Abstract
Objectives Lung cancer is the leading cause of cancer related death in the US and the world. In some parts of the US, American Indian adults experience extreme disparities in lung cancer incidence and mortality that mirror commercial tobacco use disparities. Lung cancer screening (LCS) with low-dose chest computed tomography has been underutilized in all groups, including in American Indian communities, although they have the greatest proportion of people who smoke older than 50 years of age eligible for LCS. Methods This is a secondary analysis of LCS knowledge, attitudes and behavior collected during a pilot study testing a culturally aligned digital tool for smoking cessation. Data were collected in 2023 via web surveys from American Indian adults residing in the Midwestern US. Results We found striking similarities to national studies showing most participants are unaware of, but open to, LCS and are looking to their doctors and clinics to provide recommendations for screening. Conclusions American Indian adults who use commercial tobacco have knowledge, attitudes and intentions similar to other Americans eligible for LCS. Healthcare organizations must find systematic ways to offer LCS to eligible persons.
Keywords: Cancer early detection; Early diagnosis of Cancer; Cancer early diagnosis; cancer screening; Screening, Cancer; American Indian
1. Introduction
More people die from lung cancer than prostate, colon, breast, and cervical cancer combined. Lung cancer health disparities in the United States are stark, particularly in the Northern Plains region and Alaska, where American Indian and Alaska Native people die of lung cancer at twice the rate of non-Hispanic White people (Melkonian et al., 2021). Previous work has reported that American Indian and Alaska Native individuals may be less knowledgeable about cancer screening than White individuals (Guadagnolo et al., 2009); reflecting greater challenges in accessing healthcare and receiving health-related information, because of various social determinants of health (resulting from structural oppression). Lung cancer deaths can be reduced through early detection with lung cancer screening (LCS). However, multiple studies have shown that most people who are eligible for LCS are unaware that the service is available, recommended, and covered by insurance. The screening test is a low-dose chest computed tomography (LDCT), recommended annually for people at an increased risk of lung cancer due to cigarette smoking (Force et al., 2021). Lung cancer screening rates have been slowly increasing in the past decade, but remain dismal at only 17 % nationally (Henderson et al., 2024).
The high lung cancer rates and need for LCS is largely driven by the higher prevalence (as high as 59 %) of cigarette smoking in some American Indian and Alaska Native communities (Forster et al., 2016) compared to the overall US. While traditional tobacco has an important role in cultural and spiritual practices and ceremonies (Boudreau et al., 2016), the legacy of settler-colonialism has led to some American Indian and Alaska Native people developing a harmful relationship with commercial tobacco.
A previous study (Anderson et al., 2023) showed that the LCS-eligible patients in an urban clinic serving American Indian and Alaska Native people, like most other LCS-eligible Americans, are unaware of LCS, but open to it if recommended by their primary care provider. Here, we present results of a secondary analysis of LCS knowledge and attitudes, including willingness to undergo LCS. This secondary analysis uses data collected during a pilot study testing QuitGuide for Natives, a culturally-aligned research version of the US National Cancer Institute's QuitGuide smartphone-based intervention for quitting smoking (Cooley et al., 2024) .The primary outcomes have previously been published. We also explored the relationship between LCS willingness and financial strain as well as discrimination due to prior studies (Korous et al., 2022; Crawley et al., 2008) finding an inverse relationship between for both. Finally, we explored whether self-reported traditional tobacco use was related to LCS attitudes or self-reported LCS behavior to understand if LCS perceptions might be impacted by the deeply complex American Indian relationship with commercial tobacco.
2. Methods
Briefly, adults identifying as American Indian, and reporting daily commercial tobacco use were recruited from American Indian-serving clinics in Minnesota and Wisconsin. Study procedures and outcomes of the culturally-aligned QuitGuide have been published elsewhere (Carroll et al., 2024). Participants were enrolled and submitted baseline data collection in 2023 through the University of Minnesota Research Electronic Data Capture (REDCap). All participants received a survey to assess LCS knowledge and attitudes at baseline. In addition, we assessed everyday discrimination and financial strain. The Everyday Discrimination Scale (Williams et al., 2008; Krieger et al., 2005) was used, and was chosen partly in accordance with recommendations from our community advisory board. Financial strain was assessed using an adapted measure (Conger et al., 1994) developed for other American Indian community-engaged research and consisted of four questions: “My family has enough money to afford the kind of __(home/clothing/food/medical care)___ we need.” Likert-scale responses were defined 1=’Strongly agree’, 2=’Agree’, 3=’Disagree’ and 4=’Strongly disagree’. Total financial strain was a total of four responses with potential scores ranging from 4 to 16 with higher scores indicating greater financial strain.
