# Evaluation of USPSTF Lung Cancer Screening Guidelines Among African American Adult Smokers

Source: https://onco.cc/key-papers/paper-aldrich-uspstf-screening-african-american-smokers-jama-oncol-2019/  
OnCo record `paper-aldrich-uspstf-screening-african-american-smokers-jama-oncol-2019` (Key paper). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

The screening rules were written from a trial in which only 4 percent of participants were Black. In a southern United States cohort, 31 percent of white smokers qualified for screening but only 17 percent of Black smokers, even though Black smokers develop lung cancer at fewer cigarettes.

## Summary

Aldrich, Mercaldo, Sandler, Blot, Grogan and Blume tested the diagnostic accuracy of the 2013 United States Preventive Services Task Force eligibility criteria in the Southern Community Cohort Study, a predominantly African American and low-income cohort recruited through community health centres across twelve southern states from 2002 to 2009 and followed for cancer incidence to the end of 2014.

The finding is a mechanical consequence of writing eligibility in pack-years: Black smokers in the United States smoke fewer cigarettes per day on average but carry a higher lung cancer risk at any given exposure, so a pack-year threshold calibrated on a mostly white trial population excludes them disproportionately. The 2021 update lowered the threshold partly in response.

## Fields

- Kind: Key paper
- Last checked: 2026-09-25
- Tags: lung-evidence
- Journal: JAMA Oncology
- Year: 2019
- DOI: 10.1001/jamaoncol.2019.1402
- Authors: Aldrich MC, Mercaldo SF, Sandler KL, et al.
- Findings: Among 48,364 ever smokers, 32,463 (67 percent) were African American and 15,901 (33 percent) were white, with 1,269 incident lung cancers.; 5,654 of 32,463 African American smokers (17 percent) were eligible for screening under the 2013 criteria, against 4,992 of 15,901 white smokers (31 percent).; The authors conclude that the guidelines may be too conservative for African American smokers and that race-specific adjustment of pack-year criteria would give more equitable screening.
- What it means: The clearest published demonstration that a screening eligibility rule can be accurate on average and systematically wrong for a group. It is the empirical core of the argument for replacing pack-year thresholds with individual risk models.
- Caveats: A single regional cohort of community health centre attenders; eligibility fractions are not national estimates.; Self-reported smoking histories from follow-up questionnaires.; It evaluates eligibility, not screening outcomes: nobody in the cohort was randomised to be screened.

## Sources

- JAMA Oncol 2019: https://doi.org/10.1001/jamaoncol.2019.1402
- PubMed: https://pubmed.ncbi.nlm.nih.gov/31246249/

## Connected records

- key papers: [NLST: yearly low-dose CT scans cut lung cancer deaths in heavy smokers](https://onco.cc/key-papers/paper-nlst-nejm-2011/), [Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement](https://onco.cc/key-papers/paper-uspstf-lung-cancer-screening-jama-2021/)
- ideas: [Decide who is screened for lung cancer by individual risk, not by pack-years](https://onco.cc/ideas/idea-lung-screening-eligibility-by-risk-not-pack-years/), [Lung screening eligibility by risk score, not pack-years, including high-risk never-smokers](https://onco.cc/ideas/idea-prev-lung-screening-risk-model-eligibility/), [Take lung screening scanners to supermarket car parks in the poorest areas](https://onco.cc/ideas/idea-prev-mobile-lung-screening-deprived-areas/), [Treat the deprivation gradient in lung cancer as a defect in delivery that can be fixed and measured](https://onco.cc/ideas/idea-lung-deprivation-gradient-treated-as-a-defect-in-delivery/)
- cancers: [Lung cancer (all types)](https://onco.cc/cancers/lung-cancer/), [Non-small-cell lung cancer](https://onco.cc/cancers/nsclc/)
- fronts: [Early Detection & Screening](https://onco.cc/fronts/early-detection/)
- technologies: [Low-dose CT lung screening](https://onco.cc/technologies/low-dose-ct-screening/)
- bottlenecks: [Fragmented care and guideline gaps](https://onco.cc/bottlenecks/b-care-fragmentation/), [Most of the world has almost no cancer care](https://onco.cc/bottlenecks/b-global-access/), [The hardest cancers are found late](https://onco.cc/bottlenecks/b-early-detection/), [Trials do not represent the people who get cancer](https://onco.cc/bottlenecks/b-trial-diversity/)
- journals: [JAMA Oncology](https://onco.cc/journals/jama-oncology/)
- roadmaps: [Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch](https://onco.cc/roadmaps/lung-cancer-evidence-roadmap/)

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