Potential Impact of Cessation Interventions at the Point of Lung Cancer Screening on Lung Cancer and Overall Mortality in the United States

Beyond lung cancer screening, an opportunity for early detection of chronic obstructive pulmonary disease and cardiovascular diseases

BACKGROUND

Lung cancer screening programs concern smokers at risk for cardiovascular diseases (CVDs) and chronic obstructive pulmonary disease (COPD). The LUMASCAN (LUng Cancer Screening, MArkers and low-dose computed tomography SCANner) study aimed to evaluate the acceptability and feasibility of screening for these 3 diseases in a community population with centralized organization and to determine low-dose computed tomography (CT) markers associated with each disease.

METHODS

This cohort enrolled participants meeting National Comprehensive Cancer Network criteria (v1.2014) in an organized lung cancer-screening program including low-dose CT scans; spirometry; evaluations of coronary artery calcifications (CACs); and a smoking cessation plan at inclusion, 1, and 2 years; then telephone follow-up. Outcomes were the participation rate and the proportion of participants affected by lung cancer, obstructive lung disease, or CVD events. Logistic-regression models were used to identify radiological factors associated with each disease.

RESULTS

Between 2016 and 2019, a total of 302 participants were enrolled: 61% men; median age 58.8 years; 77% active smoker; 11% diabetes; 38% hypertension; and 27% taking lipid-lowering agents. Inclusion, 1-year, and 2-year participation rates were 99%, 81%, 79%, respectively. After a median follow-up of 5.81 years, screenings detected 12 (4%) lung cancer, 9 of 12 via low-dose CT (78% localized) and 3 of 12 during follow-up (all stage IV), 83 (27%) unknown obstructive lung disease, and 131 (43.4%) moderate to severe CACs warranting a cardiology consultation. Preexisting COPD and moderate to severe CACs were associated with major CVD events with odds ratios of 1.98 (95% confident interval [CI] = 1.00 to 3.88) and 3.27 (95% CI = 1.72 to 6.43), respectively.

CONCLUSION

The LUMASCAN study demonstrated the feasibility of combined screening for lung cancer, COPD, and CVD in a community population. Its centralized organization enabled high participation and coordination of healthcare practitioners.

Uptake and 4-week quit rates from an opt-out co-located smoking cessation service delivered alongside community-based low-dose computed tomography screening within the Yorkshire Lung Screening Trial

BACKGROUND

Up to 50% of those attending for low-dose computed tomography screening for lung cancer continue to smoke and co-delivery of smoking cessation services alongside screening may maximise clinical benefit. Here we present data from an opt-out co-located smoking cessation service delivered alongside the Yorkshire Lung Screening Trial (YLST).

METHODS

Eligible YLST participants were offered an immediate consultation with a smoking cessation practitioner (SCP) at their screening visit with ongoing smoking cessation support over subsequent weeks.

RESULTS

Of 2150 eligible participants, 1905 (89%) accepted the offer of an SCP consultation during their initial visit, with 1609 (75%) receiving ongoing smoking cessation support over subsequent weeks. Uptake of ongoing support was not associated with age, ethnicity, deprivation or educational level in multivariable analyses, although men were less likely to engage (adjusted OR (ORadj) 0.71, 95% CI 0.56-0.89). Uptake was higher in those with higher nicotine dependency, motivation to stop smoking and self-efficacy for quitting. Overall, 323 participants self-reported quitting at 4 weeks (15.0% of the eligible population); 266 were validated by exhaled carbon monoxide (12.4%). Multivariable analyses of eligible smokers suggested 4-week quitting was more likely in men (ORadj 1.43, 95% CI 1.11-1.84), those with higher motivation to quit and previous quit attempts, while those with a stronger smoking habit in terms of cigarettes per day were less likely to quit.

CONCLUSIONS

There was high uptake for co-located opt-out smoking cessation support across a wide range of participant demographics. Protected funding for integrated smoking cessation services should be considered to maximise programme equity and benefit.

Effect of a Personalized Tobacco Treatment Intervention on Smoking Abstinence in Individuals Eligible for Lung Cancer Screening

INTRODUCTION

To determine whether personalized gain-framed messaging and biomarker feedback related to tobacco cessation or reduction decrease smoking behavior in patients undergoing or eligible for lung cancer screening.