Responses were summarized by age and sex using descriptive statistics. To investigate the effect of financial strain on willingness to get LCS, logistic regression or Fisher's exact tests were used. Odds ratios (OR) and 95 % confidence intervals (CI) were obtained. Similar analyses were performed for the effect of everyday discrimination on whether or not participants would go to a doctor or clinic for more information about LCS. Statistical analyses were performed using R (version 4.2.2, R Core Team).
This study involves human participants and was approved by University of Minnesota IRB STUDY00016190 and by the representatives of the community partners. Participants gave informed consent to participate in the study.
3. Results
Overall, 115 participants were enrolled and randomized in the trial. Table 1 shows participant characteristics including stratification by age-eligibility for LCS. The participants over 50 years old would be mostly eligible or soon-to-be eligible for LCS based on median cigarettes per day of 10 and median 42.5 years smoking. Over half of this group reported not having heard about LCS while only about 15 % reported completing LCS, with an additional 21 % having a computed tomography scan for some other reason. Of those not already screened, most would consider getting LCS (67 %), with an additional 19 % needing more information. The vast majority reported a physician or clinic being the information source they would seek for information on LCS (91 %). The study sample was largely female (77 %) and even more so in the LCS-age-eligible group (88 %). Supplemental Table 1 shows participant characteristics and responses by sex.
Table 1.
Participant characteristics of American Indian adults who use commercial tobacco in the Midwestern United States (2023), including summaries and separated by the age threshold for lung cancer screening eligibility (50 years of age).
| Variable | All randomized participants (N = 115) | Age < 50 (N = 82) | Age ≥ 50 (N = 33) |
|---|---|---|---|
| Cigarettes Per Day smoked most of the time when regularly smoking cigarettes | |||
| Mean (SD) | 13.2 (7.8) | 13.2 (8.4) | 13.3 (6.2) |
| Median (Q1, Q3) | 10.0 (8.0, 20.0) | 10.0 (8.0, 20.0) | 10.0 (10.0, 20.0) |
| Total smoking duration | |||
| Number missing | 1 | 0 | 1 |
| Mean (SD) | 28.5 (11.2) | 23.4 (7.4) | 41.7 (8.3) |
| Median (Q1, Q3) | 27.5 (21.0, 37.0) | 24.0 (18.2, 29.0) | 42.5 (37.8, 46.2) |
| Regular smoking duration | |||
| Number missing | 1 | 0 | 1 |
| Mean (SD) | 25.6 (11.7) | 20.4 (7.6) | 39.0 (9.3) |
| Median (Q1, Q3) | 24.5 (17.2, 34.5) | 22.0 (16.0, 26.0) | 38.5 (35.8, 44.2) |
| Education | |||
| 8th grade or less | 1 (0.9) | 1 (1.2) | 0 (0.0) |
| Some high school | 14 (12.2) | 13 (15.9) | 1 (3.0) |
| High school – diploma | 16 (13.9) | 14 (17.1) | 2 (6.1) |
| High school – General Educational Development | 18 (15.7) | 14 (17.1) | 4 (12.1) |
| Some college but no degree | 39 (33.9) | 26 (31.7) | 13 (39.4) |
| Associate degree – occupations/vocational | 9 (7.8) | 6 (7.3) | 3 (9.1) |
| Associate degree – academic program | 5 (4.3) | 2 (2.4) | 3 (9.1) |
| Bachelor's degree | 11 (9.6) | 5 (6.1) | 6 (18.2) |
| Master's degree | 1 (0.9) | 0 (0.0) | 1 (3.0) |
| Professional / Doctoral degree | 1 (0.9) | 1 (1.2) | 0 (0.0) |
| Sex | |||
| Female | 89 (77.4) | 60 (73.2) | 29 (87.9) |
| Male | 26 (22.6) | 22 (26.8) | 4 (12.1) |
| Heard of lung scan to check for cancer | |||
| Yes | 35 (30.4) | 21 (25.6) | 14 (42.4) |
| No | 72 (62.6) | 54 (65.9) | 18 (54.5) |
| Not sure | 8 (7.0) | 7 (8.5) | 1 (3.0) |
| Reported computed tomography scan in the last 12 months | |||
| Yes, to check for lung cancer | 5 (4.3) | 0 (0.0) | 5 (15.2) |
| Had a scan, but for some other reason | 19 (16.5) | 12 (14.6) | 7 (21.2) |
| No, did not have a scan | 86 (74.8) | 66 (80.5) | 20 (60.6) |
| Not sure | 5 (4.3) | 4 (4.9) | 1 (3.0) |
| For participants who did not report a scan in the last year | All randomized participants (N = 91) | Age < 50 (N = 70) | Age ≥ 50 (N = 21) |
| Would consider getting a lung scan to check for cancer | |||
| Yes | 63 (69.2) | 49 (70.0) | 14 (66.7) |
| No | 14 (15.4) | 11 (15.7) | 3 (14.3) |
