Utilization of Lung Cancer Screening in the Medicare Fee-for-Service Population

Current Challenges in Imaging-Based Cancer Screening, From the AJR Special Series on Screening

The early detection of cancer confers many significant benefits for patients, primarily by enabling less invasive and more effective treatments and thus lowering disease mortality. Radiology is integral to early cancer detection, playing either a primary or complementary role in screening programs. Imaging-based screening is often performed in conjunction with other screening tests and may involve multiple modalities depending on patient demographics and cancer type. When developing a screening program for cancer early detection, both its potential benefits and harms need to be assessed. These harms, although specific to the modality and cancer, often include overdiagnosis, overtreatment, and false-positive examinations. As radiology technology improves and new tools become available, the ratios of risk to harm of imaging-based screening will shift, and screening recommendations will need to adapt accordingly. Radiologists must be major partners in the development and execution of screening guidelines to ensure the highest quality of care for their patients. This review discusses the major challenges of cancer screening programs and guidelines, exploring sources of evidence as well as harms of overdiagnosis and overtreatment. The article focuses on the most common cancer types that incorporate imaging-based screening including lung cancer, breast cancer, colon cancer, prostate cancer, and hepatocellcular carcinoma.

Predictors and Uptake of Lung Cancer Screening in the US: An Integrative Literature Review

Early detection of lung cancer with low-dose computed tomography decreases lung cancer mortality significantly, yet lung cancer screening (LCS) rates in the US remain low. This integrative review estimates LCS prevalence, identifies barriers, and highlights future research needs. A medical librarian searched PubMed, CINAHL, OVID Medline, and OVID Embase for quantitative US-based studies published between 2014-2023. A dual review of the abstracts of all articles was conducted by the authors (SS, LM, EC, HP) to determine the eligible articles based on the pre-determined inclusion/ exclusion criteria. After applying the inclusion criteria, 38 studies were analyzed. Findings indicate that LCS remains underutilized, with majority of studies reporting uptake rates below 30%. Disparities in LCS use were notable among racial and ethnic minoritized adults, uninsured individuals, and residents of specific regions. These results underscore the need for further research into disparities in LCS utilization and adherence. Future researchers should focus more on the factors that may cause LCS disparities, such as organizational-level policies, LCS access, and LCS decision-making resources, to improve LCS uptake throughout the country.

Population-based systematic enrolment of individuals ensures high lung cancer screening uptake

INTRODUCTION

Lung cancer screening (LCS) is recommended by international societies, yet it is still debated how to efficiently enrol participants. The aim of this study was to evaluate systematic enrolment of patients through family physicians in a regional LCS pilot study in Estonia.

MATERIAL AND METHODS

This study was conducted in one county (with approximately 10 % of the country's population), where all family physicians were approached. In each participating practice, all 55- to 74-year-old individuals were identified and evaluated by the family physician or nurse. Two LCS inclusion criteria were used in parallel - individuals with elevated lung cancer (LC) risk, according to either smoking status (≥20 pack-years; quit <15 years ago) and/or a PLCOm2012noRace risk score (>1.5 %/6 years), underwent low-dose computed tomography (LDCT). The scans were evaluated and participants managed according to LungRADS 1.1 protocol.

RESULTS

Seventy-four participating family physician practices had 26 759 patients in the target age group. During the inclusion period 24 413 individuals were evaluated, of whom 17 215 were excluded. Of the remaining 7198 individuals, 3708 had higher LC risk and were referred for LDCT. Of the 3444 individuals who underwent LDCT, 30 were diagnosed with LC. Considering the total LCS target age group, an estimated participation rate of 79.3 % (95 %CI 78.1 %-80.5 %) was achieved.

CONCLUSION

Population-based systematic enrolment of participants for LCS by family physicians and nurses ensured very high uptake in the target group, providing a valuable reference for planning LCS programs in countries with family physicians on board.

A Community-Engaged Research Study to Inform Tailored Programming for Smoking Cessation and Lung Cancer Screening Among At-Risk LGBTQ+ Elders

Purpose. Lung cancer is the leading cause of cancer death, with most cases attributable to cigarette smoking. Many communities within the lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ+) umbrella have high rates of smoking, but focused lung cancer prevention is limited. Our objective was to utilize a community-based participatory research (CBPR) approach to guide the development of a program focused on lung cancer prevention in LGBTQ+ elders. Methods. Through community partnerships, we recruited participants who self-identified as LGBTQ+ and were eligible for lung cancer screening (LCS) to participate in semi-structured qualitative discussions with complementary surveys. Qualitative guides were developed to collect data on determinants of smoking cessation and LCS and to elicit feedback on interventions to support lung cancer prevention through a tailored approach to patient navigation. Qualitative data were analyzed using rapid templated analysis to elucidate themes. Results. The 21 enrolled participants had diverse sexual and gender identities and 57% were of minoritized race/ethnicity. Most (81%) had experience with smoking cessation but few (10%) had undergone LCS. Overall themes suggest interest in personalized (to individuals), tailored (to the LGBTQ+ community) and integrated longitudinal programs to support lung cancer prevention. Themes suggest strong endorsement of focused messaging to LGBTQ+ persons and reducing stigma related to LGBTQ+ identity and smoking. Conclusions. Themes highlight the need for integrated tobacco and LCS programming which can provide longitudinal support, and ideally, center community settings and peer support. This formative work will be utilized to adapt a patient navigation program to assist screen-eligible LGBTQ+ elders.

A Brief Report of Lung Cancer Screening Utilization Before, During, and in the Later Stages of the COVID-19 Pandemic in the United States

Introduction

Although COVID-19 has affected health care and screening utilization, its impact on lung cancer screening (LCS) uptake remains unclear. Our study investigated LCS utilization and associated predictors among adults eligible for LCS before (2019), during (2020-2021), and at a later stage (2022) of COVID-19.

Methods

We used cross-sectional, nationally representative, population-based data from the Behavioral Risk Factor Surveillance System over 4 consecutive years: 2019 (n = 4484; weighted n = 1,559,37), 2020 (n = 1239; weighted n = 200,301), 2021 (n = 1673; weighted n = 668,359), and 2022 (n = 20,804; weighted n = 9,458,907). The outcome was self-reported LCS uptake (0 = did not have LCS in the past 12 mo and 1 = underwent LCS in the past 12 mo). We conducted weighted statistics and multivariable logistic regression.

