Review of Interventions That Improve Uptake of Lung Cancer Screening

Abstract

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.

Lung cancer is the leading cause of cancer death, both in the United States and worldwide. Lung cancer screening (LCS) with low-dose CT imaging has the potential to decrease mortality from lung cancer by approximately 20%.^1,2 Yet, 1 decade since LCS was first recommended by the US Preventive Services Task Force (USPSTF), < 20% of the eligible population in the United States has been screened.^3,4 To achieve the full life expectancy benefits of LCS, it is critical to design and implement effective interventions to enhance LCS uptake.

LCS was first recommended by the USPSTF in 2013 for high-risk individuals, defined similarly in the National Lung Screening Trial as adults between the ages of 55 and 80 years with at least a 30-pack-per year history of smoking and who either actively use tobacco or had quit within the last 15 years.⁵ However, trial participants were younger, were less racially and ethnically diverse, had fewer comorbidities, and were more likely to have quit smoking than the LCS-eligible US population.⁶ Based on modeling studies, the USPSTF expanded their guidelines in 2021 to recommend LCS to younger adults with a shorter history of smoking, defined as adults 50 to 80 years of age with ≥ 20 pack-years of smoking who currently smoke or, as previously noted, had quit smoking within the past 15 years.^7,8 This change nearly doubled the number of people in the United States eligible for LCS to 14.5 million.⁹ However, this increase in the number of eligible people will not improve lung cancer mortality rates unless effective strategies to improve LCS uptake are implemented.

Barriers to the uptake of LCS exist at three key steps in the process (Fig 1). First, lack of awareness and inaccurate smoking history data limit identifying people eligible for LCS. Providers and patients often lack awareness about the availability and eligibility criteria of LCS.^{10, 11, 12, 13, 14} Additionally, smoking history is incomplete or inaccurate in the electronic health record (EHR) in 40% to 80% of patients depending on the health care system, limiting the ability to identify patients potentially eligible for LCS.^{15, 16, 17} Second, shared decision-making (SDM) between providers and patients, a requirement for Centers for Medicare and Medicaid Services reimbursement, often is cursory and can lead to a lack of patient engagement. Many providers lack sufficient time to conduct SDM with patients, and when they do discuss screening, providers may tend to overemphasize the benefits of LCS with little mention of the harms (eg, anxiety resulting from screen-detected findings, complications resulting from downstream procedures, and overdiagnosis).^{18, 19, 20, 21, 22} Additionally, many providers do not use decision aids routinely to facilitate patient understanding or to explore patient values and preferences about LCS, all of which can hinder informed, values-based, and patient-centered decisions.^{19, 20, 21} Finally, even when patients agree to screening, they may not actually undergo the initial screening. Approximately 40% of patients who agree to screening do not undergo an LCS examination in the ensuing 3 months.^23,24 Barriers to LCS include logistical factors (eg, transportation, time), coverage (eg, insurance copayments or prior authorization), and a lack of administrative support (eg, helping to schedule and manage missed visits).^{23,25, 26, 27}

Figure 1.

Diagram showing barriers to LCS at key steps. Barriers are organized into three key areas that are targets for interventions, and all the factors influencing uptake of screening are not presented. Beyond this simplified figure, barriers to LCS uptake exist at the patient, clinician, health care organization, community, and policy levels. LCS = lung cancer screening.

To improve the adoption of LCS, it is critical to address barriers across various steps and to ensure that individuals have access to patient-centered screening. Our objective was to conduct a comprehensive review analyzing interventions designed to improve initial LCS uptake to provide guidance for future intervention strategies and to optimize the overall implementation of LCS.