METHODS

Between 2016 and 2020, 188 patients were enrolled in a two-phase, sequential, randomized controlled trial. Phase 1 evaluated whether standard of care (SC) (five in-person counseling sessions and 8 weeks of nicotine patch) plus gain-framed messaging (GFM) versus SC would increase 8-week biochemically verified smoking cessation rates. In 143 participants randomized in phase 2, we tested whether feedback on smoking-related biomarkers would reduce 6-month self-reported number of cigarettes smoked per day compared with a no feedback control. Chi-square test and mixed effects repeated measures analyses were used to evaluate group differences.

RESULTS

Participants were 62.5 ± 5.6 (mean ± SD) years of age, had a 50.3 ± 21 pack-year smoking history, and were smoking 16.9 ± 9.9 cigarettes per day. At 8 weeks, there was no difference in quit rates between those randomized to SC plus GFM (n = 15 of 93, 16.1%) and those randomized to SC (n = 16 of 95, 16.8%), with p equals to 0.90. At the 6-month post-randomization follow-up, number of cigarettes smoked per day was similar in the feedback (least-squares mean = 7.5, 95% confidence interval: 6.0-9.1) and no feedback arms (7.7, 95% confidence interval: 6.2-9.3), with p equals to 0.87.

CONCLUSIONS

Gain-framed messaging and health feedback did not significantly improve quit rates relative to comprehensive standard of care. Nevertheless, the overall program achieved clinically meaningful smoking quit rates in this older high pack-year cohort, highlighting the importance of intensive tobacco treatment for patients undergoing lung cancer screening. CLINICAL TRIAL REGISTERED WITH CLINICALTRIALS.GOV: NCT02658032.

Tobacco treatment in the setting of lung cancer screening

PURPOSE OF REVIEW

Lung cancer screening by low-dose CT is an increasingly implemented preventive medicine tool. Screening for lung cancer is incomplete without addressing problematic tobacco use, the greatest modifiable risk factor in the development of lung cancer. This review describes recent work related to lung cancer screening and treatment of tobacco use in that context.

RECENT FINDINGS

Implementation of lung cancer screening demonstrates socioeconomic disparities in terms of adherence to screening as well as likelihood of successful tobacco dependence treatment. Active tobacco dependence is a common comorbidity for patients undergoing lung cancer screening. The optimal implementation of tobacco dependence treatment in the context of lung cancer screening is still an area of active investigation.

SUMMARY

Treatment of tobacco dependence at time of lung cancer screening is a major opportunity for clinicians to intervene to reduce the major modifiable risk factor for lung cancer, tobacco use. Providing comprehensive tobacco dependence treatment is most effective using combination pharmacologic and behavioral interventions. Practices providing comprehensive treatment will benefit from accurate documentation for billing and coding and supplementing with external resources such as state Quit Lines.

Assessing the impact of increasing lung screening eligibility by relaxing the maximum years-since-quit threshold: A simulation modeling study

BACKGROUND

In 2021, the US Preventive Services Task Force expanded its lung screening recommendation to include persons aged 50-80 years who had ever smoked and had at least 20 pack-years of exposure and less than 15 years since quitting (YSQ). However, studies have suggested that screening persons who formerly smoked with longer YSQ could be beneficial.

METHODS

The authors used two validated lung cancer models to assess the benefits and harms of screening using various YSQ thresholds (10, 15, 20, 25, 30, and no YSQ) and the age at which screening was stopped. The impact of enforcing the YSQ criterion only at entry, but not at exit, also was evaluated. Outcomes included the number of screens, the percentage ever screened, screening benefits (lung cancer deaths averted, life-years gained), and harms (false-positive tests, overdiagnosed cases, radiation-induced lung cancer deaths). Sensitivity analyses were conducted to evaluate the effect of restricting screening to those who had at least 5 years of life expectancy.

RESULTS

As the YSQ criterion was relaxed, the number of screens and the benefits and harms of screening increased. Raising the age at which to stop screening age resulted in additional benefits but with more overdiagnosis, as expected, because screening among those older than 80 years increased. Limiting screening to those who had at least 5 years of life expectancy would maintain most of the benefits while considerably reducing the harms.

