Exploring Ways to Improve Access to and Minimize Risk from Lung Cancer Screening

Short abstract

Despite ample evidence of benefit, adoption of lung cancer screening efforts remains low. This commentary focuses on current efforts to improve awareness of the benefits of lung cancer screening and the available screening programs.

Several professional societies have endorsed lung cancer screening based on the results from the National Lung Screening Trial (NLST) that demonstrated a 20% relative reduction in mortality from lung cancer with low‐dose computed tomography (LDCT) scans 1. It remains the strongest evidence of reduced mortality with screening with LDCT, and it supported the recommendation by the United States Preventive Services Task Force in 2013. Under Section 2713 of the Affordable Care Act, health plans were mandated to provide coverage for a range of preventive services without cost‐sharing such as copayment and deductibles. These decisions were recently bolstered by publication of a confirmatory phase III LDCT‐screening study (NELSON) that also showed significant improvement in lung cancer–related mortality in high‐risk individuals with annual screening 2.

Despite the ample evidence of benefit, lung cancer screening adoption remains low. It is estimated that approximately 3.9% of 6.8 million eligible smokers were screened in 2015 according to the National Health Interview Survey 3. The reasons are not all clear, but it is likely correct to assume that lack of resources, geographic isolation, and uninsured status certainly contribute to this disparity. The distribution of screening programs varies significantly across states. Kale and colleagues analyzed the geographic variation of lung cancer screening facilities that are in the national registry, which is a requirement for reimbursement by the Centers for Medicare & Medicaid Services 4. They reported that a cluster of states (Alabama, Arkansas, Georgia, Kentucky, Louisiana, Missouri, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, and West Virginia) with the highest lung cancer burden had the lowest number of screening programs. It is not known whether the uptake of lung cancer screening in states who chose to expand Medicaid under the Affordable Care Act is different than in nonexpansion states, but the lack of insurance coverage may contribute to the lower number of screening programs as the Medicaid expansion could provide funds to create and sustain programs.

In their article in this month's issue of The Oncologist, Raghavan and colleagues reported the initial results of a pilot itinerant lung cancer screening program with the help of a portable CT scanner in North Carolina 5. This novel strategy provides a potential solution to address some disparities in lung cancer screening. The program benefits directly underserved populations including uninsured, minorities, and rural groups. The program follows the guidelines for screening program implementation and has the support of a multidisciplinary team. It offers social support and comprehensive resources to manage high‐risk nodules and lung cancer cases as it is connected to a large health care system. However, a large‐scale program like this one needs funding to be sustainable. The authors estimated that the early identification with this program of lung cases that can be cured would be more cost‐effective than dealing with cases diagnosed at advanced stages. They have also designed a randomized multicenter trial that will compare the outcomes of hospital‐based versus mobile LDCT screening. Hopefully, the results will confirm the positive results of the pilot and show that there is evidence to invest in lung cancer prevention and early detection in underserved populations.

Another concern that may be limiting enthusiasm and uptake of LDCT screening is the management of benign lung nodules, which are found at high rates on screening CT scans. In the NLST, overall, 24% of screened patients had a positive finding, but 96.4% of those nodules were determined eventually to be false positives 1. Careful evaluation and follow‐up is needed to avoid both missing true early lung cancers and potentially morbid interventions on benign nodules. In another publication also appearing in this month's issue of The Oncologist, Roberts and colleagues report on the outcomes from a single academic institutional experience managing pulmonary nodules 6. The Pulmonary Nodule and Lung Cancer Screening Clinic (PNLCSC) was established as a multidisciplinary program to manage these complex issues, and over 7 years more than 1,100 patients were seen, which represented a very high risk population considering 19% of these patients were eventually diagnosed with lung cancer. Patients underwent comprehensive evaluation with most patients either being discharged immediately or recommending follow‐up scans prior to recommending interventions. Patients at high risk for biopsy or surgery could be steered to less morbid procedures such as stereotactic radiation. Importantly, 95% of the patients followed the PNLCSC's recommendations. Nevertheless, even at a major tertiary care center specializing in managing these patients, 42.7% of patients undergoing biopsy and 17% of patients undergoing surgery for suspicious nodules were found to have no evidence of malignancy, highlighting the complexity of managing these patients and the critical importance of counseling and shared decision making in this process 7. Institutions planning to establish CT screening programs need to be aware of this risk and establish clear and consistent protocols to manage positive screening cases. At our own institution, for example, all positive findings on screening CTs are reviewed at a tumor board established specifically for this purpose.

Although an itinerant program helps to overcome some barriers to lung cancer screening in specific locations and populations, and multidisciplinary management of nodules may aid in managing patients with positive findings and reduce unnecessary procedures, we need to continue to study the reasons why uptake is so low nationwide. Efforts to improve awareness of the benefits of LC screening and access to screening programs, as well as efforts to minimize potential harms, will expand the impact of this important public health intervention to a larger number of eligible patients.

Disclosures

Nathan A. Pennell: AstraZeneca, Eli Lilly & Co., Regeneron (C/A), Genentech, AstraZeneca, Celgene, Merck, Bristol‐Myers Squibb, Incyte, Heat Biologics, Altor, Pfizer (RF). The other author indicated no financial relationships.

(C/A) Consulting/advisory relationship; (RF) Research funding; (E) Employment; (ET) Expert testimony; (H) Honoraria received; (OI) Ownership interests; (IP) Intellectual property rights/inventor/patent holder; (SAB) Scientific advisory board