Disparities in Lung Cancer Screening among the Hispanic Community: An Update and Review of Literature

Introduction

Lung cancer remains the leading cause of cancer-related mortality in the United States, accounting for approximately 20% of all cancer deaths.¹ Beyond mortality, lung cancer imposes a substantial economic burden, with more than $21 billion annually in lost earnings due to premature mortality in the United States.² Historically, poor survival has been driven by late-stage diagnosis; however, recent trends suggest a meaningful shift toward early detection. Localized disease has increased by 3.6% annually, and distant-stage disease has decreased by 4.6% annually.¹ This shift has coincided with expanded implementation of low-dose computed tomography (LDCT) screening, which has been shown to reduce lung cancer mortality by approximately 24% among high-risk populations and to increase early-stage detection.³ Despite clear evidence of benefit, LDCT screening uptake remains low, with only 18.1% of eligible U.S. adults undergoing screening in 2022.⁴

Adherence to ongoing screening further limits the potential impact of LDCT programs. In racially diverse cohorts, only 23.7% of patients return for annual screening at 1 year, with adherence dropping to as low as 2.8% by 2 years.⁵ Similar patterns are observed in safety-net settings, where approximately 8% of patients adhere to annual screening, and Hispanic patients demonstrate lower adherence compared with Black and White patients.⁶

Although Hispanic and Latino populations have lower overall smoking prevalence and lung cancer incidence, they are more frequently diagnosed at later stages and experience worse outcomes.^7,8 Hispanic individuals are also more likely to be diagnosed at younger ages despite having fewer pack-years yet receive lower rates of guideline-concordant treatment, including surgery, radiation therapy, and biomarker testing.⁸ These disparities reflect multilevel barriers, such as structural inequities, healthcare access, and system-level bias, which limit access to high-quality care and diminish survival advantages associated with specialized services, socioeconomic resources, and insurance coverage.⁹ Accordingly, this systematic review synthesizes existing evidence on bias in lung cancer screening and care among Hispanic populations to identify critical gaps and inform targeted, equity-focused interventions to improve outcomes.

Methods

The study was exempt from the oversight of the Institutional Review Board.

Search Strategy

A PubMed and EMBASE search was performed for English-language articles conducted with human studies. Search queries were developed to identify publications on disparity, bias, and barriers in lung cancer and screening among Hispanic/Latino (HL) populations in the United States (Supplement 1). The search was conducted on November 11, 2025. Identified articles were uploaded to Rayaan Software for continued review. Duplicates were detected and deleted. Three investigators (A.T, O.A., and C.B.) independently reviewed titles and abstracts to determine eligibility using the prespecified inclusion criteria. Disagreements were resolved by discussion and consensus, or when necessary by consultation of a fourth investigator (M.G.). Then, three investigators (A.T., M.G., and M.R.) independently reviewed full-text articles to determine eligibility using the same inclusion criteria. Discrepancy in opinions was discussed and resolved by the majority or consensus.

Inclusion and Exclusion Criteria

Original studies based in the United States and written in English with primary outcomes in disparities, bias, and barriers to lung cancer and lung cancer screenings in Hispanic/Latino populations were included. All studies that are non-USA were excluded. Publications that did not discuss disparities and were not original research, including reviews, editorials, letters to the editor, and guidelines, were excluded.

Data Extraction

Data on study design and relevant outcomes, population, sample size, study limitations, and time frame were extracted. Publication results comparing HL and non-HL populations were categorized as follows: Yes – the HL population experienced worse outcomes than the non-HL population; No – the HL population experienced outcomes that were better than or similar to those of the non-HL population; Mixed – the HL population showed better outcomes for at least one measure and worse outcomes for another.

Results

618 articles were identified, 109 duplicates. 509 articles went into title/abstract screening, and 146 articles went into full text screening. A total of 59 studies met inclusion criteria and were included in the final analysis (Table 1). Publication years ranged from 1994 to 2025; 48 studies (81.4%) were published in 2018 or later, and 40 studies (67.8%) were published in the last 5 years.

