Reply to Wilson: Improving Lung Cancer Screening Uptake

From the Authors:

We read Wilson’s response letter to both our LSUT (Lung Screen Uptake Trial) (1) and the accompanying editorial by Burnett-Hartman and Wiener (2) with great interest and value the insightful discussion they raise. Together we share in the challenge of achieving both equitable and informed uptake of low-dose computed tomography lung cancer screening by high-risk individuals, but the differences between the United Kingdom and United States that Wilson raises are important for how we intervene. The United Kingdom benefits from a coordinated and universal primary care system, and we appreciate that sending postal invitations directly from the individual’s primary care physician is a strategy that may not translate directly to the U.S. context. We also note the requirement by the Centers for Medicare and Medicaid for a separate shared decision-making session before the screening intervention in the United States. However, evidence suggests that the behavioral components of LSUT’s strategy (healthcare professional endorsement and proactively inviting and arranging appointments) are the “active ingredients” that could be implemented in different ways in the U.S. context.

We also share Wilson’s interest in broadening LSUT’s “Lung Health Check” approach to screening to include other aspects of lung and heart health in the future. Framing lung cancer screening as one optional test within a “Lung Health Check” was intended to improve engagement by minimizing fear (that could lead to information avoidance and uninformed nonparticipation) and to provide an in-person supportive environment where shared decision-making about the screening offer could be achieved. Through this we found potential for other lung and heart health interventions—the key focus of Wilson and colleagues’ point. This includes parallels with the PLuSS (Pittsburgh Lung Cancer Screening Study) (3), which found that the prevalence of emphysema and airway obstruction increased with individual lung cancer risk. For example, work led by Ruparel and colleagues (4) found a significant proportion of undiagnosed chronic obstructive pulmonary disease and untreated coronary artery calcification (5) within our LSUT cohort, suggesting opportunities for early diagnosis of chronic obstructive pulmonary disease, instigating cardiovascular risk assessment and primary prevention. The UK taxpayer’s universal healthcare system may in the future fund low-dose computed tomography screening scans, and so we would not have the financial disincentives that the United States has in this respect. However, the United Kingdom does have limited resources for subsequent healthcare provision for incidental findings. This makes the feasibility of delivering a holistic health assessment challenging and policy decision-makers would (rightly) first require evidence for the public health benefit and cost-effectiveness of such an approach.