Results

Overall, of 11,886,704 million individuals eligible for LCS, 2,129,900 received LCS in 4 years (2019-2022). National rates of LCS among individuals eligible for screening were 16.3% (95% confidence interval [CI]:14.4-18.5), 19.4% (95% CI:15.3-24.3), 18.3% (95% CI:15.6-21.3), and 18.1% (95% CI:17.1-19.2) in 2019, 2020, 2021, and 2022, respectively. Respondents reporting lung disease and cancer (other than lung cancer) history were more likely to receive LCS across all 4 years. During the pandemic (2020), Hispanic (versus White), and rural (versus urban) residents had lower odds of LCS utilization. In 2022, men had increased odds of reporting LCS use relative to women. No sex differences in LCS use were observed in previous years.

Conclusions

Our findings indicate consistently low LCS utilization (<20%) over 4 years. Nationwide efforts to boost LCS awareness and utilization are essential for mitigating the lung cancer burden in the United States.

Understanding Washington State's Low Uptake of Lung Cancer Screening in Two Steps: A Geospatial Analysis of Patient Travel Time and Health Care Availability of Imaging Sites

BACKGROUND

Early detection of lung cancer reduces cancer mortality; yet uptake for lung cancer screening (LCS) has been limited in Washington State. Geographic disparities contribute to low uptake, but do not wholly explain gaps in access for underserved populations. Other factors, such as an adequate workforce to meet population demand and the capacity of accredited screening facility sites, must also be considered.

RESEARCH QUESTION

What proportion of the eligible population for LCS has access to LCS facilities in Washington State?

STUDY DESIGN AND METHODS

We used the enhanced two-step floating catchment area (E2SFCA) model to evaluate how geographic accessibility in addition to availability of LCS imaging centers contribute to disparities. We used available data on radiologic technologist volume at each American College of Radiology (ACR)-accredited screening facility site to estimate the capacity of each site to meet potential population demand. Spearman rank correlation coefficients of the spatial access ratios were compared with the 2010 Rural-Urban Commuting Area codes and area deprivation index quintiles to identify characteristics of populations at risk for lung cancer with greater and lesser levels of access.

RESULTS

A total of 549 radiologic technologists were identified across the 95 ACR-accredited screening facilities. We observed that 95% of the eligible population had proximate geographic access to any ACR facility. However, when we incorporated the E2SFCA method, we found significant variation of access for eligible populations. The inclusion of the availability measure attenuated access for most of the eligible population. Furthermore, we observed that rural areas were substantially correlated, and areas with greater socioeconomic disadvantage were modestly correlated, with lower access.

INTERPRETATION

Rural and socioeconomically disadvantaged areas face significant disparities. The E2SFCA models demonstrated that capacity is an important component and how geographic access and availability jointly contribute to disparities in access to LCS.

Emerging Trends in Lung Cancer Presentation at a Leading Tertiary Oncology Center and the Need for Lung Cancer Screening in Pakistan

Background Lung cancer is a significant global health concern, with Pakistan lacking a national cancer registry. Methods A retrospective study analyzed 345 lung cancer patients at Shifa International Hospital from 2018 to 2020. Demographics, symptoms, cancer stage, site, and histological types were assessed using descriptive statistics and Pearson's chi-square test. Results Most patients were male (267, 77.4%) with a mean age of 45-75 years. Common symptoms included patients with cough (168, 49%), blood in sputum (114, 33%), and chest pain (120, 35%). Most cases presented at advanced stages (81% at stage 4). Adenocarcinoma (131, 38%) was the most common histological type, with significant differences noted between smokers and non-smokers. Conclusion Gender disparities exist in lung cancer incidence, with a higher proportion of male patients. Both smokers and non-smokers are affected, emphasizing the need for comprehensive screening. Early detection and intervention strategies are crucial, especially considering the advanced stage of presentation. Tailored approaches considering histological types are essential for effective management. This study underscores the urgency of implementing screening programs and raising awareness to mitigate the burden of lung cancer in Pakistan.

Review of Interventions That Improve Uptake of Lung Cancer Screening: A Cataloging of Strategies That Have Been Shown to Work (or Not)

TOPIC IMPORTANCE

Lung cancer screening (LCS) has the potential to decrease mortality from lung cancer by 20%. Yet, more than a decade since LCS was established as an evidence-based practice, < 20% of the eligible population in the United States has been screened. This review focuses on critically appraising interventions that have been designed to increase the initial uptake of LCS, including how they address known barriers to LCS and their effectiveness in overcoming these barriers.

REVIEW FINDINGS

Studies were categorized based on the primary barriers that they addressed: (1) identifying eligible patients (including enhancing awareness through smoking history collection, outreach, and education), (2) shared decision-making-related interventions, and (3) patient navigation interventions. Four of the studies included multicomponent interventions, which often included patient navigation as one of the components. Overall, the effectiveness of the studies reviewed at improving LCS uptake generally was modest and was limited by the multilevel barriers that need to be overcome. Multicomponent interventions generally were more effective at improving LCS uptake, but most studies still had relatively low completion of screening.

SUMMARY

Improving uptake of LCS requires learning from prior interventions to design multilevel interventions that address barriers to LCS at key steps and identifying which components of these interventions are effective and generalizable.

Qualitative interviews for hospitalists addressing lung cancer screening

Novel strategies are needed to improve low rates of lung cancer screening (LCS) in the US. Seeking to determine hospitalists' perspectives on leveraging hospitalizations to identify patients eligible for LCS, we performed qualitative interviews with eight hospitalists from two hospitals within a large integrated healthcare system. The interviews used semi-structured questions to assess (1) knowledge and practice of general screening and LCS guidelines from the United States Preventive Services Task Force (USPSTF), (2) identification of smoking history, and (3) hospitalists' views on how data obtained during hospitalization may be utilized to improve general screening and LCS post hospitalization. We ultimately reached the conclusion that hospitalists would support a dedicated program to identify hospitalized patients eligible for LCS and facilitate testing after discharge. Efforts to identify patients and arrange subsequent screening should be performed by team members outside the inpatient team.

Prediction-Augmented Shared Decision-Making and Lung Cancer Screening Uptake

Importance

Addressing poor uptake of low-dose computed tomography lung cancer screening (LCS) is critical, especially for those having the most to gain-high-benefit persons with high lung cancer risk and life expectancy more than 10 years.

Objective

To assess the association between LCS uptake and implementing a prediction-augmented shared decision-making (SDM) tool, which enables clinicians to identify persons predicted to be at high benefit and encourage LCS more strongly for these persons.

Design, Setting, and Participants

Quality improvement interrupted time series study at 6 Veterans Affairs sites that used a standard set of clinical reminders to prompt primary care clinicians and screening coordinators to engage in SDM for LCS-eligible persons. Participants were persons without a history of LCS who met LCS eligibility criteria at the time (aged 55-80 years, smoked ≥30 pack-years, and current smoking or quit <15 years ago) and were not documented to be an inappropriate candidate for LCS by a clinician during October 2017 through September 2019. Data were analyzed from September to November 2023.