Literature Search

We conducted a comprehensive literature search according to a prespecified protocol registered at the International Prospective Register of Systematic Reviews (Identifier: CRD42023376289). To identify relevant literature, a librarian formulated a comprehensive search strategy tailored for MEDLINE detailing the specific conditions and subsequently adapted it for use in other databases (see e-Appendix 1 for full search strings for each database). All searches were conducted in February 2023. No date, language, or study filters were used during database searching. Additional citations located through PubMed searching also were added to the aggregate citation pool (Fig 2). Citations were exported to the systematic review software Covidence (Veritas Health Innovation) and duplicates were removed.

Figure 2.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart. LCS = lung cancer screening; LDCT = low-dose CT.

Studies were included if they used an intervention to support LCS. Studies were excluded if they did not focus on initial LCS via low-dose CT imaging of the chest, if no measure of LCS completion was included, or if no comparison group was included. Excluded study types included other reviews (eg, systematic, scoping, narrative, meta-analyses) and qualitative, epidemiologic, and modeling studies. Studies not available in English and dating from before 2011 were excluded because LCS was not an evidence-based practice before this time (ie, before publication of the National Lung Screening Trial).

Five reviewers worked independently to perform an initial screen of titles and abstracts. Each study was screened for inclusion by two reviewers, with a third reviewer arbitrating when the votes were split. Then, two reviewers conducted a full-text review to determine final eligibility. A third reviewer resolved any conflicts from the full-text review. Risk of bias was assessed using the National Heart, Lung, and Blood Institute quality assessment tools for randomized controlled trials, observational studies, and before-and-after designs and were rated as good, fair, or poor based on the performance on the criterion. We present a narrative review of the identified studies (Table 1),^{28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39} as well as relevant studies identified through full-text review.

Table 1.

