Expanding preventive screening advice may boost health equity

Traditional lung cancer screening criteria fall short

The traditional criteria for receiving a lung cancer screening, as outlined by the U.S. Preventive Services Task Force (USPSTF), has been found to be restrictive and exclude individuals who did, in fact, have lung cancer.

In 2013, USPSTF recommended that individuals aged 55 who smoked around 30 pack-years get lung cancer screenings. In observing racial and sex-based disparities emerging from these recommendations, the Task Force reduced the age to 50 and the smoking intensity requirements to 20 pack-years.

Still, racial and sex-based disparities persist, the researchers said. Women and Black people, in particular, often did not qualify for lung cancer screening despite still being susceptible to the disease and, in some cases, having it. But since they often did not qualify for lung cancer screening, their diagnoses were often missed before it was too late.

"Therefore, [lung cancer screening] eligibility criteria must continue to evolve toward greater equity, with the aim of identifying more lung cancers early and reducing disparities, while maintaining the efficiency and safety of screening," the researchers proposed in the study's introduction.

Expanding cancer screening eligibility improves diagnosis

The researchers compared the following lung cancer screening eligibility criteria among an early-detection cohort of 43,521 individuals:

• USPSTF eligibility.
• Potter criteria, which focuses on those with a 20-year smoking history.
• American Cancer Society (ACS) criteria, which focuses on those with 20 pack-years with no duration of quitting.
• Combined Potter and ACS criteria.
• Expanded criteria, which expands to include those with just 10 years of smoking history or 10 pack-years.

Naturally, expanding screening guidelines increased the number of those eligible for lung cancer screening. While 13% of study participants qualified for lung cancer screening under the typical USPSTF guidelines, 16% were under the Potter criteria, 18% were under the ACS criteria and 21% were under the Potter/ACS criteria.

That expanded criteria also resulted in more diverse patient populations, creating potential for greater health equity, the study authors added.

Specifically, the Potter criteria led to more women and Black people being eligible for the screenings. Under USPSTF guidelines, 48% of women were eligible for lung cancer screening compared to 55% under Potter criteria. For Black people, the comparison was 22% under USPSTF and 35% under Potter criteria.

Expanding screening has a small impact on efficiency

Expanding the number of people eligible to receive lung cancer screening didn't adversely impact cancer screening efficiency, which is an important finding, the researchers remarked. Eligibility guidelines are set in place for any kind of preventive screening to ensure limited hospital resources are used on folks at the highest risk for a certain illness, in this case, lung cancer.

But the results showed this wasn't the case.

Among those who met USPSTF criteria, the researchers were able to identify one lung cancer for every 25.2 individuals screened. That's about a 4% detection rate.

When looking at the total study population, the USPSTF criteria yielded a 21.3% cancer detection rate and expanded criteria yielded a 16.7% cancer detection rate. Although the expanded criteria had a lower cancer detection rate, significantly more people would be eligible for screening, ultimately leading to 28% more cancers being detected under this model.

In other words, expanded criteria might be less efficient, but it would ultimately lead to more cancer detection and, ideally, greater health equity.

"Our study suggests that relaxed smoking history requirements may provide better access to [lung cancer screening] while maintaining diagnostic efficiency," the researchers concluded. "Including 20 pack-years or a 20-year smoking history with no pack-year requirement and eliminating the quit duration requirement included more females and Black individuals while maintaining reasonable efficiency and still reaching the most socially disadvantaged groups."

Sara Heath has reported news related to patient engagement and health equity since 2015.