FormalPara Key Points

  • American Indians and Alaska Natives (AI/AN) face unique regional differences in lung cancer incidence and mortality rates compared to US White populations.

  • AI/AN have the highest prevalence of smoking of all US ethnic groups.

  • The majority of AI/AN populations live geographically distant from lung cancer screening access, with a mean distance of 43.6–48.9 miles to screening.

Cancer of the lung and bronchus is the most common cancer among the American Indian and Alaska Native (AI/AN) population of the United States [1]. The incidence of lung cancer varies dramatically by region. For example, lung cancer rates for AI/AN in the Southwest are approximately 16/100,000, seven times lower than in the Northern Plains (109.3/100,000) [1]. In contrast, among White populations in the United States, there is little regional difference in lung cancer prevalence. The regional differences in lung cancer incidence among AI/AN correspond to regional differences in tobacco use [1]. Also, unique to AI/AN is the similar or higher incidence of lung cancer in women compared to men in some locations. This is particularly evident along the Pacific Coast, on the Northern Plain, and in the East [1].

Lung cancer incidence rates and rates of late-stage disease are up to 1.5 times higher among AI/AN. This is especially evident among Northern Plains, Alaska, Southern Plains, and Pacific Coast populations, where lung cancer rates are, in some places, up to 70% higher among AI/AN patients than White patients in the same region [1, 2]. Among all major groups in the United States, AI/AN have the highest prevalence of smoking and the lowest rates of smoking cessation and make fewer attempts to cease tobacco use. Smoking prevalence in AI/AN populations is 1.5–8 times higher than among other ethnic groups in the United States [3].

Mortality

Lung cancer mortality rates are 12% higher overall in AI/AN populations compared to White populations. This difference may be partly related to later tumor stage at the time of detection [1]. Just as AI/AN lung cancer incidence rates vary by region, lung cancer mortality rates also demonstrate large regional differences. This is unique to the AI/AN population, with White populations having minimal geographic differences in lung cancer mortality rates.

The stage of lung cancer at diagnosis correlates to a history of smoking and delays in detection. Between 61.6% and 71.8% of AI/AN women diagnosed with lung cancer present with later-stage cancer, compared to 58.6–67.3% among White women. The death rate among AI/AN women is up to 50% higher than the national average, and has been slow to improve [4].

Reasons for Disparities

Lung cancer survival is related to less-timely or lower-quality medical care, inadequate or delayed detection, and/or treatment gaps. A significant barrier is the difficult and confusing access to cancer screening centers, influenced by a complex combination of factors, including geographic distance, cost, health insurance coverage, rurality, level of social vulnerability, language, race, household problems, and transportation. Access is especially compromised by longer travel distances to lung cancer screening centers and treatment centers, resulting in disparities in services among AI/AN populations [5]. In the absence of screening, the early detection of cancer is far less likely, thus compromising survival owing to the later stage of disease at detection. Lung cancer screening, which requires regular computed tomography (CT) scans of the lungs, needs to be of high quality and should be easily accessible to save the lives of those who use tobacco. Culturally informed, community-based interventions also are needed to reduce exposure to tobacco, promote smoking cessation, and enable recommended screening for lung cancer [5]. The cultural significance of traditional tobacco use complicates messaging, compounded by reduced access to medical care and smoking cessation programs. Of more significance is the greater amount of tobacco marketing targeted at AI/AN populations.

Screening for Lung Cancer

The early detection of lung cancer is possible with CT scans and is proven to reduce lung cancer mortality among smokers [6]. Without improved screening, improved efforts to prevent smoking, and increased smoking cessation, lung cancer outcomes cannot improve. Furthermore, lung cancer screening is not universally accessible. Barriers to screening are particularly evident among low-income, rural, and Tribal communities and across state lines. Among all AI/AN populations, 76.4% (454 of 594) report lung cancer screening centers within a distance of 200 miles, with a mean distance of 43.6–48.9 miles. Among those lung cancer screening centers located within 200 miles of AI/AN communities, only 26.9% (122 of 454) are accredited by the American College of Radiology, and quality or outcomes may not be assured [6]. Programs are needed to increase equity in screening across AI/AN communities [6].

There has been limited research on lung cancer screening in AI/AN communities, with outcomes or implementation understudied and underreported. Limitations to lung cancer screening are related to costs, which for many AI/AN healthcare systems depend on congressional appropriation. In addition, other barriers persist—for example, an urban Minnesota community clinic serving Tribal populations found that barriers to lung cancer screening included provider knowledge, patient trust, and patient fear of screening [5].

AI/AN Tribes may experience cancer screening “deserts,” similar to other deserts described in the medical and sociological literature. These deserts are defined as geographic areas with a lack of access to nearby services or resources. Across all US states, there is a more than 26-fold variation in mean distance from an AI/AN community to the nearest lung cancer screening center. An increase in access to accredited cancer screening centers is imperative to improve early cancer detection rates and advance equity in cancer-related outcomes. Recent advancements in telehealth may help address the significant geographic barriers that AI/AN populations continue to face [6].

Following lung cancer diagnosis, treatment typically includes radiation therapy. Studies of AI/AN access to radiation therapy are limited, and more research is needed [7]. In South Dakota, the Walking Forward navigation program, in which patient navigators provide patients with services during their cancer care, has resulted in fewer days of interrupted radiotherapy for cancer patients [8, 9]. Improving access to care, making screening services available (e.g., mobile lung cancer screening units), and increasing efforts to reach underserved groups could increase screening uptake.

Lung cancer screening is lifesaving. While the overall lung cancer survival rate is 20% at 5 years, the disease is curable if detected early. Culturally tailored, community-centered approaches have greater success and increase motivation and support for screening and smoking cessation [10]. One example of community efforts is the Caring Ambassadors Lung Cancer Program, which supports screening and treatment for AI/AN communities. More programs are needed in which patient navigators enable patients to comply with screening protocols and engage in treatment and follow-up care when lung cancer is detected [11].

Raising awareness about the statistics, barriers, and opportunities for screening for lung cancer is essential. The American Indian Cancer Foundation is a national organization that provides educational resources, such as culturally tailored infographics, toolkits, and webinars for smoking cessation and for lung cancer screening guidance. These resources enable patient education and outreach activities. The foundation engages in multiple activities, including community cancer prevention education and outreach, early detection, encouraging positive health behaviors, providing system support for cancer screening and tracking systems, and assisting community-based research [12].