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Slatore CG, Hooker ER, Shull S, Golden SE, Melzer AC. Association of patient and health care organization factors with incidental nodule guidelines adherence: A multi-system observational study. Lung Cancer 2024; 190:107526. [PMID: 38452601 PMCID: PMC10999337 DOI: 10.1016/j.lungcan.2024.107526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 02/01/2024] [Accepted: 02/26/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Health care organizations are increasingly developing systems to ensure patients with pulmonary nodules receive guideline-adherent care. Our goal was to determine patient and organization factors that are associated with radiologist adherence as well as clinician and patient concordance to 2005 Fleischner Society guidelines for incidental pulmonary nodule follow-up. MATERIALS Trained researchers abstracted data from the electronic health record from two Veterans Affairs health care systems for patients with incidental pulmonary nodules as identified by interpreting radiologists from 2008 to 2016. METHODS We classified radiology reports and patient follow-up into two categories. Radiologist-Fleischner Adherence was the agreement between the radiologist's recommendation in the computed tomography report and the 2005 Fleischner Society guidelines. Clinician/Patient-Fleischner Concordance was agreement between patient follow-up and the guidelines. We calculated multivariable-adjusted predicted probabilities for factors associated with Radiologist-Fleischner Adherence and Clinician/Patient-Fleischner Concordance. RESULTS Among 3150 patients, 69% of radiologist recommendations were adherent to 2005 Fleischner guidelines, 4% were more aggressive, and 27% recommended less aggressive follow-up. Overall, only 48% of patients underwent follow-up concordant with 2005 Fleischner Society guidelines, 37% had less aggressive follow-up, and 15% had more aggressive follow-up. Radiologist-Fleischner Adherence was associated with Clinician/Patient-Fleischner Concordance with evidence for effect modification by health care system. CONCLUSION Clinicians and patients seem to follow radiologists' recommendations but often do not obtain concordant follow-up, likely due to downstream differential processes in each health care system. Health care organizations need to develop comprehensive and rigorous tools to ensure high levels of appropriate follow-up for patients with pulmonary nodules.
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Affiliation(s)
- Christopher G Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA; Section of Pulmonary & Critical Care Medicine, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA; Division of Pulmonary & Critical Care Medicine, Department of Medicine, and Department of Radiation Medicine, Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
| | - Elizabeth R Hooker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA
| | - Sarah Shull
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA
| | - Sara E Golden
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA
| | - Anne C Melzer
- Section of Pulmonary & Critical Care Medicine, VA Minneapolis Health Care System, 1 Veterans Dr, Minneapolis, MN 55417, USA
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2
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Lin X, Lei F, Lin J, Li Y, Chen Q, Arbing R, Chen WT, Huang F. Promoting Lung Cancer Screen Decision-Making and Early Detection Behaviors: A Systematic Review and Meta-analysis. Cancer Nurs 2024:00002820-990000000-00227. [PMID: 38498799 DOI: 10.1097/ncc.0000000000001334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND Promoting lung cancer screening (LCS) is complex. Previous studies have overlooked that LCS behaviors are stage based and thus did not identify the characteristics of LCS interventions at different screening stages. OBJECTIVE The aims of this study were to explore the characteristics and efficacy of interventions in promoting LCS decision making and behaviors and to evaluate these interventions. METHODS We conducted a study search from the inception of each bibliographic database to April 8, 2023. The precaution adoption process model was used to synthesize and classify the evidence. The RE-AIM framework was used to evaluate the effectiveness of LCS programs. Heterogeneity tests and meta-analysis were performed using RevMan 5.4 software. RESULTS We included 31 studies that covered 4 LCS topics: knowledge of lung cancer, knowledge of LCS, value clarification exercises, and LCS supportive resources. Patient decision aids outperformed educational materials in improving knowledge and decision outcomes with a significant reduction in decision conflict (standardized mean difference, 0.81; 95% confidence interval, -1.15 to -0.47; P < .001). Completion rates of LCS ranged from 3.6% to 98.8%. Interventions that included screening resources outperformed interventions that used patient decision aids alone in improving LCS completion. The proportions of reported RE-AIM indicators were highest for reach (69.59%), followed by adoption (43.87%), effectiveness (36.13%), implementation (33.33%), and maintenance (9.68%). CONCLUSION Evidence from 31 studies identified intervention characteristics and effectiveness of LCS interventions based on different stages of decision making. IMPLICATIONS FOR PRACTICE It is crucial to develop targeted and systematic interventions based on the characteristics of each stage of LCS to maximize intervention effectiveness and reduce the burden of lung cancer.
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Affiliation(s)
- Xiujing Lin
- Author Affiliations: School of Nursing, Fujian Medical University (Mss X Lin, J Lin, Li, and Q Chen, and Dr Huang), Fuzhou, China; School of Nursing, University of Minnesota (Dr Lei), Twin Cities, Minneapolis; and School of Nursing, University of California Los Angeles (Dr W-T Chen and Ms Arbing)
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3
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Milanese G, Silva M, Ledda RE, Iezzi E, Bortolotto C, Mauro LA, Valentini A, Reali L, Bottinelli OM, Ilardi A, Basile A, Palmucci S, Preda L, Sverzellati N. Study rationale and design of the PEOPLHE trial. LA RADIOLOGIA MEDICA 2024; 129:411-419. [PMID: 38319494 PMCID: PMC10943160 DOI: 10.1007/s11547-024-01764-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/03/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE Lung cancer screening (LCS) by low-dose computed tomography (LDCT) demonstrated a 20-40% reduction in lung cancer mortality. National stakeholders and international scientific societies are increasingly endorsing LCS programs, but translating their benefits into practice is rather challenging. The "Model for Optimized Implementation of Early Lung Cancer Detection: Prospective Evaluation Of Preventive Lung HEalth" (PEOPLHE) is an Italian multicentric LCS program aiming at testing LCS feasibility and implementation within the national healthcare system. PEOPLHE is intended to assess (i) strategies to optimize LCS workflow, (ii) radiological quality assurance, and (iii) the need for dedicated resources, including smoking cessation facilities. METHODS PEOPLHE aims to recruit 1.500 high-risk individuals across three tertiary general hospitals in three different Italian regions that provide comprehensive services to large populations to explore geographic, demographic, and socioeconomic diversities. Screening by LDCT will target current or former (quitting < 10 years) smokers (> 15 cigarettes/day for > 25 years, or > 10 cigarettes/day for > 30 years) aged 50-75 years. Lung nodules will be volumetric measured and classified by a modified PEOPLHE Lung-RADS 1.1 system. Current smokers will be offered smoking cessation support. CONCLUSION The PEOPLHE program will provide information on strategies for screening enrollment and smoking cessation interventions; administrative, organizational, and radiological needs for performing a state-of-the-art LCS; collateral and incidental findings (both pulmonary and extrapulmonary), contributing to the LCS implementation within national healthcare systems.
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Affiliation(s)
- Gianluca Milanese
- Unit of Radiological Sciences, University Hospital of Parma, University of Parma, Parma, Italy
| | - Mario Silva
- Unit of Radiological Sciences, University Hospital of Parma, University of Parma, Parma, Italy
| | - Roberta Eufrasia Ledda
- Unit of Radiological Sciences, University Hospital of Parma, University of Parma, Parma, Italy
| | | | - Chandra Bortolotto
- Diagnostic Imaging Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100, Pavia, Italy
- Radiology Unit-Diagnostic Imaging I, Department of Diagnostic Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Letizia Antonella Mauro
- Radiology Unit 1, University Hospital Policlinico G. Rodolico-San Marco, Catania, Catania, Italy
| | - Adele Valentini
- Radiology Unit-Diagnostic Imaging I, Department of Diagnostic Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Linda Reali
- Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, University Hospital Policlinico G. Rodolico-San Marco, Catania, Italy
| | - Olivia Maria Bottinelli
- Diagnostic Imaging Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100, Pavia, Italy
| | - Adriana Ilardi
- Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, University Hospital Policlinico G. Rodolico-San Marco, Catania, Italy
| | - Antonio Basile
- Radiology Unit 1-Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, University Hospital Policlinico G. Rodolico-San Marco, Catania, Italy
| | - Stefano Palmucci
- UOSD I.P.T.R.A.-Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, University Hospital Policlinico G. Rodolico-San Marco, Catania, Italy
| | - Lorenzo Preda
- Diagnostic Imaging Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100, Pavia, Italy
- Radiology Unit-Diagnostic Imaging I, Department of Diagnostic Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Nicola Sverzellati
- Unit of Radiological Sciences, University Hospital of Parma, University of Parma, Parma, Italy.
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4
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Lee G, Hill LP, Schroeder MC, Kraus SJ, El-Abiad KMB, Hoffman RM. Adherence to Annual Lung Cancer Screening in a Centralized Academic Program. Clin Lung Cancer 2024; 25:e18-e25. [PMID: 37925362 DOI: 10.1016/j.cllc.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/23/2023] [Accepted: 10/09/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Adherence to lung cancer screening (LCS) protocols is critical for achieving mortality reductions. However, adherence rates, particularly for recommended annual screening among patients with low-risk findings, are often sub-optimal. We evaluated annual LCS adherence for patients with low-risk findings participating in a centralized screening program at a tertiary academic center. PATIENTS AND METHODS We conducted a retrospective, observational cohort study of a centralized lung cancer screening program launched in July 2018. We performed electronic medical review of 337 patients who underwent low-dose CT (LDCT) screening before February 1, 2021 (to ensure ≥ 15 months follow up) and had a low-risk Lung-RADS score of 1 or 2. Captured data included patient characteristics (smoking history, Fagerstrom score, environmental exposures, lung cancer risk score), LDCT imaging dates, and Lung-RADS results. The primary outcome measure was adherence to annual screening. We used multivariable logistic regression models to identify factors associated with adherence. RESULTS Overall, 337 patients had an initial Lung-RADS result of 1 (n = 189) or 2 (n = 148). Among this cohort, 139 (73.5%) of Lung-RADS 1 and 111 (75.0%) of Lung-RADS 2 patients completed the annual repeat LDCT within 15 months, respectively. The only patient characteristic associated with adherence was having Medicaid coverage; compared to having private insurance, Medicaid patients were less adherent (adjusted OR = 0.37, 95% CI = 0.15-0.92). No other patient characteristic was associated with adherence. CONCLUSION Our centralized screening program achieved a high initial annual adherence rate. Although LCS has first-dollar insurance coverage, other socioeconomic concerns may present barriers to annual screening for Medicaid recipients.
