New study finds barriers still exist with lung cancer screening access

November 12, 2021
Smoking cessation counseling session
Nurse practitioner Alex Ingram (left) meets with patient Chrys Steele (right) to discuss lung cancer screening and nodule management options at MUSC Health Lancaster Medical Center. Photo provided

A new study finds that the recent changes to lung cancer screening guidelines may paradoxically increase health disparities rather than reduce them, given a gap of insurance coverage for some people. The study, published in JAMA Network Open in October, was led by Gerard Silvestri, M.D., a pulmonologist and MUSC Hollings Cancer Center researcher.

“The current lung cancer screening guidelines from the United States Preventive Services Task Force target current or former smokers,” Silvestri said. “However, these people tend to reside in a different population than nonsmokers. These are people who tend to be disadvantaged because a higher proportion of those who currently smoke, or formerly smoked, live in rural areas, are less educated and come from a lower socioeconomic status and thus don’t have access to screening services.”

Gerard A. Silvestri, M.D., MS 
Dr. Gerard Silvestri

It’s estimated that more than 4,500 South Carolinians will be diagnosed with lung cancer this year, due in large part to the prevalence of tobacco. Lung cancer is the leading cause of cancer-related deaths in South Carolina, resulting in more deaths each year than breast, colorectal and prostate cancers combined.

In 2021, following a large-scale study completed in Europe, lung cancer screening guidelines were revised, increasing the stated age range from 55 to 77 to 50 to 77. And in terms of a person’s smoking history, that threshold also changed from smoking a pack of cigarettes daily for 30 years to a pack daily for 20 years.

These changes were made to expand eligibility to around 7 million more Americans in the hopes of diagnosing lung cancer at an earlier more curable stage and reducing mortality. These proposed changes seemingly would have been of great benefit to Blacks, as they develop lung cancer at a younger age and with less of a smoking history. However, Silvestri’s team found that while the intent of expanding screening eligibility was good, it did not resolve the barrier of access.

“We have much higher uninsured rates in that age group of 50 to 64 among Blacks than we do among whites,” he said. “In fact, the change in screening guidelines could actually increase disparities.”

Researchers found significant disparities in the number of Blacks under 65 being screened versus the number of Blacks over 65 being screened. At age 65, everyone becomes eligible for Medicare and has access to insurance.

“We looked at the rate of whites and Blacks who were eligible for screening that actually had gotten screened,” Silvestri said. “In white respondents age 55 to 64, 48.8% reported being screened compared with 51.2% of those respondents age 65 to 80. However, in Black respondents ages 55 to 64, only 21.1% reported being screened compared with 79% of those Black respondents ages 65 to 80. That’s a significant difference.”

Silvestri said the rates of being screened should be even among eligible respondents under 65 and over 65. “Improving eligibility is the first step in reducing health disparities. But, without health insurance, it doesn’t matter if you’re eligible because the patient can’t afford the screening service.”

"These are people who tend to be disadvantaged because a higher proportion of those who currently smoke, or formerly smoked, live in rural areas, are less educated and come from a lower socioeconomic status and thus don’t have access to screening services.”
— Dr. Gerard Silvestri

This is of particular concern in South Carolina where nearly 30% of the state’s population is Black. Even for those patients with health insurance, lack of access to screening is still a widespread problem. It’s why MUSC Health announced plans to expand its lung cancer screening program to regional hospitals that are closer to rural and medically underserved communities. 

“As the only National Cancer Institute-designated cancer center in the state, Hollings has a responsibility to all South Carolinians, no matter where they live,” Silvestri said. “Lung cancer is the leading cause of cancer-related deaths in our state. Improving access to screening is one big way we can improve lung cancer mortality.”

The lung cancer screening program is already in place at the MUSC Health Lancaster Medical Center and MUSC Health Chester Medical Center. The goal is to expand it to the MUSC Health Florence Medical Center in December, followed by MUSC Health Columbia Medical Center Downtown and MUSC Health Kershaw Medical Center in March of 2022.

“The more you peel back the onion of health disparities, the more you see that it is a complex issue,” he said. “It’s not just insurance coverage, it is also access. When we talk about disparities it isn’t just Black and white. There are disparities based on living in rural areas. By bringing screening to these communities, we can make a big difference.”

Silvestri said the study shows that more needs to be done to improve lung cancer screening rates than just expanding eligibility requirements.

About the Author

Josh Birch
MUSC Hollings Cancer Center

Keywords: Cancer