CONCLUSIONS

Expanding screening to persons who formerly smoked and have greater than 15 YSQ would result in considerable increases in deaths averted and life-years gained. Although additional harms would occur, these could be moderated by ensuring that screening is restricted to only those with reasonable life expectancy.

Contribution of smoking, disease history, and survival to lung cancer disparities in Black individuals

BACKGROUND

Lung cancer is the leading cause of cancer deaths and disproportionately affects self-identified Black or African American ("Black") people, especially considering their relatively low self-reported smoking intensity rates. This study aimed to determine the relative impact of smoking history and lung cancer incidence risk, histology, stage, and survival on these disparities.

METHODS

We used 2 lung cancer models (MichiganLung-All Races and MichiganLung-Black) to understand why Black people have higher rates of lung cancer deaths. We studied how different factors, such as smoking behaviors, cancer development, histology, stage at diagnosis, and lung cancer survival, contribute to these differences.

RESULTS

Adjusted for smoking history, approximately 90% of the difference in lung cancer deaths between the overall and Black populations (born in 1960) was the result of differences in the risk of getting lung cancer. Differences in the histology and stage of lung cancer and survival had a small impact (4% to 6% for each). Similar results were observed for the 1950 and 1970 birth cohorts, regardless of their differences in smoking patterns from the 1960 cohort.

CONCLUSIONS

After taking smoking into account, the higher rate of lung cancer deaths in Black people can mostly be explained by differences in the risk of developing lung cancer. As lung cancer treatments and detection improve, however, other factors may become more important in determining differences in lung cancer mortality between the Black and overall populations. To prevent current disparities from becoming worse, it is important to make sure that these improvements are available to everyone in an equitable way.

Motivation, acceptability and attitudes toward lung cancer screening among persons who attend a tobacco cessation program: A multicenter survey in Italy

This study aimed to evaluate smoking cessation (SC) motivation and the acceptability of a lung cancer screening (LCS) program with low-dose computed tomography (LDCT) among people who attend SC programs. A multicenter survey was conducted in the period January-December 2021 involving 197 people who attended group or individual SC courses in Reggio Emilia and Tuscany. Questionnaires, information sheets, and decision aids about the potential benefits and harms of LCS with LDCT were distributed at different time points during the course. The wish to protect own health (66%) was the most frequent reason given for quitting smoking, followed by cigarette dependence (40.6%) and current health problems (30.5%). Half of the participants (56%) considered periodic health checks including LDCT, as an advantageous activity. The great majority of participants were in favor of LCS (92%), with only 8% being indifferent, and no one was against these programs. Interestingly, those with sufficiently high smoking-related LC risk to be eligible for LCS and those attending the individual course were less in favor of LCS but also less concerned about the possible harms associated with LCS. The type of counseling was a significant predictor for both LCS acceptability and perceived harm of LCS. The favorable perception of LCS in people attending SC courses, despite the considerable preoccupation with potential harms, is an important finding of this study. Introducing a discussion on the benefits and harms of LCS in SC programs may prepare persons who smoke to make informed decisions on utilizing LCS.

Serum procalcitonin as a tumor marker in lung adenocarcinoma with ovarian metastasis: a case report

Primary lung cancer is the leading cause of mortality worldwide. The major sites of lung cancer metastasis are the bones, liver, brain, lung, and adrenal glands. However, secondary localizations in the genital tract are extremely rare.

CASE PRESENTATION

The authors report the case of a 36-year-old woman who consulted for a right scapular swelling evolving for 4 months associated with a chronic cough. Clinical examination showed a hard fixed right scapular mass with any inflammatory signs. The extension assessment followed by histological analysis concluded in a secondary ovarian location of a lung adenocarcinoma. A very high serum procalcitonin level unrelated to sepsis was detected in the patient along with a substantial hematological paraneoplastic disease. The patient died after 6 months of palliative chemotherapy.

CLINICAL DISCUSSION

Ovarian localization is found in only 0.4% of metastatic ovarian tumors, which is extremely low, the differentiation between primary and secondary ovarian adenocarcinoma is fundamental since the treatment and prognosis are very different. The serum procalcitonin can be elevated in lung adenocarcinoma.