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Affiliation(s)
- Grace Lee
- University of Iowa Carver College of Medicine, Iowa City, IA.
| | - Laura P Hill
- Internal Medicine Primary Care, Mercy Hospital, St. Louis, MO
| | - Mary C Schroeder
- Division of Health Services Research, University of Iowa College of Pharmacy, Iowa City, IA
| | - Sara J Kraus
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Richard M Hoffman
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa Carver College of Medicine, Iowa City, IA
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Gnanaraj J, Ijaz SH, Khaliq W. Prevalence of hospitalized women at high-risk for developing lung cancer. Postgrad Med 2023; 135:750-754. [PMID: 37773631 DOI: 10.1080/00325481.2023.2265987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 09/28/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Lung cancer screening with low-dose computer tomography (CT) has been shown to reduce the lung cancer mortality in high-risk individuals by 20%. Despite the proven mortality benefit, the utilization of lung cancer screening among high-risk populations remains low. OBJECTIVE This study explores the prevalence of high-risk population for developing lung cancer among hospitalized women and evaluates the screening behavior toward other common cancers during a hospital stay. METHODS This is a cross-sectional study in which 248 cancer-free hospitalized women aged 50-75 years who reported current or prior smoking were enrolled during hospital admission at an academic center. A bedside survey was conducted to collect socio-demographic, cancer screening behavior, and medical comorbidities for the study patients. Unpaired t-test and Chi-square tests were used to compare characteristics and common cancer screening behavior by lung cancer risk stratification. RESULTS Forty-three percent of the hospitalized women were at intermediate to high-risk for developing lung cancer risk. Intermediate to high-risk women were more likely to be older, Caucasian, retired, or with a disability, and had higher comorbidity burden as compared to the low-risk group. Women at low and intermediate to high risk were equally non-adherent with breast (35% vs 31%, p = 0.59) and colorectal (32% vs 24%, p = 0.20) cancers screening guidelines. Only 38% of women from the intermediate to the high-risk group had a CT chest within the last year. CONCLUSION The study's findings suggest that almost half of the hospitalized women who report current or past smoking are at high-risk for developing lung cancer.
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Affiliation(s)
- Jerome Gnanaraj
- Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sardar H Ijaz
- Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Waseem Khaliq
- Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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6
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Shi Y, Guo D, Chun Y, Liu J, Liu L, Tu L, Xu J. A lung cancer risk warning model based on tongue images. Front Physiol 2023; 14:1154294. [PMID: 37324390 PMCID: PMC10267397 DOI: 10.3389/fphys.2023.1154294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/12/2023] [Indexed: 06/17/2023] Open
Abstract
Objective: To investigate the tongue image features of patients with lung cancer and benign pulmonary nodules and to construct a lung cancer risk warning model using machine learning methods. Methods: From July 2020 to March 2022, we collected 862 participants including 263 patients with lung cancer, 292 patients with benign pulmonary nodules, and 307 healthy subjects. The TFDA-1 digital tongue diagnosis instrument was used to capture tongue images, using feature extraction technology to obtain the index of the tongue images. The statistical characteristics and correlations of the tongue index were analyzed, and six machine learning algorithms were used to build prediction models of lung cancer based on different data sets. Results: Patients with benign pulmonary nodules had different statistical characteristics and correlations of tongue image data than patients with lung cancer. Among the models based on tongue image data, the random forest prediction model performed the best, with a model accuracy of 0.679 ± 0.048 and an AUC of 0.752 ± 0.051. The accuracy for the logistic regression, decision tree, SVM, random forest, neural network, and naïve bayes models based on both the baseline and tongue image data were 0.760 ± 0.021, 0.764 ± 0.043, 0.774 ± 0.029, 0.770 ± 0.050, 0.762 ± 0.059, and 0.709 ± 0.052, respectively, while the corresponding AUCs were 0.808 ± 0.031, 0.764 ± 0.033, 0.755 ± 0.027, 0.804 ± 0.029, 0.777 ± 0.044, and 0.795 ± 0.039, respectively. Conclusion: The tongue diagnosis data under the guidance of traditional Chinese medicine diagnostic theory was useful. The performance of models built on tongue image and baseline data was superior to that of the models built using only the tongue image data or the baseline data. Adding objective tongue image data to baseline data can significantly improve the efficacy of lung cancer prediction models.
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Affiliation(s)
- Yulin Shi
- Experimental Education Center of Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Dandan Guo
- School of Basic Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yi Chun
- School of Basic Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jiayi Liu
- School of Basic Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lingshuang Liu
- Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Liping Tu
- School of Basic Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jiatuo Xu
- School of Basic Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Kim RY, Rendle KA, Mitra N, Saia CA, Neslund-Dudas C, Greenlee RT, Burnett-Hartman AN, Honda SA, Simoff MJ, Schapira MM, Croswell JM, Meza R, Ritzwoller DP, Vachani A. Socioeconomic Status as a Mediator of Racial Disparity in Annual Lung Cancer Screening Adherence. Am J Respir Crit Care Med 2023; 207:777-780. [PMID: 36306485 PMCID: PMC10037473 DOI: 10.1164/rccm.202208-1590le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Roger Y. Kim
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Katharine A. Rendle
- Department of Family Medicine and Community Health
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | - Stacey A. Honda
- Center for Integrated Healthcare Research, Kaiser Permanente Hawaii, Oahu, Hawaii
- Hawaii Permanente Medical Group, Oahu, Hawaii
| | - Michael J. Simoff
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Marilyn M. Schapira
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, Pennsylvania
| | - Jennifer M. Croswell
- Healthcare Delivery Research Program, National Cancer Institute, Bethesda, Maryland
| | - Rafael Meza
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | | | - Anil Vachani
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
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Sayani A, Ali MA, Dey P, Corrado AM, Ziegler C, Nicholson E, Lofters A. Interventions Designed to Increase the Uptake of Lung Cancer Screening: An Equity-Oriented Scoping Review. JTO Clin Res Rep 2023; 4:100469. [PMID: 36938372 PMCID: PMC10015251 DOI: 10.1016/j.jtocrr.2023.100469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/17/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Introduction Participation in lung cancer screening (LCS) is lower in populations with the highest burden of lung cancer risk (through the social patterning of smoking behavior) and lowest levels of health care utilization (through structurally inaccessible care) leading to a widening of health inequities. Methods We conducted a scoping review using the Arksey and O'Malley methodological framework to inform equitable access to LCS by illuminating knowledge and implementation gaps in interventions designed to increase the uptake of LCS. We comprehensively searched for LCS interventions (Ovid Medline, Excerpta Medica database, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Scopus from 2000 to June 22, 2021) and included peer-reviewed articles and gray literature published in the English language that describe an intervention designed to increase the uptake of LCS, charted data using our previously published tool and conduced a health equity analysis to determine the intended-unintended and positive-negative outcomes of the interventions for populations experiencing the greatest inequities. Results Our search yielded 3572 peer-reviewed articles and 54,292 pieces of gray literature. Ultimately, we included 35 peer-reviewed articles and one gray literature. The interventions occurred in the United States, United Kingdom, Japan, and Italy, focusing on shared decision-making, the use of electronic health records as reminders, patient navigation, community-based campaigns, and mobile computed tomography scanners. We developed an equity-oriented LCS framework and mapped the dimensions and outcomes of the interventions on access to LCS on the basis of approachability, acceptability, availability, affordability, and appropriateness of the intervention. No intervention was mapped across all five dimensions. Most notably, knowledge and implementation gaps were identified in dimensions of acceptability, availability, and affordability. Conclusions Interventions that were most effective in improving access to LCS targeted priority populations, raised community-level awareness, tailored materials for sociocultural acceptability, did not depend on prior patient engagement/registration with the health care system, proactively considered costs related to participation, and enhanced utilization through informed decision-making.
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Affiliation(s)
- Ambreen Sayani
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Corresponding author. Address for correspondence: Ambreen Sayani, MD, PhD, Women’s College Research Institute, Women’s College Hospital, 76 Grenville St., Toronto, ON M5S 1B2, Canada.
| | - Muhanad Ahmed Ali
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Pooja Dey
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Ann Marie Corrado
- Peter Gilgan Centre for Women’s Cancers, Women’s College Hospital, Toronto, Ontario, Canada
| | - Carolyn Ziegler
- Library Services, Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Aisha Lofters
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Peter Gilgan Centre for Women’s Cancers, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family Medicine, Women’s College Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
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Toumazis I, Cao P, de Nijs K, Bastani M, Munshi V, Hemmati M, Ten Haaf K, Jeon J, Tammemägi M, Gazelle GS, Feuer EJ, Kong CY, Meza R, de Koning HJ, Plevritis SK, Han SS. Risk Model-Based Lung Cancer Screening : A Cost-Effectiveness Analysis. Ann Intern Med 2023; 176:320-332. [PMID: 36745885 PMCID: PMC11025620 DOI: 10.7326/m22-2216] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In their 2021 lung cancer screening recommendation update, the U.S. Preventive Services Task Force (USPSTF) evaluated strategies that select people based on their personal lung cancer risk (risk model-based strategies), highlighting the need for further research on the benefits and harms of risk model-based screening. OBJECTIVE To evaluate and compare the cost-effectiveness of risk model-based lung cancer screening strategies versus the USPSTF recommendation and to explore optimal risk thresholds. DESIGN Comparative modeling analysis. DATA SOURCES National Lung Screening Trial; Surveillance, Epidemiology, and End Results program; U.S. Smoking History Generator. TARGET POPULATION 1960 U.S. birth cohort. TIME HORIZON 45 years. PERSPECTIVE U.S. health care sector. INTERVENTION Annual low-dose computed tomography in risk model-based strategies that start screening at age 50 or 55 years, stop screening at age 80 years, with 6-year risk thresholds between 0.5% and 2.2% using the PLCOm2012 model. OUTCOME MEASURES Incremental cost-effectiveness ratio (ICER) and cost-effectiveness efficiency frontier connecting strategies with the highest health benefit at a given cost. RESULTS OF BASE-CASE ANALYSIS Risk model-based screening strategies were more cost-effective than the USPSTF recommendation and exclusively comprised the cost-effectiveness efficiency frontier. Among the strategies on the efficiency frontier, those with a 6-year risk threshold of 1.2% or greater were cost-effective with an ICER less than $100 000 per quality-adjusted life-year (QALY). Specifically, the strategy with a 1.2% risk threshold had an ICER of $94 659 (model range, $72 639 to $156 774), yielding more QALYs for less cost than the USPSTF recommendation, while having a similar level of screening coverage (person ever-screened 21.7% vs. USPSTF's 22.6%). RESULTS OF SENSITIVITY ANALYSES Risk model-based strategies were robustly more cost-effective than the 2021 USPSTF recommendation under varying modeling assumptions. LIMITATION Risk models were restricted to age, sex, and smoking-related risk predictors. CONCLUSION Risk model-based screening is more cost-effective than the USPSTF recommendation, thus warranting further consideration. PRIMARY FUNDING SOURCE National Cancer Institute (NCI).