Summary of Studies That Used Interventions to Improve LCS

Study	Study Design	Description of Intervention and Control Groups	Study Population	Primary Outcome LCS Completion Outcome	Completed LCS Intervention vs Control Groups	Outcome Effect Estimate (Second Intervention)	Study Quality
Interventions to improve smoking history documentation
Begnaud et al (2017)28	Randomized controlled trial	Participants who were assigned to electronic promotion were sent messages in the patient portal that informed them of their potential eligibility for LCS. The message included a questionnaire that was linked to their smoking history in the EHR, which could be reviewed and modified by the patients. All respondents were sent a follow-up portal message to indicate eligibility for LCS and to inform them of the risks and benefits of screening. If eligible, an order for LCS was placed in the chart and the patient was provided imaging scheduling information. Participants in the usual care group did not receive electronic messages.	Adults aged 55-79 y who formerly smoked. Excluded those with Medicare insurance.	LCS completion within 6 mo of study enrollment	4 of 99 (4%) vs 1 of 101 (1%); P = .13	NA	Good
Interventions to improve awareness through outreach and education
Cardarelli et al (2017)29	Before and after implementation study	Multicomponent outreach campaign across two intervention regions in Kentucky to raise LCS awareness, including: (1) mailing 54,600 postcards to 64 primary care and public health locations, (2) physician LCS roundtable event in one of the intervention regions, (3) community newspaper ads recurring every 2 wk for 6 mo, and (4) local public radio station ads twice daily for 6 mo. Control group was a neighboring region that did not receive outreach campaign.	Three eastern Kentucky regions	Monthly totals of LCS in 2014 (before intervention) compared with 2015 (during and after intervention)	Average increase of approximately 20 and 2 vs 3.2 LCS per month per 100,000 people in the two intervention regions vs control region, respectively	NA	Fair
Jessup et al (2018)30	Before and after implementation study	A pay-per-click-campaign on Google and Facebook targeted adults aged 55 y and older with LCS content including images, videos, and search results during a 20-wk intervention period from May through September 2016. A concurrent pay-per-click campaign using LinkedIn and Twitter targeted health care providers (eg, physicians, nurse practitioners, and physician assistants) with content focused on LCS mortality benefits and eligibility criteria.	Targeted adults aged ≥ 55 y and caregivers ≥ 18 y	Completed LCS examinations at the academic medical center over the course of 20 wk before, during, and after the digital awareness campaigns	Before campaign vs campaign: 20.4 ± 5.4 vs 17.4 ± 7.5 LCS completed/wk (P = .16)	Campaign vs after campaign: 20.4 ± 5.4 vs 26.2 ± 6.4 LCS completed/wk (P < .001)	Fair
Raz et al (2021)32	Randomized controlled trial	Intervention group invited to view an online LCS education video, “Lung Cancer Screening: Options,” with a total viewing time < 30 min. Control group received usual care and was not invited to receive any educational intervention.	Adults aged 55-79 y with ≥ 30-PY smoking history who completed smoking cessation counseling	Chest CT imaging performed for screening or diagnostic purposes at 6 mo	87 of 1,026 (8.5%) vs 22 of 255 (8.6%); P = .94	NA	Good
Interventions to improve awareness through varied messaging
Ruparel et al (2019)34	Randomized controlled trial	Control group participants were given a 10-page informational booklet. Intervention participants were shown a 5-min information film and given the same information booklet. Both discussed benefits and harms of LCS, the LDCT imaging examination, and possible LCS results.	Individuals meeting LSUT eligibility criteriaa	LCS completion during study period	78.7% vs 76.7% (P = .66)	NA	Good
Quaife et al (2020)33	Randomized controlled trial	All participants received the same postal invitation letters from their primary care practice. The control group received an informational booklet based on LCS facts. The intervention group received an accompanying leaflet designed to target psychological barriers to attendance (fear, fatalism, and stigma), to be low burden, and to be stepped (full information given at the appointment).	Adults aged 60-75 y with history of smoking in the last 5 y	LCS completion during study period	386 of 1,006 (38.4%) vs 384 of 1,006 (38.2%); adjusted OR, 0.63 (95% CI, 0.37-1.05)	NA	Good
SDM-related interventions
