Changing recommendations for lung cancer screening: National Lung Cancer Roundtable member perspectives

Eberth JM, Gieske MR, Silvestri GA. Changing Recommendations for Lung Cancer Screening: National Lung Cancer Roundtable Member Perspectives. CANCER (2023), DOI: https://doi.org/10.1002/cncr.34798

This paper reports the results of a small (n=13), informal email survey in April 2021 of lung cancer specialists about their perspectives on the new USPSTF screening recommendations released in March 2021. The goal of the survey was to gather perspectives from a wide variety of viewpoints in the lung cancer field (radiology, pulmonology, oncology, psychology, surgery, primary care, nursing, public health, and survivor). Analysis of the survey results showed five themes of interest: the effect of the new guidelines on disparities, the necessity of including individualized approaches and shared decision-making to increase engagement and promote equitable care, addressing the suboptimal uptake of lung cancer screening services, improving the implementation of screening in practice, and possibly changing the overall benefit-harm ratio of screening because of the increased size and differential risk characteristics of the expanded eligible population.

Outcomes From More Than 1 Million People Screened for Lung Cancer With Low-Dose CT Imaging

Silvestri GA, Goldman L, Tanner NT, Burleson J, Gould M, Kazerooni
EA, Mazzone PJ, Rivera MP, Doria-Rose VP, Rosenthal LS, Simanowith M, Smith RA, Fedewa S, Outcomes from more than a million persons screened for lung cancer with low-dose computed tomography., CHEST (2023), doi: 10.1016/j.chest.2023.02.003.

This study computed some predictors of adherence to annual lung cancer screening for a cohort of individuals who received a baseline low-dose computed tomography (LDCT) scan for lung cancer screening between 2015 and 2019. On the baseline screen, 83% of the study population had negative screening results, and 17% had positive screening results. The study found annual screening adherence rates of 22.3% and two predictors of poor adherence to be current smoking status and Hispanic or Black race. The overall cancer detection rate in the study population was 0.56%. The cancer stage distribution was 53.5% at stage I cancer and 14.3% at stage IV cancer. A significant stage shift towards early-stage lung cancer was observed, but adherence to annual screening was poor and likely contributed to the lower-than-expected cancer detection rate.

Characteristics of Persons Screened for Lung Cancer in the United States

Silvestri GA, Goldman L, Burleson J, et al. Characteristics of Persons Screened for Lung Cancer in the United States. Ann Intern Med. Published online October 11, 2022. doi:10.7326/M22-1325.

This cohort study analyzed the data reported by 3625 institutions to the American College of Radiology Lung Cancer Screening Registry (ACR LCSR) for over 1 million individuals who received low-dose CT (LDCT) screening from 2014 to 2019. Ninety-one percent of the individuals screened met the 2013 USPSTF guidelines. However, the adherence to repeat annual LDCT screening is low at 22.3%. Individuals screened are generally older, have higher rates of smoking, and are more likely to be female than the population at risk. These considerations are important when interpreting the utility of testing, as the benefits of testing decrease as individuals age. The authors report that screening programs are most effective when individuals are screened early enough to have significant survival outcomes. Additionally, screening recommendations should identify individuals at high risk for lung cancer while also having a life expectancy long enough to benefit from screening.

Geographic access to lung cancer screening among eligible adults living in rural and urban environments in the United States

Sahar L, Wills VAD, Liu KK, Fedewa SA, Rosenthal LS, Kazerooni EA, Dyer DS, Smith RA. Geographic access to lung cancer screening among eligible adults living in rural and urban environments in the United States. Cancer. 2022;128(8):1584-1594. doi:10.1002/cncr.33996

The study used geospatial analysis to evaluate access to lung cancer screening in urban and rural areas within the United States. The analysis expanded on previous studies by using 2021 US Preventive Services Task Force lung cancer screening eligibility recommendations and by evaluating urban-rural differences. Distances of 10, 20, 30, 40, 50, and 100 miles to a screening facility were assessed by census tract and by county. The authors concluded that across all distances and geographies, a larger percentage of rural residents had no access to facilities compared to urban residents. The total number of urban residents who do not have access to screening is larger than the total number of rural residents who do not have access to lung cancer screening.