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Affiliation(s)
- Iakovos Toumazis
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas (I.T., M.H.)
| | - Pianpian Cao
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan (P.C., J.J.)
| | - Koen de Nijs
- Erasmus MC-University Medical Center, Rotterdam, the Netherlands (K. de N., K. ten H., H.J. de K.)
| | - Mehrad Bastani
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York (M.B.)
| | - Vidit Munshi
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts (V.M., G.S.G.)
| | - Mehdi Hemmati
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas (I.T., M.H.)
| | - Kevin Ten Haaf
- Erasmus MC-University Medical Center, Rotterdam, the Netherlands (K. de N., K. ten H., H.J. de K.)
| | - Jihyoun Jeon
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan (P.C., J.J.)
| | - Martin Tammemägi
- Department of Health Sciences, Brock University, St. Catharines, Ontario, Canada (M.T.)
| | - G Scott Gazelle
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts (V.M., G.S.G.)
| | - Eric J Feuer
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (E.J.F.)
| | - Chung Yin Kong
- Division of General Internal Medicine, Department of Medicine, Mount Sinai Hospital, New York, New York (C.Y.K.)
| | - Rafael Meza
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan, and Department of Integrative Oncology, BC Cancer Research Institute, British Columbia, Canada (R.M.)
| | - Harry J de Koning
- Erasmus MC-University Medical Center, Rotterdam, the Netherlands (K. de N., K. ten H., H.J. de K.)
| | - Sylvia K Plevritis
- Department of Biomedical Data Sciences, Stanford University, Stanford, California (S.K.P.)
| | - Summer S Han
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California (S.S.H.)
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10
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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 1 Million People Screened for Lung Cancer With Low-Dose CT Imaging. Chest 2023:S0012-3692(23)00175-7. [PMID: 36773935 DOI: 10.1016/j.chest.2023.02.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/18/2023] [Accepted: 02/01/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Lung cancer screening (LCS) with low-dose CT (LDCT) imaging was recommended in 2013, making approximately 8 million Americans eligible for LCS. The demographic characteristics and outcomes of individuals screened in the United States have not been reported at the population level. RESEARCH QUESTION What are the outcomes among people screened and entered in the American College of Radiology's Lung Cancer Screening Registry compared with those of trial participants? STUDY DESIGN AND METHODS This was a cohort study of individuals undergoing baseline LDCT imaging for LCS between 201 and 2019. Predictors of adherence to annual screening were computed. LDCT scan interpretations by Lung Imaging Reporting and Data System (Lung-RADS) score, cancer detection rates (CDRs), and stage at diagnosis were compared with National Lung Cancer Screening Trial (NLST) data. RESULTS Adherence was 22.3%, and predictors of poor adherence included current smoking status and Hispanic or Black race. On baseline screening, 83% of patients showed negative results and 17% showed positive screening results. The overall CDR was 0.56%. The percentage of people with cancer detected at baseline was higher in the positive Lung-RADS categories at 0.4% for Lung-RADS category 3, 2.6% for Lung-RADS category 4A, 11.1% for Lung-RADS category 4B, and 19.9% for Lung-RADS category 4X. The cancer stage distribution was similar to that observed in the NLST, with 53.5% of patients receiving a diagnosis of stage I cancer and 14.3% with stage IV cancer. Underreporting into the registry may have occurred. INTERPRETATION This study revealed both the positive aspects of CT scan screening for lung cancer and the challenges that remain. Findings on CT imaging were correlated accurately with lung cancer detection using the Lung-RADS system. A significant stage shift toward early-stage lung cancer was present. Adherence to LCS was poor and likely contributes to the lower than expected cancer detection rate, all of which will impact the outcomes of patients undergoing screening for lung cancer.
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Affiliation(s)
- Gerard A Silvestri
- Division of Pulmonary Medicine, Thoracic Oncology Research Group, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC.
| | | | - Nichole T Tanner
- Division of Pulmonary Medicine, Thoracic Oncology Research Group, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC
| | | | - Michael Gould
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Ella A Kazerooni
- Departments of Radiology and Internal Medicine, University of Michigan/Michigan Medicine, Ann Arbor, MI
| | | | - M Patricia Rivera
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, NC
| | - V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | | | | | | | - Stacey Fedewa
- Intramural Research Department, American Cancer Society, Atlanta, GA
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11
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Nam J, Krishnan G, Shofer S, Navuluri N. Interventions to improve lung cancer screening among racially and ethnically minoritized groups: A scoping review. Lung Cancer 2023; 176:46-55. [PMID: 36610272 DOI: 10.1016/j.lungcan.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/23/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022]
Abstract
Lung cancer screening (LCS) decreases lung cancer related mortality among high-risk people who smoke cigarettes and has been endorsed by the US Preventive Services Task Force (USPSTF) since 2013. However, adoption of LCS has been limited, and disparities in LCS among racially and ethnically minoritized groups have become apparent. While recommendations to improve disparities in LCS have been made, there is a lack of information on how these recommendations have been implemented and their relative effectiveness in improving screening disparities. This scoping review addresses this knowledge gap by examining interventions that have been implemented to improve LCS among racially and ethnically minoritized groups in the United States. A comprehensive search of MEDLINE (via PubMed), EMBASE (via Elsevier), CINAHL Complete (via EBSCO), and Scopus (via Elsevier), for articles from the period 1 January 2010 through 22 October 2021 was completed. Out of 17,045 references screened, only 11 studies describing an intervention to improve disparities in LCS were identified, underscoring the dearth of data on established interventions. The interventions discussed could be categorized into three groups -- patient level (n = 3), clinic/institution level (n = 3), and community level (n = 5) interventions. Of those studies reporting effectiveness data (n = 8), there was substantial heterogeneity in the outcomes measured and their relative effectiveness. We found that interventions which streamlined the LCS process at the level of a single clinic or institution were the most effective in improving LCS. Community-level interventions that focused on engagement and education had the greatest potential to target racially and ethnically minoritized groups. Our study underscores the need for more robust research on addressing barriers to LCS by identifying effective patient, clinic, and community-level interventions to improve LCS disparities and the need for potential standardization of intervention effectiveness outcomes.
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Affiliation(s)
- Jason Nam
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC 27710, USA; Department of Medicine, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - Govind Krishnan
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC 27710, USA.
| | - Scott Shofer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC 27710, USA; Durham Veterans Affairs Medical Center, Durham, NC 27710, USA
| | - Neelima Navuluri
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC 27710, USA; Durham Veterans Affairs Medical Center, Durham, NC 27710, USA; Duke Global Health Institute, Duke University, Durham, NC, USA
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12
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Pérez-Morales J, Pathak R, Reyes M, Tolbert H, Tirbene R, Gray JE, Simmons VN, Schabath MB, Quinn GP. Qualitative Findings From a Survey on Patient Experiences and Satisfaction with Lung Cancer Screening. Cancer Control 2023; 30:10732748231167963. [PMID: 36971270 PMCID: PMC10052477 DOI: 10.1177/10732748231167963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND To reveal successes and potential limitations of the lung cancer screening program, we conducted a survey that included both quantitative and open-ended questions to measure patient experiences and satisfaction with screening. METHODS We report on the five open-ended items related to barriers to returning for screening, experience with other cancer prevention screenings, positive and negative experiences, and suggestions for improving future appointments. The open-ended responses were analyzed using constant comparison method and inductive content analysis. RESULTS Respondents (182 patients, 86% response rate for open-ended questions) provided generally positive comments about their lung cancer screening experience. Negative comments were related to desire for more information about results, long wait times for results, and billing issues. Suggestions for improvements included: scheduling on-line appointments and text or email reminders, lower costs, and responding to uncertainty about eligibility criteria. CONCLUSION Findings provide insights about patient experiences and satisfaction with lung cancer screening which is important given low uptake. Ongoing patient-centered feedback may improve the lung cancer screening experience and increase follow-up screening rates.
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Affiliation(s)
- Jaileene Pérez-Morales
- Department of Cancer Epidemiology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Rashmi Pathak
- Department of Cancer Epidemiology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Monica Reyes
- Department of Cancer Epidemiology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Haley Tolbert
- Department of Thoracic Oncology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Rajwantee Tirbene
- Department of Cancer Epidemiology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jhanelle E Gray
- Department of Thoracic Oncology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Vani N Simmons
- Department of Health Outcomes and Behavior, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Matthew B Schabath
- Department of Cancer Epidemiology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- Department of Thoracic Oncology, 25301H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Gwendolyn P Quinn
- Departments of Obstetrics and Gynecology and Population Health, 12296New York University Grossman School of Medicine, New York, NY, USA
- Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
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13
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Abstract
Lung cancer screening with low-dose computed tomography (LDCT) reduces lung cancer deaths by early detection. The United States Preventive Services Task Force recommends lung cancer screening with LDCT in adults of age 50 years to 80 years who have at least a 20 pack-year smoking history and are currently smoking or have quit within the past 15 years. The implementation of a lung-cancer-screening program is complex. High-quality screening requires the involvement of a multidisciplinary team. The aim of a screening program is to find balance between mortality reduction and avoiding potential harms related to false-positive findings, overdiagnosis, invasive procedures, and radiation exposure. Components and processes of a high-quality lung-cancer-screening program include the identification of eligible individuals, shared decision-making, performing and reporting LDCT results, management of screen-detected lung nodules and non-nodule findings, smoking cessation, ensuring adherence, data collection, and quality improvement.
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Affiliation(s)
- Humberto K Choi
- Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue Mail Code A90, Cleveland, OH 44195, USA.
| | - Peter J Mazzone
- Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue Mail Code A90, Cleveland, OH 44195, USA
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14
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Silvestri GA, Goldman L, Burleson J, Gould M, Kazerooni EA, Mazzone PJ, Rivera MP, Doria-Rose VP, Rosenthal LS, Simanowith M, Smith RA, Tanner NT, Fedewa S. Characteristics of Persons Screened for Lung Cancer in the United States : A Cohort Study. Ann Intern Med 2022; 175:1501-1505. [PMID: 36215712 DOI: 10.7326/m22-1325] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Lung cancer screening (LCS) with low-dose computed tomography (LDCT) was recommended by the U.S. Preventive Services Task Force (USPSTF) in 2013, making approximately 8 million Americans eligible for screening. The demographic characteristics and adherence of persons screened in the United States have not been reported at the population level. OBJECTIVE To define sociodemographic characteristics and adherence among persons screened and entered into the American College of Radiology's Lung Cancer Screening Registry (LCSR). DESIGN Cohort study. SETTING United States, 2015 to 2019. PARTICIPANTS Persons receiving a baseline LDCT for LCS from 3625 facilities reporting to the LCSR. MEASUREMENTS Age, sex, and smoking status distributions (percentages) were computed among persons who were screened and among respondents in the 2015 National Health Interview Survey (NHIS) who were eligible for screening. The prevalence between the LCSR and the NHIS was compared with prevalence ratios (PRs) and 95% CIs. Adherence to annual screening was defined as having a follow-up test within 11 to 15 months of an initial LDCT. RESULTS Among 1 159 092 persons who were screened, 90.8% (n = 1 052 591) met the USPSTF eligibility criteria. Compared with adults from the NHIS who met the criteria (n = 1257), screening recipients in the LCSR were older (34.7% vs. 44.8% were aged 65 to 74 years; PR, 1.29 [95% CI, 1.20 to 1.39]), more likely to be female (41.8% vs. 48.1%; PR, 1.15 [CI, 1.08 to 1.23]), and more likely to currently smoke (52.3% vs. 61.4%; PR, 1.17 [CI, 1.11 to 1.23]). Only 22.3% had a repeated annual LDCT. If follow-up was extended to 24 months and more than 24 months, 34.3% and 40.3% were adherent, respectively. LIMITATIONS Underreporting of LCS and missing data may skew demographic characteristics of persons reported to be screened. Underreporting of adherence may result in underestimates of follow-up. CONCLUSION Approximately 91% of persons who had LCS met USPSTF eligibility criteria. In addition to continuing to target all eligible adults, men, those who formerly smoked, and younger eligible patients may be less likely to be screened. Adherence to annual follow-up screening was poor, potentially limiting screening effectiveness. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Gerard A Silvestri
- Division of Pulmonary Medicine, Thoracic Oncology Research Group, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina (G.A.S., N.T.T.)
