Determinants Associated With Longitudinal Adherence to Annual Lung Cancer Screening: A Retrospective Analysis of Claims Data

Adherence to Annual Lung Cancer Screening in a Centralized Academic Program

BACKGROUND

Adherence to lung cancer screening (LCS) protocols is critical for achieving mortality reductions. However, adherence rates, particularly for recommended annual screening among patients with low-risk findings, are often sub-optimal. We evaluated annual LCS adherence for patients with low-risk findings participating in a centralized screening program at a tertiary academic center.

PATIENTS AND METHODS

We conducted a retrospective, observational cohort study of a centralized lung cancer screening program launched in July 2018. We performed electronic medical review of 337 patients who underwent low-dose CT (LDCT) screening before February 1, 2021 (to ensure ≥ 15 months follow up) and had a low-risk Lung-RADS score of 1 or 2. Captured data included patient characteristics (smoking history, Fagerstrom score, environmental exposures, lung cancer risk score), LDCT imaging dates, and Lung-RADS results. The primary outcome measure was adherence to annual screening. We used multivariable logistic regression models to identify factors associated with adherence.

RESULTS

Overall, 337 patients had an initial Lung-RADS result of 1 (n = 189) or 2 (n = 148). Among this cohort, 139 (73.5%) of Lung-RADS 1 and 111 (75.0%) of Lung-RADS 2 patients completed the annual repeat LDCT within 15 months, respectively. The only patient characteristic associated with adherence was having Medicaid coverage; compared to having private insurance, Medicaid patients were less adherent (adjusted OR = 0.37, 95% CI = 0.15-0.92). No other patient characteristic was associated with adherence.

CONCLUSION

Our centralized screening program achieved a high initial annual adherence rate. Although LCS has first-dollar insurance coverage, other socioeconomic concerns may present barriers to annual screening for Medicaid recipients.

Slipping through the cracks: Who is eligible but does not receive a healthcare provider recommendation for lung cancer screening?

INTRODUCTION

Receiving a healthcare provider recommendation to screen is an important predictor for whether individuals at high risk for lung cancer undergo lung cancer screening. Although sociodemographic and socioeconomic characteristics are associated with differential screening participation, it is unknown whether those characteristics are associated with receiving a healthcare provider recommendation for lung cancer screening.

METHODS

This cross-sectional study used Facebook-targeted advertising to recruit a national sample of lung cancer screening-eligible adults (N = 515) who completed questionnaires on sociodemographic information (age, gender, race, marital status), socioeconomic characteristics (income, insurance status, education, rurality of residence), smoking status, and receiving a healthcare provider recommendation to screen. Pearson's chi-square tests and independent samples t-tests evaluated whether sociodemographic, socioeconomic, and smoking-related characteristics were associated significantly with receiving a healthcare provider recommendation to screen.

RESULTS

Higher household income, having insurance coverage, and being married were associated significantly with receiving a healthcare provider recommendation to screen (all p <.05). Age, gender, race, education, rurality of residence, and smoking status were not associated significantly with receiving a recommendation to screen.

DISCUSSION

Particular subgroups of individuals at high risk for lung cancer-including those with lower income, without insurance coverage, and who are not married-are less likely to receive a recommendation to screen from their healthcare provider, despite being at high risk for lung cancer and eligible for screening. Future research should test whether differential screening participation and low screening uptake could be addressed by clinician-focused interventions that encourage ubiquitous discussion and recommendation to undergo screening for people at high risk for lung cancer.

Receipt of Recommended Follow-up Care After a Positive Lung Cancer Screening Examination

Importance

Maximizing benefits of lung cancer screening requires timely follow-up after a positive screening test. The American College of Radiology (ACR) Lung CT Screening Reporting and Data System (Lung-RADS) recommends testing and follow-up timing based on the screening result.

Objective

To determine rates of and factors associated with recommended follow-up after a positive lung cancer screening examination by Lung-RADS category.

