A 2026 multi-cohort analysis published in Chest pooled 175,259 adults with a smoking history across three cohorts that oversample Black, Hispanic, and Asian American populations and tested how the American Cancer Society's October 2023 lung-cancer-screening guideline update changed eligibility (Manful et al., Chest 2026; PMID 41580073). Under the prior US Preventive Services Task Force 2021 framework, 27 percent of the cohort was eligible. Under the new ACS recommendations, 33 percent was eligible. The expansion increased eligibility sensitivity from 0.34 to 0.44 and decreased specificity from 0.87 to 0.77.
Among former smokers who later developed lung cancer, the Black-white eligibility disparity under USPSTF criteria was 7 percentage points; under the ACS expansion, that disparity widened to 12 percentage points. The Manful team's verbatim summary: "These changes differed in magnitude across racial and ethnic groups, resulting in larger eligibility disparities."
The 2023 ACS guideline expansion was a screening extension intended to extend eligibility to populations the USPSTF 2021 framework excluded. It was not a Black-disregarding choice. The disparity widened because the expansion criterion, removal of the 15-year-since-quitting cap, advantaged populations with longer-ago smoking patterns, which skew white.
The USPSTF baseline disparity that the ACS expansion was meant to address
A 2019 cohort study at Vanderbilt led by Melinda C. Aldrich evaluated the USPSTF 2013 lung-cancer-screening criteria in the Southern Community Cohort Study, a 12-southern-state cohort with 67 percent African American enrollment (Aldrich et al., JAMA Oncology 2019; PMID 31246249). Among 48,364 ever-smokers, 17 percent of African American smokers were eligible for USPSTF screening compared with 31 percent of white smokers. The 14-percentage-point Black-vs-white eligibility gap was statistically significant.
The mechanism Aldrich and colleagues identified is structural: African American smokers tend to start smoking at older ages, smoke fewer cigarettes per day, and present with lung cancer at younger ages and lower pack-year histories than the population on which the USPSTF criteria were derived. The original 2013 USPSTF criteria study population included only 4 percent African American smokers; the criteria were not race-stratified in their derivation. The 2021 USPSTF update lowered the age floor to 50 and the pack-year floor to 20, closing some of the eligibility gap, but retained the 15-year-since-quitting cap that the structural-mechanism analysis suggests was the criterion most likely to under-cover Black smokers' shorter quit-duration patterns.
What the 2023 ACS guideline change was, and what it changed
The ACS Guideline Development Group, led by Andrew M.D. Wolf, MD, FACP, published the 2023 lung-cancer-screening guideline update in CA: A Cancer Journal for Clinicians in November 2023 (Wolf et al., CA Cancer J Clin 2024; PMID 37909877). The recommendation maintains annual lung-cancer screening with low-dose computed tomography for adults aged 50 to 80 with a 20-pack-year smoking history, but explicitly states, verbatim: "For individuals who formerly smoked, the number of YSQ is not an eligibility criterion to begin or to stop screening." The 15-year-since-quitting cap was removed.
The basis for the change was a years-since-quitting systematic review showing lung-cancer risk remains elevated beyond 15 years after smoking cessation. The guideline-development analysis modeled benefit-to-radiation-risk ratios across age and smoking-history strata. It did not include a race-stratified projection of what removing the quit-duration cap would do to eligibility for Black, Hispanic, Asian American, or Native Hawaiian populations specifically.
How the Manful 2026 analysis tested the expansion
The Manful team pooled three multi-cohort studies that recruit and follow Black-, Hispanic-, and Asian-American-heavy populations: the Black Women's Health Study, the Multiethnic Cohort Study, and the Southern Community Cohort Study. The pooled cohort is 42 percent Black or African American, 25 percent White American, 15 percent Japanese American, 12 percent Hispanic or Latino, 5 percent Native Hawaiian, and 1 percent multiracial or other. Recruitment ran from 1993 through 2009 with lung-cancer-incidence follow-up to 2019.
Within that cohort, 11,671 individuals would have qualified for screening under the new ACS criteria but not under the prior USPSTF criteria. Of those, 382 (3 percent) had developed lung cancer. The expansion captured real cases. But the magnitude of the eligibility increase differed by race and ethnicity. The Black-vs-white disparity in former-smoker-with-lung-cancer eligibility went from 7 percentage points under USPSTF to 12 percentage points under ACS. The Hispanic-or-Latino-vs-white disparity moved from 12 percentage points to 22 percentage points over the same comparison.
The expansion criterion that advantaged longer-quit smokers benefited white former smokers more, because the longer-since-quitting smoking-history pattern skews white in the cohort. The structural mechanism Aldrich documented in 2019, of Black smokers starting later and smoking fewer cigarettes per day, also produces a shorter quit-duration distribution; an expansion that targets longer quit-durations naturally captures fewer of them.
The screening-policy paradox
The pattern fits a primitive that has shown up in multiple recent guideline expansions for Black-relevant clinical questions. The October 2023 ACS guideline change was not a Black-disregarding choice; it was a coverage-broadening response to evidence that lung-cancer risk persists beyond 15 years post-cessation. The disparity widened because the expansion criterion was applied without race-stratified design.