| | - Lenka Goldman
- American College of Radiology, Reston, Virginia (L.G., J.B., M.S.)
| | - Judy Burleson
- American College of Radiology, Reston, Virginia (L.G., J.B., M.S.)
| | - Michael Gould
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California (M.G.)
| | - Ella A Kazerooni
- Departments of Radiology and Internal Medicine, University of Michigan/Michigan Medicine, Ann Arbor, Michigan (E.A.K.)
| | - Peter J Mazzone
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio (P.J.M.)
| | - M Patricia Rivera
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina (M.P.R.)
| | - V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (V.P.D.)
| | - Lauren S Rosenthal
- Cancer Prevention and Early Detection Department, American Cancer Society, Atlanta, Georgia (L.S.R., R.A.S.)
| | | | - Robert A Smith
- Cancer Prevention and Early Detection Department, American Cancer Society, Atlanta, Georgia (L.S.R., R.A.S.)
| | - Nichole T Tanner
- Division of Pulmonary Medicine, Thoracic Oncology Research Group, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina (G.A.S., N.T.T.)
| | - Stacey Fedewa
- Intramural Research Department, American Cancer Society, Atlanta, Georgia (S.F.)
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15
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Rivera MP, Durham DD, Long JM, Perera P, Lane L, Lamb D, Metwally E, Henderson LM. Receipt of Recommended Follow-up Care After a Positive Lung Cancer Screening Examination. JAMA Netw Open 2022; 5:e2240403. [PMID: 36326760 PMCID: PMC9634495 DOI: 10.1001/jamanetworkopen.2022.40403] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022] Open
Abstract
Importance Maximizing benefits of lung cancer screening requires timely follow-up after a positive screening test. The American College of Radiology (ACR) Lung CT Screening Reporting and Data System (Lung-RADS) recommends testing and follow-up timing based on the screening result. Objective To determine rates of and factors associated with recommended follow-up after a positive lung cancer screening examination by Lung-RADS category. Design, Setting, and Participants This prospective cohort study of lung cancer screening examinations performed from January 1, 2015, through July 31, 2020, with follow-up through July 31, 2021, was conducted at 5 academic and community lung cancer screening sites in North Carolina. Participants included 685 adults with a positive screening examination, Lung-RADS categories 3, 4A, 4B, or 4X. Statistical analysis was performed from December 2020 to March 2022. Exposures Individual age, race, sex, smoking exposure, year of lung cancer screening examination, chronic obstructive pulmonary disease, body mass index, referring clinician specialty, rural or urban residence. Main Outcomes and Measures Adherence, defined as receipt of recommended follow-up test or procedure after the positive screen per ACR Lung-RADS timeframes: 6 months for Lung-RADS 3 and 3 months for Lung-RADS 4A. For Lung-RADS 4B or 4X, adherence was defined as follow-up care within 4 weeks, as ACR Lung-RADS does not specify a timeframe. Results Among the 685 individuals included in this study who underwent lung cancer screening with low-dose computed tomography, 416 (60.7%) were aged at least 65 years, 123 (18.0%) were Black, 562 (82.0%) were White, and 352 (51.4%) were male. Overall adherence to recommended follow-up was 42.6% (292 of 685) and varied by Lung-RADS category: Lung-RADS 3 = 30.0% (109 of 363), Lung-RADS 4A = 49.5% (96 of 194), Lung-RADS 4B or 4X = 68.0% (87 of 128). Extending the follow-up time increased adherence: Lung-RADS 3 = 68.6% (249 of 363) within 9 months, Lung-RADS 4A = 77.3% (150 of 194) within 5 months, and Lung-RADS 4B or 4X = 80.5% (103 of 128) within 62 days. For Lung-RADS 3, recommended follow-up was less likely among those currently smoking vs those who quit (adjusted odds ratio [aOR], 0.48; 95% CI, 0.29-0.78). In Lung-RADS 4A, recommended follow-up was less likely in Black individuals vs White individuals (aOR, 0.35; 95% CI, 0.15-0.86). For Lung-RADS 4B or 4X, recommended follow-up was more likely in female individuals vs male individuals (aOR, 2.82; 95% CI, 1.09-7.28) and less likely in those currently smoking vs those who quit (aOR, 0.31; 95% CI, 0.12-0.80). Conclusions and Relevance In this cohort study, adherence to recommended follow-up after a positive screening examination was low but improved among nodules with a higher suspicion of cancer and after extending the follow-up timeline. However, the association of extending the follow-up time of screen-detected nodules with outcomes at the population level, outside of a clinical trial, is unknown. These findings suggest that studies to understand why recommended follow-up is lower in Black individuals, male individuals, and individuals currently smoking are needed to develop strategies to improve adherence.
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Affiliation(s)
- M. Patricia Rivera
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rochester University Medical Center, Rochester, New York
- Wilmot Cancer Institute, University of Rochester, Rochester, New York
| | | | - Jason M. Long
- Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina, Chapel Hill
| | - Pasangi Perera
- Department of Radiology, The University of North Carolina, Chapel Hill
| | - Lindsay Lane
- Department of Radiology, The University of North Carolina, Chapel Hill
| | - Derek Lamb
- Department of Radiology, The University of North Carolina, Chapel Hill
| | - Eman Metwally
- Lineberger Comprehensive Cancer Center, The University of North Carolina, Chapel Hill
| | - Louise M. Henderson
- Department of Radiology, The University of North Carolina, Chapel Hill
- Lineberger Comprehensive Cancer Center, The University of North Carolina, Chapel Hill
- Department of Epidemiology, The University of North Carolina, Chapel Hill
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16
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Kim RY, Rendle KA, Mitra N, Saia CA, Neslund-Dudas C, Greenlee RT, Burnett-Hartman AN, Honda SA, Simoff MJ, Schapira MM, Croswell JM, Meza R, Ritzwoller DP, Vachani A. Racial Disparities in Adherence to Annual Lung Cancer Screening and Recommended Follow-Up Care: A Multicenter Cohort Study. Ann Am Thorac Soc 2022; 19:1561-1569. [PMID: 35167781 PMCID: PMC9447384 DOI: 10.1513/annalsats.202111-1253oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/14/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: Black patients receive recommended lung cancer screening (LCS) follow-up care less frequently than White patients, but it is unknown if this racial disparity persists across both decentralized and centralized LCS programs. Objectives: To determine adherence to American College of Radiology Lung Imaging Reporting and Data System (Lung-RADS) recommendations among individuals undergoing LCS at either decentralized or centralized programs and to evaluate the association of race with LCS adherence. Methods: We performed a multicenter retrospective cohort study of patients receiving LCS at five heterogeneous U.S. healthcare systems. We calculated adherence to annual LCS among patients with a negative baseline screen (Lung-RADS 1 or 2) and recommended follow-up care among those with a positive baseline screen (Lung-RADS 3, 4A, 4B, or 4X) stratified by type of LCS program and evaluated the association between race and adherence using multivariable modified Poisson regression. Results: Of the 6,134 total individuals receiving LCS, 5,142 (83.8%) had negative baseline screens, and 992 (16.2%) had positive baseline screens. Adherence to both annual LCS (34.8% vs. 76.1%; P < 0.001) and recommended follow-up care (63.9% vs. 74.6%; P < 0.001) was lower at decentralized compared with centralized programs. Among individuals with negative baseline screens, a racial disparity in adherence was observed only at decentralized screening programs (interaction term, P < 0.001). At decentralized programs, Black race was associated with 27% reduced adherence to annual LCS (adjusted relative risk [aRR], 0.73; 95% confidence interval [CI], 0.63-0.84), whereas at centralized programs, no effect by race was observed (aRR, 0.98; 95% CI, 0.91-1.05). In contrast, among those with positive baseline screens, there was no significant difference by race for adherence to recommended follow-up care by type of LCS program (decentralized aRR, 0.95; 95% CI, 0.81-1.11; centralized aRR, 0.81; 95% CI, 0.71-0.93; interaction term, P = 0.176). Conclusions: In this large multicenter study of individuals screened for lung cancer, adherence to both annual LCS and recommended follow-up care was greater at centralized screening programs. Black patients were less likely to receive annual LCS than White patients at decentralized compared with centralized LCS programs. Our results highlight the need for further study of healthcare system-level mechanisms to optimize longitudinal LCS care.
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Affiliation(s)
- Roger Y. Kim
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Katharine A. Rendle
- Department of Family Medicine and Community Health
- Department of Biostatistics, Epidemiology, and Informatics, and
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, and
| | | | | | | | | | - Stacey A. Honda
- Center for Health Research, Kaiser Permanente Hawaii, Oahu, Hawaii
| | - Michael J. Simoff
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Marilyn M. Schapira
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer M. Croswell
- Healthcare Delivery Research Program, National Cancer Institute, Bethesda, Maryland; and
| | - Rafael Meza
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | | | - Anil Vachani
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
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17
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Smith HB, Schneider E, Tanner NT. An Evaluation of Annual Adherence to Lung Cancer Screening in a Large National Cohort. Am J Prev Med 2022; 63:e59-e64. [PMID: 35365394 DOI: 10.1016/j.amepre.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 01/03/2022] [Accepted: 01/23/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Lung cancer screening reduces mortality in large RCTs where adherence is high. Unfortunately, recently published adherence rates do not replicate those seen in trials. Previous publications support a centralized approach to ensure patient eligibility and improve adherence. METHODS Investigators reviewed a large, geographically diverse cohort of patients from 14 health systems, with 73 centers across the U.S. Lung cancer screening patients were screened from 2015 to 2019 and tracked utilizing a commercial system. Data were analyzed in 2019-2021. Demographics, eligibility, imaging results, and cancer diagnosis were collected. Overall return was calculated for 2 years (Time 0-Time 1 and Time 1-Time 2) on the basis of follow-up through March 31, 2020. Only U.S. Preventive Services Task Force-eligible patients with a normal or benign result (Lung-Reporting and Data System 1 or 2) at baseline (Time 0) were included in annual adherence calculations. RESULTS A total of 30,166 patients were screened; 50% were male, with a mean age of 65 years. Most individuals currently smoked (58.3%), with an average of 48.3 pack years. A total of 58% were White, 6% were Black, and 34% had race information unavailable. U.S. Preventive Services Task Force eligibility criteria were not met by 10.6%. Of the 26,958 patients eligible at baseline, 76% were Lung-Reporting and Data System 1 or 2. Annual adherence at Year 1 (Time 0-Time 1) was 48.4%. Adherence at Year 2 (Time 1-Time 2) was 44.4%. A total of 93 U.S. Preventive Services Task Force‒eligible patients were diagnosed with lung cancers, mostly during the first annual follow-up. CONCLUSIONS In this large cohort screened and managed primarily using a commercial tracking platform, most patients were U.S. Preventive Services Task Force eligible. However, annual adherence was poor despite this resource, suggesting that additional interventions are needed to recognize the full mortality benefit from screening programs.