Design, Setting, and Participants

This prospective cohort study of lung cancer screening examinations performed from January 1, 2015, through July 31, 2020, with follow-up through July 31, 2021, was conducted at 5 academic and community lung cancer screening sites in North Carolina. Participants included 685 adults with a positive screening examination, Lung-RADS categories 3, 4A, 4B, or 4X. Statistical analysis was performed from December 2020 to March 2022.

Exposures

Individual age, race, sex, smoking exposure, year of lung cancer screening examination, chronic obstructive pulmonary disease, body mass index, referring clinician specialty, rural or urban residence.

Main Outcomes and Measures

Adherence, defined as receipt of recommended follow-up test or procedure after the positive screen per ACR Lung-RADS timeframes: 6 months for Lung-RADS 3 and 3 months for Lung-RADS 4A. For Lung-RADS 4B or 4X, adherence was defined as follow-up care within 4 weeks, as ACR Lung-RADS does not specify a timeframe.

Results

Among the 685 individuals included in this study who underwent lung cancer screening with low-dose computed tomography, 416 (60.7%) were aged at least 65 years, 123 (18.0%) were Black, 562 (82.0%) were White, and 352 (51.4%) were male. Overall adherence to recommended follow-up was 42.6% (292 of 685) and varied by Lung-RADS category: Lung-RADS 3 = 30.0% (109 of 363), Lung-RADS 4A = 49.5% (96 of 194), Lung-RADS 4B or 4X = 68.0% (87 of 128). Extending the follow-up time increased adherence: Lung-RADS 3 = 68.6% (249 of 363) within 9 months, Lung-RADS 4A = 77.3% (150 of 194) within 5 months, and Lung-RADS 4B or 4X = 80.5% (103 of 128) within 62 days. For Lung-RADS 3, recommended follow-up was less likely among those currently smoking vs those who quit (adjusted odds ratio [aOR], 0.48; 95% CI, 0.29-0.78). In Lung-RADS 4A, recommended follow-up was less likely in Black individuals vs White individuals (aOR, 0.35; 95% CI, 0.15-0.86). For Lung-RADS 4B or 4X, recommended follow-up was more likely in female individuals vs male individuals (aOR, 2.82; 95% CI, 1.09-7.28) and less likely in those currently smoking vs those who quit (aOR, 0.31; 95% CI, 0.12-0.80).

Conclusions and Relevance

In this cohort study, adherence to recommended follow-up after a positive screening examination was low but improved among nodules with a higher suspicion of cancer and after extending the follow-up timeline. However, the association of extending the follow-up time of screen-detected nodules with outcomes at the population level, outside of a clinical trial, is unknown. These findings suggest that studies to understand why recommended follow-up is lower in Black individuals, male individuals, and individuals currently smoking are needed to develop strategies to improve adherence.

Racial Disparities in Adherence to Annual Lung Cancer Screening and Recommended Follow-Up Care: A Multicenter Cohort Study

Rationale: Black patients receive recommended lung cancer screening (LCS) follow-up care less frequently than White patients, but it is unknown if this racial disparity persists across both decentralized and centralized LCS programs. Objectives: To determine adherence to American College of Radiology Lung Imaging Reporting and Data System (Lung-RADS) recommendations among individuals undergoing LCS at either decentralized or centralized programs and to evaluate the association of race with LCS adherence. Methods: We performed a multicenter retrospective cohort study of patients receiving LCS at five heterogeneous U.S. healthcare systems. We calculated adherence to annual LCS among patients with a negative baseline screen (Lung-RADS 1 or 2) and recommended follow-up care among those with a positive baseline screen (Lung-RADS 3, 4A, 4B, or 4X) stratified by type of LCS program and evaluated the association between race and adherence using multivariable modified Poisson regression. Results: Of the 6,134 total individuals receiving LCS, 5,142 (83.8%) had negative baseline screens, and 992 (16.2%) had positive baseline screens. Adherence to both annual LCS (34.8% vs. 76.1%; P < 0.001) and recommended follow-up care (63.9% vs. 74.6%; P < 0.001) was lower at decentralized compared with centralized programs. Among individuals with negative baseline screens, a racial disparity in adherence was observed only at decentralized screening programs (interaction term, P < 0.001). At decentralized programs, Black race was associated with 27% reduced adherence to annual LCS (adjusted relative risk [aRR], 0.73; 95% confidence interval [CI], 0.63-0.84), whereas at centralized programs, no effect by race was observed (aRR, 0.98; 95% CI, 0.91-1.05). In contrast, among those with positive baseline screens, there was no significant difference by race for adherence to recommended follow-up care by type of LCS program (decentralized aRR, 0.95; 95% CI, 0.81-1.11; centralized aRR, 0.81; 95% CI, 0.71-0.93; interaction term, P = 0.176). Conclusions: In this large multicenter study of individuals screened for lung cancer, adherence to both annual LCS and recommended follow-up care was greater at centralized screening programs. Black patients were less likely to receive annual LCS than White patients at decentralized compared with centralized LCS programs. Our results highlight the need for further study of healthcare system-level mechanisms to optimize longitudinal LCS care.