Exposure

Decision support tool augmented by a prediction model that helps clinicians personalize SDM for LCS, tailoring the strength of screening encouragement according to predicted benefit.

Main outcome and measure

LCS uptake.

Results

In a cohort of 9904 individuals, the median (IQR) age was 64 (57-69) years; 9277 (94%) were male, 1537 (16%) were Black, 8159 (82%) were White, 5153 (52%) were predicted to be at intermediate (preference-sensitive) benefit and 4751 (48%) at high benefit, and 1084 (11%) received screening during the study period. Following implementation of the tool, higher rates of LCS uptake were observed overall along with an increase in benefit-based LCS uptake (higher screening uptake among persons anticipated to be at high benefit compared with those at intermediate benefit; primary analysis). Mean (SD) predicted probability of getting screened for a high-benefit person was 24.8% (15.5%) vs 15.8% (11.8%) for a person at intermediate benefit (mean absolute difference 9.0 percentage points; 95% CI, 1.6%-16.5%).

Conclusions and Relevance

Implementing a robust approach to personalized LCS, which integrates SDM, and a decision support tool augmented by a prediction model, are associated with improved uptake of LCS and may be particularly important for those most likely to benefit. These findings are timely given the ongoing poor rates of LCS uptake.

Lung cancer screening provider recommendation and completion in black and White patients with a smoking history in two healthcare systems: a survey study

BACKGROUND

Annual lung cancer screening (LCS) with low dose CT reduces lung cancer mortality. LCS is underutilized. Black people who smoke tobacco have high risk of lung cancer but are less likely to be screened than are White people. This study reports provider recommendation and patient completion of LCS and colorectal cancer screening (CRCS) among patients by race to assess for utilization of LCS.

METHODS

3000 patients (oversampled for Black patients) across two healthcare systems (in Rhode Island and Minnesota) who had a chart documented age of 55 to 80 and a smoking history were invited to participate in a survey about cancer screening. Logistic regression analysis compared the rates of recommended and received cancer screenings.

RESULTS

1177 participants responded (42% response rate; 45% White, 39% Black). 24% of respondents were eligible for LCS based on USPSTF2013 criteria. One-third of patients eligible for LCS reported that a doctor had recommended screening, compared to 90% of patients reporting a doctor recommended CRCS. Of those recommended screening, 88% reported completing LCS vs. 83% who reported completion of a sigmoidoscopy/colonoscopy. Black patients were equally likely to receive LCS recommendations but less likely to complete LCS when referred compared to White patients. There was no difference in completion of CRCS between Black and White patients.

CONCLUSIONS

Primary care providers rarely recommend lung cancer screening to patients with a smoking history. Systemic changes are needed to improve provider referral for LCS and to facilitate eligible Black people to complete LCS.

Identification of pancreatic cancer risk factors from clinical notes using natural language processing

OBJECTIVES

Screening for pancreatic ductal adenocarcinoma (PDAC) is considered in high-risk individuals (HRIs) with established PDAC risk factors, such as family history and germline mutations in PDAC susceptibility genes. Accurate assessment of risk factor status is provider knowledge-dependent and requires extensive manual chart review by experts. Natural Language Processing (NLP) has shown promise in automated data extraction from the electronic health record (EHR). We aimed to use NLP for automated extraction of PDAC risk factors from unstructured clinical notes in the EHR.

METHODS

We first developed rule-based NLP algorithms to extract PDAC risk factors at the document-level, using an annotated corpus of 2091 clinical notes. Next, we further improved the NLP algorithms using a cohort of 1138 patients through patient-level training, validation, and testing, with comparison against a pre-specified reference standard. To minimize false-negative results we prioritized algorithm recall.

RESULTS

In the test set (n = 807), the NLP algorithms achieved a recall of 0.933, precision of 0.790, and F1-score of 0.856 for family history of PDAC. For germline genetic mutations, the algorithm had a high recall of 0.851, while precision and F1-score were lower at 0.350 and 0.496 respectively. Most false positives for germline mutations resulted from erroneous recognition of tissue mutations.

CONCLUSIONS

Rule-based NLP algorithms applied to unstructured clinical notes are highly sensitive for automated identification of PDAC risk factors. Further validation in a large primary-care patient population is warranted to assess real-world utility in identifying HRIs for pancreatic cancer screening.

Shortage of thoracic surgeons in the United States: Implications for treatment and survival for stage I lung cancer patients

OBJECTIVES

To evaluate whether there is a shortage of thoracic surgeons in the United States and whether any potential shortage is impacting lung cancer treatment and outcomes.

DESIGN

Using the US Area Health Resources File and Surveillance Epidemiology End Results database, we assessed the number of cardiothoracic surgeons per 100,000 people and the number of stage I non-small cell lung cancer (NSCLC) diagnoses in the US in 2010 versus 2018. Changes in the percentage of patients diagnosed with stage I NSCLC who underwent surgery and stereotactic body radiotherapy and changes in overall survival of patients with stage I NSCLC from 2010 to 2018 in the National Cancer Database were evaluated using multivariable logistic regression and Cox proportional hazards modeling.

RESULTS

From 2010 to 2018, the number of cardiothoracic surgeons per 100,000 people in the US decreased by 12% (P < .001), while the number of patients diagnosed with stage I NSCLC increased by 40% (P < .001). Over the same period, the percentage of patients who underwent surgery for stage I NSCLC decreased from 81.0% to 72.3% (adjusted odds ratio, 0.59; 95% confidence interval, 0.55-0.63); this decrease was similarly seen in a subgroup of young and otherwise healthy patients. Greater decreases in the percentage of patients who underwent surgery in nonmetropolitan and underserved regions corresponded with worse improvements in survival among patients in these regions from 2010 to 2018.

CONCLUSIONS

Recent declines in the US cardiothoracic surgery workforce may have led to significantly fewer patients undergoing surgery for stage I NSCLC and worsening disparities in survival between different patient populations.

An alternating-intervention pilot trial on the impact of an informational handout on patient-reported outcomes and follow-up after lung cancer screening

INTRODUCTION

Lung cancer screening (LCS) can reduce lung cancer mortality; however, poor understanding of results may impact patient experience and follow-up. We sought to determine whether an informational handout accompanying LCS results can improve patient-reported outcomes and adherence to follow-up.

STUDY DESIGN

This was a prospective alternating intervention pilot trial of a handout to accompany LCS results delivery.

