The Impact of the 2023 American Cancer Society Screening Recommendations on Racial, Ethnic, and Sex Disparities in Lung Cancer Screening Eligibility

BACKGROUND: Because lung cancer risk remains elevated beyond 15 years after smoking cessation, the American Cancer Society (ACS) recommended in 2023 to remove the quit duration criterion from the US Preventive Services Task Force (USPSTF) lung cancer screening guidelines. RESEARCH QUESTION: How do the ACS recommendations impact racial, ethnic, and sex disparities in lung screening eligibility? STUDY DESIGN AND METHODS: We identified adults who currently and formerly smoked from the Black Women's Health Study, Multiethnic Cohort Study, and Southern Community Cohort Study recruited between 1993 and 2009 and followed up through 2019 for lung cancer incidence. Data across cohorts were harmonized. We evaluated the performance of the USPSTF guidelines and ACS recommendations across race, ethnicity, and sex. RESULTS: Among 175,259 adults with a smoking history included (42% Black/African American [AA], 25% White American, 15% Japanese American, 12% Hispanic or Latino, 5% Native Hawaiian, and 1% multiracial or other race), 27% (n = 46,702) were eligible for screening according to USPSTF guidelines and 33% (n = 58,373) were eligible according to ACS recommendations. Among those eligible with ACS recommendations but not with USPSTF guidelines (n = 11,671 individuals who formerly smoked), 382 participants (3%) developed lung cancer. ACS recommendations increased eligibility sensitivity, but decreased eligibility specificity among all participants who formerly smoked (USPSTF: sensitivity, 0.34 [95% CI, 0.32-0.35]; specificity, 0.87 [95% CI, 0.87-0.87]; ACS: sensitivity, 0.44 [95% CI, 0.42-0.45]; specificity, 0.77 [95% CI, 0.77-0.77]). These changes differed in magnitude across racial and ethnic groups, resulting in larger eligibility disparities. White American individuals who formerly smoked and developed lung cancer were 3 to 10 percentage points more likely to be eligible for screening with ACS vs USPSTF when compared with their non-White counterparts. The increased disparity was most evident between Black or AA individuals and White American individuals (USPSTF disparity, 7 percentage points; ACS disparity, 12 percentage points) and between Hispanic or Latino and White American individuals (USPSTF disparity, 12 percentage points; ACS disparity, 22 percentage points). INTERPRETATION: ACS recommendations increased screening eligibility regardless of cancer status, potentially leading to unnecessary screening of people without lung cancer. Despite increased eligibility sensitivity, changes were not uniform across groups, resulting in larger disparities in race and ethnicity and in sex.