Kathuria et al (2022)35	Randomized controlled trial	Intervention participants received inpatient SDM: (1) to SDM using a decision aid; (2) to connect interested patients directly to LCS (nurse practitioner notifies PCP of patients desiring LCS through the EHR, encouraging PCPs to place referral); and (3) to motivate patients to stop smoking within the LCS context. In a subsequent pilot, the inpatient SDM was adapted by adding community health worker-delivered navigation to observe participants for 3 mo or until LCS completion, assisting with scheduling, transportation, and arranging subsidized phone services. Control group participants received the LCS patient decision aid, but did not review it together, and participants were instructed to let their PCP know if they were interested in LCS.	Patients aged 55-80 y hospitalized at a safety net hospital currently smoking with ≥ 30 PY history who received an inpatient tobacco treatment consult	LCS completion at 3 mo	Inpatient SDM vs control: 2 of 52 (4%) vs 1 of 43 (2%); P = .60	Inpatient SDM plus navigation vs control: 5 of 10 (50%) vs 1 of 9 (11%); P < .05	Good
Volk et al (2020)39	Randomized controlled trial	The intervention group received a PDA, a 9.5-min narrated video “Lung Cancer Screening: Is It Right for Me?” The narrated PDA included information about: (1) LCS eligibility; (2) lung cancer epidemiologic features and risk factors; (3) a video of a patient in a CT imaging scanner; (4) graphical depiction of mortality reduction, false-positive results, and harms resulting from invasive diagnostic procedures; and (5) radiation exposure. The control group received educational material that was a 2-page brochure from a lung cancer advocacy group.	Adults aged 55-77 y from 13 states with ≥ 30-PY smoking history who had used a tobacco quit line	LCS completion at 6 mo	57 of 259 (22.0%) vs 68 of 257 (26.5%); adjusted OR, 1.27 (95% CI, 0.52-3.11); P = .60	NA	Good
Multicomponent interventions
DiCarlo et al (2022)31	Randomized controlled trial	For the outreach contact participants, the care coordinator reviewed the mailed intervention materials and assessed interest in screening. For the outreach contact and decision coaching group participants, the care coordinator reviewed the mailed intervention materials and used an online interactive decision aid tool (the Decision Counseling Program) to guide participants through a brief (approximately 10-min) decision counseling session. Both groups were offered to schedule an LCS program appointment. Usual care group did not receive any intervention contacts.	Adults who potentially were eligible for LCS	Time to completion of LCS calculated from the date of randomization	Combined outreach and decision coaching group vs control group: 5.5% vs 1.8%; HR, 3.28 (95% CI, 1.98 to 5.41); P = .001	Outreach and decision vs outreach alone: 21 of 302 (7.0%) vs 12 of 297 (1.8%); HR, 1.75 (95% CI, 0.86-3.55); P = .12	Good
Fabbrini et al (2018)37	Prospective cohort	Phase 1: Eligible patients were mailed SDM materials followed by two letters with instructions to call the LCS program. The program manager then contacted patients via telephone to all invitation nonrespondents to review SDM materials and discuss any questions. Phase 2: The same mailed SDM materials followed by two letters inviting them to call the LCS program to discuss LCS and schedule an LDCT imaging examination.	Adults aged 55-80 y with ≥ 30 PY and who either currently smoke or quit < 15 y ago	LCS completion at 219 d after randomization	Phase 1, 165 of 766 (22%) vs phase 2, 13 of 152 (9%); P < .001	Completed telephone contact with LCS program manager: 165 of 280 (59%)	Poor (lack of randomization and adherence to protocol)
Lewis et al (2022)38	Retrospective cohort	Eight VA medical centers that were part of the Demonstration Project each hired a coordinators and used clinical reminders and educational materials. Coordinators conducted eligibility assessment, SDM, and tobacco cessation; ordered LCS; communicated results; and coordinated follow-up. The eight sites were compared with level 1a or 1b VA medical centers that applied but were not selected to participate in the demonstration project.	Veterans screened for lung cancer	Monthly screening rates across three periods: (1) before (January 1, 2011-June 30, 2013), (2) during (July 1, 2013-June 30, 2015), and (3) after (July 1, 2015-December 31, 2018)	17.7 LCS/1,000 eligible people/mo vs 0.3 LCS/1,000 eligible people/mo (95% CI, 12.6-22.3)	NA	Fair
Percac-Lima et al (2018)36	Randomized controlled trial	Four part-time lay patient navigators determined LCS eligibility, overcame barriers to LCS, introduced SDM, and empowered patients to discuss the risks and benefits of screening with their PCP. If the patient was interested in screening, the navigator arranged an SDM appointment with their PCP. Patients randomized to the control arm received usual care.	Adults aged 55-77 y who currently smoke	Chest CT scan for screening or diagnostic purposes during the study period	124 of 400 (31%) vs 138 of 800 (17.3%); P < .0001	NA	Good