Retrospective cohort studies accounted for 44 of 59 studies (74.6%), while cross-sectional survey-based studies comprised 4 studies (6.8%), non-survey cross-sectional analyses accounted for 4 studies (6.8%), prospective cohort studies accounted for 3 studies (5.1%), and registry-based cross-sectional and qualitative studies each represented 2 studies (3.4%). Study sample sizes varied widely (Range: 32 to 3,600,000). The median sample size was 78,227.

The outcomes evaluated across studies were heterogeneous, including screening eligibility or uptake, stage at diagnosis, diagnostic timeliness, treatment patterns, or survival. Specifically, 14 studies (23.7%) primarily evaluated survival outcomes, 11 studies (18.6%) focused on stage at diagnosis or diagnostic delay, and 6 studies (10.2%) examined treatment-related or perioperative outcomes, while only 5 studies (8.5%) directly evaluated screening eligibility or utilization. The remaining studies evaluated broader or mixed lung cancer screening disparity outcomes.

Among the 52 studies (88.1%) in which disparities were explicitly assessed and coded, 29 studies (55.8%) reported evidence of disparities affecting Latino populations, 16 studies (30.8%) reported no statistically significant disparities, and 7 studies (13.5%) reported mixed findings depending on the outcome or subgroup analyzed. The proportion of studies reporting disparities was similar across time, with disparities identified in 18 of 32 studies (56.3%) published before 2020 and 11 of 20 studies (55.0%) published from 2020 onward. Among retrospective cohort studies with a coded disparity outcome (n = 40), 21 studies (52.5%) reported disparities, 14 studies (35.0%) reported no disparities, and 5 studies (12.5%) reported mixed findings. Chi-square test showed no difference in disparity reporting by study design (p = 0.24).

Discussion

Disparities affecting Hispanic and Latino populations persist across the lung cancer care continuum despite substantial advances in screening guidelines and diagnostic technologies. Across the studies included in this review, more than half identified disparities affecting Latino patients, most frequently during early phases of care such as risk assessment, screening access, eligibility determination, and diagnostics. At the same time, the existing evidence is complex and often difficult to untangle, as studies examine different populations, clinical contexts, and outcomes, leading to seemingly contradictory findings. Heterogeneity within Hispanic and Latino populations, including country of origin and geographic location,^{14,19,20,26,27,37} complicates both lung cancer risk assessment and the identification of inequities across the care continuum. Hispanic and Latino populations encompass diverse subgroups that differ meaningfully in smoking behaviors,⁶⁹ lung cancer incidence,^19,70 and underlying tumor biology,^71,72 yet are frequently analyzed as a single category. These differences intersect with upstream system-level challenges: multiple studies document incomplete capture of smoking history, nativity, language preference, and socioeconomic indicators among Hispanic and Latino patients, limiting accurate risk stratification and eligibility determination for lung cancer screening.^73,74 However, most studies included in this review do not include more granular data describing this population. Treating Hispanic and Latino patients as a single, uniform group therefore obscures meaningful variation by subpopulation and context, contributes to inconsistent findings across studies, and limits the effectiveness of interventions. This review synthesizes existing evidence of lung cancer disparities among Hispanic and Latino populations to inform future research and intervention efforts.

Screening and Diagnostics

Latino populations consistently demonstrate lower participation in lung cancer screening, representing a critical barrier to early detection. Although expansion of screening eligibility criteria by the U.S. Preventive Services Task Force (USPSTF) was intended to broaden access, several studies suggest that guideline modifications may unintentionally exacerbate disparities when healthcare systems lack mechanisms to identify and engage newly eligible patients.^5,7,75 Hispanic populations, both foreign-born and U.S.-born, had lower likelihood of lung cancer screening being ordered.²⁷ Incomplete documentation, such as a lack of pack-year history more common in foreign-born Latinos, can further exacerbate access.²⁷ However, some studies suggest that disparities are driven primarily by inequitable screening access rather than patient refusal.^11,33 This is exemplified by studies among Hispanic and Latino veterans, who were less likely to decline lung cancer screening when access was facilitated, demonstrating that disparities in screening uptake can diminish when structural barriers are reduced.⁴⁵

