Abstract
This quality improvement study evaluates lung cancer screening eligibility among US Black women under the 2013 and 2021 USPSTF guidelines.
The 2021 US Preventive Services Task Force (USPSTF) lung cancer screening guidelines1 have increased the number of smokers eligible for screening by lowering the age eligibility from 55 to 50 years and reducing the requisite pack-years of smoking from 30 to 20. While these changes should increase the proportion of Black individuals eligible for screening,2 it is possible that many high-risk Black women will continue to be ineligible.3,4 In this quality improvement study, we evaluate lung cancer screening eligibility among US Black women under the 2013 and 2021 USPSTF guidelines.
Methods
Participants of the Black Women’s Health Study (BWHS), which includes self-identified Black women from across the US (n = 58 973), were enrolled in 1995 by completing a health questionnaire with detailed information on cigarette smoking and other exposures; information was updated by biennial questionnaires.5 The study was approved by the Boston University Medical Campus Institutional Review Board. Incident lung cancers were identified by self-report and annual linkages with state cancer registries and the National Death Index. We evaluated the proportion of women diagnosed with lung cancer who would have been eligible under the 2013 vs 2021 USPSTF lung cancer screening guidelines. We also estimated the sensitivity and specificity of the USPSTF guidelines and alternative guidelines based on different criteria for pack-year smoking history and years since quitting (YSQ). Analyses were conducted using SAS, version 9.4 (SAS Institute).
Results
During follow-up of 58 973 BWHS participants from July 1995 through December 2017, 559 women were diagnosed with lung cancer, with mean (SD) age at diagnosis of 64.0 (10.9) years (median [IQR], 65.0 [57.0-72.0] years); 43% were current smokers, 42% were former smokers, and 15% were never smokers. Mean (SD) number of pack-years were 27.6 (15.7) (median [IQR], 18.3 [11.0-32.0]) and 23.0 (17.3) (median [IQR], 17.0 [11.0-32.0]) among current and former smokers, respectively; among former smokers, mean (SD) YSQ was 22.6 (16.6) years (median [IQR], 26.0 [8.0-38.0] years).
Under 2013 USPSTF guidelines, 22.7% of BWHS participants with lung cancer who had a smoking history would have been eligible for lung cancer screening. Under the new 2021 guidelines, the proportion of women eligible for screening increased to 33.9%, representing a 50% increase in eligibility (McNemar test, P < .001). Among the 314 smokers who would not have been eligible for screening under the 2021 guidelines, 67.8% were ineligible because they had fewer than 20 pack-years smoking history, and 46.2% were ineligible because they quit smoking more than 15 years ago (Table 1).
Table 1. Reasons for Ineligibility Under 2013 and 2021 USPSTF Guidelines Among Black Women’s Health Study Participants With Lung Cancer Who Were Current or Former Smokers.
| 2013 USPSTF guidelines | 2021 USPSTF guidelines | |
|---|---|---|
| Total cases ineligible for screening | 367 | 314 |
| Reason for ineligibility, No. (%)a | ||
| Age <55 y (2013) or <50 y (2021) | 94 (25.6) | 50 (15.9) |
| Age >80 y | 15 (4.1) | 15 (4.8) |
| Pack-years <30 (2013) or <20 (2021) | 283 (77.1) | 213 (67.8) |
| Years since quitting >15 | 145 (39.5) | 145 (46.4) |
Abbreviation: USPSTF, US Preventive Services Task Force.
Categories are not mutually exclusive.
Sensitivity and specificity of the 2021 guidelines among the 21 604 BWHS participants who were ever smokers were 33.9% and 86.5%, respectively (Table 2). Removing the requirement that former smokers must have quit smoking within the past 15 years was associated with an increase in sensitivity, to 48.2%, and a decrease in specificity, to 78.9%. Reducing the required number of pack-years to 15 or 10 years was associated with further increased sensitivity and decreased specificity.
