Determinants of lung cancer preventive care in at-risk urban American Indians and Alaska Natives

Lung cancer is the leading cause of cancer-related deaths among American Indian and Alaska Native (AI/AN) individuals, where lung cancer incidence remains disproportionately high compared to other racial and ethnic groups in the United States. This disparity is particularly alarming given that AI/AN populations also experience the highest rates of cigarette smoking, a key risk factor for lung cancer. While lung cancer incidence has been decreasing in the general U.S. population, AI/AN communities have seen slower declines, especially in regions like the Northern and Southern Plains, Alaska, and the Pacific Coast.

However, despite the clear risk, AI/AN individuals face numerous challenges in accessing preventive care, including lung cancer screening (LCS) and smoking cessation services. Lung cancer screening using low-dose chest CT scans has been shown to reduce lung cancer mortality by up to 20% when combined with smoking cessation efforts, and LCS is recommended for people with significant smoking histories. Despite these recommendations, uptake of LCS among AI/AN populations is notably low. Studies have suggested that various social determinants—such as healthcare access, medical mistrust, and a lack of culturally-appropriate resources—contribute to these lower screening rates. For AI/AN people living in urban areas, these challenges are even more pronounced, as many receive care outside of traditional tribal healthcare settings, where culturally appropriate care may be more readily available.

A recent study published in Preventive Medicine Report by Dr. Matthew Triplette, Ursula Tsosie and colleagues aimed to identify the barriers and facilitators that affect AI/AN individuals’ participation in lung cancer preventive care, specifically focusing on lung cancer screening and smoking cessation programs. This research is particularly important because it fills a significant gap in the literature by addressing the unique challenges faced by AI/AN individuals living in urban environments. These individuals often encounter limited access to culturally tailored healthcare services, compounded by experiences of discrimination within the healthcare system.

The researchers employed a mixed-methods approach that combined qualitative discussions and quantitative surveys conducted in Seattle, Washington. The study engaged AI/AN participants aged 40 or older who had a history of smoking for at least 10 years. Data collection included surveys that addressed participants' demographics, tobacco use history, health literacy, and attitudes toward LCS. The qualitative component involved focus groups and interviews that provided deeper insights into participants' personal experiences with tobacco use, their interactions with the healthcare system, and their preferences for preventive care delivery.

Several barriers to LCS participation emerged from the study. A lack of awareness about lung cancer screening was a major issue; many participants were unfamiliar with the concept of LCS and often mistook it for diagnostic imaging related to respiratory symptoms. Access to healthcare was another significant barrier, with issues such as transportation difficulties and concerns about the costs of screening preventing many from seeking care. In addition, fear of receiving a cancer diagnosis and negative past experiences with the healthcare system—including instances of discrimination—discouraged some participants from undergoing screening. Participants also revealed a complex relationship with tobacco, using it as a coping mechanism for stress and trauma, which further complicated their willingness to engage in cessation programs or cancer screenings.

Despite these barriers, participants expressed enthusiasm for culturally tailored healthcare interventions. Many favored programs designed by and for AI/AN people, believing that such initiatives would increase their engagement with preventive care. Participants also emphasized the importance of incorporating traditional AI/AN cultural elements into health education and healthcare delivery. These findings highlight the necessity of addressing not only logistical barriers like healthcare costs and transportation but also the cultural and emotional dimensions of tobacco use and healthcare access.

The outcome of this study demonstrates a critical need for lung cancer prevention programs that are culturally sensitive and tailored to the specific needs of AI/AN populations. Interventions that address logistical barriers, medical mistrust, and the emotional and cultural complexities surrounding tobacco use are essential. Patient navigation services, which guide individuals through the healthcare system and help them manage the challenges of accessing care, could be particularly effective in this context. Moreover, extending healthcare interventions beyond clinical settings and into community spaces would likely enhance participation in LCS and smoking cessation programs.

Future research should focus on developing models of care that incorporate smoking cessation and lung cancer screening within the same continuum, provide community support throughout the process, and integrate AI/AN cultural and traditional practices into healthcare delivery. Addressing these barriers through culturally sensitive and community-oriented interventions has the potential to improve both lung cancer screening rates and overall health outcomes for AI/AN populations.

The Fred Hutch/University of Washington/Seattle Children’s Cancer Consortium facilitated access to AI/AN communities, provided resources for collaborative research, and supported the use of community-based participatory research (CBPR) methods. Partial funding for the development grant was provided by the Fred Hutch Lung SPORE. The Office of Community Outreach and Engagement’s Indigenous Cancer Health Equity Initiative, in collaboration with the Indigenous Collaborative, played a key role in community engagement and offered support throughout the research process.

This work was funded by the American Lung Association, American Thoracic Society, CHEST Foundation and the National Cancer Institute.

Tsosie, U., Anderson, N., Woo, N., Dee, C., Echo-Hawk, A., Baker, L., Rusk, A. M., Barrington, W., Parker, M., & Triplette, M. (2024). Understanding determinants of lung cancer preventive care in at-risk urban American Indians and Alaska Natives: A mixed-methods study. Preventive medicine reports, 45, 102822.