The same primitive showed up in the FDA's April 2026 approval of Auvelity for Alzheimer's-related agitation, where the registration trial Black-enrollment percentages were below the Black share of the dementia population and the larger registration-supportive trials had not posted race data. It showed up again in the HHS Make America Healthy Again Action Plan's blanket-overprescribing-reduction frame, which assumes an overprescribed population that US Medicare data shows is the opposite for Black patients. The lever for closing the disparity in each case is the same: criteria designed with race-stratified inputs from the start, not bolted on after the population-level effect appears.
Five voices on the evidence layer
The published evidence base is anchored by Adoma Manful, PhD, of Vanderbilt University Department of Medicine (lead author Manful 2026 Chest); Hilary Tindle, MD, MPH, also of Vanderbilt (senior author Manful 2026); Melinda C. Aldrich, PhD, MPH, of the Vanderbilt University Medical Center Department of Thoracic Surgery (Aldrich 2019 USPSTF-criteria-fail paper); Andrew M.D. Wolf, MD, FACP, lead of the ACS Guideline Development Group for the 2023 update; and Julie Palmer, ScD, principal investigator of the Black Women's Health Study at the Slone Epidemiology Center, Boston University (senior co-author Manful 2026).
What the evidence does not yet tell us
Three things the published record does not currently pin down. The exact race-stratified pack-year distribution that would close the disparity in a redesigned criteria framework has not been published; both USPSTF 2021 and ACS 2023 declined to include race-stratified inputs in their derivation analyses. A national survey of state-level community programs offering lung-cancer-screening criteria-relaxation beyond ACS 2023 has not been published; a 2025 community-cohort study in the US South tested several alternative criteria including a 10-year-smoking-history-or-10-pack-year threshold and is the only contemporary empirical anchor for what relaxed criteria look like in practice (Smeltzer et al., JAMA Network Open 2025; PMID 40553471). The post-implementation Medicaid-expansion-vs-non-expansion lung-cancer-screening growth differential was null in a 2016-2019 ACR registry analysis (Gupta et al., Clinical Imaging 2021; PMID 33321465), suggesting Medicaid expansion alone does not close the screening-criteria-eligibility disparity.
Two concrete things to ask, depending on who you are
For Black readers who smoked and either currently smoke or quit. If you fall outside ACS criteria (under 50, fewer than 20 pack-years, or for any other reason a clinician has told you do not qualify), ask your primary-care clinician this specific question: "Given my family history and pack-year exposure, what is your screening recommendation outside ACS criteria?" The Smeltzer 2025 community-cohort study indicates that some US-South health systems have piloted relaxed criteria including a 10-year-smoking-history-or-10-pack-year threshold. If your state has a community-based program that uses expanded criteria, that program may cover a low-dose computed tomography scan that the ACS criteria would not. The CDC's National Comprehensive Cancer Control Program (cdc.gov/cancer/ncccp) is the federal catalog of state-level programs.
For Black readers who currently smoke. The same screening-criteria expansion question applies, but the more immediate clinical conversation is about smoking cessation. ACS data shows that quitting at any age and any smoking-history level lowers lung-cancer-mortality risk substantially over the 10-to-20 years that follow. The structural eligibility-expansion debate is downstream; the cessation conversation with a clinician who treats cessation as a multi-attempt process, not a single quit-date event, is upstream. The Black Health provider directory lists primary-care clinicians and pulmonologists with verified active licenses for readers who want a clinician comfortable with the cessation-and-screening pair of conversations together.
Update plan
We will update this piece when the next race-stratified national lung-cancer-screening criteria evaluation publishes, when a major national professional society (ACS, USPSTF, ATS, CHEST) revises the 2023 ACS guidelines, when state-level community-program coverage of relaxed criteria is documented at scale, or when a Black-led pulmonary-advocacy organization publishes a position statement on the disparity-widening finding.
Citations
- Manful A, Amanna N, Park SL, Petrick JL, Rosenberg L, Tindle H, Palmer J, Wilkens L, et al. The Impact of the 2023 American Cancer Society Screening Recommendations on Racial, Ethnic, and Sex Disparities in Lung Cancer Screening Eligibility. Chest. 2026. PMID 41580073.
- Wolf AMD, Oeffinger KC, Shih TYC, Walter LC, Church TR, et al. Screening for lung cancer: 2023 guideline update from the American Cancer Society. CA: A Cancer Journal for Clinicians. 2024. PMID 37909877.
- Aldrich MC, Mercaldo SF, Sandler KL, Blot WJ, Grogan EL, Blume JD. Evaluation of USPSTF Lung Cancer Screening Guidelines Among African American Adult Smokers. JAMA Oncology. 2019. PMID 31246249.
- Smeltzer MP, Liao W, Goss J, Qureshi T, Johnson S, et al. Reducing Smoking Requirements for Lung Screening to Address Health Disparities in a Community Cohort. JAMA Network Open. 2025. PMID 40553471.
- Gupta N, Halpern EJ, Rao VM. Association between Medicaid expansion status and lung cancer screening exam growth: findings from the ACR lung cancer registry. Clinical Imaging. 2021. PMID 33321465.