Table 2. Sensitivity and Specificity of Varying Guidelines for Lung Cancer Screening, Based on 22 079 Ever Smokers in the Black Women’s Health Study.
| Possible guidelines | No. eligible among 475 women with lung cancer | Sensitivity, % (95% CI) | No. ineligible among 21 604 women without lung cancer | Specificity, % (95% CI) |
|---|---|---|---|---|
| 2013 Guidelines: age 55-80 y and ≥30 pack-years and current smoker or quit <15 y ago | 108 | 22.7 (18.9-26.5) | 20 100 | 93.0 (92.7-93.3) |
| 2021 Guidelines: age 50-80 y and ≥20 pack-years and current smoker or quit <15 y ago | 161 | 33.9 (29.6-38.2) | 18 697 | 86.5 (86.0-87.0) |
| ≥20 Pack-years and age 50-80 y | 229 | 48.2 (43.7-52.7) | 17 050 | 78.9 (78.4-79.4) |
| ≥15 Pack-years and age 50-80 y | 294 | 61.9 (57.5-66.3) | 14 964 | 69.3 (68.7-69.9) |
| ≥10 Pack-years and age 50-80 y | 348 | 73.3 (69.3-77.3) | 12 330 | 57.1 (56.4-57.8) |
| ≥15 Pack-years and age 50-80 y, and 15 y since quit | 207 | 43.6 (39.1-48.1) | 17 386 | 80.5 (80.0-81.0) |
| ≥10 Pack-years and age 50-80 y, and 15 y since quit | 243 | 51.2 (46.7-55.7) | 16 008 | 74.1 (73.5-74.7) |
Discussion
In the present analysis, the proportion of Black women diagnosed with lung cancer who would have been eligible for screening increased by 50% under 2021 USPSTF screening guidelines compared with 2013 guidelines, yet 66% of the patients with lung cancer still would have been ineligible for screening. We found that revising the new USPSTF guidelines by removing the 15 YSQ requirement for former smokers would increase the proportion of Black women eligible for screening from 33.9% to 48.2%, with a small reduction in specificity. The 2021 USPSTF relaxation of age and pack-years requirements was prompted in part by the need to increase the proportion of Black individuals eligible for screening given their younger age at diagnosis of lung cancer and higher risk of lung cancer associated with fewer smoking pack-years compared with White individuals.2,6
Our findings suggest that removing the 15 YSQ criteria in the current USPSTF guidelines may be beneficial for Black women. Further research should be prioritized to determine if there is a need for sex and/or race and ethnicity differentiation in future revisions to the guidelines. A limitation of the current study was the lack of data on the use of lung cancer screening by eligible individuals in our cohort during the study period. Such information may be available in future studies.
References
- 1.Landy R, Young CD, Skarzynski M, et al. Using prediction-models to reduce persistent racial/ethnic disparities in draft 2020 USPSTF lung-cancer screening guidelines. J Natl Cancer Inst. 2021;djaa211. doi: 10.1093/jnci/djaa211 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Aldrich MC, Mercaldo SF, Sandler KL, Blot WJ, Grogan EL, Blume JD. Evaluation of USPSTF lung cancer screening guidelines among African American adult smokers. JAMA Oncol. 2019;5(9):1318-1324. doi: 10.1001/jamaoncol.2019.1402 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.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(5):395-409. doi: 10.1056/NEJMoa1102873 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.de Koning HJ, van der Aalst CM, de Jong PA, et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382(6):503-513. doi: 10.1056/NEJMoa1911793 [DOI] [PubMed] [Google Scholar]
- 5.Rosenberg L, Adams-Campbell L, Palmer JR. The Black Women’s Health Study: a follow-up study for causes and preventions of illness. J Am Med Womens Assoc (1972). 1995;50(2):56-58. [PubMed] [Google Scholar]
- 6.Han SS, Chow E, Ten Haaf K, et al. Disparities of national lung cancer screening guidelines in the US population. J Natl Cancer Inst. 2020;112(11):1136-1142. doi: 10.1093/jnci/djaa013 [DOI] [PMC free article] [PubMed] [Google Scholar]
