A Lung Cancer Screening Education Program Impacts both Referral Rates and Provider and Medical Assistant Knowledge at Two Federally Qualified Health Centers

Review of Interventions That Improve Uptake of Lung Cancer Screening: A Cataloging of Strategies That Have Been Shown to Work (or Not)

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.

Access to Lung Cancer Screening

Rural and racial/ethnic minority communities experience higher risk and mortality from lung cancer. Lung cancer screening with low-dose computed tomography reduces mortality. However, disparities persist in the uptake of lung cancer screening, especially in marginalized communities. Barriers to lung cancer screening are multilevel and include patient, provider, and system-level barriers. This discussion highlights the key barriers faced by rural and racial/ethnic minority communities.

Development and Evaluation of Brief Web-Based Education for Primary Care Providers to Address Inequities in Lung Cancer Screening and Smoking Cessation Treatment

Annual lung cancer screening (LCS) is recommended for individuals at high risk for lung cancer. However, primary care provider-initiated discussions about LCS and referrals for screening are low overall, particularly among Black or African Americans and other minoritized racial and ethnic groups. Disparities also exist in receiving provider advice to quit smoking. Effective methods are needed to improve provider knowledge about LCS and tobacco-related disparities, and to provide resources to achieve equity in LCS rates. We report the feasibility and impact of pairing a self-directed Lung Cancer Health Disparities (HD) Web-based course with the National Training Network Lung Cancer Screening (LuCa) course on primary care providers' knowledge about LCS and the health disparities associated with LCS. In a quasi-experimental study, primary care providers (N = 91) recruited from the MedStar Health System were assigned to complete the LuCa course only vs. the LuCa + HD courses. We measured pre-post-LCS-related knowledge and opinions about the courses. The majority (60.4%) of providers were resident physicians. There was no significant difference between groups on post-test knowledge (p > 0.05). However, within groups, there was an improvement in knowledge from pre- to post-test (LuCa only (p = 0.03); LuCa + HD (p < 0.001)). The majority of providers (81%) indicated they planned to improve their screening and preventive practices after having reviewed the educational modules. These findings provide preliminary evidence that this e-learning course can be used to educate providers on LCS, smoking cessation, and related disparities impacting patients.

Overcoming Barriers to Tobacco Cessation and Lung Cancer Screening among Racial and Ethnic Minority Groups and Underserved Patients in Academic Centers and Community Network Sites: The City of Hope Experience

BACKGROUND

Tobacco control is important for cancer patient health, but delivering effective low-dose CT (LDCT) screening and tobacco cessation is more difficult in underserved and patients from racial and ethnic minority groups. At City of Hope (COH), we have developed strategies to overcome barriers to the delivery of LDCT and tobacco cessation.

METHODS

We performed a needs assessment. New tobacco control program services were implemented focusing on patients from racial and ethnic minority groups. Innovations included Whole Person Care with motivational counseling, placing clinician and nurse champions at points of care, training module and leadership newsletters, and a patient-centric personalized medicine Personalized Pathways to Success (PPS) program.

RESULTS

Emphasis on patients from racial and ethnic minority groups was implemented by training cessation personnel and lung cancer control champions. LDCT increased. Tobacco use assessment increased and abstinence was 27.2%. The PPS pilot program achieved 47% engagement in cessation, with self-reported abstinence at 3 months of 38%, with both results slightly higher in patients from racial and ethnic minority groups than in Caucasian patients.

CONCLUSIONS

Tobacco cessation barrier-focused innovations can result in increased lung cancer screening and tobacco cessation reach and effectiveness, especially among patients from racial and ethnic minority groups. The PPS program is promising as a personalized medicine patient-centric approach to cessation and lung cancer screening.

Lung Cancer Screening Knowledge and Perceived Barriers Among US Physicians

Introduction

Lung cancer remains the leading cause of cancer death in the United States and has historically been detected late in its course. Low-dose computed tomography scan (LDCT) reduces lung cancer mortality by 20% and is currently recommended by clinical practice guidelines. However, compared with other cancer screening modalities, LDCT utilization remains low. This study surveyed office-based primary care physicians across the United States to better understand LDCT utilization.

Methods

A total of 1500 family and internal medicine physicians selected from the American Medical Association’s physician master file were surveyed between April and July 2019 regarding LDCT practices, eligibility, clinical scenarios, and perceived barriers.

Results

The American Association for Public Opinion Research response rate 3 was 59% (652 respondents); 599 completed supplemental questions regarding lung cancer screening. A total of 88% of respondents discussed LDCT in the previous year, and 78% had ordered at least one LDCT. Most (59%) knew the tobacco exposure criteria for LDCT and correctly identified appropriate clinical scenarios (49%–86% responded correctly). Less than half of respondents correctly identified the age eligibility criteria (44%–45% responded correctly). In general, male physicians, those who graduated after 1990, and family medicine physicians were more likely to report accurate knowledge regarding LDCT eligibility. The top perceived barriers to LDCT were cost to the patient (48% identified as a major barrier), insurance not covering screening (46% major), and patients being unaware of lung cancer screening (40% major).

Conclusion

Knowledge and practices about lung cancer screening are improving, though remain suboptimal. The most common barriers remain cost or insurance-based and suggest the need for a systems-based response to increase awareness and reduce the underutilization of LDCT.