SETTING/PARTICIPANTS

Patients undergoing LCS in a multisite program over a 6-month period received a mailing containing either: 1) a standardized form letter of LCS results (control) or 2) the LCS results letter and the handout (intervention).

INTERVENTION

A two-sided informational handout on commonly asked questions after LCS created through iterative mixed-methods evaluation with both LCS patients and providers.

OUTCOME MEASURES

The primary outcomes of 1)patient understanding of LCS results, 2)correct identification of next steps in screening, and 3)patient distress were measured through survey. Adherence to recommended follow-up after LCS was determined through chart review. Outcomes were compared between the intervention and control group using generalized estimating equations.

RESULTS

389 patients were eligible and enrolled with survey responses from 230 participants (59% response rate). We found no differences in understanding of results, identification of next steps in follow-up or distress but did find higher levels of knowledge and understanding on questions assessing individual components of LCS in the intervention group. Follow-up adherence was overall similar between the two arms, though was higher in the intervention group among those with positive findings (p = 0.007).

CONCLUSIONS

There were no differences in self-reported outcomes between the groups or overall follow-up adherence. Those receiving the intervention did report greater understanding and knowledge of key LCS components, and those with positive results had a higher rate of follow-up. This may represent a feasible component of a multi-level intervention to address knowledge and follow-up for LCS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05265897.

Study rationale and design of the PEOPLHE trial

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.

Segmentectomy versus lobectomy in the United States: Outcomes after resection for first primary lung cancer and treatment patterns for second primary lung cancers

OBJECTIVE

The study objective was to identify whether the results of JCOG0802 could be generalized to US clinical settings.

METHODS

Patients diagnosed with clinical stage IA (≤2 cm) non-small cell lung cancer who underwent segmentectomy versus lobectomy (2004-2017) in the National Cancer Database were identified. Overall survival of patients in the National Cancer Database was assessed using propensity score-matched analysis. A separate analysis of the Surveillance Epidemiology End Results database was conducted to evaluate treatment patterns of second primary lung cancers among patients who underwent segmentectomy versus lobectomy for a first primary lung cancer.

RESULTS

Of the 23,286 patients in the National Cancer Database meeting inclusion criteria, 1397 (6.0%) underwent segmentectomy and 21,889 (94.0%) underwent lobectomy. In a propensity score-matched analysis of all patients in the study cohort, there were no significant differences in overall survival between patients undergoing segmentectomy versus lobectomy (5-year overall survival: 79.9% [95% CI, 76.7%-82.0%] vs 81.8% [95% CI, 78.7%-84.4%], log-rank: P = .72). In subgroup analyses by tumor grade and histologic subtype, segmentectomy was associated with similar overall survival compared with lobectomy in all subgroups evaluated. In a propensity score-matched analysis of patients in the Surveillance Epidemiology End Results database, there were no significant differences in treatment patterns of second primary lung cancers between patients who underwent segmentectomy and patients who underwent lobectomy for their first primary lung cancer.

CONCLUSIONS

In this national analysis of US patients diagnosed with stage IA (≤2 cm) non-small cell lung cancer, there were no significant differences in overall survival between segmentectomy and lobectomy in the overall cohort or in subgroup analyses by tumor grade or histologic subtype.

Current and Future Perspectives on Computed Tomography Screening for Lung Cancer: A Roadmap From 2023 to 2027 From the International Association for the Study of Lung Cancer

Low-dose computed tomography (LDCT) screening for lung cancer substantially reduces mortality from lung cancer, as revealed in randomized controlled trials and meta-analyses. This review is based on the ninth CT screening symposium of the International Association for the Study of Lung Cancer, which focuses on the major themes pertinent to the successful global implementation of LDCT screening and develops a strategy to further the implementation of lung cancer screening globally. These recommendations provide a 5-year roadmap to advance the implementation of LDCT screening globally, including the following: (1) establish universal screening program quality indicators; (2) establish evidence-based criteria to identify individuals who have never smoked but are at high-risk of developing lung cancer; (3) develop recommendations for incidentally detected lung nodule tracking and management protocols to complement programmatic lung cancer screening; (4) Integrate artificial intelligence and biomarkers to increase the prediction of malignancy in suspicious CT screen-detected lesions; and (5) standardize high-quality performance artificial intelligence protocols that lead to substantial reductions in costs, resource utilization and radiologist reporting time; (6) personalize CT screening intervals on the basis of an individual's lung cancer risk; (7) develop evidence to support clinical management and cost-effectiveness of other identified abnormalities on a lung cancer screening CT; (8) develop publicly accessible, easy-to-use geospatial tools to plan and monitor equitable access to screening services; and (9) establish a global shared education resource for lung cancer screening CT to ensure high-quality reading and reporting.

Risk of developing subsequent primary lung cancer after receiving radiation for breast cancer

Background

Radiotherapy (RT) is integral to breast cancer treatment, especially in the current era that emphasizes breast conservation. The aim of our study was to determine the incidence of subsequent primary lung cancer after RT exposure for breast cancer over a time span of 3 decades to quantify this risk over time as modern oncologic treatment continues to evolve.

Methods

The SEER (Surveillance, Epidemiology, and End Results) database was queried from 1988 to 2014 for patients diagnosed with nonmetastatic breast cancer. Patients who subsequently developed primary lung cancer were identified. Multivariable regression modeling was performed to identify independent factors associated with the development of lung cancer stratified by follow up intervals of 5 to 9 years, 10 to 15 years, and >15 years after breast cancer diagnosis.

Results

Of the 612,746 patients who met our inclusion criteria, 319,014 (52%) were irradiated. primary lung cancer developed in 5556 patients (1.74%) in the RT group versus 4935 patients (1.68%) in the non-RT group. In a multivariable model stratified by follow-up duration, the overall HR of developing subsequent ipsilateral lung cancer in the RT group was 1.14 (P = .036) after 5 to 9 years of follow-up, 1.28 (P = .002) after 10 to 15 years of follow-up, and 1.30 (P = .014) after >15 years of follow-up. The HR of contralateral lung cancer was not increased at any time interval.

Conclusions

The increased risk of developing a primary lung cancer secondary to RT exposure for breast cancer is much lower than previously published. Modern RT techniques may have contributed to the improved risk profile, and this updated study is important for counseling and surveillance of breast cancer patients.

Lung Cancer Screening in Clinical Practice: A 5-Year Review of Frequency and Predictors of Lung Cancer in the Screened Population

PURPOSE

The aims of this study were to evaluate (1) frequency, type, and lung cancer stage in a clinical lung cancer screening (LCS) population and (2) the association between patient characteristics and Lung CT Screening Reporting & Data System (Lung-RADS®) with lung cancer diagnosis.

