Participation in lung cancer screening is lower in populations with the highest burden of lung cancer risk (through the social patterning of smoking behavior) and lowest levels of healthcare utilization (through care which is structurally inaccessible). This leads to a widening of health inequities. In this webinar, participants will learn about inequities across the lung cancer care continuum. They will also learn to understand the need to take an equity-oriented approach to lung cancer screening, and consider future directions for improving access to lung cancer screening in all eligible population groups.

1. Equity-Oriented Lung Screening: Key
concepts and future directions
Dr. Ambreen Sayani, MD PhD
24th November 2022

2. Agenda
1. Key concepts
2. Inequities across the lung cancer care
continuum
3. Equity-oriented lung screening
4. Research: Past and current
5. Considerations

3. KEY CONCEPTS
3

4. Equity in health:
Health equity
• The absence of differences
in health outcomes
between groups of people
that are:
– Socially produced
– Systematic
– Unfair
– Avoidable
Equity in health systems
• The absence of differences
in access to healthcare
between groups of people
that are:
– Socially produced
– Systemic
– Unfair
– Avoidable
4
Source: Braveman, P. (2006). Health disparities and health equity: Concepts and measurement. Annual Review of Public Health, 27, 167–194; Braveman, P., & Gruskin, S.
(2003). Defining equity in health. Journal of Epidemiology and Community Health, 57(4), 254–258; Whitehead, M. (1992). The concepts and principles of equity and health.
International Journal of Health Services: Planning, Administration, Evaluation, 22(3), 429–445; Whitehead, M., & Dahlgren, G. (2006). Concepts and principles for tackling social
inequities in health. Levelling up. Part 1. | National Collaborating Centre for Determinants of Health.

5. Equity in health:
Health equity
• The absence of differences
in health outcomes
between groups of people
that are:
– Socially produced
– Systematic
– Unfair
– Avoidable
Equity in health systems
• The absence of differences
in access to healthcare
between groups of people
that are:
– Socially produced
– Systemic
– Unfair
– Avoidable
5
Source: Braveman, P. (2006). Health disparities and health equity: Concepts and measurement. Annual Review of Public Health, 27, 167–194; Braveman, P., & Gruskin, S.
(2003). Defining equity in health. Journal of Epidemiology and Community Health, 57(4), 254–258; Whitehead, M. (1992). The concepts and principles of equity and health.
International Journal of Health Services: Planning, Administration, Evaluation, 22(3), 429–445; Whitehead, M., & Dahlgren, G. (2006). Concepts and principles for tackling social
inequities in health. Levelling up. Part 1. | National Collaborating Centre for Determinants of Health.
Equal
opportunities

6. Access:
Access to healthcare
• Opportunity to have
healthcare needs met
Dimensions of access
• Approachability
• Acceptability
• Availability
• Affordability
• Appropriateness
6
Source: Khanassov V, Pluye P, Descoteaux S, et al. Organizational interventions improving access to community-based primary health care for vulnerable populations: a scoping
review. International Journal for Equity in Health. 31. Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health
systems and populations. Int J Equity Health. 2013;12:18..

7. Equity in access:
Access to healthcare
• Opportunity to have
healthcare needs met
Dimensions of access
• Approachability
• Acceptability
• Availability
• Affordability
• Appropriateness
7
Source: Khanassov V, Pluye P, Descoteaux S, et al. Organizational interventions improving access to community-based primary health care for vulnerable populations: a scoping
review. International Journal for Equity in Health. 31. Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health
systems and populations. Int J Equity Health. 2013;12:18..
Equal
opportunities

8. Social location
8
Sayani A. (2019), Social Class and Health Inequalities, Bryant, T., Raphael, & Rioux, M. H. (Eds), In Staying Alive: Critical Perspectives on Health, Illness and Healthcare,
3rd edition. Toronto: Canadian Scholars Press Inc

