ES12.01 Patient Perspective on Lung Cancer Screening and Health Disparities

Abstract

Lung cancer is the leading cause of cancer deaths in much of the world. Over 80% of lung cancer deaths are caused by tobacco. Systematic reviews show smoking rates are higher in low socio-economic status individuals.(1) This is true even in low and middle income countries(2). In the United States Native Americans and Alaska Natives have the highest tobacco use; 32.3% of Native Americans/Alaska Natives use any tobacco product as compared to 21.9% of Whites. In Canada, the Intuit have the highest smoking rates; 74% of Intuits in Canada smoke as compared to 23% of non-Aboriginal individuals in Ontario.(3) Smoking rates in Australian Indigenous populations are about double those of Non-indigenous populations.(4) Indigenous/Native populations and Blacks are at higher risk of lung cancer than non-indigenous populations and Whites. They are diagnosed at a younger age and have higher lung cancer incidence and mortality rates. In the US, Black men have 15% higher lung cancer incidence rates and 19% higher mortality rates than whites. Overall US indigenous/native populations have 8.8% higher lung cancer incidence rates than non-Hispanic whites with local incidence rates up to 80% higher in Alaska Native, Southern and Northern Plain populations.(5) Similarly, in Australia indigenous populations have higher lung cancer incidence and mortality rates and a younger age at diagnosis. (4) In the Ontario province in Canada lung cancer incidence rates are 19% higher for indigenous men and 48% higher for indigenous women as compared to non-Indigenous men and women respectively. Mortality in indigenous men is 13% higher and 43% higher in women than non-indigenous men and women respectively.(6) Age and smoking history don’t capture everyone at equivalent risk. Blacks are less likely to meet current CT lung screening criteria in the US than whites. Aldrich et al. assessed eligibility for CT lung screening using 2013 USPSTF screening guidelines in the Southern Community Cohort.(7) In their sample of 48,364 individuals, 17% of Blacks were eligible for screening as compared to 31% of whites. In the subset diagnosed with lung cancer (n= 1269): 32% of Blacks would have been eligible for screening as compared to 56% of whites. The American Lung Association 2020 State of Lung Cancer Report shows US CT lung screening rates are still low. The national average is 5.7% with large state to state variation. Massachusetts has the highest screening rate at 18.5% and Utah the lowest at 1%. Significant challenges remain for patients, especially those in disadvantage populations. These include lack of access to care, lack of awareness of the option for screening, difficult to understand eligibility criteria, distrust of the medical community, stigma and implicit bias due to the close association with smoking, nihilism and low perceived risk of getting lung cancer. Disadvantaged populations experience double stigma; the stigma of their lung cancer and the stigma of their disadvantage. It’s imperative to address eligibility, awareness, and access to CT lung screening for Blacks, indigenous/native populations and other disadvantaged populations to avoid increasing the current mortality and morbidity disparity for these populations. Encouragingly, in the US, the USPSTF updated draft CT lung screening recommendations lower the age of eligibility from 55 to 50 and the smoking history from 30 to 20 pack years. This will help address the disparity in screening eligibility between Blacks and whites of equivalent risk. A better approach to screen those at highest equivalent risk is to use a lung cancer risk prediction model as part of eligibility criteria. Recommended interventions include: Implementation of outreach programs to raise awareness and to provide CT lung screening in underserved communities. A good example of this is the Crosbie et al. UK mobile van lung health check study (8) Develop relationships with national and local minority organizations and partner with native/indigenous community leaders Form multidisciplinary state/provincial/local CT lung screening coalitions and learning collaboratives. Share lessons learned. Include lung cancer risk prediction model risk score in eligibility criteria. Example approaches include the Cancer Care Ontario program in Canada and the International Lung Screening Trial. Education to address stigma and clinician implicit bias and nihilism. Position lung cancer screening as health choice, similar to mammography and colonoscopy, co-develop culturally tailored education materials, public health campaigns raising awareness about stigma and implicit bias including information on glamorization of smoking in the early days when many eligible for CT lung screening started smoking.