EHR = electronic health record; HR = hazard ratio; LCS = lung cancer screening; LDCT = low-dose CT; LSUT = Lung Screen Uptake Trial; NA = not applicable; PCP = primary care provider; PDA = patient decision aid; PY = pack-year; SDM = shared decision-making; VA = Veterans Health Administration.

^aOne of three criteria: (1) US National Lung Screening Trial > 30-pack-y smoking history and still smoking or quit ≤ 15 y earlier; (2) prostate, lung, colorectal, and ovarian score ≥ 1.51%; or (3) Liverpool Lung Project score > 2.5%.

Evidence Review

Interventions That Improve Patient Identification

Interventions to Improve Smoking History Documentation

Improving the accuracy of smoking history documentation in EHRs can help to expand the identification of eligible patients. Health systems can collect updated smoking history from patients using varying strategies including telephone calls, EHR portal messages, text messages, or integration into outpatient visits. Begnaud et al²⁸ conducted a randomized pilot trial and found no difference in initial LCS completion comparing usual care (ie, primary care provider [PCP]-based screening) to an intervention that sent an EHR portal message to patients with a prior smoking history (4 of 101 in the control group vs 1 of 99 in the intervention group). Patients were prompted by the EHR portal message to review and modify their smoking history, which then was followed by a second message informing patients of their LCS eligibility, as well as the risks and benefits of LCS. If eligible, LCS was ordered, and the patient was provided with imaging scheduling information. Of note, they found that after updating the smoking history (eg, quit date, total pack-years), only 10% of patients in both the control and intervention groups were eligible for LCS, highlighting the challenges in accurately identifying eligible populations.

Provider-facing EHR tools, such as the Veterans Health Administration’s clinical reminder tool to notify providers of a patient’s potential LCS eligibility, may improve LCS uptake.^40,41 Other studies have explored embedding the collection of smoking history documentation outside routine primary care visits, such as tobacco treatment clinics and mammography visits, to reach broader populations and successfully have yielded equitable increases in the number of new eligible patients identified.^42,43 Careful consideration of digital equity when leveraging technologies such as patient portal messages or text messages must be weighed because LCS-eligible individuals—who are older (aged 50-80 years) and currently or previously smoked (which is more common in people with lower socioeconomic status)—often have limited access to the internet and patient portals or have lower digital literacy.⁴⁴ Additionally, close coordination with local information technology departments and users of the tools is crucial to develop and implement user-centered EHR tools that integrate with clinical workflows.

Interventions to Improve Awareness Through Outreach and Education

Interventions that improve LCS awareness and knowledge, including media campaigns, direct patient outreach, and educational programs aimed at both patients and providers, are appealing strategies to improve LCS use. Cardarelli et al²⁹ demonstrated that a multimodal media campaign including 54,600 mailed postcards, advertisements in 17 community newspapers, and local public radio announcements for 6 months resulted in higher uptake of LCS in counties randomized to receive the intervention compared with the control region. Jessup et al³⁰ conducted a pay-per-click social media campaign targeting patients (eg, Facebook, Google) and providers (eg, Twitter, LinkedIn) with LCS content. Results showed increased weekly LCS examinations during the 20-week intervention (20.4 vs 17.4) and sustained uptake in the period after the intervention (26.2 examinations/wk). The authors comment that the study may have had some confounding bias because the 20-week period after intervention included November, which is lung cancer awareness month, overlapping with their health care system’s lung health campaign. When conducting awareness campaigns, it is important to consider the intervention’s reach, cost, and target population. For example, social media may have a broader reach and may be more cost-effective than traditional media such as newspapers, but effectiveness may vary in older adults.⁴⁵

Focusing outreach and education efforts on those with a documented smoking history has the potential to produce effective and high-yield strategies. DiCarlo et al³¹ conducted a three-arm randomized controlled trial comparing usual care with outreach only as well as with outreach plus SDM (discussed in the Multicomponent Interventions section). They demonstrated that people who received educational materials in the mail followed by a telephone call were more likely to undergo screening compared with those who received usual care (12 of 297 [4.0%] in the outreach group vs 31 of 1,748 [1.8%] in the usual care group). In contrast, Raz et al³² found that a 30-min web-based LCS educational video, emailed to patients who previously received smoking cessation counseling, did not markedly enhance LCS uptake (37 of 1,026 [3.6%] in the intervention group vs 11 of 255 [4.3%] in the control group). It may be that targeted outreach to improve knowledge and awareness alone, without follow-up from clinical staff, is insufficient to increase screening rates.⁴⁶ However, this must be balanced with the increased costs and necessary resources of directly contacting patients, which may not be cost-effective.⁴⁷

Considering providers’ limited familiarity with the details of LCS guidelines and the benefits and risks of screening, educational interventions targeting providers also may present a promising strategy.^11,13,26 Akhtar et al⁴⁸ conducted two 60-min educational training sessions delivered to faculty and staff meetings and found an increasing number of low-dose CT imaging examinations ordered from before to after the intervention. However, other studies have not found any differences in LCS uptake when targeting education solely at providers.⁴⁹ Provider education is a necessary component of multilevel interventions to improve LCS uptake because patients rely on providers’ recommendations, but improving the provider awareness and knowledge in isolation is unlikely to result in a substantial increase in screening rates because of the time constraints and competing demands during routine clinical visits.