[Translated article] Lung Cancer Screening: Survival in an Extensive Early Detection Program in Spain (I-ELCAP)

INTRODUCTION

Lung cancer (LC) is usually diagnosed at advanced stages with only a 12% 5-year survival. Trials as NLST and NELSON show a mortality decrease, which justifies implementation of lung cancer screening in risk population. Our objective was to show survival results of the largest LC screening program in Spain with low dosage computed tomography (LDCT).

METHODS

Clinical records from International Early Lung Cancer Detection Program (IELCAP) at Valencia, Spain were analyzed. This program recruited volunteers, ever-smokers aged 40-80 years, since 2008. Results are compared to those from other similar sizeable programs.

RESULTS

A total of 8278 participants were screened with at least two-rounds until November 2020. A mean of 6 annual screening rounds were performed. We detected 239 tumors along 12-year follow-up. Adenocarcinoma was the most common histology, being 61.3% at stage I. The lung cancer prevalence and incidence proportion was 1.5% and 1.4%, respectively with an annual detection rate of 0.17. One-year survival and 10-year survival were 90% and 80.1%, respectively. Adherence was 96.84%.

CONCLUSION

Largest lung cancer screening in Spain shows that survival is improved when is performed in multidisciplinary team experienced in management of LC, and is comparable to similar screening programs.

Racial Differences in Lung Cancer Screening Beliefs and Screening Adherence

BACKGROUND

One challenge in high-quality lung cancer screening (LCS) is maintaining adherence with annual and short-interval follow-up screens among high-risk individuals who have undergone baseline low-dose CT (LDCT). This study aimed to characterize attitudes and beliefs toward lung cancer and LCS and to identify factors associated with LCS adherence.

METHODS

We administered a questionnaire to 269 LCS participants to assess attitudes and beliefs toward lung cancer and LCS. Clinical data including sociodemographics and screening adherence were obtained from the LCS Program Registry.

RESULTS

African-American individuals had significantly greater lung cancer worries compared with Whites (6.10 vs. 4.66, P < .001). In making the decision to undergo LCS, African-American participants described screening convenience and cost as very important factors significantly more frequently than Whites (60% vs. 26.8%, P< .001 and 58.4% vs. 37.8%, P = .001; respectively). African-American individuals with greater than high school education had significantly higher odds of LCS adherence (aOR 2.55; 95% CI, 1.14-5.60) than Whites with less than high school education. Participants who described screening convenience and cost as "very important" had significantly lower odds of completing screening follow-up after adjusting for demographic and other factors (aOR 0.56; 95% CI, 0.33-0.97 and aOR 0.54; 95% CI, 0.33-0.91, respectively).

CONCLUSION

Racial differences in beliefs about lung cancer and LCS exist among African-American and White individuals enrolled in an LCS program. Cost, convenience, and low educational attainment may be barriers to LCS adherence, specifically among African-American individuals.

IMPACT

More research is needed on how barriers can be overcome to improve LCS adherence.