METHODS

This retrospective study enrolled individuals undergoing LCS between January 1, 2015, and June 30, 2020. Individuals' sociodemographic characteristics, Lung-RADS scores, pathology-proven lung cancers, and tumor characteristics were determined via electronic health record and the health system's tumor registry. Associations between the outcome of lung cancer diagnosis within 1 year after LCS and covariates of sociodemographic characteristics and Lung-RADS score were determined using logistic regression.

RESULTS

Of 3,326 individuals undergoing 5,150 LCS examinations, 102 (3.1%) were diagnosed with lung cancer within 1 year of LCS; most of these cancers were screen detected (97 of 102 [95.1%]). Over the study period, there were 118 total LCS-detected cancers in 113 individuals (3.4%). Most LCS-detected cancers were adenocarcinomas (62 of 118 [52%]), 55.9% (65 of 118) were stage I, and 16.1% (19 of 118) were stage IV. The sensitivity, specificity, positive predictive value, and negative predictive value of Lung-RADS in diagnosing lung cancer within 1 year of LCS were 93.1%, 83.8%, 10.6%, and 99.8%, respectively. On multivariable analysis controlling for sociodemographic characteristics, only Lung-RADS score was associated with lung cancer (odds ratio for a one-unit increase in Lung-RADS score, 4.68; 95% confidence interval, 3.87-5.78).

CONCLUSIONS

The frequency of LCS-detected lung cancer and stage IV cancers was higher than reported in the National Lung Screening Trial. Although Lung-RADS was a significant predictor of lung cancer, the positive predictive value of Lung-RADS is relatively low, implying opportunity for improved nodule classification.

Historical Perspective on Lung Cancer Screening

Lung cancer represents a large burden on society with a staggering incidence and mortality rate that has steadily increased until recently. The impetus to design an effective screening program for the deadliest cancer in the United States and worldwide began in 1950. It has taken more than 50 years of numerous clinical trials and continued persistence to arrive at the development of modern-day screening program. As the program continues to grow, it is important for clinicians to understand its evolution, track outcomes, and continually assess the impact and bias of screening on the medical, social, and economic systems.

The Impact of Downstream Procedures on Lung Cancer Screening Adherence

OBJECTIVE

(1) Evaluate downstream procedures after lung cancer screening (LCS), including imaging and invasive procedures, in screened individuals without screen-detected lung cancer. (2) Determine the association between repeat LCS and downstream procedures and patient characteristics.

METHODS

Individuals receiving LCS between January 1, 2015, and November 30, 2020, from Optum's deidentified Clinformatics Data Mart Database were included. Individuals with lung cancer after LCS were excluded. We determined frequency and costs of downstream procedures after LCS, including diagnostic imaging (chest CT, PET, or CT using fluorine-18-2-fluoro-2-deoxy-D-glucose imaging) and invasive procedures (bronchoscopy, needle biopsy, thoracic surgery). A generalized estimating equation was used to model repeat LCS as a function of downstream procedures and patient characteristics. The primary outcome was repeat screening within 1 year of index LCS, and a secondary analysis evaluated the outcome of repeat screening with 2 years of index LCS.

RESULTS

In all, 23,640 individuals receiving 30,521 LCS examinations were included in the primary analysis; 17.7% of LCS examinations (5,414 of 30,521) prompted downstream testing, with chest CT within 4 months being most common (9.1%, 2,769 of 30,521). At multivariable analysis adjusted for patient characteristics, the occurrence of a downstream diagnostic imaging test or invasive procedure was associated with a decreased likelihood of repeat annual LCS (adjusted odds ratio, 95% confidence interval: 0.38, 0.34-0.44; adjusted odds ratio, 95% confidence interval: 0.75, 0.63-0.90, respectively).

DISCUSSION

Downstream imaging and invasive procedures after LCS are potential barriers to LCS adherence. Efforts to reduce false-positives at LCS and reduce patient costs from downstream procedures are likely necessary to ensure that downstream workup after LCS does not discourage screening adherence.

Developing a pan-European technical standard for a comprehensive high-quality lung cancer computed tomography screening programme: an ERS technical standard

BACKGROUND

Screening for lung cancer with low radiation dose computed tomography (LDCT) has a strong evidence base. The European Council adopted a recommendation in November 2022 that lung cancer screening (LCS) be implemented using a stepwise approach. The imperative now is to ensure that implementation follows an evidence-based process that delivers clinical and cost-effectiveness. This European Respiratory Society (ERS) Task Force was formed to provide a technical standard for a high-quality LCS programme.

METHOD

A collaborative group was convened to include members of multiple European societies. Topics were identified during a scoping review and a systematic review of the literature was conducted. Full text was provided to members of the group for each topic. The final document was approved by all members and the ERS Scientific Advisory Committee.

RESULTS

Topics were identified representing key components of a screening programme. The actions on findings from the LDCT were not included as they are addressed by separate international guidelines (nodule management and clinical management of lung cancer) and by a linked ERS Task Force (incidental findings). Other than smoking cessation, other interventions that are not part of the core screening process were not included (e.g. pulmonary function measurement). 56 statements were produced and areas for further research identified.

CONCLUSIONS

This European collaborative group has produced a technical standard that is a timely contribution to implementation of LCS. It will serve as a standard that can be used, as recommended by the European Council, to ensure a high-quality and effective programme.

Comparison of Lung Cancer Screening Eligibility and Use between Commercial, Medicare, and Medicare Advantage Enrollees

OBJECTIVE

Lung cancer screening does not require patient cost-sharing for insured people in the U.S. Little is known about whether other factors associated with patient selection into different insurance plans affect screening rates. We examined screening rates for enrollees in commercial, Medicare Fee-for-Service (FFS), and Medicare Advantage plans.

METHODS

County-level smoking rates from the 2017 County Health Rankings were used to estimate the number of enrollees eligible for lung cancer screening in two large retrospective claims databases covering: a 5% national sample of Medicare FFS enrollees; and 100% sample of enrollees associated with large commercial and Medicare Advantage carriers. Screening rates were estimated using observed claims, stratified by payer, before aggregation into national estimates by payer and demographics. Chi-square tests were used to examine differences in screening rates between payers.

RESULTS

There were 1,077,142 enrollees estimated to be eligible for screening. The overall estimated screening rate for enrollees by payer was 1.75% for commercial plans, 3.37% for Medicare FFS, and 4.56% for Medicare Advantage plans. Screening rates were estimated to be lowest among females (1.55%-4.02%), those aged 75-77 years (0.63%-2.87%), those residing in rural areas (1.88%-3.56%), and those in the West (1.16%-3.65%). Among Medicare FFS enrollees, screening rates by race/ethnicity were non-Hispanic White (3.71%), non-Hispanic Black (2.17%) and Other (1.68%).