CONCLUSION

This case report highlights the interest to encourage doctors to look for ovarian metastasis during the clinical course of lung cancer, and explain the elevation of serum procalcitonin during lung adenocarcinoma.

Defining the road map to a UK national lung cancer screening programme

Lung cancer screening with low-dose CT was recommended by the UK National Screening Committee (UKNSC) in September, 2022, on the basis of data from trials showing a reduction in lung cancer mortality. These trials provide sufficient evidence to show clinical efficacy, but further work is needed to prove deliverability in preparation for a national roll-out of the first major targeted screening programme. The UK has been world leading in addressing logistical issues with lung cancer screening through clinical trials, implementation pilots, and the National Health Service (NHS) England Targeted Lung Health Check Programme. In this Policy Review, we describe the consensus reached by a multiprofessional group of experts in lung cancer screening on the key requirements and priorities for effective implementation of a programme. We summarise the output from a round-table meeting of clinicians, behavioural scientists, stakeholder organisations, and representatives from NHS England, the UKNSC, and the four UK nations. This Policy Review will be an important tool in the ongoing expansion and evolution of an already successful programme, and provides a summary of UK expert opinion for consideration by those organising and delivering lung cancer screenings in other countries.

Smoking Disparities by Level of Educational Attainment and Birth Cohort in the U.S

INTRODUCTION

Little is known about how U.S. smoking patterns of initiation, cessation, and intensity vary by birth cohort across education levels or how these patterns may be driven by other demographic characteristics.

METHODS

Smoking data for adults aged ≥25 years was obtained from the National Health Interview Surveys 1966-2018. Age-period-cohort models were developed to estimate the probabilities of smoking initiation, cessation, intensity, and prevalence by age, cohort, calendar year, and gender for education levels: ≤8th grade, 9th-11th grade, high school graduate or GED, some college, and college degree or above. Further analyses were conducted to identify the demographic factors (race/ethnicity and birthplace) that may explain the smoking patterns by education. Analyses were conducted in 2020-2021.

RESULTS

Smoking disparities by education have increased by birth cohort. In recent cohorts, initiation probabilities were highest among individuals with 9th-11th-grade education and lowest among individuals with at least a college degree. Cessation probabilities were higher among those with higher education. Current smoking prevalence decreased over time across all education groups, with important differences by gender. However, it decreased more rapidly among individuals with ≤8th grade education, resulting in this group having the second lowest prevalence in recent cohorts. This may be driven by the increasing proportion of non-U.S. born Hispanics in this group.

CONCLUSIONS

Although smoking is decreasing by cohort across all education groups, disparities in smoking behaviors by education have widened in recent cohorts. Demographic changes for the ≤8th-grade education group need special consideration in analyses of tobacco use by education.

Mortality Relative Risks by Smoking, Race/Ethnicity, and Education

INTRODUCTION

The impact of cigarette smoking on mortality is well studied, with estimates of the relative mortality risks for the overall population widely available. However, age-specific mortality estimates for different sociodemographic groups in the U.S. are lacking.

METHODS

Using the 1987-2018 National Health Interview Survey Linked Mortality Files through 2019, all-cause mortality relative risks (RRs) were estimated for current smokers or recent quitters and long-term quitters compared with those for never smokers. Stratified Cox proportional hazards regression models were used to estimate RRs by age, gender, race/ethnicity, and educational attainment. RRs were also assessed for current smokers or recent quitters by smoking intensity and for long-term quitters by years since quitting. The analysis was conducted in 2021-2022.

RESULTS

All-cause mortality RRs among current smokers or recent quitters were generally highest for non-Hispanic White individuals than for never smokers, followed by non-Hispanic Black individuals, and were lowest for Hispanic individuals. RRs varied greatly by educational attainment; generally, higher-education groups had greater RRs associated with smoking than lower-education groups. Conversely, the RRs by years since quitting among long-term quitters did not show clear differences across race/ethnicity and education groups. Age-specific RR patterns varied greatly across racial/ethnic and education groups as well as by gender.

CONCLUSIONS

Age-specific all-cause mortality rates associated with smoking vary considerably by sociodemographic factors. Among high-education groups, lower underlying mortality rates for never smokers result in correspondingly high RR estimates for current smoking. These estimates can be incorporated in modeling analyses to assess tobacco control interventions' impact on smoking-related health disparities between different sociodemographic groups.