9. Clustering of disadvantage & smoking
9

10. Life-course model of health inequities
10

11. Equity-Oriented Healthcare
• An approach to care that considers:
• The distribution of the social determinants of health
• The systemic nature of social stratification
• The history of unfair healthcare experiences related to
stigma, discrimination and racism
• And intentionally creates opportunities to reduce
avoidable differences in access to care.
11
Source: Sayani, A., Manthorne, J., Nicholson, E., Bloch, G., Parsons, J. A., Hwang, S. W., Amenu, B., Freedman, H., Rathbone, M., Jeji, T., Wathen, N., Browne, A. J., Varcoe,
C., & Lofters, A. (2022). Toward equity-oriented cancer care: A Strategy for Patient-Oriented Research (SPOR) protocol to promote equitable access to lung cancer screening.
Research Involvement and Engagement, 8(1), 1

12. LUNG CANCER CONTINUUM
12

13. Social gradient in lung cancer survival
13
Source: Dabbikeh, A., Peng, Y., Mackillop, W. J., Booth, C. M., & Zhang-Salomons, J. (2017). Temporal trends in the association between socioeconomic status and cancer survival in Ontario: A population-based retrospective study.
Canadian Medical Association Open Access Journal, 5(3), E682–E689

14. Social location
14
Sayani A. (2019), Social Class and Health Inequalities, Bryant, T., Raphael, & Rioux, M. H. (Eds), In Staying Alive: Critical Perspectives on Health, Illness and Healthcare,
3rd edition. Toronto: Canadian Scholars Press Inc

15. Inequities across the lung cancer
continuum
15

16. Poverty and the lung cancer
continuum
16
Source: Jarvis, M. J., & Wardle, J. (2005). Social patterning of individual health behaviours: the case of cigarette smoking. In M. Marmot & R. G. Wilkinson (Eds.),
Social Determinants of Health. Oxford: Oxford University Press

17. Poverty and the lung cancer
continuum
17
Source: Kotz, D., & West, R. (2009). Explaining the social gradient in smoking cessation: it’s not in the trying, but in the succeeding. Tobacco Control, 18(1), 43–
46.

18. Poverty and the lung cancer
continuum
18
Source: Schütte, S., Dietrich, D., Montet, X., & Flahault, A. (2018). Participation in lung cancer screening programs: are there gender and social differences? A
systematic review. Public Health Reviews, 39

19. Poverty and the lung cancer
continuum
19
Source: Mitra, D. (2015). Social determinants of lung cancer incidence in Canada: A 13-year prospective study. Health Reports, 26(6), 11.

20. Poverty and the lung cancer
continuum
20
Source: Crawford, S. M., Sauerzapf, V., Haynes, R., Zhao, H., Forman, D., & Jones, A. P. (2009). Social and geographical factors affecting access to treatment of
lung cancer. British Journal of Cancer, 101(6), 897–901.

21. Poverty and the lung cancer
continuum
21
Source: Hart, C. L., Hole, D. J., Gillis, C. R., Smith, G. D., Watt, G. C., & Hawthorne, V. M. (2001). Social class differences in lung cancer mortality: risk factor
explanations using two Scottish cohort studies. International Journal of Epidemiology, 30(2), 268–274.
.

22. Equity-Oriented Lung Cancer Care
• An approach to care that considers:
• The distribution of the social determinants of health
• The systemic nature of social stratification
• The history of unfair healthcare experiences related
to stigma, discrimination and racism
• And intentionally creates opportunities to reduce
avoidable differences in access to care.
22
Source: Sayani, A., Manthorne, J., Nicholson, E., Bloch, G., Parsons, J. A., Hwang, S. W., Amenu, B., Freedman, H., Rathbone, M., Jeji, T., Wathen, N., Browne, A. J., Varcoe,
C., & Lofters, A. (2022). Toward equity-oriented cancer care: A Strategy for Patient-Oriented Research (SPOR) protocol to promote equitable access to lung cancer screening.
Research Involvement and Engagement, 8(1), 1

23. Lung cancer inequities in Canada
23
Source: Canadian Partnership Against Cancer. (2020). Lung Cancer and Equity: A Focus on Income and Geography
• First Nations, Inuit and Metis peoples
• Lower income groups
• Rural communities

24. The gradient: widening or reducing?
24
Source: Tetzlaff, F., Epping, J., Tetzlaff, J., Golpon, H., & Geyer, S. (2021). Socioeconomic inequalities in lung cancer – a time trend analysis with German health insurance data.
BMC Public Health, 21(1), 538