CONCLUSIONS

Considerable variation exists in lung cancer screening between different payers and across patient characteristics. Efforts targeting historically vulnerable populations could present opportunities to increase screening.

Interventions Designed to Increase the Uptake of Lung Cancer Screening: An Equity-Oriented Scoping Review

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.

Disparities in thoracic surgical oncology

Disparities in access and outcomes of thoracic surgical oncology are long standing. This article examines the patient, population, and systems-level factors that contribute to these disparities and inequities. The need for research and policy to identify and solve these problems is apparent. As leaders in the field of thoracic oncology, surgeons will be instrumental in narrowing these gaps and moving the discipline forward.

Repeat Annual Lung Cancer Screening After Baseline Screening Among Screen-Negative Individuals: No-Cost Coverage Is Not Enough

PURPOSE

Adherence to lung cancer screening (LCS) is central to effective screening. The authors evaluated the likelihood of repeat annual LCS in a national commercially insured population and associations with individual characteristics, insurance characteristics, and annual out-of-pocket cost (OOPC) burden.

METHODS

Using claims data from an employer-insured population (Clinformatics), individuals 55 to 80 years of age undergoing LCS between January 1, 2015, to September 30, 2019, with "negative" LCS were included. Repeat LCS was defined as low-dose chest CT occurring 10 to 15 months after the preceding LCS. Analysis was conducted over a 6-year period. Multivariable logistic regression was used to evaluate associations between repeat LCS and individual characteristics, insurance characteristics, and total OOPC incurred by the individual in the year of the index LCS, even if unrelated to LCS.

RESULTS

Of 14,943 individuals with negative LCS, 4,561 (30.5%) underwent repeat LCS. Likelihood of repeat LCS was decreased for men (adjusted odds ratio [aOR], 0.91; 95% confidence interval [CI], 0.86-0.97), Hispanic ethnicity (aOR, 0.82; 95% CI, 0.69-0.97), and indemnity insurance plans (aOR, 0.36; 95% CI, 0.25-0.53). Relative to New England, individuals in nearly all US geographic regions were less likely to undergo repeat LCS. Finally, individuals with total OOPC in the highest two quartiles were less likely to undergo repeat LCS (aOR, 0.85 [95% CI, 0.77-0.92] for OOPC >$1,069.02-$2,475.09 vs $0-$351.82; aOR, 0.75 [95% CI, 0.68-0.82] for OOPC >$2,475.09 vs $0-$351.82).

CONCLUSIONS

Although federal policies facilitate LCS without cost sharing, individuals incurring high OOPC, even when unrelated to LCS, are less likely to undergo repeat LCS. Future policy design should consider the permeative burden of OOPC across the health continuum on preventive services use.

Qualitative Findings From a Survey on Patient Experiences and Satisfaction with Lung Cancer Screening

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.

Evidence of Racial Disparities in the Lung Cancer Screening Process: a Systematic Review and Meta-Analysis

BACKGROUND

Annual lung cancer screening (LCS) with low-dose chest computed tomography for high-risk individuals reduces lung cancer mortality, with greater reduction observed in Black participants in clinical trials. While racial disparities in lung cancer mortality exist, less is known about disparities in LCS participation. We conducted a systematic review to explore LCS participation in Black compared with White patients in the USA.

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 LCS participation and compared rates by race. Studies were pooled using random-effects meta-analysis.

RESULTS

We screened 18,300 titles/abstracts; 229 studies were selected for full-text review, of which nine studies met inclusion criteria. Studies were categorized into 2 groups: studies that reported the screening rate among an LCS-eligible patient population, and studies that reported the screening rate among a patient population referred for LCS. Median LCS participation rates were 14.4% (range 1.7 to 62.6%) for eligible patient studies and 68.5% (range 62.6 to 88.8%) for referred patient studies. The meta-analyses showed screening rates were lower in the Black compared to White population among the LCS-eligible patient studies ([OR]=0.43, [95% CI: 0.25, 0.74]). However, screening rates were the same between Black and White patients in the referred patient studies (OR=0.94, [95% CI: 0.74, 1.19]).

DISCUSSION

Black LCS-eligible patients are being screened at a lower rate than White patients but have similar rates of participation once referred. Differences in referrals by providers may contribute to the racial disparity in LCS participation. More studies are needed to identify barriers to LCS referral and develop interventions to increase provider awareness of the importance of LCS in Black patients. Trial Registry PROSPERO; No.: CRD42020214213; URL: http://www.crd.york.ac.uk/PROSPERO.

Use and Outcomes of Low-Dose CT Scan Lung Cancer Screening in the Medicare Population

BACKGROUND

Relatively little is known about various aspects of low-dose CT (LDCT) scan lung cancer screening in US clinical practice, including characteristics of cases diagnosed after screening. We assessed this using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database.

RESEARCH QUESTION

What were the characteristics of patients with lung cancer, including stage and survival, whose disease was diagnosed after LDCT scan screenings?

STUDY DESIGN AND METHODS

We created an LDCT scan use cohort consisting of everyone in the 5% SEER-Medicare sample with ≥ 12 months of non-health maintenance organization (HMO) Part A and B coverage while 65 to 77 years of age from 2015 through 2019. LDCT scan use and lung cancer diagnosis rates were assessed in this cohort. Additionally, we created a lung cancer cohort consisting of patients who received a diagnosis between 2015 and 2017 at 65 to 78 years of age with complete (non-HMO Part A and B) coverage the year before diagnosis. The cases cohort comprised those screened or unscreened based on undergoing screening during that period; lung cancer characteristics and survival were compared between these groups.

RESULTS

In the LDCT scan use cohort (n = 414,358), use rates increased from 0.10 (per 100 person-years) in 2015 to 1.3 in 2019. Among those with first screenings, 39.2% underwent a subsequent screen within 18 months. The 1-year cumulative lung cancer diagnosis rate after initial screenings was 2.4%. Claims for prescreen counseling were infrequent (about 10%). Of 48,891 patients in the lung cancer cohort, 1,150 (2.4%) underwent screening. Among screened patients, 52.3%, 11.0%, 20.7%, and 16.0% received diagnoses of stages I, II, III, and IV disease, respectively. Lung cancer-specific survival through 3 years was significantly greater in screened versus unscreened patients overall and for all stages except stage II; 3-year lung cancer-specific survival was 89.0% in screened patients with stage I disease.

INTERPRETATION

LDCT scan use was low but increased over time. The lung cancer yield was substantial; cases among those who underwent screening primarily were in the early stage with high survival rates. Although screening rates were unacceptably low, screening outcomes in those Medicare recipients undergoing screening were favorable.

