Lung Cancer Screening in a Safety-Net Hospital: Rare Harms Inform Decision Making

Dismal adherence to lung cancer screening in a diverse urban population

OBJECTIVES

High-risk populations for lung cancer, including Black men and those with lower socioeconomic status, experience worse outcomes when treated. The mortality benefit of lung cancer screening cannot be realized without adherence to annual screening. Our study aims to understand annual adherence to lung cancer screening in a population traditionally experiencing health disparities, thus identifying lung cancer screening's impact on lung cancer disparities.

METHODS

A 10-year retrospective review of patients obtaining initial lung cancer screening (T0) at a safety-net institution was performed. Adherence was defined as lung cancer screening completed 12 to 15 months from prior screening (1 annual = T1, 2 annual = T2, 3 annual = T3). Extended adherence was defined as lung cancer screening completed 12 to 18 months from prior screening. Data were stratified demographically for comparative analysis.

RESULTS

A total of 6983 patients received lung cancer screening over 10 years. Only 8.13% adhered to T1, 3.68% adhered to T2, and 1.35% adhered to T3. Extending the adherence criteria showed minimal improvement: T1 10.54%, T2 4.64%, and T3 3.47%. At all intervals, male patients (vs female patients; T1: 7.37% vs 9.04%, T2: 3.39% vs 4.11%, T3: 2.06% vs 2.33%) and Hispanics (vs Black and White; T1: 7.82% vs 8.53% vs 9.47%, T2: 2.12% vs 3.42% vs 5.12%, T3: 1.02% vs 1.69% vs 3.30%) had worse adherence. A small cohort presented early (1-11 months), a form of adherence not previously reported.

CONCLUSIONS

In a safety-net institution with a diverse population traditionally experiencing disparities, adherence to annual lung cancer screening was low (8.13%) and declining each subsequent year, especially among male and Hispanic patients. Targeted education regarding importance of annual lung cancer screening is needed to realize the lifesaving potential of lung cancer screening.

Utilization of Diagnostic Procedures After Lung Cancer Screening in the National Lung Screening Trial

OBJECTIVE

To examine utilization patterns of diagnostic procedures after lung cancer screening among participants enrolled in the National Lung Screening Trial.

METHODS

Using a sample of National Lung Screening Trial participants with abstracted medical records, we assessed utilization of imaging, invasive, and surgical procedures after lung cancer screening. Missing data were imputed using multiple imputation by chained equations. For each procedure type, we examined utilization within a year after the screening or until the next screen, whichever came first, across arms (low-dose CT [LDCT] versus chest X-ray [CXR]) and by screening results. We also explored factors associated with having these procedures using multivariable negative binomial regressions.

RESULTS

After baseline screening, our sample had 176.5 and 46.7 procedures per 100 person-years for those with a false-positive and negative result, respectively. Invasive and surgical procedures were relatively infrequent. Among those who screened positive, follow-up imaging and invasive procedures were 25% and 34% less frequent in those screened with LDCT, compared with CXR. Postscreening utilization of invasive and surgical procedures was 37% and 34% lower at the first incidence screen compared with baseline. Participants with positive results at baseline were six times more likely to undergo additional imaging than those with normal findings.

DISCUSSION

Use of imaging and invasive procedures to evaluate abnormal findings varied by screening modality, with a lower rate for LDCT than CXR. Invasive and surgical workup were less prevalent after subsequent screening examinations compared with baseline screening. Utilization was associated with older age but not gender, race or ethnicity, insurance status, or income.

The Philadelphia Lung Cancer Learning Community: a multi-health-system, citywide approach to lung cancer screening

BACKGROUND

Lung cancer screening uptake for individuals at high risk is generally low across the United States, and reporting of lung cancer screening practices and outcomes is often limited to single hospitals or institutions. We describe a citywide, multicenter analysis of individuals receiving lung cancer screening integrated with geospatial analyses of neighborhood-level lung cancer risk factors.

METHODS

The Philadelphia Lung Cancer Learning Community consists of lung cancer screening clinicians and researchers at the 3 largest health systems in the city. This multidisciplinary, multi-institutional team identified a Philadelphia Lung Cancer Learning Community study cohort that included 11 222 Philadelphia residents who underwent low-dose computed tomography for lung cancer screening from 2014 to 2021 at a Philadelphia Lung Cancer Learning Community health-care system. Individual-level demographic and clinical data were obtained, and lung cancer screening participants were geocoded to their Philadelphia census tract of residence. Neighborhood characteristics were integrated with lung cancer screening counts to generate bivariate choropleth maps.

RESULTS

The combined sample included 37.8% Black adults, 52.4% women, and 56.3% adults who currently smoke. Of 376 residential census tracts in Philadelphia, 358 (95.2%) included 5 or more individuals undergoing lung cancer screening, and the highest counts were geographically clustered around each health system's screening sites. A relatively low percentage of screened adults resided in census tracts with high tobacco retailer density or high smoking prevalence.

CONCLUSIONS

The sociodemographic characteristics of lung cancer screening participants in Philadelphia varied by health system and neighborhood. These results suggest that a multicenter approach to lung cancer screening can identify vulnerable areas for future tailored approaches to improving lung cancer screening uptake. Future directions should use these findings to develop and test collaborative strategies to increase lung cancer screening at the community and regional levels.