Lung cancer is the second most common type of cancer and the leading cause of cancer death in the United States. Each year, more people die of lung cancer than of colon, breast and prostate cancers combined.
Although the primary risk factor for lung cancer is cigarette smoking, use of other tobacco products and exposure to radon are also culprits. The American Cancer Society estimates that in 2021 there will be about 235,760 new lung cancer cases in the U.S. and 131,880 lung cancer-related deaths.
Tragically, lung cancer does not often show symptoms until later stages when it has already spread, and only about 30 percent of cases are diagnosed early. One of the key tools in finding the disease before symptoms appear is lung cancer screening (LCS) with annual low-dose computed tomography (LDCT). Also referred to as low-dose helical CT, LCS aims to reduce cancer mortality through increased lung cancer detection at a curable stage. It’s utilized instead of screening with chest x-rays and/or sputum cytology, which do not decrease the risk of dying from lung cancer.
Recommendations From the U.S. Preventive Services Task Force
Lung cancer screening recommendations are designed to provide the largest health benefits to the greatest number of people possible. In 2014, the U.S. Preventive Services Task Force (USPSTF) recommended LCS for adults in generally good health and at high lung cancer risk based on age and smoking history. However, as experts have more data, screening recommendations often are adjusted.
A prime example of this type of adjustment occurred recently when the USPSTF announced it now recommends annual lung cancer screening with LDCT in adults aged 50-80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Based on the findings in its evidence review, the USPSTF made these two notable changes to the current draft recommendation concerning screening eligibility:
- First, the task force recommended that clinicians begin lung cancer screening in patients beginning at age 50 rather than 55.
- Second, the USPSTF reduced the pack-years of smoking history that would make people eligible for screening from 30 to 20.
Promoting Early Diagnosis of Lung Cancer
LCS is one of the first cancer screenings to target a high-risk group or behavior and provides myriad advantages. For example, the preventive measure increases early detection, decreases mortality, commonly detects incidental findings in other organ systems, identifies other modifiable conditions associated with smoking and increases opportunities for tobacco cessation.
There are multiple studies that indicate that low-dose CT screening for at-risk populations can be successful in promoting early diagnosis. According to Dr. Bernard J. Park, a lung surgeon and the clinical director of the lung screening service at Memorial Sloan Kettering Cancer Center in New York, an estimated 75-85 percent of the cancers found with this screening are Stage 1 and curable with just surgery or radiation. The five-year survival rate for Stage 1A lung cancer is 73 percent, whereas the five-year survival rate for patients at advanced-stage lung cancer is less than 10 percent.
Studies from the National Institute of Health’s Cancer Intervention and Surveillance Modeling Network (CISNET) found that USPSTF’s revised LCS recommendations would reduce lung cancer mortality by 13 percent and avert 503 lung cancer deaths per 100,000. Under the new criteria, 14.5 million people in the U.S. will qualify for the screening, an increase of 6.4 million. The USPSTF notes that expanding who is eligible for screening will be helpful in finding lung cancer sooner in people who do or don’t experience symptoms.
Expanding Screening for Minorities
The new USPSTF guidelines will include many more African-Americans and women than in the past and have the potential to reduce lung cancer morbidity and decrease disparities in access to lung cancer screening by increasing eligibility among smokers. Although black males have the highest lung cancer death rates, they’re typically lighter smo
kers than their Caucasian counterparts. However, the following statistics indicate why lung cancer is an especially prevalent health problem among African-Americans and other minorities:
- African American individuals are more likely to start smoking at a later age, smoke fewer cigarettes per day, have a longer duration of smoking, are less likely to quit and tend to be diagnosed with lung cancer at an earlier age.
- Women and African-Americans tend to develop lung cancer earlier and from less tobacco exposure than do Caucasian men.
- In terms of outcomes in cancer care, disparities in time to diagnosis, curative treatment and cancer-specific and overall mortality have been noted among African-American, Hispanic and Asian patients with nearly every tumor type.
Barriers to Lung Cancer Screening
Multi-level barriers to lung cancer screening include the cost of the screening or copay, reaching people in medically underserved areas who may not engage with the health system and a lack of plain language in educational materials about the dangers of smoking. Lower socioeconomic status (SES), a problem experienced by many minorities and other individuals, is associated with increased likelihood of smoking and lung cancer and lower access to preventive medical care, including screening. Similarly, indices of low socioeconomic status and low health literacy have been associated with increased cancer incidence and cancer mortality.
Researchers estimate that only 6-18 percent of those who qualify and could be helped by lung cancer screening have taken advantage of it, some due to cost. In November 2020, screenings were down by 30 percent compared to 2019, and the number of lung biopsies also had dropped. Another issue is that studies have shown that self-reported smoking history information recorded in patients’ electronic medical records is wrong roughly 90 percent of the time.
Population Health Patient Outreach
For lung cancer screening to be effective, implementation guides stress the importance of formal programs, including eligibility confirmation, effective patient tracking, adherence to structured nodule reporting and evaluation and access to a multidisciplinary committee of clinical specialists. The American Medical Association (AMA) points out that primary care physicians have a major role to play in preventing lung cancer deaths.
Population health management is an essential part of ensuring that information about lung cancer screening is directed at the most at-risk populations and addressing social determinants of health (SDOH) to do so. As clinical medicine becomes more personalized, targeting these higher-risk individuals will help enhance population health and economic efficiency.
Outreach campaigns for population health management from health systems, hospitals and physician practices should be personalized with the goal of increasing adherence to appointments and preventive care such as lung cancer screening. They should prioritize current smokers and smokers from minority populations to close care gaps, minimize costly emergency department visits and improve patient engagement and outcomes.
Through tools such as HIPAA-compliant two-way text messaging, physicians and other health care providers can send personalized messages to chronic disease populations, including those at risk for lung cancer, and help them develop ways to meaningfully reach and engage patient populations. In addition, they can improve patient access and better identify and manage those high-risk patients through virtual triage and remote monitoring.
Providertech’s CareX solution can help you engage your patients and members in preventative care, resulting in lower costs, improved communication and understanding of recommended care, and minimized emergency department visits. The platform can automatically pull records from your EMR based on your appointment types, providers and clinics or digest existing internal patient registries. Patient responses are displayed in your self-service portal and can be pushed directly into your practice management system.
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