Progress lies not in enhancing what is, but in advancing toward what will be.Khalil Gibran

Lung cancer is associated with poor 5-year survival (19%), as most are metastatic at diagnosis.1Siegel R.L. Miller K.D. Jemal A. Lung cancer screening (LCS) diagnoses more stage I non-small cell lung cancers that can receive curative treatment, thereby reducing mortality.2Aberle D.R. Adams A.M. Berg C.D. et al.The National Lung Screening Trial Research Team: reduced lung-cancer mortality with low-dose computed tomographic screening.,3de Koning H.J. van der Aalst C.M. de Jong P.A. et al.Reduced lung-cancer mortality with volume CT screening in a randomized trial. Although LCS has been endorsed in the United States since 2015, a major challenge in implementation remains the identification of high-risk individuals most likely to benefit from screening. The basis of LCS eligibility criteria are age and smoking history; however, these risk factors may not uniformly identify the highest-risk individuals in all populations. Because lung cancer incidence and mortality vary based on sex, race, and ethnic differences, considerable debate exists about whether current LCS eligibility criteria adequately identify all those at high risk for lung cancer.4Rivera M.P. Katki H.A. Tanner N.T. et al.Addressing disparities in lung cancer screening eligibility and healthcare access: an official American Thoracic Society statement., 5Aldrich M.C. Mercaldo S.F. Sandler K.L. Blot W.J. Grogan E.L. Blume J.D. Evaluation of USPSTF lung cancer screening guidelines among African American adult smokers., 6Pinsky P.F. Church T.R. Izmirlian G. Kramer B.S. The National Lung Screening Trial: results stratified by demographics, smoking history, and lung cancer histology.In this issue of CHEST, Pinsky and colleagues7Pinsky P.F. Lau Y.K. Doubeni C.A. Potential disparities by sex and race or ethnicity in lung cancer screening eligibility rates. use data from the 2015 National Health Interview Survey (NHIS) to analyze the performance of six different established, proposed, and extrapolated LCS eligibility criteria stratified by demographic factors (age, sex, race, and ethnicity) and smoking status. Using the Surveillance, Epidemiology, and End Results (SEER) database, lung cancer incidence rates were estimated from each cohort to provide calculated eligibility-to-incidence ratio (E-I). A lower E-I ratio suggests possible disparities. The authors found that LCS eligibility varied widely across the six LCS criteria and by patient demographics. In all criteria studied, higher E-I ratios were consistently observed in non-Hispanic (NH) Whites compared with those among NH Blacks, Hispanics, and Asians, and lower E-I ratios were observed in women of all racial/ethnic groups compared with men. Although NH Black men had the lowest E-I ratio by most criteria, the greatest difference was observed in younger (ages 50-64) NH Black men. Lowering the age to initiate screening to 50 and the cumulative smoking history to ≥20 pack-years, as recently recommended by the United States Preventative Services Task Force (USPSTF),8Meza R. Jeon J. Toumazis I. et al.Evaluation of the benefits and harms of lung cancer screening with low-dose computed tomography: modeling study for the US Preventive Services Task Force. increased eligibility for LCS in NH-Black men and women, but disparities persisted between LCS eligibility and lung cancer incidence.This study supports the mounting evidence that current LCS eligibility criteria do not uniformly identify high-risk populations in different racial groups. Differential eligibility is likely reflected by racial differences in smoking patterns. This is particularly illustrated with Black men, for whom lung cancer incidence and mortality are higher than in White men, despite lower cumulative cigarette consumption.9Haiman C.A. Stram D.O. Wilkens L.R. et al.Ethnic and racial differences in the smoking-related risk of lung cancer. Furthermore, Black men are diagnosed with lung cancer at a younger age than their White counterparts.10Robbins H.A. Engels E.A. Pfeiffer R.M. Shiels M.S. Age at cancer diagnosis for blacks compared with whites in the United States. The 2021 USPSTF LCS recommendations expand eligibility criteria to include younger individuals with a lower cumulative smoking history to minimize disparities in eligibility.11Reese T.J. Schlechter C.R. Potter L.N. et al.Evaluation of revised US Preventive Services Task Force lung cancer screening guideline among women and racial/ethnic minority populations. However, as demonstrated by Pinsky and colleagues,7Pinsky P.F. Lau Y.K. Doubeni C.A. Potential disparities by sex and race or ethnicity in lung cancer screening eligibility rates. disparities persist. A recent study using the 2015 NIHS data found that racial inequities in LCS did not decrease in 2021 vs 2013 USPSTF eligibility criteria.12

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 [published online ahead of print January 5, 2021]. J Natl Cancer Inst. https://doi.org/10.1093/jnci/djaa211.