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Affiliation(s)
- Harrison B Smith
- Thoracic Oncology Research Group (TORG), Division of Pulmonary and Critical Care, College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | | | - Nichole T Tanner
- Thoracic Oncology Research Group (TORG), Division of Pulmonary and Critical Care, College of Medicine, Medical University of South Carolina, Charleston, South Carolina; Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.
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18
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The Chain of Adherence for Incidentally Detected Pulmonary Nodules after an Initial Radiologic Imaging Study: A Multisystem Observational Study. Ann Am Thorac Soc 2022; 19:1379-1389. [PMID: 35167780 DOI: 10.1513/annalsats.202111-1220oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Rationale: Millions of people are diagnosed with incidental pulmonary nodules every year. Although most nodules are benign, it is universally recommended that all patients be assessed to determine appropriate follow-up and ensure that it is obtained. Objectives: To determine the degree of concordance and adherence to 2005 Fleischner Society guidelines among radiologists, clinicians, and patients at two Veterans Affairs healthcare systems with incidental nodule tracking systems. Methods: Trained researchers abstracted data from the electronic health records of patients with incidental pulmonary nodules as identified by interpreting radiologists from 2008 to 2016. We classified radiology reports and patient follow-up into three categories. Radiologist-Fleischner adherence was the agreement between the radiologist's recommendation in the computed tomography (CT) report and the 2005 Fleischner Society guidelines. Clinician/patient-Fleischner concordance was agreement between patient follow-up and the guidelines. Clinician/patient-radiologist adherence was agreement between the radiologist's recommendation and patient follow-up. We evaluated whether the recommendation or follow-up was more (e.g., sooner) or less (e.g., later) aggressive than recommended. Results: After exclusions, 4,586 patients with 7,408 imaging tests (n = 4,586 initial chest CT scans; n = 2,717 follow-up chest CT scans; n = 105 follow-up low-dose CT scans) were included. Among radiology reports that could be classified in terms of Fleischner Society guidelines (n = 3,150), 80% had nonmissing radiologist recommendations. Among those reports, radiologist-Fleischner adherence was 86.6%, with 4.8% more aggressive and 8.6% less aggressive. Among patients whose initial scans could be classified, clinician/patient-Fleischner concordance was 46.0%, 14.5% were more aggressive, and 39.5% were less aggressive. Clinician/patient-radiologist adherence was 54.3%. Veterans whose radiology reports were adherent to Fleischner Society guidelines had a substantially higher proportion of clinician/patient-Fleischner concordance: 52.0% concordance among radiologist-Fleischner adherent versus 11.6% concordance among radiologist-Fleischner nonadherent. Conclusions: In this multi-health system observational study of incidental pulmonary nodule follow-up, we found that radiologist adherence to 2005 Fleischner Society guidelines may be necessary but not sufficient. Our results highlight the many facets of care processes that must occur to achieve guideline-concordant care.
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19
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Bernstein E, Bade BC, Akgün KM, Rose MG, Cain HC. Barriers and facilitators to lung cancer screening and follow-up. Semin Oncol 2022; 49:S0093-7754(22)00058-6. [PMID: 35927099 DOI: 10.1053/j.seminoncol.2022.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 12/15/2022]
Abstract
Two randomized trials have shown that lung cancer screening (LCS) with low dose computed tomography (LDCT) reduces lung cancer mortality in patients at high-risk for lung malignancy by identifying early-stage cancers, when local cure and control is achievable. The implementation of LCS in the United States has revealed multiple barriers to preventive cancer care. Rates of LCS are disappointingly low with estimates between 5%-18% of eligible patients screened. Equally concerning, follow-up after baseline screening is far lower than that of clinical trials (44-66% v >90%). To optimize the benefits of LCS, programs must identify and address factors related to LCS participation and follow-up while concurrently recognizing and mitigating barriers. As a relatively new screening test, the most effective processes for LCS are uncertain. Therefore, LCS programs have adopted a wide range of approaches without clearly established best practices to guide them, particularly in rural and resource-limited settings. In this narrative review, we identify barriers and facilitators to LCS, focusing on those studies in non-clinical trial settings - reflecting "real world" challenges. Our goal is to identify effective and scalable LCS practices that will increase LCS participation, improve adherence to follow-up, inform strategies for quality improvement, and support new research approaches.
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Affiliation(s)
- Ethan Bernstein
- Veterans Administration (VA) Connecticut Healthcare System, Section of Pulmonary, Critical Care, and Sleep Medicine, West Haven, CT, USA; Yale School of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, New Haven, CT, USA
| | - Brett C Bade
- Veterans Administration (VA) Connecticut Healthcare System, Section of Pulmonary, Critical Care, and Sleep Medicine, West Haven, CT, USA; Yale School of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, New Haven, CT, USA; Veterans Administration (VA) Connecticut Healthcare System, Pain Research, Informatics, Multi-morbidities, and Education Center, West Haven, CT, USA
| | - Kathleen M Akgün
- Veterans Administration (VA) Connecticut Healthcare System, Section of Pulmonary, Critical Care, and Sleep Medicine, West Haven, CT, USA; Yale School of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, New Haven, CT, USA; Veterans Administration (VA) Connecticut Healthcare System, Pain Research, Informatics, Multi-morbidities, and Education Center, West Haven, CT, USA
| | - Michal G Rose
- Veterans Administration (VA) Connecticut Healthcare System, Section of Hematology/Oncology, West Haven, CT, USA; Yale School of Medicine, Section of Medical Oncology, New Haven, CT, USA
| | - Hilary C Cain
- Veterans Administration (VA) Connecticut Healthcare System, Section of Pulmonary, Critical Care, and Sleep Medicine, West Haven, CT, USA; Yale School of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, New Haven, CT, USA.
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20
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Maurice NM, Tanner NT. Lung cancer screening at the VA: Past, present and future. Semin Oncol 2022; 49:S0093-7754(22)00041-0. [PMID: 35831214 DOI: 10.1053/j.seminoncol.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 06/04/2022] [Indexed: 11/11/2022]
Abstract
Lung cancer is responsible for more deaths annually in the United States than breast, prostate and colon cancers combined. Lung cancer screening with annual low-dose computed tomography reduces lung cancer mortality in high-risk patients through early detection. The incidence of lung cancer is higher in the veteran population compared to the general population due, in part, to the prevalence of tobacco use. Early detection of lung cancer is therefore an important goal of the Veterans Health Administration (VHA), the largest integrated health care system in the United States. The following will review previous and current initiatives undertaken by the VHA to implement and expand access to lung cancer screening and will highlight target areas of interest to improve uptake and quality of lung cancer screening. Through these initiatives and programs, the VHA aims to provide high quality and equitable access to lung cancer screening for all Veterans that incorporates research that will improve outcomes and potentially inform and optimize the practice of Lung cancer screening across the United States.
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Affiliation(s)
- Nicholas M Maurice
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA, U.S.A.; Atlanta Veterans Affairs Health Care System, Decatur, GA.
| | - Nichole T Tanner
- Ralph H. Johnson Veterans Affairs Hospital, Health Equity and Rural Outreach Innovation Center (HEROIC), Charleston, SC, U.S.A.; Medical University of South Carolina, Thoracic Oncology Research Group, Division of Pulmonary and Critical Care, Charleston, SC, U.S.A
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21
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Spalluto LB, Lewis JA, Samuels LR, Callaway-Lane C, Matheny ME, Denton J, Robles JA, Dittus RS, Yankelevitz DF, Henschke CI, Massion PP, Moghanaki D, Roumie CL. Association of Rurality With Annual Repeat Lung Cancer Screening in the Veterans Health Administration. J Am Coll Radiol 2022; 19:131-138. [PMID: 35033300 PMCID: PMC8830608 DOI: 10.1016/j.jacr.2021.08.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE Lung cancer causes the largest number of cancer-related deaths in the United States. Lung cancer incidence rates, mortality rates, and rates of advanced stage disease are higher among those who live in rural areas. Known disparities in lung cancer outcomes between rural and nonrural populations may be in part because of barriers faced by rural populations. The authors tested the hypothesis that among Veterans who receive initial lung cancer screening, rural Veterans would be less likely to complete annual repeat screening than nonrural Veterans. METHODS A retrospective cohort study was conducted of 10 Veterans Affairs medical centers from 2015 to 2019. Rural and nonrural Veterans undergoing lung cancer screening were identified. Rural status was defined using the rural-urban commuting area codes. The primary outcome was annual repeat lung cancer screening in the 9- to 15-month window (primary analysis) and 31-day to 18-month window (sensitivity analysis) after the first documented lung cancer screening. To examine rurality as a predictor of annual repeat lung cancer screening, multivariable logistic regression models were used. RESULTS In the final analytic sample of 11,402 Veterans, annual repeat lung cancer screening occurred in 27.7% of rural Veterans (641 of 2,316) and 31.8% of nonrural Veterans (2,891 of 9,086) (adjusted odds ratio: 0.86; 95% confidence interval: 0.73-1.03). Similar results were seen in the sensitivity analysis, with 41.6% of rural Veterans (963 of 2,316) versus 45.2% of nonrural Veterans (4,110 of 9,086) (adjusted odds ratio: 0.88; 95% confidence interval: 0.73-1.04) having annual repeat screening in the expanded 31-day to 18-month window. CONCLUSIONS Among a national cohort of Veterans, rural residence was associated with numerically lower odds of annual repeat lung cancer screening than nonrural residence. Continued, intentional outreach efforts to increase annual repeat lung cancer screening among rural Veterans may offer an opportunity to decrease deaths from lung cancer.