25. Priority population approach
• According to Ontario Public Health Standards
populations can be prioritized by:
– Taking specific action on reducing disease burden
for populations that is proportional to their
specific needs;
– Designing interventions that are proportional to
the burden of disease; and
– Allocating resources and services based on the
anticipated need of the population.
25
Source: Ministry of Health and Long Term Care, Ontario. (2014). Ontario Public Health Standards 2008 Revised May 1, 2014; Sayani, A., et al. (2021). Interventions designed to
increase the uptake of lung cancer screening and implications for priority populations: A scoping review protocol. BMJ Open, 11(7)

26. LUNG SCREENING
26

27. Lung cancer screening with Low Dose
Computed Tomography - LDCT
The National Lung Screening Trial Research Team. (2011). Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening. New England
Journal of Medicine, 365(5), 395–409.

28. Status of lung cancer screening in
Canada
*BC’s CPAC funded project has been completed as of March 2022
Source: Canadian Partnership Against Cancer. (2022). Lung Screening in Canada: 2021/2022 Environmental Scan.

29. Eligibility criteria
Canadian Task Force on Preventive Health Care
recommends:​
LDCT annual screening up to 3 consecutive times​
for people 55-74 years​
current or former (quit ≤15 years) smokers​
with ≥30 pack-year smoking history​

30. Screening pathway
Source: Canadian Partnership Against Cancer. (2022). Lung Screening in Canada: 2021/2022 Environmental Scan.

31. Health system induced inequities
31

32. Health equity and lung screening
• Two very specific challenges:
• 1. Disease distribution that is proportionate to
the degree of social disadvantage; and
• 2. Opportunity to screen for the disease in the
target population, but with a low uptake.
32
Source: Sayani, A., et al. (2021). Interventions designed to increase the uptake of lung cancer screening and implications for priority populations: A scoping review protocol. BMJ
Open, 11(7)

33. Priority population approach to
lung screening
• Populations that have a higher burden of lung cancer risk due
to the social patterning of smoking consumption.
• Populations that experience barriers in accessing lung cancer
screening due to economic, structural, and geographic
barriers, as well as stigma associated with smoking.
33
Source: Sayani, A., et al. (2021). Interventions designed to increase the uptake of lung cancer screening and implications for priority populations: A scoping review protocol. BMJ
Open, 11(7)

34. Access to lung screening
Access to healthcare
• Opportunity to have healthcare needs met
Dimensions of access
• Approachability
• Acceptability
• Availability
• Affordability
• Appropriateness
34
Source: Sayani, A., Ali, M. A., Dey P,. Corrado, A. M., Ziegler, C., Sadler, A., Williams, C., & Lofters, A. (FORTHCOMING). Interventions designed to increase the uptake of lung
cancer screening: an equity-oriented scoping study.

35. RESEARCH
35

36. Research question
• Research question: What are the health
impacts (intended/unintended and
positive/negative) of interventions designed
to increase the uptake of lung cancer
screening on priority populations?
Source: Sayani, A., Ali, M. A., Dey P,. Corrado, A. M., Ziegler, C., Sadler, A., Williams, C., & Lofters, A. (FORTHCOMING). Interventions designed to increase the uptake of lung cancer screening: an equity-oriented scoping study. Sayani,
A., et al. (2021). Interventions designed to increase the uptake of lung cancer screening and implications for priority populations: A scoping review protocol. BMJ Open, 11(7)

37. Scoping study
37
Source: Sayani, A., Ali, M. A., Dey P,. Corrado, A. M., Ziegler, C., Sadler, A., Williams, C., & Lofters, A. (FORTHCOMING). Interventions designed to increase the uptake of lung
cancer screening: an equity-oriented scoping study. Sayani, A., et al. (2021). Interventions designed to increase the uptake of lung cancer screening and implications for priority
populations: A scoping review protocol. BMJ Open, 11(7)

38. Scoping study
38
Source: Sayani, A., Ali, M. A., Dey P,. Corrado, A. M., Ziegler, C., Sadler, A., Williams, C., & Lofters, A. (FORTHCOMING). Interventions designed to increase the uptake of lung
cancer screening: an equity-oriented scoping study.

39. Research question
• What influences the ‘choice’ participate in
lung cancer screening for individuals living
with low income and at a high-risk of
developing lung cancer?
Screeners
Non-Screeners
Sayani, A., et al. (2021). Advancing health equity in cancer care: The lived experiences of poverty and access to lung cancer screening. Plos One, 16(5), e0251264.

