Black Americans have the highest lung cancer mortality rate in the U.S. Like many other minority populations, this community faces severe health disparities due to bias and access barriers.1 However, proper community outreach programs can help close the health equity gap. The Bulletin spoke with Ashley E. Prosper, MD, assistant clinical professor of radiology at the University of California, Los Angeles (UCLA), to talk about her ACR Innovation Fund grant-funded community outreach project, screening barriers among Black people, and how physicians earn the trust of underserved communities.
How did your project get started?
I am a co-director of the lung cancer screening (LCS) program at UCLA, along with Brett Schussel, NP, and Denise R. Aberle, MD, professor of radiology at the UCLA School of Medicine, who was the principal investigator of the National Lung Cancer Screening Trial (NLST). The degree of increased morbidity and mortality that plagues the Black community when it comes to cancer is astounding. Black men in particular have the highest degree of mortality and the highest risk of developing lung cancer of any racial or ethnic group. This is concerning because Black men consume less cigarettes, on average. In reviewing the NLST, we noticed that Black patients experienced the greatest improvement in mortality reduction when provided with low-dose chest CT (LDCT) screening.2 I realized we needed a pipeline between LDCT and the community that needs it most. The goal of this project is to coordinate outreach sessions with churches and community groups and develop educational tools such as videos and a website — specifically for the Black community to make sure that the public is aware of this elevated risk to this population and understands just how powerful of a tool LDCT screening can be.
Why is it important for public health interventions to involve stakeholders from these communities?
LCS is a population health issue. To operate in the field of population health, you must utilize nontraditional approaches, methods, and partnerships. While I happen to be a Black physician, that doesn’t mean that my views represent those of the entire Black community. For our LCS project to be successful, we must reach multiple perspectives, and the only way to do that is to include a wide variety of viewpoints in a stakeholder panel. This is not a one-time discussion either. You should have ongoing feedback from the very beginning to the end of the project. Another thing to keep in mind is establishing trust in the communities that the programs are hoping to reach. The Black community has unfortunately had a dark history with medicine and science, including studies that took advantage of vulnerable Black patients. The last thing I’d want to do is propose any outreach project to an underserved community without community representation. I want to make sure the community is represented and has an opportunity to shape and inform the policies and deliverables of an outreach project.
How can radiologists work with PCPs to find out who is eligible for screening, when to screen, and establish workflows for shared decision-making?
There are a couple of things I’d advocate for. The first is establishing LCS as a health metric in your health system. Cancer screening exams such as breast cancer, colorectal cancer, and cervical cancer screening are already widely adopted as health measures within primary care. Recognition of LCS as an important health metric facilitates implementation of tools to increase the number of patients receiving the screening for which they are eligible, such as reminder systems built into the EMR. However, I realize that this might not be an immediate step, nor is it the easiest thing to implement first. On your way to reaching this goal, you have to demonstrate your excellence as a program and your willingness to take ownership of the patients you screen — as well as your willingness to be a part of a multidisciplinary team. At UCLA, we do this by promoting screening as a comprehensive program and facilitating the shared decision-making process. We take responsibility for maintaining a screening database and ensure that patients come back on time and are aware of their annual screenings. We hold multidisciplinary conferences and go to primary care offices to offer journal clubs, lunchtime lectures, and Grand Rounds to make sure that everyone is aware of the intricacies and health benefits of LCS.
How can radiologists develop interventions to address the stigma and implicit bias many patients experience when they come in for LCS?
LDCT is different from other imaging screenings because we are screening former and current smokers, who often face barriers to screening such as stigma and shame for smoking or having previously smoked. It’s important to realize that these patients may feel vulnerable and judged. We have to make sure that patients understand why we’re there — to provide resources and save lives. We are not interested in passing judgment. Making sure that message comes across, being aware of potential psychological barriers to screening, and working to mitigate them are critically important.