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Affiliation(s)
- Lucy B. Spalluto
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Department of Radiology, Vanderbilt University Medical Center, Nashville, TN,Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Jennifer A. Lewis
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Vanderbilt-Ingram Cancer Center, Nashville, TN,Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Lauren R. Samuels
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Carol Callaway-Lane
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN
| | - Michael E. Matheny
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | - Jason Denton
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | - Jennifer A. Robles
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Veterans Health Administration – Tennessee Valley Healthcare System, Surgery Service, Nashville, TN,Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Robert S. Dittus
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | | | - Claudia I. Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY,Phoenix Veterans Health Care System, Phoenix, AZ
| | - Pierre P. Massion
- Vanderbilt-Ingram Cancer Center, Nashville, TN,Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN,Veterans Health Administration – Tennessee Valley Healthcare System, Medical Service, Nashville, TN
| | - Drew Moghanaki
- Radiation Oncology, Greater Los Angeles Veterans Affairs Medical Center, Los Angeles, CA,Department of Radiation Oncology, University of California at Los Angeles, Los Angeles, CA
| | - Christianne L. Roumie
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
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22
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Toumazis I, de Nijs K, Cao P, Bastani M, Munshi V, ten Haaf K, Jeon J, Gazelle GS, Feuer EJ, de Koning HJ, Meza R, Kong CY, Han SS, Plevritis SK. Cost-effectiveness Evaluation of the 2021 US Preventive Services Task Force Recommendation for Lung Cancer Screening. JAMA Oncol 2021; 7:1833-1842. [PMID: 34673885 PMCID: PMC8532037 DOI: 10.1001/jamaoncol.2021.4942] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
IMPORTANCE The US Preventive Services Task Force (USPSTF) issued its 2021 recommendation on lung cancer screening, which lowered the starting age for screening from 55 to 50 years and the minimum cumulative smoking exposure from 30 to 20 pack-years relative to its 2013 recommendation. Although costs are expected to increase because of the expanded screening eligibility criteria, it is unknown whether the new guidelines for lung cancer screening are cost-effective. OBJECTIVE To evaluate the cost-effectiveness of the 2021 USPSTF recommendation for lung cancer screening compared with the 2013 recommendation and to explore the cost-effectiveness of 6 alternative screening strategies that maintained a minimum cumulative smoking exposure of 20 pack-years and an ending age for screening of 80 years but varied the starting ages for screening (50 or 55 years) and the number of years since smoking cessation (≤15, ≤20, or ≤25). DESIGN, SETTING, AND PARTICIPANTS A comparative cost-effectiveness analysis using 4 independently developed microsimulation models that shared common inputs to assess the population-level health benefits and costs of the 2021 recommended screening strategy and 6 alternative screening strategies compared with the 2013 recommended screening strategy. The models simulated a 1960 US birth cohort. Simulated individuals entered the study at age 45 years and were followed up until death or age 90 years, corresponding to a study period from January 1, 2005, to December 31, 2050. EXPOSURES Low-dose computed tomography in lung cancer screening programs with a minimum cumulative smoking exposure of 20 pack-years. MAIN OUTCOMES AND MEASURES Incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) of the 2021 vs 2013 USPSTF lung cancer screening recommendations as well as 6 alternative screening strategies vs the 2013 USPSTF screening strategy. Strategies with a mean ICER lower than $100 000 per QALY were deemed cost-effective. RESULTS The 2021 USPSTF recommendation was estimated to be cost-effective compared with the 2013 recommendation, with a mean ICER of $72 564 (range across 4 models, $59 493-$85 837) per QALY gained. The 2021 recommendation was not cost-effective compared with 6 alternative strategies that used the 20 pack-year criterion. Strategies associated with the most cost-effectiveness included those that expanded screening eligibility to include a greater number of former smokers who had not smoked for a longer duration (ie, ≤20 years and ≤25 years since smoking cessation vs ≤15 years since smoking cessation). In particular, the strategy that screened former smokers who quit within the past 25 years and began screening at age 55 years was associated with screening coverage closest to that of the 2021 USPSTF recommendation yet yielded greater cost-effectiveness, with a mean ICER of $66 533 (range across 4 models, $55 693-$80 539). CONCLUSIONS AND RELEVANCE This economic evaluation found that the 2021 USPSTF recommendation for lung cancer screening was cost-effective; however, alternative screening strategies that maintained a minimum cumulative smoking exposure of 20 pack-years but included individuals who quit smoking within the past 25 years may be more cost-effective and warrant further evaluation.
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Affiliation(s)
- Iakovos Toumazis
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
| | - Koen de Nijs
- Erasmus Medical Center, Rotterdam, the Netherlands
| | - Pianpian Cao
- Department of Epidemiology, University of Michigan, Ann Arbor
| | - Mehrad Bastani
- Feinstein Institute for Medical Research, Northwell Health, New York, New York
| | - Vidit Munshi
- Department of Radiology, Massachusetts General Hospital, Boston
| | | | - Jihyoun Jeon
- Department of Epidemiology, University of Michigan, Ann Arbor
| | | | - Eric J. Feuer
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | | | - Rafael Meza
- Department of Epidemiology, University of Michigan, Ann Arbor
| | - Chung Yin Kong
- Division of General Internal Medicine, Department of Medicine, Mount Sinai Hospital, New York, New York
| | - Summer S. Han
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California
| | - Sylvia K. Plevritis
- Department of Biomedical Data Sciences, Stanford University, Stanford, California
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23
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Bastani M, Patel D, Silvestri G, Raoof S, Chusid J, Cohen SL. Factors Associated With Lung Cancer Screening Adherence Among Patients With Negative Baseline CT Results in a Community Health Care Setting. J Am Coll Radiol 2021; 19:232-239. [PMID: 34861204 DOI: 10.1016/j.jacr.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/01/2021] [Accepted: 10/01/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Lung cancer screening (LCS) decreases lung cancer mortality; however, that reduction depends upon screening adherence. The purpose of this study was to determine factors associated with adherence rate for LCS among patients with negative baseline CT results in a multi-integrated health care network. METHODS A retrospective analysis was conducted among patients with negative baseline CT results in a multi-integrated health care network LCS program between January 2015 and January 2020. The two outcomes were adherence for the first and second subsequent LCS studies. Negative baseline result was defined as a Lung CT Screening Reporting and Data System score 0, 1, or 2. Adherence was defined as undergoing a follow-up study within 11 to 15 months of a prior scan. Multivariable logistic regression was used to determine significant predictors of adherence, adjusting for patient demographics, median household income (on the basis of geocoding ZIP codes from the US Census Bureau), smoking history, screening sites, and provider specialty. RESULTS A total of 30.7% (512 of 1,668) and 16.3% (270 of 1,660) of patients were adherent for the first two annual subsequent screens, respectively. First-year adherence was higher among former smokers and varied by site and provider specialty. Second-year adherence was higher among former smokers and varied by site, provider specialty, and pack-years smoked. CONCLUSIONS Adherence to LCS in a multihospital integrated health care network was poor and even lower at year 2. The identified factors associated with adherence may serve as targets to increase LCS adherence and decrease lung cancer mortality.
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Affiliation(s)
- Mehrad Bastani
- Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York.
| | - Dhara Patel
- Department of Pulmonary Medicine, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Manhasset, New York
| | - Gerard Silvestri
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Suhail Raoof
- Department of Pulmonary Medicine, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Manhasset, New York
| | - Jesse Chusid
- Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York
| | - Stuart L Cohen
- Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York; Department of Pulmonary Medicine, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Manhasset, New York
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24
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Mazzone PJ, Silvestri GA, Souter LH, Caverly TJ, Kanne JP, Katki HA, Wiener RS, Detterbeck FC. Screening for Lung Cancer: CHEST Guideline and Expert Panel Report. Chest 2021; 160:e427-e494. [PMID: 34270968 PMCID: PMC8727886 DOI: 10.1016/j.chest.2021.06.063] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/11/2021] [Accepted: 06/16/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Low-dose chest CT screening for lung cancer has become a standard of care in the United States, in large part because of the results of the National Lung Screening Trial (NLST). Additional evidence supporting the net benefit of low-dose chest CT screening for lung cancer, and increased experience in minimizing the potential harms, has accumulated since the prior iteration of these guidelines. Here, we update the evidence base for the benefit, harms, and implementation of low-dose chest CT screening. We use the updated evidence base to provide recommendations where the evidence allows, and statements based on experience and expert consensus where it does not. METHODS Approved panelists reviewed previously developed key questions using the Population, Intervention, Comparator, Outcome format to address the benefit and harms of low-dose CT screening, and key areas of program implementation. A systematic literature review was conducted using MEDLINE via PubMed, Embase, and the Cochrane Library on a quarterly basis since the time of the previous guideline publication. Reference lists from relevant retrievals were searched, and additional papers were added. Retrieved references were reviewed for relevance by two panel members. The quality of the evidence was assessed for each critical or important outcome of interest using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Meta-analyses were performed when enough evidence was available. Important clinical questions were addressed based on the evidence developed from the systematic literature review. Graded recommendations and ungraded statements were drafted, voted on, and revised until consensus was reached. RESULTS The systematic literature review identified 75 additional studies that informed the response to the 12 key questions that were developed. Additional clinical questions were addressed resulting in seven graded recommendations and nine ungraded consensus statements. CONCLUSIONS Evidence suggests that low-dose CT screening for lung cancer can result in a favorable balance of benefit and harms. The selection of screen-eligible individuals, the quality of imaging and image interpretation, the management of screen-detected findings, and the effectiveness of smoking cessation interventions can impact this balance.
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Affiliation(s)
| | | | | | - Tanner J Caverly
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI; University of Michigan Medical School, Ann Arbor, MI
| | - Jeffrey P Kanne
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA; Boston University School of Medicine, Boston, MA
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Smith HB, Ward R, Frazier C, Angotti J, Tanner NT. Guideline-Recommended Lung Cancer Screening Adherence Is Superior With a Centralized Approach. Chest 2021; 161:818-825. [PMID: 34536385 DOI: 10.1016/j.chest.2021.09.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND To recognize fully the benefit of lung cancer screening (LCS), annual adherence must approach the high levels seen in the National Lung Screening Trial. Emerging data suggest that annual adherence is poor and that a centralized approach to screening improves adherence. RESEARCH QUESTIONS Do differences in adherence exist between a centralized and decentralized approach to LCS within a hybrid program and what are predictors of adherence? STUDY DESIGN A retrospective evaluation of a single-center hybrid LCS program was conducted to compare outcomes including patient eligibility and adherence between the centralized and decentralized approaches. METHODS Patient demographics and outcomes were compared between those screened with a centralized and decentralized approach and between adherent and nonadherent patients using two-sample t tests, χ 2 tests, or analyses of variance, as appropriate. Annual adherence analysis was conducted using data from patients who remained eligible for screening with a baseline Lung CT Screening Reporting and Data System (Lung-RADS) score of 1 or 2. Logistic regression was used to estimate the association between adherence and the primary exposure, adjusting for potential confounders. RESULTS A cohort of 1,117 patients underwent baseline low-dose CT imaging. Two hundred eleven patients (19%) were ineligible by United States Preventative Services Task Force criteria and most (90%) were screened with the decentralized approach. After exclusions, 765 patients with Lung-RADS score of 1 or 2 remained eligible for annual screening. Overall adherence was 56%; however, adherence in the centralized program was 70%, compared with 41% with the decentralized approach (P < .001). Individuals screened in a decentralized approach were 73% less likely to be adherent (OR, 0.27; 95% CI, 0.19-0.37). A greater proportion of patients with three or more comorbidities were screened outside the centralized program. INTERPRETATION Those screened using a centralized approach were more likely to meet eligibility criteria for LCS and more likely to return for annual screening than those screened using a decentralized approach.
