FHLC = family history of lung cancer; LC = lung cancer; NHIS = National Health Interview Survey.

Figure 2.

Percent of the population missed for screening by the USPSTF criteria vs risk-based criteria (>1.51% threshold) in (A) younger ages 50–54 years, (B) middle ages 55–70 years, and (C) older ages 71–80 years in the 1950 birth cohort. All = all racial and ethnic group combined; A = Asians; B = blacks; H = Hispanic; W = non-Hispanic white; USPSTF = US Preventive Services Task Force.

Figure 3.

Impact of varied 6-year LC risk threshold (1.3–2.5%) on the percent of the population missed by the USPSTF criteria vs risk-based criteria in (A) younger ages 50–54 years, (B) middle ages 55–70 years, and (C) older ages 71–80 years in the 1950 birth cohort. USPSTF = US Preventive Services Task Force.

Figure 4.

Percent of the population missed for screening by the USPSTF criteria vs risk-based criteria (>1.51% threshold) in younger ages 50–54 years (first rows), middle ages 55–70 years, and older ages 71–80 (second rows) in the 1950 birth cohort. COPD = chronic obstructive pulmonary disease; FHLC = family history of lung cancer; Postcol = post-college; USPSTF = US Preventive Services Task Force.