Evaluation of USPSTF Lung Cancer Screening Guidelines Among African American Adult Smokers.

Abstract

Importance\nThe United States Preventive Services Task Force (USPSTF) recommends low-dose computed tomography screening for lung cancer. However, USPSTF screening guidelines were derived from a study population including only 4% African American smokers, and racial differences in smoking patterns were not considered.\n\n\nObjective\nTo evaluate the diagnostic accuracy of USPSTF lung cancer screening eligibility criteria in a predominantly African American and low-income cohort.\n\n\nDesign, Setting, and Participants\nThe Southern Community Cohort Study prospectively enrolled adults visiting community health centers across 12 southern US states from March 25, 2002, through September 24, 2009, and followed up for cancer incidence through December 31, 2014. Participants included African American and white current and former smokers aged 40 through 79 years. Statistical analysis was performed from May 11, 2016, to December 6, 2018.\n\n\nExposures\nSelf-reported race, age, and smoking history. Cumulative exposure smoking histories encompassed most recent follow-up questionnaires.\n\n\nMain Outcomes and Measures\nIncident lung cancer cases assessed for eligibility for lung cancer screening using USPSTF criteria.\n\n\nResults\nAmong 48\u202f364 ever smokers, 32\u202f463 (67%) were African American and 15\u202f901 (33%) were white, with 1269 incident lung cancers identified. Among all 48\u202f364 Southern Community Cohort Study participants, 5654 of 32\u202f463 African American smokers (17%) were eligible for USPSTF screening compared with 4992 of 15\u202f901 white smokers (31%) (P\u2009<\u2009.001). Among persons diagnosed with lung cancer, a significantly lower percentage of African American smokers (255 of 791; 32%) was eligible for screening compared with white smokers (270 of 478; 56%) (P\u2009<\u2009.001). The lower percentage of eligible lung cancer cases in African American smokers was primarily associated with fewer smoking pack-years among African American vs white smokers (median pack-years: 25.8 [interquartile range, 16.9-42.0] vs 48.0 [interquartile range, 30.2-70.5]; P\u2009<\u2009.001). Racial disparity was observed in the sensitivity and specificity of USPSTF guidelines between African American and white smokers for all ages. Lowering the smoking pack-year eligibility criteria to a minimum 20-pack-year history was associated with an increased percentage of screening eligibility of African American smokers and with equitable performance of sensitivity and specificity compared with white smokers across all ages (for a 55-year-old current African American smoker, sensitivity increased from 32.2% to 49.0% vs 56.5% for a 55-year-old white current smoker; specificity decreased from 83.0% to 71.6% vs 69.4%; P\u2009<\u2009.001).\n\n\nConclusions and Relevance\nCurrent USPSTF lung cancer screening guidelines may be too conservative for African American smokers. The findings suggest that race-specific adjustment of pack-year criteria in lung cancer screening guidelines would result in more equitable screening for African American smokers at high risk for lung cancer.