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Affiliation(s)
- Harrison B Smith
- Thoracic Oncology Research Group, Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC
| | - Ralph Ward
- Department of Public Health, the Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veteran Affairs Hospital, Charleston, SC
| | - Cassie Frazier
- Department of Public Health, the Hollings Cancer Center, Medical University of South Carolina, Charleston, SC
| | - Jonathan Angotti
- Thoracic Oncology Research Group, Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC
| | - Nichole T Tanner
- Thoracic Oncology Research Group, Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC; Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veteran Affairs Hospital, Charleston, SC.
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26
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Kunitomo Y, Bade B, Gunderson CG, Akgün KM, Brackett A, Cain H, Tanoue L, Bastian LA. Racial Differences in Adherence to Lung Cancer Screening Follow-Up: A Systematic Review and Meta-Analysis. Chest 2021; 161:266-275. [PMID: 34390706 DOI: 10.1016/j.chest.2021.07.2172] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/17/2021] [Accepted: 07/28/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND In 2013 the United States Preventive Services Taskforce (USPSTF) instituted recommendations for annual lung cancer screening (LCS) with low dose chest computed tomography for high-risk individuals. LCS reduces lung cancer mortality, with greater reduction observed in Black participants in clinical trials. While racial disparities in lung cancer mortality have been well documented, less is known about disparities in LCS participation and adherence to follow-up in clinical practice. RESEARCH QUESTION What is the association between race and adherence to LCS follow-up? STUDY DESIGN & METHODS A systematic review was conducted through a search of published studies in MEDLINE, PubMed, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health Literature Database, from database inception through October 2020. We included studies that examined rates of adherence to LCS follow-up and compared rates by race. Studies were pooled using random-effects meta-analysis. RESULTS We screened 18,300 titles/abstracts and 229 studies were selected for full-text review. Nine studies met inclusion criteria; seven were included in the meta-analysis. Median adherent follow-up rate was 37% (range 16-82%). Notable differences among the studies included the proportion of the Black population (range 4-47%) and the structure of the LCS programs. The meta-analyses showed lower adherence to LCS follow-up in the Black population (Odds Ratio [OR]=0.67, [95% CI: 0.55, 0.80]). This disparity persisted across all malignancy risk levels determined by initial screening results. INTERPRETATION There is lower adherence to LCS follow-up in Black compared to White patients despite the higher potential lung cancer mortality benefit. Literature specifically addressing race-related barriers to LCS adherence is still limited. To ensure equity in LCS benefits, greater outreach to eligible Black patients should be implemented through increased physician education and utilization of screening program coordinators to focus on this patient population.
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Affiliation(s)
- Yukiko Kunitomo
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut, United States; Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Yale School of Medicine, New Haven, Connecticut, United States
| | - Brett Bade
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut, United States; Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Yale School of Medicine, New Haven, Connecticut, United States
| | - Craig G Gunderson
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut, United States; Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Yale School of Medicine, New Haven, Connecticut, United States
| | - Kathleen M Akgün
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut, United States; Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Yale School of Medicine, New Haven, Connecticut, United States
| | - Alexandria Brackett
- Harvey Cushing/John Hay Whitney Medical Library, Yale School of Medicine, New Haven, Connecticut, United States
| | - Hilary Cain
- Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Yale School of Medicine, New Haven, Connecticut, United States
| | - Lynn Tanoue
- Yale School of Medicine, New Haven, Connecticut, United States
| | - Lori A Bastian
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut, United States; Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Yale School of Medicine, New Haven, Connecticut, United States.
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27
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Adherence to Lung Cancer Screening: What Exactly Are We Talking About? Ann Am Thorac Soc 2021; 18:1951-1952. [PMID: 34380008 DOI: 10.1513/annalsats.202106-724vp] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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28
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Hirsch EA, Barón AE, Risendal B, Studts JL, New ML, Malkoski SP. Determinants Associated With Longitudinal Adherence to Annual Lung Cancer Screening: A Retrospective Analysis of Claims Data. J Am Coll Radiol 2021; 18:1084-1094. [PMID: 33798496 PMCID: PMC8349785 DOI: 10.1016/j.jacr.2021.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Lung cancer screening (LCS) efficacy is highly dependent on adherence to annual screening, but little is known about real-world adherence determinants. We used insurance claims data to examine associations between LCS annual adherence and demographic, comorbidity, health care usage, and geographic factors. MATERIALS AND METHODS Insurance claims data for all individuals with an LCS low-dose CT scan were obtained from the Colorado All Payer Claims Dataset. Adherence was defined as a second claim for a screening CT 10 to 18 months after the index claim. Cox proportional hazards regression was used to define the relationship between annual adherence and age, gender, insurance type, residence location, outpatient health care usage, and comorbidity burden. RESULTS After exclusions, the final data set consisted of 9,056 records with 3,072 adherent, 3,570 nonadherent, and 2,414 censored (unclassifiable) individuals. Less adherence was associated with ages 55 to 59 (hazard ratio [HR] = 0.80, 99% confidence interval [CI] = 0.67-0.94), 60 to 64 (HR = 0.83, 99% CI = 0.71-0.97), and 75 to 79 (HR = 0.79, 99% CI = 0.65-0.97); rural residence (HR = 0.56, 99% CI = 0.43-0.73); Medicare fee-for-service (HR = 0.45, 99% CI = 0.39-0.51), and Medicaid (HR = 0.50, 99% CI = 0.40-0.62). A significant interaction between outpatient health care usage and comorbidity was also observed. Increased outpatient usage was associated with increased adherence and was most pronounced for individuals without comorbidities. CONCLUSIONS This population-based description of LCS adherence determinants provides insight into populations that might benefit from specific interventions targeted toward improving adherence and maximizing LCS benefit. Quantifying population-based adherence rates and understanding factors associated with annual adherence are critical to improving screening adherence and reducing lung cancer death.
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Affiliation(s)
- Erin A Hirsch
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Anna E Barón
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Betsy Risendal
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jamie L Studts
- Division of Medical Oncology and Cancer Prevention and Control Program, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Melissa L New
- Pulmonary Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado; Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Stephen P Malkoski
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, University of Washington, WWAMI-Spokane, Spokane, Washington; Sound Critical Care, Sacred Heart Medical Center, Spokane, Washington.
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Núñez ER, Caverly TJ, Zhang S, Glickman ME, Qian SX, Boudreau JH, Slatore CG, Miller DR, Wiener RS. Adherence to Follow-up Testing Recommendations in US Veterans Screened for Lung Cancer, 2015-2019. JAMA Netw Open 2021; 4:e2116233. [PMID: 34236409 PMCID: PMC8267608 DOI: 10.1001/jamanetworkopen.2021.16233] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Lung cancer screening (LCS) can reduce lung cancer mortality with close follow-up and adherence to management recommendations. Little is known about factors associated with adherence to LCS in real-world practice, with data limited to case series from selected LCS programs. OBJECTIVE To analyze adherence to follow-up based on standardized follow-up recommendations in a national cohort and to identify factors associated with delayed or absent follow-up. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted in Veterans Health Administration (VHA) facilities across the US. Veterans were screened for lung cancer between 2015 to 2019 with sufficient follow-up time to receive recommended evaluation. Patient- and facility-level logistic regression analyses were performed. Data were analyzed from November 26, 2019, to December 16, 2020. MAIN OUTCOMES AND MEASURES Receipt of the recommended next step after initial LCS according to Lung CT Screening Reporting & Data System (Lung-RADS) category, as captured in VHA or Medicare claims. RESULTS Of 28 294 veterans (26 835 [94.8%] men; 21 969 individuals [77.6%] were White; mean [SD] age, 65.2 [5.5] years) who had an initial LCS examination, 17 863 veterans (63.1%) underwent recommended follow-up within the expected timeframe, whereas 3696 veterans (13.1%) underwent late evaluation, and 4439 veterans (15.7%) had no apparent evaluation. Facility-level differences were associated with 9.2% of the observed variation in rates of late or absent evaluation. In multivariable-adjusted models, Black veterans (odds ratio [OR], 1.19 [95% CI, 1.10-1.29]), veterans with posttraumatic stress disorder (OR, 1.13 [95% CI, 1.03-1.23]), veterans with substance use disorders (OR, 1.11 [95% CI, 1.01-1.22]), veterans with lower income (OR, 0.88 [95% CI, 0.79-0.98]), and those living at a greater distance from a VHA facility (OR, 1.06 [95% CI, 1.02-1.10]) were more likely to experience delayed or no follow-up; veterans with higher risk findings (Lung-RADS category 4 vs Lung-RADS category 1: OR, 0.35 [95% CI, 0.28-0.43]) and those screened in high LCS volume facilities (OR, 0.38 [95% CI, 0.21-0.67]) or academic facilities (OR, 0.86 [95% CI, 0.80-0.92]) were less likely to experience delayed or no follow-up. In sensitivity analyses, varying how stringently adherence was defined, expected evaluation ranged from 14 486 veterans (49.7%) under stringent definitions to 20 578 veterans (78.8%) under liberal definitions. CONCLUSIONS AND RELEVANCE In this cohort study that captured follow-up care from the integrated VHA health care system and Medicare, less than two-thirds of patients received timely recommended follow-up after initial LCS, with higher risk of delayed or absent follow-up among marginalized populations, such as Black individuals, individuals with mental health disorders, and individuals with low income, that have long experienced disparities in lung cancer outcomes. Future work should focus on identifying facilities that promote high adherence and disseminating successful strategies to promote equity in LCS among marginalized populations.
