Very few of the heavy smokers who are eligible for lung cancer screening in the United States have undergone such screening, a nationwide analysis has found.
The US Preventive Services Task Force (USPSTF) recommended in 2013 that all individuals aged 55 to 80 years who have a smoking history of 30 pack-years or longer and who currently smoke or have quit within the past 15 years should be screened annually for lung cancer with low-dose CT (LDCT).
There are an estimated 7 million such individuals in the United States.
In 2016, fewer than 2% of those eligible underwent LDCT at one of the nearly 1800 screening centers across the country.
The findings, which will be presented at the forthcoming American Society of Clinical Oncology (ASCO) 2018 annual meeting on June 3 (abstract 6504), were highlighted at a press briefing held ahead of the meeting.
They follow the publishing of recent data, reported by Medscape Medical News, that the majority of patients who are referred to lung cancer screening live close to the screening site, suggesting that underserved populations living in remote areas are being left out.
This very low rate of lung cancer screening is particularly stark when compared with screening rates for breast cancer. About 65% of women aged 40 or older underwent a mammogram in 2015, commented lead author Danh Pham, MD, a medical oncologist at the James Graham Brown Cancer Center, University of Louisville, Kentucky.
“This ultimately begs the question of the root of the disparity,” he said at the press briefing.
“Are physicians not referring enough? Or perhaps are eligible patients not wanting screening, even if they knew a test was available?” he continued.
Although it is “still speculation at this point,” he wondered whether there may be a stigma associated with screening for lung cancer, a disease that is “attributed to a modifiable risk factor through heavy smoking, and the at-risk population may be deterred from wanting screening if diagnosing cancer will result in confirming a poor lifestyle choice.”
This has been described as the “ostrich effect,” a term recently coined to describe frightened patients who, when faced with a major health problem, want to “stick their heads in the sand” and make it all go away.
Pham emphasized that, whatever the reason, the findings are “a call to action on everyone’s part to increase much-needed screening, whether it’s through increasing awareness or conducting additional research to urgently increase the screening of the number one cancer killer in America.”
Bruce E. Johnson, MD, president of ASCO, agreed that the low rates of lung cancer screening are “very disappointing.”
He underlined that previous estimates for lung cancer screening suggested that it saves 12,000 lives every year. By comparison, the findings of the current study indicate that 250 lives are saved each year.
However, Johnson also pointed out that, given that reimbursement for screening was only approved by the Centers for Medicare & Medicaid (CMS) in 2015 and that the analysis was conducted in 2016, the results show what happened in “the first year, so this is a measure not of a steady-state situation.”
Approached for comment, Daniel Oh, MD, clinical assistant professor of surgery at Keck School of Medicine of the University of California (USC), Los Angeles, and cofounder of the USC/Norris Lung Cancer Program, agreed that the history of lung cancer screening should be taken into account when interpreting the results.
Results from the landmark National Lung Screening Trial, which showed that screening could save lives, were published in June 2011. The USPSTF recommended screening in 2013, but it was not until February 2015 that coverage of costs by CMS was approved. “There had been concerns among clinicians that CMS was not going to approve it, which placed many physicians in limbo about whether or not to offer LDCT, due to insurance coverage concerns,” he said.
He also pointed out that, when CMS finally approved LDCT screening, “they stipulated that screening centers must report to a CMS-approved registry, which is essentially the American College of Radiology [ACR] Lung Cancer Screening Registry.”
His center was “among the first applicants for entry into the ACR registry, and we still did not become a participant until July 2015,” he said. “Taking into consideration logistics and the resolution of coverage issues, 2016 is a more accurate baseline measurement of lung cancer screening,” he noted.
The study illustrates that our nation still has not embraced lung cancer screening in earnest.
“That said, the study illustrates that our nation still has not embraced lung cancer screening in earnest, and we need to raise awareness among primary care physicians to improve adoption of LDCT,” he commented.
“When you consider that 60% of eligible patients receive colonoscopies, which are far more unpleasant than an LDCT, it is clear that we need to do better,” he added.