40. The ‘choice’ to participate in lung
screening
40
Sayani, A., et al. (2021). Advancing health equity in cancer care: The lived experiences of poverty and access to lung cancer screening. Plos One, 16(5), e0251264.
Screeners
Non-Screeners

41. Applying an equity-lens to everything

42. Pathways of disadvantage
“I was working as a subcontractor…… I was paid by the job, yeah. I was paid by
the job and not by hour, not by hour……...I used to work and then I got sick and
when I get in and out from the hospital. I lost my job and yeah I lost my job, I
don't have no income.”
Sayani, A., et al. (2021). Advancing health equity in cancer care: The lived experiences of poverty and access to lung cancer screening. Plos One, 16(5), e0251264.

43. Lung cancer risk and early-detection
“I quit smoking for over a year but then I moved into the building where I am
now at Sherbourne and Dundas and the stress of all the stuff going on in the
building and all the crackheads and drug dealers on the corner I started
smoking again.”
Sayani, A., et al. (2021). Advancing health equity in cancer care: The lived experiences of poverty and access to lung cancer screening. Plos One, 16(5), e0251264.

44. Safe spaces of care
“I got treated really bad from doctors and I didn't want to go into another
office and get treated like a piece of garbage because you come out and you
feel twice as bad.”
Sayani, A., et al. (2021). Advancing health equity in cancer care: The lived experiences of poverty and access to lung cancer screening. Plos One, 16(5), e0251264.

45. The ‘choice’ to participate in lung
screening
45
Sayani, A., et al. (2021). Advancing health equity in cancer care: The lived experiences of poverty and access to lung cancer screening. Plos One, 16(5), e0251264.

46. The ‘choice’ to participate in lung
screening
46
Source: Sayani, A., et al. (2021). Advancing health equity in cancer care: The lived experiences of poverty and access to lung cancer screening. Plos One, 16(5),
e0251264.

47. Research question
• What are the perspectives of family physicians
towards access to lung cancer screening for
individuals living with low income?
Source: Sayani, A., Vahabi, M., O’Brien, M. A., Liu, G., Hwang, S. W., Selby, P., Nicholson, E., & Lofters, A. (2021). Perspectives of family physicians towards access to lung cancer screening for
individuals living with low income – a qualitative study. BMC Family Practice, 22(1), 10.

48. Gate-keepers to lung screening
48
Source: Sayani, A., Vahabi, M., O’Brien, M. A., Liu, G., Hwang, S. W., Selby, P., Nicholson, E., & Lofters, A. (2021). Perspectives of family physicians towards access to lung cancer screening for
individuals living with low income – a qualitative study. BMC Family Practice, 22(1), 10.

49. Gate-keepers to lung screening
49
Source: Sayani, A., Vahabi, M., O’Brien, M. A., Liu, G., Hwang, S. W., Selby, P., Nicholson, E., & Lofters, A. (2021). Perspectives of family physicians towards access to lung cancer screening for
individuals living with low income – a qualitative study. BMC Family Practice, 22(1), 10.

50. Gate-keepers to lung screening
50
Source: Sayani, A., Vahabi, M., O’Brien, M. A., Liu, G., Hwang, S. W., Selby, P., Nicholson, E., & Lofters, A. (2021). Perspectives of family physicians towards access to lung cancer screening for
individuals living with low income – a qualitative study. BMC Family Practice, 22(1), 10.

51. Gate-keepers to lung screening
51
Source: Sayani, A., Vahabi, M., O’Brien, M. A., Liu, G., Hwang, S. W., Selby, P., Nicholson, E., & Lofters, A. (2021). Perspectives of family physicians towards access to lung cancer screening for
individuals living with low income – a qualitative study. BMC Family Practice, 22(1), 10.

52. Gate-keepers to lung screening
52
Source: Sayani, A., Vahabi, M., O’Brien, M. A., Liu, G., Hwang, S. W., Selby, P., Nicholson, E., & Lofters, A. (2021). Perspectives of family physicians towards access to lung cancer screening for
individuals living with low income – a qualitative study. BMC Family Practice, 22(1), 10.