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Affiliation(s)
- Eduardo R. Núñez
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Tanner J. Caverly
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- University of Michigan School of Medicine, Ann Arbor
| | - Sanqian Zhang
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
- Department of Statistics, Harvard University, Cambridge, Massachusetts
| | - Mark E. Glickman
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
- Department of Statistics, Harvard University, Cambridge, Massachusetts
| | - Shirley X. Qian
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Jacqueline H. Boudreau
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland
| | - Donald R. Miller
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
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30
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Barta JA, Shusted CS, Ruane B, Pimpinelli M, McIntire RK, Zeigler-Johnson C, Myers RE, Evans NR, Kane GC, Juon HS. Racial Differences in Lung Cancer Screening Beliefs and Screening Adherence. Clin Lung Cancer 2021; 22:570-578. [PMID: 34257020 DOI: 10.1016/j.cllc.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/05/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND One challenge in high-quality lung cancer screening (LCS) is maintaining adherence with annual and short-interval follow-up screens among high-risk individuals who have undergone baseline low-dose CT (LDCT). This study aimed to characterize attitudes and beliefs toward lung cancer and LCS and to identify factors associated with LCS adherence. METHODS We administered a questionnaire to 269 LCS participants to assess attitudes and beliefs toward lung cancer and LCS. Clinical data including sociodemographics and screening adherence were obtained from the LCS Program Registry. RESULTS African-American individuals had significantly greater lung cancer worries compared with Whites (6.10 vs. 4.66, P < .001). In making the decision to undergo LCS, African-American participants described screening convenience and cost as very important factors significantly more frequently than Whites (60% vs. 26.8%, P< .001 and 58.4% vs. 37.8%, P = .001; respectively). African-American individuals with greater than high school education had significantly higher odds of LCS adherence (aOR 2.55; 95% CI, 1.14-5.60) than Whites with less than high school education. Participants who described screening convenience and cost as "very important" had significantly lower odds of completing screening follow-up after adjusting for demographic and other factors (aOR 0.56; 95% CI, 0.33-0.97 and aOR 0.54; 95% CI, 0.33-0.91, respectively). CONCLUSION Racial differences in beliefs about lung cancer and LCS exist among African-American and White individuals enrolled in an LCS program. Cost, convenience, and low educational attainment may be barriers to LCS adherence, specifically among African-American individuals. IMPACT More research is needed on how barriers can be overcome to improve LCS adherence.
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Affiliation(s)
- Julie A Barta
- The Jane and Leonard Korman Respiratory Institute at Thomas Jefferson University, Division of Pulmonary and Critical Care Medicine, Philadelphia, PA
| | - Christine S Shusted
- The Jane and Leonard Korman Respiratory Institute at Thomas Jefferson University, Department of Medicine, Philadelphia, PA
| | - Brooke Ruane
- The Jane and Leonard Korman Respiratory Institute at Thomas Jefferson University, Division of Pulmonary and Critical Care Medicine, Philadelphia, PA
| | - Marcella Pimpinelli
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Russell K McIntire
- Thomas Jefferson University, Jefferson College of Population Health, Philadelphia, PA
| | - Charnita Zeigler-Johnson
- Thomas Jefferson University, Department of Medical Oncology, Division of Population Science, Philadelphia, PA
| | - Ronald E Myers
- Thomas Jefferson University, Department of Medical Oncology, Division of Population Science, Philadelphia, PA
| | - Nathaniel R Evans
- The Jane and Leonard Korman Respiratory Institute at Thomas Jefferson University, Division of Thoracic Surgery, Philadelphia, PA
| | - Gregory C Kane
- The Jane and Leonard Korman Respiratory Institute at Thomas Jefferson University, Department of Medicine, Philadelphia, PA
| | - Hee-Soon Juon
- Thomas Jefferson University, Department of Medical Oncology, Division of Population Science, Philadelphia, PA.
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31
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Mortman KD, Devlin J, Giang B, Mortman R, Sparks AD, Napolitano MA. Patient Adherence in an Academic Medical Center's Low-dose Computed Tomography Screening Program. Am J Clin Oncol 2021; 44:264-268. [PMID: 33795600 DOI: 10.1097/coc.0000000000000817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Low-dose computed tomography (LDCT) screening is an important tool for reducing lung cancer mortality. This study describes a single center's experience with LDCT and attempts to identify any barriers to compliance with standard guidelines. MATERIALS AND METHODS This is a retrospective review of a single university-based hospital system from 2015 to 2019. All individuals who met eligibility for lung cancer screening were entered into a database. The definition of adherence with the screening program was determined by the recommended timeline for the follow-up LDCT. Cohorts were split by adherence and demographics were compared. RESULTS A total of 203 LDCTs were performed in 121 patients who met eligibility for LDCT and had appropriate surveillance from 2015 to 2019. The average age was 64 years old. The overall adherence rate for prescribed LDCTs was 59.1%. Patients with Lung-RADS score 2 had 2.43 times higher odds of adherence relative to patients with Lung-RADS score 1 (odds ratio [OR]=2.43; 95% confidence interval [CI]: 1.23-4.83; P=0.011). African American patients had 42% lower odds of adherence relative to white patients (OR=0.58; 95% CI: 0.32-1.06; P=0.076). Patients with non-District of Columbia zip codes had 57% higher odds of adherence relative to those with District of Columbia zip codes, although this did not reach statistical significance (OR=1.57; 95% CI: 0.87-2.82; P=0.136). CONCLUSIONS Despite the implementation of a multidisciplinary, academic LDCT screening program, overall adherence rate to prescribed follow-up scans was suboptimal. Socioeconomic disparities and African American race may negatively affect adherence to lung cancer screening LDCT guidelines. Patients with concerning findings on initial LDCT had a higher association of adherence to guidelines.
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Affiliation(s)
- Keith D Mortman
- Department of Surgery, Division of Thoracic Surgery, The George Washington University Hospital
| | - Joseph Devlin
- Department of Surgery, Division of Thoracic Surgery, The George Washington University Hospital
| | - Brian Giang
- The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Ryan Mortman
- The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Andrew D Sparks
- Department of Surgery, Division of Thoracic Surgery, The George Washington University Hospital
| | - Michael A Napolitano
- Department of Surgery, Division of Thoracic Surgery, The George Washington University Hospital
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Lam V, Scott R, Billings P, Cabebe E, Young R. Utility of incorporating a gene-based lung cancer risk test on uptake and adherence in a community-based lung cancer screening pilot study. Prev Med Rep 2021; 23:101397. [PMID: 34040933 PMCID: PMC8142278 DOI: 10.1016/j.pmedr.2021.101397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/31/2021] [Accepted: 05/08/2021] [Indexed: 11/24/2022] Open
Abstract
Based on the results of randomized control trials, screening for lung cancer using computed tomography (CT) is now widely recommended. However, adherence to screening remains an issue outside the clinical trial setting. This study examines the utility of biomarker-based risk assessment on uptake and subsequent adherence in a community screening study. In a single arm pilot study, current or former smokers > 50 years old with 20 + pack year history were recruited following local advertising. One hundred and fifty seven participants volunteered to participate in the study that offered an optional gene-based lung cancer risk assessment followed by low-dose CT according to a standardised screening protocol. All 157 volunteers who attended visit 1 underwent the gene-based risk assessment comprising of a clinical questionnaire and buccal swab. Of this group, 154 subsequently attended for CT screening (98%) and were followed prospectively for a median of 2.7 years. A participant’s adherence to screening was influenced by their baseline lung cancer risk category, with overall adherence in those with a positive scan being significantly greater in the “very high” risk group compared to “moderate” and “high” risk categories (71% vs 52%, Odds ratio = 2.27, 95% confidence interval of 1.02–5.05, P = 0.047). Those in the “moderate” risk group were not different to those in the “high” risk group (52% and 52%, P > 0.05). In this proof-of-concept study, personalised gene-based lung cancer risk assessment was well accepted, associated with a 98% uptake for screening and increased adherence for those in the highest risk group.
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Affiliation(s)
- V.K. Lam
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
- El Camino Hospital, Mountain View, CA, USA
| | - R.J. Scott
- Department of Medicine, Faculty of Medical and Health Science, University of Auckland, Auckland Hospital, New Zealand
- Corresponding author at: Medicine and Molecular Genetics, P. O. Box 26161 Epsom, Auckland 1344, New Zealand.
| | | | - E. Cabebe
- El Camino Hospital, Mountain View, CA, USA
| | - R.P. Young
- Department of Medicine, Faculty of Medical and Health Science, University of Auckland, Auckland Hospital, New Zealand
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33
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Sakoda LC, Rivera MP, Zhang J, Perera P, Laurent CA, Durham D, Huamani Velasquez R, Lane L, Schwartz A, Quesenberry CP, Minowada G, Henderson LM. Patterns and Factors Associated With Adherence to Lung Cancer Screening in Diverse Practice Settings. JAMA Netw Open 2021; 4:e218559. [PMID: 33929519 PMCID: PMC8087957 DOI: 10.1001/jamanetworkopen.2021.8559] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE For lung cancer screening to confer mortality benefit, adherence to annual screening with low-dose computed tomography scans is essential. Although the National Lung Screening Trial had an adherence rate of 95%, current data are limited on screening adherence across diverse practice settings in the United States. OBJECTIVE To evaluate patterns and factors associated with adherence to annual screening for lung cancer after negative results of a baseline examination, particularly in centralized vs decentralized screening programs. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study was conducted at 5 academic and community-based sites in North Carolina and California among 2283 individuals screened for lung cancer between July 1, 2014, and March 31, 2018, who met US Preventive Services Task Force eligibility criteria, had negative results of a baseline screening examination (American College of Radiology Lung Imaging Reporting and Data System category 1 or 2), and were eligible to return for a screening examination in 12 months. EXPOSURES To identify factors associated with adherence, the association of adherence with selected baseline demographic and clinical characteristics, including type of screening program, was estimated using multivariable logistic regression. Screening program type was classified as centralized if individuals were referred through a lung cancer screening clinic or program and as decentralized if individuals had a direct clinician referral for the baseline low-dose computed tomography scan. MAIN OUTCOMES AND MEASURES Adherence to annual lung cancer screening, defined as a second low-dose computed tomography scan within 11 to 15 months after baseline screening. RESULTS Among the 2283 eligible individuals (1294 men [56.7%]; mean [SD] age, 64.9 [5.8] years; 1160 [50.8%] aged ≥65 years) who had negative screening results at baseline, overall adherence was 40.2% (n = 917), with higher adherence among those who underwent screening through centralized (46.0% [478 of 1039]) vs decentralized (35.3% [439 of 1244]) programs. The independent factor most strongly associated with adherence was type of screening program, with a 2.8-fold increased likelihood of adherence associated with centralized screening (adjusted odds ratio [aOR], 2.78; 95% CI, 1.99-3.88). Another associated factor was age (65-69 vs 55-59 years: aOR, 1.38; 95% CI, 1.07-1.77; 70-74 vs 55-59 years: aOR, 1.47; 95% CI, 1.10-1.96). CONCLUSIONS AND RELEVANCE After negative results of a baseline examination, adherence to annual lung cancer screening was suboptimal, although adherence was higher among individuals who were screened through a centralized program. These results support the value of centralized screening programs and the need to further implement strategies that improve adherence to annual screening for lung cancer.
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Affiliation(s)
- Lori C. Sakoda
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - M. Patricia Rivera
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill
| | - Jie Zhang
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Pasangi Perera
- Department of Radiology, The University of North Carolina at Chapel Hill, Chapel Hill
| | - Cecile A. Laurent
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Danielle Durham
- Department of Radiology, The University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Lindsay Lane
- Department of Radiology, The University of North Carolina at Chapel Hill, Chapel Hill
| | - Adam Schwartz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill
| | | | - George Minowada
- Department of Pulmonary Medicine, Kaiser Permanente Northern California, Vallejo
| | - Louise M. Henderson
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill
- Department of Radiology, The University of North Carolina at Chapel Hill, Chapel Hill
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill
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