Racial Disparities in Lung Cancer Screening

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The lung cancer diagnosis was a shock for Ferguson, who’d never been a cigarette smoker and did not have a family history of the disease, but she agreed to the aggressive treatment plan her thoracic surgeon ordered. The plan was for her to have surgery to remove the mass and four rounds of chemotherapy. Three years later, Fergurson proudly reports being cancer-free.

A growing body of research reveals that, as a Black person, she is especially lucky to have beaten the disease that kills more than 125,000 Americans a year — more than breast, colon and prostate cancers combined. Lung cancer is more difficult to treat in its advanced stages, so early detection through screening greatly increases a person’s chance of survival. Yet racial disparities exist.

Studies have found that Black lung cancer patients were 15% less likely than white patients to be diagnosed early and they had the lowest five-year survival rate of any racial group. Black Americans tended to develop lung cancer at higher rates and at younger ages than their white counterparts, despite smoking fewer cigarettes on average. According to the American Lung Association, the disease claimed the lives of more than 14,000 Black Americans in 2021, the most recent year for available data.

Addressing persistent disparities in lung cancer early diagnosis and survival rates is central to the work being carried out by Melinda Aldrich, M.D., an associate professor at Vanderbilt University Medical Center. The groundbreaking 2019 study she co-authored with five colleagues found that screening eligibility guidelines exclude Black smokers more than other people of other races. The healthcare industry has been slow to respond to the growing push to change that, including medical insurance companies that determine what is considered preventive care and covered at low or no cost.

Aldrich’s research found that the U.S. Preventive Services Task Force (USPSTF), the government group that sets screening guidelines, required that a person had to be between 55 and 80 years old and have smoked the equivalent of a pack a day for 30 years to qualify for a life-saving early detection screening known as a low-dose CT scan. In addition to these criteria, a person needs to be either a current or former smoker, and former smokers need to have quit within the prior 15 years. Aldrich’s analysis of more than 84,000 adult smokers revealed that under that criteria, Black patients at relatively high risk of lung cancer were being disproportionately excluded from the eligible screening pool. More than 2 out of 3 Black smokers who were diagnosed with lung cancer did not meet the age and smoking history criteria at the time of their diagnosis.

“Based on those guidelines, we saw that of people who were diagnosed with lung cancer, 68% of African American individuals … would not have been eligible for lung cancer screening. And this is in contrast to 44% of white Americans who would not be eligible,” she said. “So, [there are] strong racial disparities in terms of eligibility and who’s able to get in the door to be screened.”

The work of Aldrich and her co-authors was cited in a 2021 decision by the USPSTF to make two changes that have nearly doubled the number of people eligible for lung cancer screening — lowering the age from 55 to 50 and reducing the number of smoking history pack years from 30 to 20.

“They didn’t do exactly what we proposed: something that might be considered controversial, which is making a race-specific change in the guidelines,” she said. “They made the guideline changes for everyone. So, actually, the disparities remain. They just made more people eligible.”

Aldrich said raising awareness about the screening test that has been widely available for well over a decade now is critical to helping improve outcomes and survival rates for lung cancer patients, especially Black patients. Still, she said, the medical industry needs to answer the call to go a step further to allow more people to qualify for early screening based on additional risk factors, such as race and ethnicity and family history. “If you have a history of smoking, talk to your doctor about whether you’re eligible for lung screening,” advised Aldrich. “We also need to remove the stigma associated with smoking; we should unite the community rather than associating blame.”

Ferguson said that although race-specific screening guideline changes most likely would not have helped in her case as a nonsmoker, she supports the shift to expand screening eligibility. “I don’t care if you are 30 or 70. If you smoked every day for 10 years or more, you should be able to say to your doctor, ‘I want a lung cancer screening’ and get it,” she said. “It’s money spent on the front end and money saved on the back end. And more importantly, it’s going to save more lives.”

This educational resource was created with support from Merck.