Investigating the Roles of Patient Beliefs, Stigma, and Physician Implicit Bias on Disparities in Lung Cancer Screening

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Lung cancer is particularly aggressive, lethal, and stigmatized by its strong association with cigarette smoking, with a 5-year survival rate <15%. The burden of lung cancer in the United States falls disproportionally on minorities. Blacks have the highest incidence of lung cancer and both Black and Hispanic patients have worse outcomes than their white counterparts. Lung cancer screening, consisting of an annual low-dose computed tomography (LDCT) scan, is currently recommended by the United States Preventive Services Task Force to the 8 million smokers who are at high risk of developing lung cancer, and is poised to substantially reduce lung cancer deaths. Alarmingly, emerging national data demonstrates that only 3% of black eligible smokers received screening compared to 12% of white smokers in 2017. Prior research on cancer disparities fails to address issues that are specific to lung cancer (stigma, high mortality, and fatalism) and LDCT screening (new test, increased radiation exposure) and greatly limits the generalizability of the findings from these studies to lung cancer screening. In this project, we plan to assess modifiable health beliefs as well as examine psychological responses to discrimination, such as stigma and medical mistrust that may influence lung cancer screening use among minority smokers. We also plan to evaluate the role of implicit bias among physicians. Given the newness and unique challenges of lung cancer screening, efforts to accurately identify barriers and engage Black and Hispanics in LDCT screening early in its adoption are imperative to achieving an early correction to this disparity. The Specific Aims of the study are to: 1) Assess racial and ethnic differences in beliefs about lung cancer and LDCT screening and their association with lower rates of agreement to undergo screening and LDCT completion; 2) Evaluate if racial and ethnic differences in stigma and medical mistrust are associated with lower rates of agreement to undergo screening and LDCT completion and underlie screening disparities; and 3) Assess the association of implicit bias with racial and ethnic disparities in lung cancer screening referral and LDCT completion. To achieve these aims, we will recruit lung cancer screening-eligible smokers and their primary care providers from a vast network of primary care practices in New York City. We plan to measure patient’s beliefs about lung cancer and LDCT screening, stigma, and medical mistrust, as well as measure physicians’ bias and test associations with lung cancer screening referral and completion. The results of the study will directly guide the development of targeted strategies to improve lung cancer screening rates among minorities.