Risk Model-Based Lung Cancer Screening : A Cost-Effectiveness Analysis

BACKGROUND

In their 2021 lung cancer screening recommendation update, the U.S. Preventive Services Task Force (USPSTF) evaluated strategies that select people based on their personal lung cancer risk (risk model-based strategies), highlighting the need for further research on the benefits and harms of risk model-based screening.

OBJECTIVE

To evaluate and compare the cost-effectiveness of risk model-based lung cancer screening strategies versus the USPSTF recommendation and to explore optimal risk thresholds.

DESIGN

Comparative modeling analysis.

DATA SOURCES

National Lung Screening Trial; Surveillance, Epidemiology, and End Results program; U.S. Smoking History Generator.

TARGET POPULATION

1960 U.S. birth cohort.

TIME HORIZON

45 years.

PERSPECTIVE

U.S. health care sector.

INTERVENTION

Annual low-dose computed tomography in risk model-based strategies that start screening at age 50 or 55 years, stop screening at age 80 years, with 6-year risk thresholds between 0.5% and 2.2% using the PLCOm2012 model.

OUTCOME MEASURES

Incremental cost-effectiveness ratio (ICER) and cost-effectiveness efficiency frontier connecting strategies with the highest health benefit at a given cost.

RESULTS OF BASE-CASE ANALYSIS

Risk model-based screening strategies were more cost-effective than the USPSTF recommendation and exclusively comprised the cost-effectiveness efficiency frontier. Among the strategies on the efficiency frontier, those with a 6-year risk threshold of 1.2% or greater were cost-effective with an ICER less than $100 000 per quality-adjusted life-year (QALY). Specifically, the strategy with a 1.2% risk threshold had an ICER of $94 659 (model range, $72 639 to $156 774), yielding more QALYs for less cost than the USPSTF recommendation, while having a similar level of screening coverage (person ever-screened 21.7% vs. USPSTF's 22.6%).

RESULTS OF SENSITIVITY ANALYSES

Risk model-based strategies were robustly more cost-effective than the 2021 USPSTF recommendation under varying modeling assumptions.

LIMITATION

Risk models were restricted to age, sex, and smoking-related risk predictors.

CONCLUSION

Risk model-based screening is more cost-effective than the USPSTF recommendation, thus warranting further consideration.

PRIMARY FUNDING SOURCE

National Cancer Institute (NCI).

The impact of low-dose CT on smoking behavior among non-smokers, former-smokers, and smokers: A population-based screening cohort in rural China

BACKGROUND

Lung cancer screening may provide a "teachable moment" for the smoking cessation and relapse prevention. However, the impact of lung cancer screening on smoking initiation in non-smokers has not been reported.

METHODS

A baseline smoking behavior survey was conducted in 2000 participants who were screened by low-dose computed tomography (LDCT) from 2014 to 2018. All participants were re-surveyed on their smoking behavior in 2019. Of these, 312 participants were excluded, leaving 1688 participants in the final analysis. The smoking initiation rate in baseline non-smokers, the relapse rate in baseline former smokers, and the abstinence rate in baseline current smokers were calculated, respectively. The associations between screening results, demographic characteristics, and smoking behavior change were analyzed using multivariable logistic regression.

RESULTS

From 2014 to 2019, smoking prevalence significantly decreased from 52.6% to 49.1%. The prevalence of smoking initiation, relapse, and abstinence in baseline non-smokers, former, and current smokers was 16.8%, 22.9%, and 23.7%, respectively. The risk of smoking initiation in baseline non-smokers was significantly higher in those with negative screening result (adjusted OR = 2.97, 95% CI: 1.27-6.94). Compared to smokers who only received baseline screening, the chance of smoking abstinence in baseline current smokers was reduced by over 80% in those who attended 5 rounds of screening (adjusted OR = 0.15, 95% CI:0.08-0.27). No significant associations were found between smoking relapse and prior screening frequency, with at least one positive screening result. Age, gender, occupational exposure, income, and smoking pack years were also associated with smoking behavior changes.