Interventions to Improve LCS Awareness Through Varied Messaging

Two studies comparing different content or methods of outreach for LCS did not demonstrate differences in uptake rates. Quaife et al³³ found no difference between an educational postal invitation (control group) and an educational leaflet specifically designed to target psychological barriers to attendance (eg, fear, fatalism, stigma), with LCS completion rates of 38.2% vs 38.4%, respectively. Ruparel et al³⁴ observed no difference in LCS completion between an informational booklet alone and a combination of an informational booklet with an accompanying informational film in individuals with previously confirmed LCS eligibility (78.9% vs 76.7%). Although neither study showed a difference between study arms, it is notable that LCS uptake was much higher in Ruparel et al’s study than in the overall LCS-eligible US population (< 20%), likely the result of a healthy volunteer effect, because patients in this study already had agreed to participate in the Lung Screen Uptake Trial. Future work is needed to identify when tailored messaging may be needed to increase LCS uptake; for example, tailoring messaging that is culturally sensitive and resonates with community members may be particularly important for certain underserved groups that are less likely to undergo LCS (eg, racial and ethnic minority populations).⁵⁰

SDM-Related Interventions

Interventions to improve SDM have the potential to improve patient engagement in LCS, including improving patient knowledge about the eligibility criteria, benefits, and harms of LCS.⁵¹ Recognizing that PCPs have many competing demands that may make completion of SDM difficult, some studies leveraged other personnel to initiate SDM about LCS with eligible people. Kathuria et al³⁵ demonstrated that initiating SDM during a hospitalization could be an opportunity to engage underserved populations in LCS. In their initial pilot study, having a trained tobacco treatment specialist conduct inpatient SDM, followed by PCP notification of patients’ preferences, did not increase LCS uptake significantly (2 of 52 [2.8%] in the intervention group vs 1 of 48 [2.1%] in the enhanced usual care group). However, in a subsequent small pilot trial, they modified the intervention to include two additional components: (1) community health worker (CHW)-delivered navigation to overcome barriers to completing LCS and (2) an LCS program nurse practitioner who placed LCS orders instead of the PCP. With this modified intervention, they were able to show improved LCS completion (5 of 10 intervention group vs 1 of 9 control group). Given the difference between the first and second pilot study, the increased uptake may have been more likely because of CHW navigation, rather than the SDM intervention, or perhaps a combination of both.

Importantly, in interventions in which SDM decision aids are used without a dedicated facilitator, increases in LCS completion have not been demonstrated. Volk et al³⁹ found no difference between mailed educational materials (control group) and a 9.5-min video-based decision aid (“Lung Cancer Screening: Is It Right for Me?”): 68 of 257 patients (26.5%) in the control group vs 57 of 259 patients (22.0%) in the intervention group. SDM-related interventions alone, when not immediately followed by an LCS order, scheduled appointment, or effective navigation of barriers, may not enhance the uptake of LCS meaningfully.

Patient Navigation

Patient navigation to address logistical barriers to completing LCS (eg, transportation, access to a working phone to be reminded of appointments, and insurance copayments and prior authorizations) can be successful at improving other cancer screening methods.⁵² Prior studies in LCS suggest that implementing patient navigation can decrease the duration between the PCP’s order for LCS and the initial scan, as well as enhance the timeliness of notifying patients about the results.^53,54 No studies have compared the use of navigation in LCS with a control group in isolation; navigation interventions usually are embedded in multicomponent interventions.

