Work Must Persist to Further Lung Cancer Screening and Equity

Studies show that while expansion of guideline eligibility did not reduce disparities, state policies may hold the key to improving screening rates.

Researcher: Stacey Fedewa, MPH, PhD
Institution: American Cancer Society
Area of Focus: Surveillance & Health Equity Science

“The increasing, but still low, use of lung cancer screening reflects both ongoing efforts to screen eligible adults, and the many challenges to do so. Kentucky, which has supported screening implementation efforts, is unique, as its screening rates are more than twice the national average and four times that of other high lung-cancer burden states like West Virginia and Arkansas.”—Stacey Fedewa, MPH, PhD

The Challenge: In 2013, the US Preventive Task Force (USPSTF) and the American Cancer Society (ACS) started recommending that people with a high risk for developing lung cancer get screened each year with low-dose CT scans (LDCT). While other cancer screening guidelines focus on people at average risk for a certain cancer, these lung cancer screening guidelines were the first to only be recommended for a high-risk group.

Since the guidelines were released, researchers began to question if the simple eligibility criteria, based only on age and smoking history, adequately selected people for screening. They were especially concerned about the inclusion of Black people for screening. Compared to a White population, Black people are diagnosed with lung cancer at a younger age and have a higher risk of developing and dying from lung cancer, yet they smoke fewer cigarettes.

In 2020, to expand the number of eligible people across all racial and ethnic groups, the USPSTF lung cancer screening guideline was adapted to recommend screening beginning at a younger age. The most recent version of the ACS guideline is currently being reviewed and updated, so the ACS recommends people at increased risk for lung cancer follow recently updated recommendations from the USPSTF or other organizations.

However, many cancer screening programs were paused during the COVID-19 pandemic. Research was needed to study how many people were getting screened under the original guidelines and how those rates have been impacted by the change in guidelines and the COVID-19 pandemic. Research was also needed to better understand the barriers to screening and racial disparities in screening rates.

The Research:  Stacy Fedewa, MPH, PhD, is the senior principal scientist of risk factors and screening surveillance research at the ACS. Over the last year, she’s published several studies about lung cancer screening. Here are some of her findings.

Lung cancer screening rates varied greatly by state between 2016 and 2018. Fedewa, along with 4 other ACS researchers (Ahmedin Jemal, DVM, PhD, Helmneh Sineshaw, MD, MPH, Priti Bandi, PhD, and Robert Smith, PhD) studied data about LDCT update from 2016 to 2018 and published their results in the summer of 2021. They learned that:

  • The screening rate was low but steady between 2016 and 2017, with a little over 3% of those eligible getting screened.
  • Screening rates increased to 5% of those eligible getting screened in 2018.
  • Except for Kentucky, screening rates did not correspond with the burden of lung cancer in states. Kentucky has the nation’s highest lung cancer death rate and in 2018, and it also had one of the highest screening rates—almost 14%. In contrast, several states with high numbers of people with lung cancer—Mississippi, West Virginia, and Arkansas—had less than 4% of those eligible getting screened in 2018. And several states with high screening rates (from 13 to 15%) that year had a lower lung-cancer burden—Massachusetts, Vermont, and New Hampshire.

The study authors note that the increasing, but low use of lung-cancer screening reflects “both ongoing efforts to screen eligible adults and the many challenges of doing so.”

One effort that likely helped increase screening rates was that Medicare and most commercial health insurers started covering lung cancer screening in 2015. In addition, several states launched programs designed to increase lung cancer screening rates. For example, Kentucky, which had one of the highest screening rates, does not require preauthorization for LDCT, which is a known barrier to screening.

Still, there are multiple barriers that make efforts to increase screening rates challenging:

  • Health care providers may not collect smoking histories that are detailed enough to identify those eligible for screening.
  • People who smoke are known to have less contact with primary care providers who make recommendations for screening.
  • Lung cancer screening may be viewed as less beneficial than other cancer screenings.
  • People eligible for screening may not believe the screening will improve their health, lack confidence in its effectiveness, are worried about false positives, and are unwilling to receive surgery if cancer is detected.
  • Logistical barriers, such as lack of sick leave.

To improve lung cancer screening rates, Fedewa and her colleagues recommended “resonating messages and educational tools along with adapting the screening process to meet patients’ needs, schedules, and values.”

In 19 states, lung cancer screening rates increased during the COVID-19 pandemic. The results of another study, about how the COVID-19 pandemic has affected lung cancer screening, was also published in 2021, by the same ACS team of Surveillance & Health Equity researchers, along with Gerard Silvestri, MD, from the Division of Pulmonary and Critical Care Medicine at the Medical University of South Carolina.

This study examined annual lung-cancer screening rates before (2019) and during (2020) the pandemic both nationally and by state. The researchers found that overall national screening rates remained low and unchanged. However, their state-by-state analysis found that lung-cancer screening rates were:

  • Unchanged in 25 states, with about 7% of those eligible getting screened
  • Significantly increased in 19 states
  • Increased by more than 20% in 4 states: Nevada, West Virginia, Maine, and Kentucky
  • Decreased in 5 states: Utah, Rhode Island, Vermont, Hawaii, and Maryland

As in the previous study, the authors suggest that best practices from successful state and local lung cancer screening programs could inform ongoing efforts to detect lung cancers early.

Changing lung cancer screening guidelines to include younger people has not reduced racial disparities. Fedewa and Silvestri published an editorial in early 2021 about the challenges of reducing disparities in lung cancer screening.

Under the 2020 USPSTF updated guideline, an additional 6.5 million people were eligible for lung cancer screening. The increase in eligibility was across all racial/ethnic groups, with a 16% increase of eligibility for White people, 14% for Black people, 10% for Hispanic people, and 8% for Asian people.

The greater pool of those eligible for annual screening did help reduce the death rate overall and increased the number of years people with a heavy smoking history lived. But those gains did not eliminate racial disparities.

Lowering the screening age increased the number of eligible adults. But many of these newly-eligible people have Medicaid, no health insurance, or disruptions in their coverage. These circumstances are more common in minorities and are related to lower rates of cancer screening.

The ability of health providers to identify eligible adults is another barrier to lung cancer screening. For instance, providers need the time and systems in place to compute a patient’s individual risk and life expectancy, and this may be especially challenging in the under-resourced health care facilities where Black and Hispanic people frequently receive care.

Disparities in cancer treatment are also still a problem. Even when lung cancer is found at an earlier stage, it’s harder to treat than other types of cancer. And, Black people with lung cancer are less likely than White people to receive standard treatment and recommended plans of care.

Why Does It Matter? Lung cancer is the leading cause of death from cancer in the United States for men and women across all major racial groups. Studies show that when people who formerly smoked or currently smoke heavily receive an annual screening with low-dose computed tomography (LDCT), they reduce their risk of dying from lung cancer by 20%. Yet screening rates are low among eligible people.

This research shows that, while increasing the number of eligible people did increase screening rates even during the COVID-19 pandemic, it did not address racial disparities in who is getting screened for lung cancer. But it also suggests that looking deeper into the differences in screening rates by state could offer valuable insight into effective strategies for increasing lung cancer screening rates, reducing disparities, and decreasing the death rate from lung cancer nationwide.