CONCLUSIONS

The overall decreased smoking prevalence indicated an overwhelming effect of "teachable moment" on "license to smoke." A tailored smoking cessation strategy should be integrated into lung cancer screening.

Protocol for a randomized controlled trial of the Enhanced Smoking Cessation Approach to Promote Empowerment (ESCAPE) digitalized intervention to promote lung health in high-risk individuals who smoke

Low dose computed tomography (LDCT) is an effective screening test to decrease lung cancer deaths. Lung cancer screening may be a teachable moment helping people who smoke to quit, which may result in increased benefit of screening. Innovative strategies are needed to engage high-risk individuals in learning about LDCT screening. More precise methods such as polygenic risk scores quantify genetic predisposition to tobacco use, and optimize lung health interventions. We present the ESCAPE (Enhanced Smoking Cessation Approach to Promote Empowerment) protocol. This study will test a smoking cessation intervention using personal stories and a lung cancer screening decision-aide compared to standard care (brief advice, referral to a quit line, and a lung cancer screening decision-aide), examine the relationship between a polygenic risk score and smoking abstinence, and describe perceptions about integration of genomic information into smoking cessation treatment. A randomized controlled trial followed by a sequential explanatory mixed methods approach will compare the efficacy of the interventions. Interviews will add insight into the use of genomic information and risk perceptions to tailor smoking cessation treatment. Two-hundred and fifty individuals will be recruited from primary care, community-based organizations, mailing lists and through social media. Data will be collected at baseline, 1, 3 and 6-months. The primary outcomes are 7-day point prevalence smoking abstinence and stage of lung cancer screening at 6-months. The results from this study will provide information to refine the ESCAPE intervention and facilitate integration of precision health into future lung health interventions. Clinical trial registration number: NCT0469129T.

Co-development of an evidence-based personalised smoking cessation intervention for use in a lung cancer screening context

BACKGROUND

Optimising smoking cessation services within a low radiation-dose computed tomography (LDCT) lung cancer screening programme has the potential to improve cost-effectiveness and overall efficacy of the programme. However, evidence on the optimal design and integration of cessation services is limited. We co-developed a personalised cessation and relapse prevention intervention incorporating medical imaging collected during lung cancer screening. The intervention is designed to initiate and support quit attempts among smokers attending screening as part of the Yorkshire Enhanced Stop Smoking study (YESS: ISRCTN63825779). Patients and public were involved in the development of an intervention designed to meet the needs of the target population.

METHODS

An iterative co-development approach was used. Eight members of the public with a history of smoking completed an online survey to inform the visual presentation of risk information in subsequent focus groups for acceptability testing. Three focus groups (n = 13) were conducted in deprived areas of Yorkshire and South Wales with members of the public who were current smokers or recent quitters (within the last year). Exemplar images of the heart and lungs acquired by LDCT, absolute and relative lung cancer risk, and lung age were shown. Data were analysed thematically, and discussed in stakeholder workshops. Draft versions of the intervention were developed, underpinned by the Extended Parallel Processing Model to increase self-efficacy and response-efficacy. The intervention was further refined in a second stakeholder workshop with a patient panel.

RESULTS

Individual LDCT scan images of the lungs and heart, in conjunction with artistic impressions to facilitate interpretation, were considered by public participants to be most impactful in prompting cessation. Public participants thought it important to have a trained practitioner guiding them through the intervention and emphasising the short-term benefits of quitting. Presentation of absolute and relative risk of lung cancer and lung age were considered highly demotivating due to reinforcement of fatalistic beliefs.

CONCLUSION

An acceptable personalised intervention booklet utilising LDCT scan images has been developed for delivery by a trained smoking cessation practitioner. Our findings highlight the benefit of co-development during intervention development and the need for further evaluation of effectiveness.