| Need more information | 14 (15.4) | 10 (14.3) | 4 (19.0) |
| Would go to doctor or clinic to get more information about a lung scan to check for cancer | |||
| Yes | 79 (86.8) | 60 (85.7) | 19 (90.5) |
| No | 12 (13.2) | 10 (14.3) | 2 (9.5) |
| Would go to the internet to get more information about a lung scan to check for cancer | |||
| Yes | 20 (22.0) | 18 (25.7) | 2 (9.5) |
| No | 71 (78.0) | 52 (74.3) | 19 (90.5) |
| Would go to friends and family to get more information about a lung scan to check for cancer | |||
| Yes | 8 (8.8) | 5 (7.1) | 3 (14.3) |
| No | 83 (91.2) | 65 (92.9) | 18 (85.7) |
| Would go to social media to get more information about a lung scan to check for cancer | |||
| Yes | 5 (5.5) | 5 (7.1) | 0 (0.0) |
| No | 86 (94.5) | 65 (92.9) | 21 (100.0) |
| Would go to another source to get more information about a lung scan to check for cancer | |||
| No | 91 (100.0) | 70 (100.0) | 21 (100.0) |
Categorical variables are summarized with n (%).
Table 2 shows the effect of financial strain and traditional tobacco use on LCS willingness and behavior while Supplemental Table 2 shows the relationship between everyday discrimination and participant LCS behavior characteristics.
Table 2.
Participant-reported financial strain and traditional tobacco use and the effect of those on willingness to get a lung scan amongst American Indian adults who use commercial tobacco in the Midwestern United States (2023).
| Variable | All participants who have not or weren't sure if they've had computed tomography scan in the last 12 months (N = 91) | Participants who “Would consider getting a lung scan to check for cancer” (N = 63) | Participants who “Would not consider or need more information” (N = 28) | OR (95 % CI)1 |
|---|---|---|---|---|
| Total financial strain score2 | 1 (0.84, 1.19) | |||
| Mean (SD) | 9.5 (2.6) | 9.5 (2.8) | 9.5 (2.3) | |
| Median (Q1, Q3) | 9.0 (8.0, 11.0) | 9.0 (8.0, 11.5) | 9.0 (8.0, 11.0) | |
| We have enough money to afford the kind of medical care we need2 | 0.97 (0.59, 1.61) | |||
| Mean (SD) | 2.3 (0.9) | 2.3 (1.0) | 2.4 (0.8) | |
| Median (Q1, Q3) | 2.0 (2.0, 3.0) | 2.0 (2.0, 3.0) | 2.0 (2.0, 3.0) | |
| Used tobacco for ceremonial prayer or in a sacred way3 | 0.64 (0.1, 2.78) | |||
| Yes | 78 (100.0) | 53 (67.9) | 25 (32.1) | |
| No | 13 (100.0) | 10 (76.9) | 3 (23.1) |
Logistic regression was used to investigate the effect of finance strain (total and medical) on willingness to get a lung scan. Fisher's exact test was used for traditional tobacco use due to low cell counts.
Likert-scale responses were defined 1=’Strongly agree’, 2=’Agree’, 3=’Disagree’ and 4=’Strongly disagree’. Total financial strain was a total of four responses with potential scores ranging from 4 to 16 with higher scores indicating greater financial strain.
Summarized with n (%).
As shown in Table 2, we did not find any significant effect on willingness to get LCS related to reported financial strain (OR: 1, 95 % CI: 0.84–1.19) or traditional tobacco use (OR: 0.64, 95 % CI: 0.59–1.61). Additionally, we did not find any effect of everyday discrimination on whether participants would go to a doctor or clinic for more information about LCS (OR: 0.98, 95 % CI: 0.88–1.1, Supplemental Table 2).
4. Discussion
Despite widespread approval by professional societies, the US Preventive Services Task Force, and insurance payers, an estimated 17 % of eligible adults received LCS in the US. American Indian people historically have lower cancer screening rates than White people for other types of cancer (Pandhi et al., 2011), yet nearly a quarter of American Indian adults over 50 are likely eligible for LCS, a greater proportion than any other racial group (Narayan et al., 2021). We report here rates of LCS awareness comparably low to other studies (Monu et al., 2020; Schiffelbein et al., 2020). Self-reported LCS completion rates were also similarly low (less than 20 %) compared to a recent analysis of the national Behavioral Risk Factor Surveillance System (Henderson et al., 2024). Participants in our study overwhelmingly thought a doctor or clinic was the best source of information about LCS.
