Individual- and Group-Level Disparities Between Racial and Ethnic Groups in Lung Cancer Screening Eligibility Criteria.

Importance: Lung cancer screening guidelines result in differential screening eligibility among individuals who might benefit equally from screening and in population-level differences in screening eligibility and benefit across races and ethnicities. Objective: To inform lung cancer screening policy development by evaluating how enforcing (1) equal lung cancer screening eligibility for all individuals with equal benefit and (2) equal program sensitivity across racial and ethnic subgroups are associated with screening eligibility and benefit. Design, Setting, and Participants: This cross-sectional comparative effectiveness study included 6915 members of the US noninstitutionalized population aged 50 to 80 years who ever smoked and who participated in the 2015 National Health Interview Survey. Statistical analysis was performed from May 2022 to April 2024. Exposure: Lung cancer screening eligibility is based on the LYFS-CT (life-years gained from screening-computed tomography) prediction model, which predicts gain in life expectancy from screening, where individuals are eligible if their predicted benefit exceeds a threshold across all possible thresholds. Main Outcomes and Measures: The proportion of individuals aged 50 to 80 years who ever smoked who are eligible for screening, the percentage of predicted gainable life gained from screening (program sensitivity), and the number needed to screen to gain 10 years of life (screening efficiency), by race and ethnicity. Results: The 6915 participants aged 50 to 80 years who ever smoked represented 44 million individuals (mean age, 63 years [IQR, 56-69 years]; 53% male; 68% formerly smoked; 10% African American individuals, 3% Asian American individuals, 8% Hispanic American individuals, and 79% non-Hispanic White individuals). To ensure equal screening eligibility for each race and ethnicity required race- and ethnicity-specific eligibility thresholds. To achieve 36% eligibility for each race and ethnicity, the required days of life gained (under the LYFS-CT model) screening eligibility thresholds would be 5.2 for Hispanic American individuals, 5.6 for Asian American individuals, 9.5 for non-Hispanic White indivduals, and 12.4 for African American individuals, so individuals of different races and ethnicities with the same benefit would have different eligibility. With a fixed eligibility threshold of 16.2 days, screening eligibility would differ across races and ethnicities; 7% of Hispanic American individuals, 9% of Asian American individuals, 20% of non-Hispanic White individuals, and 27% of African American individuals aged 50 to 80 years who ever smoked would be eligible for screening. Similar differences existed for the program sensitivity of screening benefit. African American individuals consistently maintained the most efficient number needed to screen across all thresholds; Hispanic American individuals had the least efficient number needed to screen and thus may experience the worst benefit-harm balance when equalizing program sensitivity between races and ethnicities. Conclusions and Relevance: This comparative effectiveness study of lung cancer screening eligibility suggests that screening eligibility criteria cannot result in both equal eligibility for all individuals with the same benefit and equal program sensitivity for each race and ethnicity. In general, race- and ethnicity-specific thresholds that result in equal group-level sensitivity on 1 metric cannot result in equal sensitivities on other metrics. Thus, only 1 metric can be equalized, requiring a value judgment on which to prioritize.