Disparities in Lung Cancer Screening in Hispanic Head and Neck Cancer Survivors

Abstract

Effective cancer screening is essential for early detection and improved survival outcomes. Cancer is a leading cause of death for Hispanics/Latinx, who represent the largest minority group in the U.S. Despite lower tobacco use, lung cancer is the leading cause of cancer death in Hispanic/Latinx men and the second leading cause in women. Late-stage diagnoses, due to limited screening opportunities, contribute to poor survival rates. Cancer survivors, especially those previously diagnosed with head and neck cancer, face a significantly increased risk of developing lung cancer. Approximately one-fourth of head and neck cancer survivors die from a second malignancy, with lung cancer accounting for over half of these cases. These individuals are nearly three times more likely to develop lung cancer compared to the general population of smokers. In this manuscript, we detail the importance of implementing lung cancer screening in these high-risk populations.

Plain Language Summary

Head and neck cancer survivors are developing lung cancer at much higher incidences than the average population of smokers. Hispanics/Latinx are also dying from LC at a faster rate than any other malignancy. Disparities exist pertaining to the LC survival in both HNC survivors and H/L populations. However, the exact data is unknown given the lack of dedicated studies to understand the behaviors and risk factors of these 2 populations. Therefore, by extrapolating the data for each population separately, we infer that disparities in early detection of LC and the overall LC mortality are higher in these groups combined. To overcome this unmet need, further studies are in dire need to address LCS inequalities in H/L HNC survivors and explore the role of non invasive modalities for LCS.

Effective cancer screening is critical for early detection leading to the best chances for a cure. Unlike non-Hispanic Whites (NHW), cancer is a leading cause of death for Hispanics/Latinx. ¹ As of 2020, Hispanics/Latinx are the largest minority group in the United States (U.S.), comprising 18.9% of the total United States (U.S.) population.^2,3 By 2045, the Hispanics/Latinx population is projected to surpass NHW and become the leading racial/ethnic group in the U.S. ³ Despite lower tobacco use, lung cancer is the leading cause of cancer death in Hispanics/Latinx men and the second leading cause in Hispanics/Latinx women. ⁴ The poor survival rates are partly due to late-stage diagnosis from lack of adequate lung cancer screening opportunities, including eligibility and implementation. ⁵ According to the American Cancer Society Hispanics/Latinx with lung cancer are less likely to receive an early diagnosis and 9% less likely to survive 5 years when diagnosed, as compared to NHWs. ⁶

Cancer survivors are another group at substantial risk for lung cancer, particularly those with previous head and neck cancer. ⁷ One fourth of head and neck cancer survivors die from a second malignancy, of which lung cancer is responsible for more than half of the cases. ⁸ Head and neck cancer survivors are developing lung cancer at an almost 3-fold higher incidence than the average population of smokers.^8,9 One study used the Surveillance, Epidemiology, and End Results (SEER) program database to evaluate the risk of second primary lung cancer. Amongst the 101,856 patients with history of head and neck cancer, 8.0% developed second primary lung cancer (P < .001). ¹⁰ Another study evaluated the risk of second primary malignancies in head and neck cancer survivors and found that from the 18.9% of patients who developed a secondary malignancy, LC carried the highest incidence at 32%. ¹¹ Moreover, a study performed a secondary analysis of the National Lung Screening Trial (NLST) to assess the incidence of second primary lung cancer in survivors of head and neck cancer. ¹² This study detected a second primary LC in 12% of the 121 head and neck cancer survivors for an incidence of lung cancer in head and neck cancer survivors of 2.1% compared to 0.6% in subjects without previous history of head and neck cancer.

The United States Preventive Services Task Force (USPSTF) first established guidelines for lung cancer screening in 2013, recommending annual low-dose computed tomography (LDCT) for adults aged 55-80 with a smoking history of 30 or more pack-years, who are either current smokers or have quit within the past 15 years. ¹³ One significant concern is that the strict eligibility criteria have disproportionately excluded racial, ethnic, and gender minorities. This exclusion stems from the fact that the guidelines were developed based on data from the NLST, where most participants (>90%) were a homogenous group of NHW individuals. ¹² As a result, the high-risk features identified in the study may not adequately reflect the risk profiles of other diverse populations. Our previous study showed that only 20% of Hispanic/LatinX with a confirmed lung cancer diagnosis met USPSTF2013 guidelines, compared to 44.4% of non-Hispanics (P = .017). ¹⁴ The underrepresentation of minority groups in these studies does not align with the current U.S. population demographics, which can lead to missed opportunities for early lung cancer detection in these communities. This highlights the need for more inclusive research and revised guidelines that account for the diversity of risk factors across different racial, ethnic, and gender groups to ensure equitable healthcare outcomes. To address disparities in screening eligibility and promote inclusiveness amongst racial and ethnic minorities, the USPSTF updated its lung cancer screening guidelines in 2021. The new recommendations lower the starting age for lung cancer screening from 55 to 50 and reduce the smoking history requirement from ≥30 to ≥20 pack-years, allowing more individuals to qualify for screening ¹³ Despite the updated guidelines, H/Ls (OR = .15; 95% CI: .10, .23; P < .001) remain less likely to be eligible for screening compared to NHWs. ¹⁵