Factors Associated With Declining Lung Cancer Screening After Discussion With a Physician in a Cohort of US Veterans

Importance

Lung cancer screening (LCS) is underused in the US, particularly in underserved populations, and little is known about factors associated with declining LCS. Guidelines call for shared decision-making when LCS is offered to ensure informed, patient-centered decisions.

Objective

To assess how frequently veterans decline LCS and examine factors associated with declining LCS.

Design, Setting, and Participants

This retrospective cohort study included LCS-eligible US veterans who were offered LCS between January 1, 2013, and February 1, 2021, by a physician at 1 of 30 Veterans Health Administration (VHA) facilities that routinely used electronic health record clinical reminders documenting LCS eligibility and veterans' decisions to accept or decline LCS. Data were obtained from the Veterans Affairs (VA) Corporate Data Warehouse or Medicare claims files from the VA Information Resource Center.

Main Outcomes and Measures

The main outcome was documentation, in clinical reminders, that veterans declined LCS after a discussion with a physician. Logistic regression analyses with physicians and facilities as random effects were used to assess factors associated with declining LCS compared with agreeing to LCS.

Results

Of 43 257 LCS-eligible veterans who were offered LCS (mean [SD] age, 64.7 [5.8] years), 95.9% were male, 84.2% were White, and 37.1% lived in a rural zip code; 32.0% declined screening. Veterans were less likely to decline LCS if they were younger (age 55-59 years: odds ratio [OR], 0.69; 95% CI, 0.64-0.74; age 60-64 years: OR, 0.80; 95% CI, 0.75-0.85), were Black (OR, 0.80; 95% CI, 0.73-0.87), were Hispanic (OR, 0.62; 95% CI, 0.49-0.78), did not have to make co-payments (OR, 0.92; 95% CI, 0.85-0.99), or had more frequent VHA health care utilization (outpatient: OR, 0.70; 95% CI, 0.67-0.72; emergency department: OR, 0.86; 95% CI, 0.80-0.92). Veterans were more likely to decline LCS if they were older (age 70-74 years: OR, 1.27; 95% CI, 1.19-1.37; age 75-80 years: OR, 1.93; 95% CI, 1.73-2.17), lived farther from a VHA screening facility (OR, 1.06; 95% CI, 1.03-1.08), had spent more days in long-term care (OR, 1.13; 95% CI, 1.07-1.19), had a higher Elixhauser Comorbidity Index score (OR, 1.04; 95% CI, 1.03-1.05), or had specific cardiovascular or mental health conditions (congestive heart failure: OR, 1.25; 95% CI, 1.12-1.39; stroke: OR, 1.14; 95% CI, 1.01-1.28; schizophrenia: OR, 1.87; 95% CI, 1.60-2.19). The physician and facility offering LCS accounted for 19% and 36% of the variation in declining LCS, respectively.

Conclusions and Relevance

In this cohort study, older veterans with serious comorbidities were more likely to decline LCS and Black and Hispanic veterans were more likely to accept it. Variation in LCS decisions was accounted for more by the facility and physician offering LCS than by patient factors. These findings suggest that shared decision-making conversations in which patients play a central role in guiding care may enhance patient-centered care and address disparities in LCS.

Barriers and facilitators to lung cancer screening and follow-up

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.

American Cancer Society's report on the status of cancer disparities in the United States, 2021

In this report, the authors provide comprehensive and up-to-date US data on disparities in cancer occurrence, major risk factors, and access to and utilization of preventive measures and screening by sociodemographic characteristics. They also review programs and resources that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. The overall cancer death rate is 19% higher among Black males than among White males. Black females also have a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. There are also substantial variations in death rates for specific cancer types and in stage at diagnosis, survival, exposure to risk factors, and receipt of preventive measures and screening by race/ethnicity, socioeconomic status, and geographic location. For example, kidney cancer death rates by sex among American Indian/Alaska Native people are ≥64% higher than the corresponding rates in each of the other racial/ethnic groups, and the 5-year relative survival for all cancers combined is 14% lower among residents of poorer counties than among residents of more affluent counties. Broad and equitable implementation of evidence-based interventions, such as increasing health insurance coverage through Medicaid expansion or other initiatives, could substantially reduce cancer disparities. However, progress will require not only equitable local, state, and federal policies but also broad interdisciplinary engagement to elevate and address fundamental social inequities and longstanding systemic racism.

Social Disparities in Lung Cancer Risk and Screening

Significant disparities exist in lung cancer incidence and screening. Geographic, racial, gender, and socioeconomic disparities affect lung cancer incidence. As the leading cause of lung cancer, smoking varies among different racioethnic groups, genders, and socioeconomic statuses. In addition, environmental pollutants, such as radon, industrial toxins, and air pollution, are significant risk factors for lung cancer development that is disproportionately seen in working-class communities, as well as underserved and disabled populations. Lung cancer incidence depends on diagnosis. Literature examining lung cancer incidence and screening disparities have its limitations, as most studies are methodologically limited and do not adjust for important risk factors.

A History of Health Policy and Health Disparity

Civil Rights legislation and court decisions influenced health care policy, which attempted to provide health care to elderly and low-income populations. Passing Medicaid and Medicare was monumental in increasing access to health insurance. The Affordable Care Act aimed to increase access to and affordability of health care to alleviate some disparities in health care. The Affordable Care Act established the National Institute of Minority and Health Disparity and Offices of Minority Health. However, disparities of access, care, morbidity, and mortality among marginalized populations persist. We in the thoracic community must leverage all means to mitigate the injustice of health disparities.

Lung cancer mortality reduction by LDCT screening: UKLS randomised trial results and international meta-analysis

BACKGROUND

The NLST reported a significant 20% reduction in lung cancer mortality with three annual low-dose CT (LDCT) screens and the Dutch-Belgian NELSON trial indicates a similar reduction. We present the results of the UKLS trial.

METHODS

From October 2011 to February 2013, we randomly allocated 4 055 participants to either a single invitation to screening with LDCT or to no screening (usual care). Eligible participants (aged 50-75) had a risk score (LLPv2) ≥ 4.5% of developing lung cancer over five years. Data were collected on lung cancer cases to 31 December 2019 and deaths to 29 February 2020 through linkage to national registries. The primary outcome was mortality due to lung cancer. We included our results in a random-effects meta-analysis to provide a synthesis of the latest randomised trial evidence.