Similarly, a cross-sectional study using data from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System survey showed that although the 2021 USPSTF criteria improve eligibility for LCS for women, Blacks, and Hispanics, LCS “inequities may persist without tailored eligibility criteria.”11Reese T.J. Schlechter C.R. Potter L.N. et al.Evaluation of revised US Preventive Services Task Force lung cancer screening guideline among women and racial/ethnic minority populations.Pinsky and colleagues also found lower LCS E-I ratios for all women, but most notably Asian women, compared with men. This is particularly relevant, because subanalyses of the two largest LCS studies, the National Lung Screening Trial (NLST) and the Dutch-Belgian Randomized Lung Cancer Screening Trial (NELSON), suggest greater mortality benefits for women who receive LCS compared with men.3de Koning H.J. van der Aalst C.M. de Jong P.A. et al.Reduced lung-cancer mortality with volume CT screening in a randomized trial.,13Black W.C. Chiles C. Church T.R. et al.Lung cancer incidence and mortality with extended follow-up in the National Lung Screening Trial National Lung screening trial writing team (1). Expansion of LCS criteria by age and smoking history alone may be insufficient, because lung cancer in women may be influenced by additional factors other than age and smoking history.14MacRosty C.R. Rivera M.P. Lung cancer in women: a modern epidemic.Using risk stratification models that incorporate additional clinical variables that impact lung cancer risk may more accurately identify those at higher risk for lung cancer who may benefit from LCS.15Ten Haaf K. Bastani M. Cao P. et al.A comparative modeling analysis of risk-based lung cancer screening strategies. The Prostate, Lung, Colorectal, Ovarian modified 2012 (PLCOM2012) risk assessment model was found to be more sensitive when compared with age- and smoking-based criteria alone, especially in those of Black race.16Pasquinelli M.M. Tammemagi M.C. Kovitz K.L. et al.Risk prediction model versus United States Preventive Services Task Force lung cancer screening eligibility criteria: reducing race disparities. Landy and colleagues12

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 [published online ahead of print January 5, 2021]. J Natl Cancer Inst. https://doi.org/10.1093/jnci/djaa211.

showed that the Black vs White disparity was nearly eliminated while the Hispanic vs. White disparity was reduced when the Life-Years From Screening Computed Tomography risk-prediction model that identifies high-benefit individuals is used to augment the 2021 USPSTF LCS criteria in individuals who smoke but do not meet USPSTF criteria.12

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 [published online ahead of print January 5, 2021]. J Natl Cancer Inst. https://doi.org/10.1093/jnci/djaa211.

The use of risk prediction models to improve eligibility for LCS is perceived to be potentially more burdensome to primary care providers, because it requires input of clinical variables.8Meza R. Jeon J. Toumazis I. et al.Evaluation of the benefits and harms of lung cancer screening with low-dose computed tomography: modeling study for the US Preventive Services Task Force. However, widespread use may be aided by embedding required factors within the electronic medical record, prompts to assess patient eligibility, and tools to allow patients to enter and assess eligibility remotely before enrollment in an LCS program.Expansion of LCS eligibility criteria will substantially impact health care utilization and costs. An estimated 14.8 million adults will be eligible under the 2021 USPSTF LCS criteria, a 78% increase from the 2013 criteria.7Pinsky P.F. Lau Y.K. Doubeni C.A. Potential disparities by sex and race or ethnicity in lung cancer screening eligibility rates. Along with a rise in imaging studies come increases in other aspects of LCS, including shared decision-making visits, tobacco treatment counseling, database management, downstream health care utilization for lung cancers, and incidental imaging findings. It will be essential to determine whether the cohort identified by expanded LCS criteria truly captures those at higher risk for developing lung cancer, because increasing screening in lower-risk individuals will likely lead to increases in false-positive findings and a lower benefit-to-risk ratio. Current estimates suggest that only 14% of those eligible by 2013 USPSTF criteria are receiving LCS in the United States,17Lung cancer screening utilization: a behavioral risk factor surveillance system analysis. with lower uptake in rural and socioeconomically disadvantaged populations.18Kale M.S. Wisnivesky J. Taioli E. Liu B. The landscape of US lung cancer screening services.,19Schutte S. Dietrich D. Montet X. Flahault A. Participation in lung cancer screening programs: are there gender and social differences? A systematic review. Although the intention of expanding LCS eligibility criteria as a means to minimize disparities is noble, it remains to be seen, as suggested by recent studies,7Pinsky P.F. Lau Y.K. Doubeni C.A. Potential disparities by sex and race or ethnicity in lung cancer screening eligibility rates.,11Reese T.J. Schlechter C.R. Potter L.N. et al.Evaluation of revised US Preventive Services Task Force lung cancer screening guideline among women and racial/ethnic minority populations.,12

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 [published online ahead of print January 5, 2021]. J Natl Cancer Inst. https://doi.org/10.1093/jnci/djaa211.

whether this will be realized. Because disparate health care utilization drives worse outcomes among vulnerable populations, future efforts must focus on equitable access to high-quality LCS programs and subsequent access to timely diagnostic and therapeutic interventions for screen-detected abnormalities. Much work is needed to optimally disseminate and implement LCS and save the lives of those with lung cancer.ReferencesSiegel R.L. Miller K.D. Jemal A.

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Public Health Rev. 39: 23Article InfoFootnotes

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: C. R. S. has served on the Scientific and Medical Advisory Boards for Biodesix, Inc, bioAffinity Technologies Inc., and as a research consultant for Bristol-Myers Squibb. Research support to the institutions is provided by the American Cancer Society , National Institutes of Health , and the Veterans Health Affairs Office of Research and Development (BLR&D). The contents of this editorial do not represent the views of VA or the United States Government. M. P. R. has NIH/NCI funding, has served on the Scientific and Medical Boards for Biodesix and bioAffinity Technologies Inc, and as a research consultant for Johnson & Johnson .

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DOI: https://doi.org/10.1016/j.chest.2021.03.043

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Published by Elsevier Inc. under license from the American College of Chest Physicians.

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