Lung Cancer Screening Eligibility and Screening Patterns Among Black and White Adults in the United States

Lozier JW, Fedewa SA, Smith RA, Silvestri GA. Lung Cancer Screening Eligibility and Screening Patterns Among Black and White Adults in the United States. JAMA Network Open. 2021;4(10):e2130350. doi:10.1001/jamanetworkopen.2021.30350

The authors analyzed data from Behavioral Risk Factor Surveillance System surveys performed between 2017 and 2019 to determine the proportion of eligible individuals who were being screened for lung cancer using low-dose CT (LDCT). The United States Preventive Services Task Force recommendations for LDCT screening were adjusted in 2021 to include younger individuals with a decreased pack-year history of smoking in hopes of reducing racial disparities. However, the authors found a significant correlation between the rate of LDCT screening and the likelihood of being covered by Medicaid. The authors suggest that racial disparities in lung cancer screening may worsen under the new screening guidelines, even though more at-risk individuals would be eligible for screening.

Lung Cancer Screening Rates During the COVID-19 Pandemic

Fedewa SA, Bandi P, Smith RA, Silvestri GA, Jemal A. Lung Cancer Screening Rates During the COVID-19 Pandemic. CHEST. 2022;161(2):586-589. doi:10.1016/j.chest.2021.07.030

Nationwide lung cancer screening rates were estimated using the number of low-dose CT (LDCT) scans recorded along with the calculated number of eligible individuals based on United States Preventive Services Task Force criteria in 2019-2020: people 55 to 80 years old who currently or formerly smoked cigarettes and quit within the past 15 years, with ≥30 pack-year smoking history. Differences in national lung cancer screening rates using LDCT were not statistically significant between 2019 and 2020. The authors hypothesize that this may be due to the overall underutilization of LDCT for lung cancer screening. However, 19 states experienced significant rate increases, which the authors attribute to concerted state-wide efforts to improve screening rates with programs in place prior to the pandemic. The authors suggest that states with successful screening campaigns could inform best practices to increase lung cancer screening rates nationwide.

If We Build It, They Will Come…Maybe

Sahar L, Smith RA. If We Build It, They Will Come … Maybe. Chest. 2021;160(1):34-35. doi:10.1016/j.chest.2021.04.029

The editorial outlines the low rates of lung cancer screening in the United States, specifically within the Veterans Health Administration (VHA) community. The authors briefly discuss factors leading to low screening rates in rural areas and the need for a governing body to assess the spatial distribution of screening facilities when determining the screening capacity and demand for screening in a specific area. Additionally, the recent broadening of screening criteria from the United States Preventive Services Task Force is attributed to limited access to screening facilities as demand has increased. The authors suggest that the VHA could utilize its unique ability to develop incentives and set expectations to lead the nation in cancer screening uptake.

Proposed Quality Metrics for Lung Cancer Screening Programs

Mazzone PJ, White CS, Kazerooni EA, Smith RA, Thomson CC. Proposed Quality Metrics for Lung Cancer Screening Programs: A National Lung Cancer Roundtable Project. Chest. 2021;160(1):368-378. doi:10.1016/j.chest.2021.01.063

The authors describe an effort by the National Lung Cancer Roundtable (NLCRT) to identify high-quality potential indicators for the quality of lung cancer screening programs. Project leaders developed a list of potential indicators and requested that the NLCRT Implementation Strategies Task Group (ISTG) revise the existing language of the potential indicators and recommend additional indicators. Of the 30 potential indicators, 15 were prioritized by several task group members. A series of surveys of the ISTG members were then used to evaluate the validity, feasibility, and relevance of the proposed indicators and to reach a consensus on six lung cancer screening quality indicators.