In our study we did not find significant effects of traditional tobacco use or financial strain impacting willingness to undergo LCS, although patients in other studies have reported concerns about cost of LCS (Kota et al., 2022). Similarly, we did not identify self-reported everyday discrimination as a barrier to seeking information about LCS from a doctor or clinic, however, healthcare discrimination, which may better reflect willingness to use healthcare services, was not measured. Our previous research shows that trusting primary care provider relationships foster willingness to accept preventive care recommendations and greater attention as to the factors that reduce mistrust may be helpful to increase LCS uptake.
This study is limited by its small size and relatively small number of participants who are old enough to be eligible for LCS by current guidelines. However, the average age of participants was 43 years, meaning many of those not eligible would potentially become eligible for LCS in several years, especially if they continued to smoke commercial tobacco cigarettes. Another limitation is the study focus on American Indian people who smoke in the Midwest so may not be generalizable to other regions. This study ultimately enrolled three times as many female American Indian adults as male, so it's not clear if it might be generalizable to males. Male and female participants had similar proportions of respondents who would: a) consider getting a lung scan to check for cancer (74 % and 68 %, respectively); and b) go to a doctor or clinic to get more information about a lung scan to check for cancer (89 % and 86 %, respectively).
The National Lung Screening Trial (National Lung Screening Trial Research T et al., 2011) showed a 20 % relative reduction in lung cancer mortality within eligible individuals using a LDCT compared to the control group who received radiography for lung cancer screening. Of note, only 190 of the 53,454 participants in the trial identified as American Indian or Alaska Native. Due to a history of structural and individual racism and discrimination, American Indian individuals have justifiable mistrust of medical researchers and government organizations, and as such, American Indian are often underrepresented in medical research. Understanding ways to engage American Indian people in medical research is an important step towards improving this population's health outcomes.
In summary, like other older individuals who currently smoke or used to smoke, our research suggests that most American Indian individuals are unaware of LCS and yet are open to LCS and primarily expect to learn about this from their healthcare team. This finding is concordant with studies conducted nationwide. It is imperative that we continue work to overcome health system barriers to identifying eligible persons and offering LCS in clinical settings. Furthermore, innovative and culturally aligned approaches to engagement may close the gap between LCS uptake in American Indian and other cancer screening rates.
CRediT authorship contribution statement
Abbie Begnaud: Writing – original draft, Investigation, Conceptualization. Wyatt Pickner: Writing – review & editing, Resources, Methodology, Investigation, Funding acquisition, Conceptualization. Antony Stately: Writing – review & editing, Supervision, Resources, Methodology, Conceptualization. Dylan Jennings: Writing – review & editing, Resources, Methodology, Investigation, Funding acquisition, Data curation, Conceptualization. Ebiere Okah: Writing – review & editing. Katelyn M. Tessier: Writing – review & editing, Validation, Software, Methodology, Formal analysis, Data curation. Michael Businelle: Writing – review & editing, Investigation. Dana Carroll: Writing – review & editing, Supervision, Resources, Project administration, Methodology, Investigation, Funding acquisition, Conceptualization.
Funding
This research was funded by the National Cancer Institute of the National Institutes of Health grant number R21CA261078 (to DM Carroll) and the National Institute on Minority Health and Health Disparities of the National Institutes of Health, grant number K01MD014795 (to DM Carroll). All statistical analyses were carried out in the Biostatistics Shared Resource of the Masonic Cancer Center, supported in part by National Cancer Institute Cancer Center Support grant P30CA077598. REDCap (Research Electronic Data Capture) services were provided by grant UM1TR004405 and UL1TR002494 from the National Center for Advancing Translational Sciences of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr. Begnaud is a paid consultant for Biodesix, a company offering blood tests to classify lung cancer risk.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgment
We appreciative Dr. Melissa Walls for sharing measures used in the Healing Pathways study, a longitudinal investigation of American Indian and First Nations adolescent (and now young adult) substance use and mental health. We also want to thank and recognize Dorothy Hatsukami, PhD for her mentorship.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.pmedr.2025.103173.
Contributor Information
Abbie Begnaud, Email: abegnaud@umn.edu.
Dana Carroll, Email: dcarroll@umn.edu.
Appendix A. Supplementary data
Supplementary Tables. Table 1 shows participant characteristics by sex. Table 2 shows the effect of everyday discrimination scores on whether they would go to a doctor or clinic for information about lung cancer screening.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Tables. Table 1 shows participant characteristics by sex. Table 2 shows the effect of everyday discrimination scores on whether they would go to a doctor or clinic for information about lung cancer screening.