Details of the Analysis
For the current analysis, Pharm and colleagues gathered data from the Lung Cancer Screening Registry of the ACR on all LDCTs performed at all 1796 accredited radiographic screening sites in the United States in 2016.
They then used data from the 2015 National Health Interview Survey to estimate the number of eligible smokers who could have been screened on the basis of USPSTF recommendations.
The data were compiled for four US census regions, the Northeast, the South, the Midwest, and the West. The researchers calculated the screening rate by dividing the number of LDCT scans by the number of smokers eligible for screening per USPSTF recommendations.
Overall, the team calculated that an estimated 7,612,975 smokers across the United States were eligible for screening. They found that 14,080 LDCT screens were performed in the 1796 centers nationwide. From these data, they calculated the overall lung cancer screening rate to be just 1.9%.
The South had the highest number of accredited centers, at 663, as well as the highest estimated number of eligible smokers, at 3,072,095, but that region had the second lowest screening rate, at just 1.6%.
The West had the lowest screening rate, at 1.0%. There were 232 accredited centers in the West, and an estimated 1,368,694 eligible smokers.
The screening rate in the Midwest, which had 497 screening centers and an estimated 2,020,045 eligible smokers, was 1.9%.
The highest screening rate was seen in the Northeast, which had a rate of 3.5%. There, there were 404 accredited centers and an estimated 1,152,141 eligible smokers.
How to Improve Lung Cancer Screening Rates?
Discussing how screening rates could be increased, Pham said: “I think the most radical thing that we could suggest based on our study so far would potentially be making lung cancer screening a national quality health measure, just the way that CMS made breast cancer and colonoscopies a national area of improvement in 2008.”
Richard Schilsky, MD, chief medical officer at ASCO, said that “could be an effective strategy, particularly since physicians are increasingly being required to report on quality measures to optimize their reimbursement.”
Schilsky emphasized that screening for cancer is typically carried out by primary care physicians, rather than oncologists. “So one of the things that we also need to do is to be sure primary care physicians are well aware of the screening data and the importance of referring the appropriate patients for screening, and that they are aware of screening centers are available in their communities.”
For Oh, the focus should be on the patients themselves. “I think individuals simply need to be aware that screening for lung cancer exists,” he said.
“People these days are very proactive about their health, but this is a topic that is not getting a lot of attention. For example, we all see numerous commercials on TV every day telling patients to ask their doctor about a new drug, but we do not see anything analogous for lung screening awareness,” he said.
Oh nevertheless agreed with Schilsky about the importance of educating primary care physicians and the need to “clarify for them the requirements for screening and ease the workflow that is involved.
“Ultimately, I think an automated reminder in patients’ electronic health records needs to be implemented, but this will take some time,” Oh commented.
“”Surprisingly, one of the biggest obstacles for this has been the lack of an accurate smoking history in patients’ records, which often goes back to the stigma of smoking,” he said.
Another solution to the low lung cancer screening rates may come from the United Kingdom, where a pilot screening program in a supermarket parking lot quadrupled detection rates of early lung cancer.
As reported by Medscape Medical News, the pilot project, which was funded by a UK charity, used LDCT to screen current and former smokers identified from general practices. Through the program, 80% of lung cancer cases were detected while the disease was at stage I or II.
Another study that was reported by Medscape Medical News suggested that the majority of patients referred to lung cancer screening live close to the screening site, leaving out remote and underserved populations.
One other issue with lung cancer screening concerns the risk-benefit ratio. LDCT screening finds many nodules in the lung that are not cancer. As reported by Medscape Medical News, in a recent study conducted by the Veterans Health Administration, 2000 high-risk individuals were screened for lung cancer. Of those patients, 1.5% were found to have lung cancer, and around 60% of patients had positive results on screening, including one or more nodules that needed to be tracked. Incidental findings were reported in around 40% of patients. The authors concluded that lung cancer screening “benefits few, but may harm many.”
This study received funding from the Bristol-Myers Squibb Foundation. Dr OH has disclosed no relevant financial relationships, but several coauthors have reported financial relationships with pharmaceutical companies, as detailed in the abstract.
American Society of Clinical Oncology (ASCO) 2018. Abstract 6504, to be presented June 1, 2018.
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