FINDINGS

1 987 participants in the intervention and 1 981 in the usual care arms were followed for a median of 7.3 years (IQR 7.1-7.6), 86 cancers were diagnosed in the LDCT arm and 75 in the control arm. 30 lung cancer deaths were reported in the screening arm, 46 in the control arm, (relative rate 0.65 [95% CI 0.41-1.02]; p=0.062). The meta-analysis indicated a significant reduction in lung cancer mortality with a pooled overall relative rate of 0.84 (95% CI 0.76-0.92) from nine eligible trials.

INTERPRETATION

The UKLS trial of single LDCT indicates a reduction of lung cancer death of similar magnitude to the NELSON and NLST trials and was included in a meta-analysis of nine randomised trials which provides unequivocal support for lung cancer screening in identified risk groups.

FUNDING

NIHR Health Technology Assessment programme; NIHR Policy Research programme; Roy Castle Lung Cancer Foundation.

Total and Out-of-Pocket Costs of Procedures After Lung Cancer Screening in a National Commercially Insured Population: Estimating an Episode of Care

OBJECTIVE

Consequences of lung cancer screening (LCS) with low-dose chest CT in clinical settings, including procedures, costs, and complications, are incompletely understood. We evaluated downstream invasive procedures after LCS, total and out-of-pocket (OOP) costs of these procedures, and correlates of procedural rates and costs.

METHODS

Using the Clinformatics Data Mart, we retrospectively included patients between ages 55 and 79 years receiving LCS between 2015 and 2017. The types and frequency of downstream invasive procedures (including needle biopsy, bronchoscopy, surgery, and cytology) were described. Treating the LCS examination and downstream procedures as a single LCS episode, we described the per-episode total costs (insurance reimbursement + OOP costs of LCS and downstream procedures) and OOP costs. Correlates of costs were determined using linear and logistic regression.

RESULTS

A total of 6,268 patients received at least one low-dose chest CT; 462 patients (7.4%) received at least one procedure within 12 months after LCS (needle biopsy 69.0%, cytology 23.6%, bronchoscopy 18.6%, surgery 23.8%). Women and patients ≥65 years were more likely to receive a downstream procedure. Ninety-three patients (20.1%) were diagnosed with lung cancer after LCS. The total cost of managing this population of lung screeners was $5,060,511.04, with an average per-episode total cost of $740.06. The aggregate OOP costs to this population of lung screeners was $427,069.74, with an average per-episode OOP cost of $62.46.

CONCLUSIONS

Rates of invasive procedures after LCS in a commercially insured population exceeded those of clinical trials. Considering LCS and associated downstream procedures as an episode of care results in modest OOP cost.

Evaluating the clinical trends and benefits of low-dose computed tomography in lung cancer patients

Background

Despite guideline recommendations, utilization of low‐dose computed tomography (LDCT) for lung cancer screening remains low. The driving factors behind these low rates and the real‐world effect of LDCT utilization on lung cancer outcomes remain limited.

Methods

We identified patients diagnosed with non‐small cell lung cancer (NSCLC) from 2015 to 2017 within the Veterans Health Administration. Multivariable logistic regression assessed the influence of LDCT screening on stage at diagnosis. Lead time correction using published LDCT lead times was performed. Cancer‐specific mortality (CSM) was evaluated using Fine–Gray regression with non‐cancer death as a competing risk. A lasso machine learning model identified important predictors for receiving LDCT screening.

Results

Among 4664 patients, mean age was 67.8 with 58‐month median follow‐up, 95% CI = [7–71], and 118 patients received ≥1 screening LDCT before NSCLC diagnosis. From 2015 to 2017, LDCT screening increased (0.1%–6.6%, mean = 1.3%). Compared with no screening, patients with ≥1 LDCT were more than twice as likely to present with stage I disease at diagnosis (odds ratio [OR] 2.16 [95% CI 1.46–3.20]) and less than half as likely to present with stage IV (OR 0.38 [CI 0.21–0.70]). Screened patients had lower risk of CSM even after adjusting for LDCT lead time (subdistribution hazard ratio 0.60 [CI 0.42–0.85]). The machine learning model achieved an area under curve of 0.87 and identified diagnosis year and region as the most important predictors for receiving LDCT. White, non‐Hispanic patients were more likely to receive LDCT screening, whereas minority, older, female, and unemployed patients were less likely.

Conclusions

Utilization of LDCT screening is increasing, although remains low. Consistent with randomized data, LDCT‐screened patients were diagnosed at earlier stages and had lower CSM. LDCT availability appeared to be the main predictor of utilization. Providing access to more patients, including those in diverse racial and socioeconomic groups, should be a priority.

Contemporary issues in the implementation of lung cancer screening

Lung cancer screening with low-dose computed tomography can reduce death from lung cancer by 20-24% in high-risk smokers. National lung cancer screening programmes have been implemented in the USA and Korea and are being implemented in Europe, Canada and other countries. Lung cancer screening is a process, not a test. It requires an organised programmatic approach to replicate the lung cancer mortality reduction and safety of pivotal clinical trials. Cost-effectiveness of a screening programme is strongly influenced by screening sensitivity and specificity, age to stop screening, integration of smoking cessation intervention for current smokers, screening uptake, nodule management and treatment costs. Appropriate management of screen-detected lung nodules has significant implications for healthcare resource utilisation and minimising harm from radiation exposure related to imaging studies, invasive procedures and clinically significant distress. This review focuses on selected contemporary issues in the path to implement a cost-effective lung cancer screening at the population level. The future impact of emerging technologies such as deep learning and biomarkers are also discussed.

The SHARED Project: A Novel Approach to Engaging African American Men to Address Lung Cancer Disparities

Black men are disproportionately impacted by lung cancer morbidity and mortality. Low-dose helical computed tomography (LDCT) lung cancer screening has demonstrated benefits for reducing lung cancer deaths by identifying cancers at earlier, more treatable stages. Despite the known benefits, LDCT screening is underutilized in black men. Studies in racially heterogeneous populations have found correlations between screening behaviors and factors such as physician trust, physician referral, and a desire to reduce the uncertainty of not knowing if they had lung cancer; yet little is known about the factors that specifically contribute to screening behaviors in black men. Community engagement strategies are beneficial for understanding barriers to health-care engagement. One community engagement approach is the citizen scientist model. Citizen scientists are lay people who are trained in research methods; they have proven valuable in increasing communities' knowledge of the importance of healthy behaviors such as screening, awareness of research, building trust in research, and improving study design and ethics. This paper proposes an intervention, grounded in community-based participatory research approaches and social network theory, to engage black men as citizen scientists in an effort to increase lung cancer screening in black men. This mixed-methods intervention will examine the attitudes, behaviors, and beliefs of black men related to uptake of evidence-based lung cancer screening.