State Variation in Low-Dose Computed Tomography Scanning for Lung Cancer Screening in the United States

Fedewa SA, Kazerooni EA, Studts JL, Smith RA, Bandi P, Sauer AG, Cotter M, Sineshaw HM, Jemal A, Silvestri GA. State Variation in Low-Dose Computed Tomography Scanning for Lung Cancer Screening in the United States. JNCI: Journal of the National Cancer Institute. 2021;113(8):1044-1052. doi:10.1093/jnci/djaa170

The authors estimated the low-dose CT lung cancer screening uptake rate between 2016 and 2018 at the state and national levels. The American College of Radiology Lung Cancer Screening Registry, US Census data, population-based surveys, and cancer registry data were used to estimate the number of eligible adults and mortality rates. Lung cancer screening rates in the estimated eligible adults were calculated yearly. Fewer than 1 in 20 eligible adults received screening nationally, and state-specific uptake varied considerably.

Using Geospatial Analysis to Evaluate Access to Lung Cancer Screening in the United States

Sahar L, Douangchai Wills VL, Liu KK, Kazerooni EA, Dyer DS, Smith RA. Using Geospatial Analysis to Evaluate Access to Lung Cancer Screening in the United States. Chest. 2021;159(2):833-844. doi:10.1016/j.chest.2020.08.2081

The authors describe a geospatial investigation of the availability of approved lung cancer screening facilities in the American College of Radiology Lung Cancer Screening Registry to explain the lack of uptake and existing screening disparities. Variations in screening access and uptake are described nationally and at the state level. These variations are combined with data on smoking and mortality rates. Full access to screening was defined as the entire age 55-79 population being within 40 miles of a screening facility. Overall, less than 6% of the age 55-79 population did not have full access to a screening facility. The authors suggest that geographic analysis should be performed regularly to identify gaps in screening accessibility. Limitations of the study and the generalizations required to reach these conclusions were described.

Cancer Outcomes Among Medicare Beneficiaries And Their Younger Uninsured Counterparts

Silvestri GA, Jemal A, Yabroff KR, Fedewa S, Sineshaw H. Cancer Outcomes Among Medicare Beneficiaries And Their Younger Uninsured Counterparts. Health Aff (Millwood). 2021;40(5):754-762. doi:10.1377/hlthaff.2020.01839

The authors describe a retrospective analysis of cancer survival rates among younger uninsured patients aged 60-64 and older Medicare patients aged 66-69. The goal of the study was to compare survival differences between younger uninsured patients and older Medicare patients. Data were taken from the National Cancer Database. The authors found that younger uninsured patients were nearly twice as likely than older Medicare patients to present with late-stage disease and were significantly less likely to receive surgery, chemotherapy, or radiotherapy. Younger, uninsured patients had a strikingly lower five-year survival rate across cancer types. The authors concluded that expanding comprehensive health insurance coverage to individuals aged 60 and above may improve cancer outcomes in the US.

The Integral Role of the Electronic Health Record and Tracking Software in the Implementation of Lung Cancer Screening—A Call to Action to Developers

Fathi JT, White CS, Greenberg GM, Mazzone PJ, Smith RA, Thomson CC. The Integral Role of the Electronic Health Record and Tracking Software in the Implementation of Lung Cancer Screening-A Call to Action to Developers: A White Paper From the National Lung Cancer Roundtable. Chest. 2020;157(6):1674-1679. doi:10.1016/j.chest.2019.12.004

This review describes the role of electronic health records (EHR) and lung cancer screening (LCS) tracking software in implementing lung cancer screening programs designed to increase the percentage of eligible individuals being screened. The authors consider customization, optimization, and integration of EHR with LCS tracking software. Current EHR platforms lack mechanisms to support LCS features directly, and proprietary software is expensive and does not easily integrate with EHR systems. However, integrating lung cancer screening-specific software into EHR has the potential for better workflow, cost savings, and more effective and higher quality patient care.