Multicomponent Interventions

Multicomponent interventions are highly promising, because improving the uptake of LCS requires addressing barriers at multiple key steps. Percac-Lima et al³⁶ conducted a randomized trial in which nonclinical patient navigators were trained to call potentially eligible clinic patients (based on a documented history of tobacco use), to determine LCS eligibility, and to explore and address any potential barriers to screening. If patients were interested in LCS, the navigator would arrange an SDM appointment with the PCP so that LCS could be discussed and ordered. This intervention improved LCS uptake compared with enhanced usual care (ie, PCP education): 94 of 400 patients (23.5%) in the intervention group vs 69 of 800 patients (8.6%) in the control group (P < .001). DiCarlo et al³¹ found that the combination of navigator outreach (ie, educational materials followed by a telephone call) and decision coaching was more effective at improving LCS uptake (21 of 302 [7.0%]) compared with usual care (31 of 1,748 [1.8%]). In their study, SDM was conducted via telephone using an online interactive decision support software (the Decision Counseling Program) to guide participants through a brief (approximately 10-min) decision counseling session focused on eliciting values and clarifying preference related to LCS. If patients preferred to undergo screening, the navigator offered to schedule an LCS program appointment and encouraged the participants to discuss LCS with their PCP at a future office visit.

Fabbrini et al³⁷ compared mailed SDM educational materials vs the same mailed information followed by a telephone call from the LCS program manager to review SDM materials and coordinate an LCS appointment if deemed eligible. They found that 59% of individuals (165 of 280) who received the phone call from the LCS program manager successfully underwent LCS compared with only 9% of individuals (13 of 152) who received only educational materials. Lewis et al³⁸ conducted a retrospective study of eight Veterans Health Administration sites that were part of the Veterans Health Administration’s Demonstration Project compared with 20 Veterans Health Administration medical centers that did not participate in the demonstration project. The demonstration project sites hired an LCS coordinator, used clinical reminders (to collect smoking history and to prompt providers for initial and annual screening), received patient and provider educational materials, and participated in a national support network. LCS coordinator responsibilities included LCS eligibility confirmation, SDM, tobacco cessation, ordering of LCS, communicating results, and ensuring timely follow-up (eg, annual repeat screening, short-term follow-up scan, or referral for diagnostic evaluation). During the intervention period, the average rate of unique patients screened at demonstration project sites was 17.7 per 1,000 eligible per month, compared with 0.3 per 1,000 eligible per month at comparison sites.

Overall, multicomponent interventions show promise in addressing key barriers to LCS uptake. Nevertheless, not all health care systems possess the required resources to implement multiple interventions for enhancing initial LCS uptake. Further research is essential to identify high-yield and feasible interventions that are generalizable.

Future Directions

Future interventions are needed to address the multilevel barriers and to improve LCS uptake effectively. Various factors contribute to low uptake of screening, including a lack of awareness of screening examination and eligibility and unfamiliarity with what to expect during the screening examination.²⁶ Additionally, some patients are limited by fear of cancer, propagated by societal stigma directed at people who smoke, which may deter them from completing the LCS referral.^10,55 To address these challenges, sensitively engaging patients where they are at, including conducting high-quality SDM and training LCS coordinators, navigators, and CHWs, can play a crucial role in guiding patients through the various barriers to accessing LCS.^56,57

Strategies for sensitively collecting smoking history through a combination of text messaging, portal messaging, or direct patient outreach may help to improve the completeness and accuracy of the documented smoking history. To optimize identification of eligible populations, health care systems could leverage not only smoking history, but also other existing EHR data with existing validated algorithms.^58,59 Additionally, natural language processing, machine learning, and artificial intelligence have the potential to improve the efficiency of identifying potential LCS-eligible patients using EHR data. To reduce false alerts to providers, EHR-based interventions need to be developed carefully. Ideally, effective interventions should be disseminated through EHR vendors (such as Epic, Cerner, MEDITECH) and subsequently adopted by individual health care systems, instead of developed by health care systems in silos, to minimize the digital divide between health care systems.