53. Research question
• How can we partner with patients to educate
providers so that lung cancer screening is
offered in a more equity-oriented way?
Source: Sayani, A., Manthorne, J., Nicholson, E., Bloch, G., Parsons, J. A., Hwang, S. W., Amenu, B., Freedman, H., Rathbone, M., Jeji, T., Wathen, N., Browne, A. J., Varcoe,
C., & Lofters, A. (2022). Toward equity-oriented cancer care: A Strategy for Patient-Oriented Research (SPOR) protocol to promote equitable access to lung cancer screening.
Research Involvement and Engagement, 8(1), 1

54. Bringing the pieces together
54
Source: Sayani, A., Manthorne, J., Nicholson, E., Bloch, G., Parsons, J. A., Hwang, S. W., Amenu, B., Freedman, H., Rathbone, M., Jeji, T., Wathen, N., Browne, A. J., Varcoe,
C., & Lofters, A. (2022). Toward equity-oriented cancer care: A Strategy for Patient-Oriented Research (SPOR) protocol to promote equitable access to lung cancer screening.
Research Involvement and Engagement, 8(1), 1

55. E-Module development
55
Source: Sayani, A., Manthorne, J., Nicholson, E., Bloch, G., Parsons, J. A., Hwang, S. W., Amenu, B., Freedman, H., Rathbone, M., Jeji, T., Wathen, N., Browne, A. J., Varcoe,
C., & Lofters, A. (2022). Toward equity-oriented cancer care: A Strategy for Patient-Oriented Research (SPOR) protocol to promote equitable access to lung cancer screening.
Research Involvement and Engagement, 8(1), 1

56. Equity oriented lung screening
Equity-
oriented
lung
screening
Trauma-
informed
Culturally
safe
Strengths-
based
56

57. E-Module plan
57
Source: Sayani, A., Manthorne, J., Nicholson, E., Bloch, G., Parsons, J. A., Hwang, S. W., Amenu, B., Freedman, H., Rathbone, M., Jeji, T., Wathen, N., Browne, A. J., Varcoe, C., & Lofters, A. (2022). Toward equity-oriented cancer care: A
Strategy for Patient-Oriented Research (SPOR) protocol to promote equitable access to lung cancer screening. Research Involvement and Engagement, 8(1), 1
Pilot test Implement Evaluate Scale

58. CONSIDERATIONS
58

59. Specific actions to reduce lung
cancer inequities
I. Target outreach to priority populations
II. Tailor interventions based on social and cultural
practices
III. Reduce financial, time, and geographic barriers
IV. Design culturally safe smoking cessation
programs
V. Consider full suite of services if diagnosed with
lung cancer
VI. Identify and work in tandem on the upstream
determinants of lung cancer risk
59
Source: Sayani, A., Ali, M. A., Dey P,. Corrado, A. M., Ziegler, C., Sadler, A., Williams, C., & Lofters, A. (FORTHCOMING). Interventions designed to increase the uptake of lung
cancer screening: an equity-oriented scoping study. Sayani, A., et al. (2021). Interventions designed to increase the uptake of lung cancer screening and implications for priority
populations: A scoping review protocol. BMJ Open, 11(7)

60. Apply a priority population approach
• Lung cancer screening interventions must take
into consideration the disproportionate
burden of lung cancer risk in populations
experiencing social disadvantage.
• Interventions should be targeted to support
the uptake in high-risk populations.
• Attention must be paid to structural drivers of
lung cancer risk and mortality to prevent an
inadvertent widening of health inequities.
60
Sayani, A., et al. (2021). Interventions designed to increase the uptake of lung cancer screening and implications for priority populations: A scoping review
protocol. BMJ Open, 11(7)

61. Thank you
• Contact: Ambreen.Sayani@Wchospital.ca
61

62. Canadian Cancer Survivor Network
Contact Info
1750 Courtwood Crescent, Suite 210
Ottawa, ON K2C 2B5
Telephone / Téléphone : 613-898-1871
E-mail: jmanthorne@survivornet.ca or info@survivornet.ca
Website: www.survivornet.ca
Twitter: @survivornetca
Facebook: www.facebook.com/CanadianSurvivorNet
Instagram: @survivornet_ca
Pinterest: http://pinterest.com/survivornetwork/