Accelerating integration of tobacco use treatment in the context of lung cancer screening: Relevance and application of implementation science to achieving policy and practice

Based on the findings from the National Lung Screening Trial, the U.S. Preventive Services Task Force recommends annual low dose computed tomography (LDCT) lung cancer screening (LCS) among high-risk adults. Approximately 54% of individuals seeking LCS report current cigarette smoking. Effective smoking cessation interventions, offered at the time of LCS, enhances the health benefits of screening that are attributable to reductions in lung cancer overall and tobacco-related mortality. Considering these data, the Centers for Medicare & Medicaid Services' (CMS) 2015 decision to cover LCS with LDCT required that radiology imaging facilities make tobacco cessation interventions available for people who smoke. In February 2022, CMS reversed their 2015 coverage requirement for delivering tobacco use treatment at the time of LDCT; CMS retained the requirement for counseling during the shared decision-making visit prior to the exam. The policy change does not diminish the importance of offering high-quality tobacco cessation services in conjunction with routine LDCT for LCS. However, LCS programs face a range of barriers to implementing tobacco use treatment in their settings. As a result, implementation has lagged. Closing the "evidence to practice" gap is the focus of implementation science, a field that offers a set of rigorous methods and a systematic approach to identifying and overcoming contextual barriers to implementing evidence-based guidelines in a range of clinical settings. In this paper, we describe how implementation science frameworks and methods can be used to help guide LCS programs in their efforts to integrate tobacco use treatment and discuss policy changes needed to further facilitate the delivery of TUT as an essential component of the LCS process.

Implementation of an Integrated Lung Cancer Prevention and Screening Program Using a Mobile Computed Tomography (CT) Unit in Brazil

INTRODUCTION

Lung cancer is the deadliest cancer worldwide and in Brazil. Despite strong evidence, lung cancer screening by low-dose computed tomography (LDCT) in high-risk individuals is far from a reality in many countries, particularly in Brazil. Brazil has a universal public health system marked with important inequalities. One affordable strategy to increase the coverage of resources is to use mobile units.

OBJECTIVES

To describe the implementation and results of an innovative lung cancer prevention program that integrates tobacco cessation and lung cancer screening using a mobile CT unit.

METHODOLOGY

From May 2019 to Dec 2020, health professionals from 18 public primary health care units in Barretos, Brazil, were trained to offer smoking cessation counseling and treatment. Eligible high-risk participants of this program were also invited to perform lung cancer screening in a mobile LDCT unit that was specially conceived to be dispatched to the community. A detailed epidemiological questionnaire was administered to the LDCT participants.

RESULTS

Among the 233 screened participants, the majority were women (54.9%), and the average age was 62 years old. A total of 52.8% of participants showed high or very high nicotine dependence. After 1 year, 27.8% of participants who were involved in smoking cessation groups had quit smoking. The first LDCT round revealed that the majority of participants (83.7%) exhibited lung-Rads 1 or 2; 7.3% exhibited lung-Rads 3; 7.7% exhibited lung-Rads 4a; and 3% exhibited lung-Rads 4b or 4x. The three participants with lung-Rads 4b were further confirmed, and their surgery led to the diagnosis of early-stage cancer (1 case of adenocarcinoma and two cases of squamous cell carcinoma), leading to a cancer diagnosis rate of 12.8/1000.

CONCLUSION

Our results indicate promising outcomes for an onsite integrative program enrolling high-risk individuals in a middle-income country. Evidence barriers and challenges remain to be overcome.

Evaluation of benefits and harms of adaptive screening schedules for lung cancer: A microsimulation study

BACKGROUND

Although lung cancer screening (LCS) has been proven effective in reducing lung cancer mortality, it is associated with some potential harms, such as false positives and invasive follow-up procedures. Determining the time to next screen based on individual risk could reduce harms while maintaining health gains. Here, we evaluate the benefits and harms of LCS strategies with adaptive schedules, and compare these with those from non-adaptive strategies.

METHODS

We extended the Lee and Zelen risk threshold method to select screening schedules based on individual's lung cancer risk and life expectancy (adaptive schedules). We compared the health benefits and harms of these adaptive schedules with regular (non-adaptive) schedules (annual, biennial and triennial) using a validated lung cancer microsimulation model. Outcomes include lung cancer deaths (LCD) averted, life years gained (LYG), discounted quality adjusted life years (QALYs) gained, and false positives per LCD averted. We also explored the impact of varying screening-related disutilities.

RESULTS

In comparison to standard regular screening recommendations, risk-dependent adaptive screening reduced screening harms while maintaining a similar level of health benefits. The net gains and the balance of benefits and harms from LCS with efficient adaptive schedules were improved compared to those from regular screening, especially when the screening-related disutilities are high.