Knowledge gaps further contribute to inequities in screening participation. Latino patients often report no awareness of lung cancer screening, yet express strong interest in undergoing screening once informed.⁵⁰ Lower health literacy have been associated with non-adherence and delayed follow-up.²¹ Patient-reported barriers can explain low screening uptake among Hispanic and Latino populations. Studies consistently identify fear of results, financial concerns, limited screening knowledge, lack of clinician recommendation, smoking-related stigma, transportation barriers, and competing life demands as key deterrents.^76,77 These factors reflect the intersection of structural barriers, sociocultural influences, and health literacy that drive screening inequities. Notably, clinician recommendation remains one of the strongest predictors of screening participation, but minority populations are less likely to receive shared decision-making,^78,79 further increasing the disparity.²⁸ This highlights a critical opportunity to improve equitable screening engagement.

Additional studies reveal disparities in access to advanced diagnostic and molecular testing, which may limit treatment personalization and survival benefits.⁸⁰ At the same time, geographic context appears to impact but not fully explain disparities, as some studies report no significant differences in stage at diagnosis between rural and urban Hispanic populations.⁶⁸ These mixed findings further emphasize that disparities are shaped by a complex interaction of health system capacity, community context, and institutional resources.

Despite lower smoking prevalence and overall lung cancer incidence, Latino patients are more likely to present with advanced-stage disease than non-Hispanic White patients, especially those from Central America.^38,81 Additionally, there is a difference in the population based on origin: patients of Puerto Rican origin were less likely to present with advanced disease compared to Cubans,¹⁴ and Mexicans and Central Americans had higher proportions of distant stage at diagnosis,¹⁹ especially Cuban males.¹⁹ This disparity is largely attributed to differences in insurance coverage, limited access to diagnostic evaluation and imaging, and delays following abnormal imaging.^19,69 Because early-stage detection is the primary determinant of surgical candidacy and survival, these findings reinforce that disparities often originate during screening and diagnostic phases and subsequently propagate throughout the care continuum.^6,7

Treatment

Lung cancer disparities are primarily failures of healthcare systems to consistently identify, screen, diagnose, and treat high-risk populations in an equitable and timely manner. Earlier studies reported lower surgical resection rates and higher mortality among Hispanic patients,⁴⁴ whereas more recent analyses demonstrate higher odds of surgery among Hispanic and Latino patients compared to Whites.⁸² Among patients who ultimately undergo surgery, diagnosis-to-surgery intervals appear similar across ethnic groups, suggesting that surgical timing among recipients does not differ systematically.^13,51 However, disparities in access to high-quality surgical care persist, as Latino patients are less likely to undergo resection at high-volume centers and have higher in-hospital mortality.⁴³

Postoperative outcomes further highlight heterogeneity, with analyses demonstrating comparable or improved adjusted outcomes among Hispanic patients despite lower socioeconomic status and higher stage of lung cancer at the time of diagnosis,³⁶ a phenomenon often described as the “Hispanic paradox.”⁸³ However, others have found no advantage among Hispanic patients with cancer.⁵² Disparities in staging and diagnostic workup may contribute to downstream differences as Hispanic patients are less likely to receive PET/CT imaging, which is associated with improved survival.⁴⁰ Hispanic patients are also more likely to present with advanced-stage disease at cancer centers, suggesting delays in access or referral.³⁴ A parallel pattern is observed for systemic therapy and multimodality treatment. Hispanic and Latino patients had lower receipt of radiation therapy, immunotherapy, and any first-course lung cancer treatment,⁸² with less than half of Hispanic patients receiving guideline-concordant care.⁵³ Importantly, when recommended therapy is delivered, outcomes appear similar across racial and ethnic groups.^46,60,84 These findings support the concept of conditional equity, in which outcome differences diminish once appropriate treatment is enacted.