Since the approval of lung cancer screening, progress in its implementation for eligible participants has been notably slow. Despite evidence from the NLST showing a 20% reduction in lung cancer mortality with LDCT screening, ¹² the uptake among eligible Americans was only 4.5% in 2023, a rate that has barely changed since 2015. ⁵ This slow adoption suggests that several barriers—such as physician awareness, the complexity of referrals, concerns about reimbursements, fear of radiation exposure, and anxiety over false positives leading to unnecessary invasive procedures^9,16,17—may be hindering the broader implementation of lung cancer screening, limiting its potential to reduce lung cancer mortality on a larger scale. In our retrospective study, we aimed to examine the patterns of lung cancer screening in patients prior to their diagnosis. We found that no self-identified Hispanic individuals or women who met the USPSTF eligibility criteria had undergone LDCT for screening. ¹⁸ Notably, only NHW men had utilized LDCT, underscoring a significant disparity in both referral practices and the implementation of lung cancer screening. ¹⁸ Some of the hypothesis for the low screening practices in Hispanic/LatinX, access to care, provider awareness and bias, health literacy and cultural barriers, as well as structural barriers may have played a role in these. A study aimed to explore the perceived benefits, barriers, and motivators for lung cancer screening among Latinos through semi-structured interviews. Participants identified several benefits, including smoking cessation, early detection of lung cancer, increased survivorship, self-care, and peace of mind. ¹⁹ However, they also noted barriers such as fear of results, costs, lack of knowledge about the procedure, feelings of self-blame, transportation challenges, and lack of time. Participants acknowledged that factors such as family encouragement, healthcare provider recommendations, educational materials, and the presence of symptoms would function as cues to prompt them to undergo lung cancer screening. ¹⁹

Like the Hispanic/LatinX population, there are also gaps in knowledge on screening access and implementation in head and neck cancer survivors. The National Comprehensive Cancer Network (NCCN) recommends lung cancer screening with low-dose computed tomography (LDCT) for head and neck cancer survivors with a 20-pack year smoking history. ²⁰ However, no designated studies have been conducted to understand or promote lung cancer screening uptake in the head and neck cancer survivor population. While LDCT remains the gold standard for lung cancer screening, the ideal screening approach for head and neck cancer survivors is not well defined because they may have unique risk profiles, different from those of the general population. Head and neck cancer survivors show pulmonary nodules at rates up to 52%, raising questions about the accuracy and sensitivity of LDCT in this population.^7,8 One study found that 43% of head and neck cancer survivors had at least 1 positive scan, leading to nearly 10% undergoing invasive procedure Given that head and neck cancer survivors face a 2.1% annual incidence of developing lung cancer—higher than that of other cancer survivors—the development of innovative, cost-effective, and minimally invasive screening tools could be a highly efficient approach to improving lung cancer screening in this high-risk population. ¹¹ A blood-based assay for lung cancer screening could mitigate many barriers to lung cancer screening in other high-risk groups. Particularly, if proven effective, it could stratify high-risk patients to LDCT, offering cost-effective benefits, reducing LDCT burdens, and minimizing the risk of unnecessary invasive procedures. Extensive Research has been conducted in this space in other tumor types. ²¹ Though the future is promising, unfortunately, to date, no blood-based assay has been approved and more studies are needed in the lung cancer screening space.

In conclusion, head and neck cancer survivors and Hispanic/Latin communities face significant disparities in lung cancer survival, yet exact data is limited due to the lack of focused studies on their unique behaviors and risk factors. By analyzing available data for each group individually, it can be inferred that disparities in early detection and overall lung cancer mortality are greater for these populations. To address these unmet needs, further research is urgently required to investigate inequalities in lung cancer screening for Hispanic/LatinX head and neck cancer survivors. This should include exploring the potential of minimally invasive blood-based assays, alongside the standard LDCT screening. Inclusive research that considers the diverse needs and risks of racial and ethnic groups is crucial to ensure equitable guidelines and to address screening barriers with tailored, rather than one-size-fits-all, approaches.