Enhancing the effectiveness of SDM involves providing support to health care providers in identifying patients who are most likely to benefit from screening. Risk prediction tools could play a pivotal role in identifying patients most likely to benefit from early detection of lung cancer and increasing LCS uptake among such patients.⁶⁰ These tools should be integrated into the EHR, ensuring easy usability during routine clinical encounters without placing an undue burden on providers.

Awareness of LCS across patients and providers remains low, especially compared with the other USPSTF-recommended cancer screenings.⁶¹ This is particularly important in underserved communities because racial and ethnic minority populations are less likely to undergo an initial LCS than White individuals.^62,63 CHWs, or promotores de salud, are frontline public health workers who often share the same racial, ethnic, or social background with the population they serve. Their shared background with the community often increases relatability, trust, and the ability to connect with people from historically marginalized groups.⁶⁴ CHWs have been shown to be both effective and economical for breast, colorectal, and cervical cancer screening, increasing screening uptake and adherence among underserved populations.^65,66 A pilot study of CHW-delivered patient outreach increased LCS knowledge, decreased lung cancer stigma, and increased LCS uptake in 37 participants, suggesting that CHWs can facilitate change in LCS.^57,67

Additionally, geographic disparities exist, particularly affecting people in rural areas, who bear a higher burden of smoking-related diseases.⁶⁸ Yet, these populations often face challenges in accessing screening facilities, resulting in a lower likelihood of undergoing screening.^69,70 Mobile CT imaging scanners present a promising strategy for engaging individuals with limited geographic access to radiology services or who have transportation difficulties. The West London LCS pilot study in the United Kingdom invited eligible participants to undergo LCS and revealed no significant difference in screening uptake between patients opting for LCS at a hospital site vs those choosing a mobile site.⁷¹ However, the findings from their study may be limited by the fact that the median distance traveled for participants was only 3 km more for those who opted for the hospital site (3.3 km vs 6.4 km). An initial pilot trial in the United States showed that mobile scanners may engage populations from diverse racial and ethnic backgrounds effectively, as well as those living in rural areas.^72,73

Importantly, the reduction of lung cancer mortality is dependent on the annual receipt of LCS, as a similar number of cancers was detected across subsequent rounds of screening in clinical trials.^1,2 Although our study focused on interventions designed to improve uptake of an initial LCS, strategies exist that may improve the receipt of the recommended follow-up after an initial low-dose CT scan (eg, LCS coordinators, databases to track screening results, multidisciplinary nodule boards to guide downstream management). Centralized screening programs, where the core functions of screening (eg, confirming eligibility, SDM, ordering and tracking LCS) are performed by program personnel, can improve adherence to annual screening compared with decentralized programs.^{74, 75, 76} A recent observational study also suggested that centralization may improve initial uptake of LCS after patients are referred to a centralized LCS program.²⁴ Achieving the full life-expectancy benefit of LCS will require effective navigation of patients through the entire LCS continuum, from initial identification and engagement to downstream follow-up, treatment, and survivorship.

Summary

Overall, several studies have designed interventions that seek to improve LCS uptake. Their effectiveness generally has been modest, which has been limited by the multilevel barriers that need to be overcome to improve LCS. Leveraging the knowledge acquired from prior studies and combining it with novel strategies promises to reveal approaches to enhance uptake. Importantly, identifying high-yield components of interventions that are generalizable to low-resource and diverse settings is crucial to eliminating disparities in lung cancer, because underserved populations often experience the highest lung cancer burden.

Funding/Support

E. R. N. is supported by the LUNGevity Foundation and by the UMass-Baystate Department of Healthcare Delivery and Population Sciences. M. I. F. is supported by the National Cancer Institute of the National Institutes of Health [Grant K08CA283304]. R. S. W. is supported in part by resources from the VA Boston Healthcare System.

Financial/Nonfinancial Disclosures

None declared.