Disparities persist in healthcare utilization. Hispanic and Latino patients experience longer hospital stays and higher inpatient charges compared with other groups,⁸⁵ highlighting inequities not captured by treatment receipt or survival alone. Although administrative data do not identify underlying mechanisms, these utilization differences coexist with conditional equity in clinical outcomes, suggesting that structural determinant, including insurance coverage, geographic access, facility resources, and health system organization, continue to influence the burden of care.^46,78 Encouragingly, integrated health systems and coordinated multidisciplinary care models have demonstrated reduced treatment disparities, reinforcing the importance of coordinated, multi-level approaches to improving equity in lung cancer outcomes.^17,82,86

Mortality and Survival

Findings on mortality are mixed and appear highly dependent on population characteristics and adjustment for socioeconomic factors. Some studies demonstrate no significant survival differences by race or ethnicity,^16,42 while others report improved overall survival and lower mortality among Hispanic patients.^56,57 Moreover, geographic location and origin matter. Rural Hispanics had a higher mortality than urban Hispanics²⁰ and foreign-born Mexicans had lower mortality risk than U.S.-born counterparts.²⁶ Hispanic patients are more likely to be uninsured and reside in low-income areas, and although they demonstrate an 11% higher mortality risk for NSCLC, socioeconomic factors account for a substantial proportion of this disparity (approximately 60%).⁴⁷ Notably, Hispanic patients are more frequently diagnosed at advanced stages, which contributes to worse outcomes despite some evidence of lower mortality in localized disease. Importantly, when controlling for treatment receipt and stage at diagnosis, Hispanic ethnicity is not independently associated with increased mortality risk, reinforcing the role of access and care delivery rather than intrinsic differences.⁶⁵

Socioeconomic Factors

Socioeconomic and structural determinants play a central role in shaping disparities in healthcare. Lower area-level socioeconomic status is strongly associated with advanced-stage diagnosis, and a substantial proportion of Hispanic patients reside in low-income and low-education areas, where access to early detection and timely care is limited.²⁴ These disparities persist even within academic and research settings, suggesting that broader systemic factors extend beyond institutional quality. Geographic barriers further compound inequities, as Hispanic patients in rural or primary care shortage areas are more likely to present with advanced disease and face delays in diagnosis and treatment, and experience higher readmissions.^22,58 Hispanic patients may have limited access to care, including difficulty obtaining needed services, which has been directly associated with increased mortality risk.²³ Insurance status also plays a critical role, with publicly insured and uninsured patients experiencing worse outcomes, and insurance type accounting for a substantial proportion of observed racial and ethnic disparities.^48,63

Importantly, when socioeconomic status is accounted for, racial and ethnic differences in treatment receipt are substantially attenuated, suggesting that structural inequities, rather than race itself, are the primary drivers of disparities in lung cancer care.⁴¹ Collectively, these findings underscore the need for multi-level interventions targeting access, insurance coverage, geographic distribution of care, and health system coordination to achieve equity in lung cancer outcomes.

Limitations

The literature is dominated by retrospective observational analyses with diverse outcome definitions, analytic approaches, and reporting of ethnicity-related variables. Few studies differentiate Latino populations by country of origin, nativity, or language preference, despite evidence demonstrating significant intra-ethnic variability in lung cancer risk and outcomes.^79,86,87 Additionally, many studies evaluate downstream treatment or survival outcomes without accounting for earlier screening and diagnostic disparities, limiting the ability to fully characterize causal pathways across the care continuum.

Conclusion

Across studies, Latino patients have lower uptake of lung cancer screening and are more often diagnosed at later stages, reflecting barriers to early risk identification, referral, and diagnostic evaluation. Although outcomes of individual treatments are often comparable to non-Hispanic White patients when care is received, disparities persist in multimodality care coordination, with lower use of combined treatments, longer hospital stays, and higher inpatient utilization. These patterns suggest that inequities stem less from treatment effectiveness and more from system-level barriers to integrated, guideline-concordant care.