Duration-based lung cancer screening may reduce racial disparities in eligibility

1. In this prospective cohort study, duration-based criteria reduced racial disparities in lung cancer screening eligibility, increasing access for minority groups compared with current US guidelines.
2. Duration-based criteria increased six-year lung cancer detection sensitivity across all racial groups, although specificity declined.

Evidence Rating Level: 2 (Good)

Study Rundown: The 2021 US Preventive Services Task Force (USPSTF-2021) lung cancer screening guidelines lowered the minimum cumulative smoking exposure from 30 to 20 pack-years and the minimum screening age from 55 to 50 years to increase screening uptake and reduce racial disparities. However, evidence suggests that smoking duration, rather than pack-years, may better predict lung cancer risk in some populations. As a result, smoking duration–based and risk-based screening criteria have been proposed. This study compared smoking duration–based screening with USPSTF-2021 guidelines and assessed duration-based screening relative to a risk-based approach. Using a 30-year smoking duration threshold (duration-based-30), eligibility rates were most comparable to USPSTF-2021 while reducing inter-racial disparities. Sensitivity for detecting lung cancer within six years increased across all racial groups, though specificity decreased. Comparing duration-based-30 with a 6-year PLCOm2012 threshold of 1.1% (risk-based-1.1%) revealed that African Americans had higher eligibility than Whites, widening the gap in their favor. For other racial groups, eligibility increased in favor of Whites, particularly widening the gap with Latinos. Overall, the risk-based approach improved sensitivity and specificity compared with duration-based-30, though sensitivity was lower among Latino individuals. Limitations include a geographically restricted cohort, enrollment in the 1990s, and inability to assess overdiagnosis. Nonetheless, the findings suggest that smoking duration–based criteria may reduce racial disparities in lung cancer screening relative to current guidelines while enhancing sensitivity across racial and ethnic groups.

Click to read this study in AIM

Relevant Reading: Pack-Year Smoking History: An Inadequate and Biased Measure to Determine Lung Cancer Screening Eligibility

In-Depth [prospective study]: This prospective cohort study compared smoking duration-based criteria with USPSTF-2021 guidelines for lung cancer screening and further assessed duration-based versus risk-based screening using the PLCOm2012update model. The cohort was drawn from the Multiethnic Cohort Study, which enrolled 214,862 adults aged 45-75 years in California and Hawaii from 1993 to 1996, including African American, Japanese American, Latino, Native Hawaiian/Other Pacific Islander, and White participants. After excluding those with missing smoking or risk factor data, 105,261 participants were analyzed. The population was 57.0% male, mean age 59.8 years, with 29.6% current smokers and 70.4% former smokers; mean pack-years and smoking duration were 18.4 and 22.5 years, respectively. Within six years, 1.4% (n = 1464) developed lung cancer. Under USPSTF-2021, 24% of participants were eligible for screening, with eligibility highest among Whites (30.2%) and lowest among Latinos (15.7%). Smoking duration thresholds of 10, 20, 30, and 40 years yielded overall eligibility rates of 48.6%, 40.5%, 27.5%, and 12.8%, respectively; the 30-year threshold (duration-based-30) most closely matched USPSTF-2021 and was used in subsequent analyses. Duration-based-30 narrowed inter-racial eligibility gaps: Whites (28.8%), African Americans (30.4%), Latinos (25.1%), Native Hawaiians (26.1%), and Japanese Americans (26.5%). Sensitivity increased across all groups using the duration-based-30 compared to USPSTF-2021 (66.1% vs. 57.7%), particularly in African Americans (60.9% vs. 44.0%) and Latinos (69.8% vs. 53.5%), though overall specificity decreased (73.0% vs. 76.5%). Compared with risk-based criteria, African Americans had higher eligibility than Whites (39.3% vs. 31.3%), whereas eligibility gaps for other minority groups widened in favor of Whites, particularly among Latinos (14.4% vs. 31.3%). Risk-based criteria improved overall sensitivity (72.0% vs. 66.1%) and specificity (73.1% vs. 73.0%), with sensitivity gains in African Americans, Japanese Americans, Native Hawaiians, and Whites, but lower sensitivity in Latinos (59.7% vs. 69.8%) with higher specificity. Overall, duration-based criteria may reduce racial disparities in screening and improve sensitivity among minority populations compared with existing USPSTF-2021 guidelines.

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