CONCLUSIONS

Adaptive screening schedules can reduce the associated harms of screening while maintaining its associated lung cancer mortality reductions and years of life gained. Our study identifies individually tailored schedules that optimize the screening benefit/harm trade-offs.

A Randomized Trial of Telephone-Based Smoking Cessation Treatment in the Lung Cancer Screening Setting

BACKGROUND

Lung cancer mortality is reduced via low-dose CT screening and treatment of early-stage disease. Evidence-based smoking cessation treatment in the lung screening setting can further reduce mortality. We report the results of a cessation trial from the NCI's SCALE collaboration.

METHODS

Eligible patients (N = 818) aged 50-80 were randomized (May 2017-January 2021) to the Intensive vs. Minimal arms (8 vs. 3 phone sessions plus 8 vs. 2 weeks of nicotine patches, respectively). Bio-verified (primary) and self-reported 7-day abstinence rates were assessed 3-, 6-, and 12-months post-randomization. Logistic regression analyses evaluated the effects of study arm. All statistical tests were two-sided.

RESULTS

Participants reported 48.0 (SD = 17.2) pack-years and 51.6% were not ready to quit in < 30 days. Self-reported 3-month quit rates were significantly higher in the Intensive vs. Minimal arm (14.3% vs. 7.9%; OR = 2.00, 95% confidence interval [CI] = 1.26,3.18). Bio-verified abstinence was lower but with similar relative differences between arms (9.1% vs. 3.9%; OR = 2.70, 95% CI = 1.44, 5.08). Compared to the Minimal arm, the Intensive arm was more effective among those with greater nicotine dependence (OR = 3.47, 95% CI = 1.55, 7.76), normal screening results (OR = 2.58, 95% CI = 1.32, 5.03), high engagement in counseling (OR = 3.03, 95% CI = 1.50, 6.14) and patch use (OR = 2.81, 95% CI = 1.39, 5.68). Abstinence rates did not differ significantly between arms at 6-months (OR = 1.2, 95% CI = 0.68, 2.11) or 12-months (OR = 1.4, 95% CI = 0.82, 2.42).

CONCLUSIONS

Delivering intensive telephone counseling and nicotine replacement with lung screening is an effective strategy to increase short-term smoking cessation. Methods to maintain short-term effects are needed. Even with modest quit rates, integrating cessation treatment into lung screening programs may have a large impact on tobacco-related mortality.

Cost-Effectiveness of a Telephone-Based Smoking Cessation Randomized Trial in the Lung Cancer Screening Setting

BACKGROUND

There are limited data on the cost-effectiveness of smoking cessation interventions in lung cancer screening settings. We conducted an economic analysis embedded in a national randomized trial of 2 telephone counseling cessation interventions.

METHODS

We used a societal perspective to compare the short-term cost per 6-month bio-verified quit and long-term cost-effectiveness of the interventions. Trial data were used to micro-cost intervention delivery, and the data were extended to a lifetime horizon using an established Cancer Intervention Surveillance and Modeling Network lung cancer model. We modeled the impact of screening accompanied by 8 weeks vs 3 weeks of telephone counseling (plus nicotine replacement) vs screening alone based on 2021 screening eligibility. Lifetime downstream costs (2021 dollars) and effects (life-years gained, quality-adjusted life-years [QALYs]) saved were discounted at 3%. Sensitivity analyses tested the effects of varying quit rates and costs; all analyses assumed nonrelapse after quitting.

RESULTS

The costs for delivery of the 8-week vs 3-week protocol were $380.23 vs $144.93 per person, and quit rates were 7.14% vs 5.96%, respectively. The least costly strategy was a 3-week counseling approach. An 8-week (vs 3-week) counseling approach increased costs but gained QALYs for an incremental cost-effectiveness ratio of $4029 per QALY. Screening alone cost more and saved fewer QALYs than either counseling strategy. Conclusions were robust in sensitivity analyses.

CONCLUSIONS

Telephone-based cessation interventions with nicotine replacement are considered cost-effective in the lung screening setting. Integrating smoking cessation interventions with lung screening programs has the potential to maximize long-term health benefits at reasonable costs.

National Cancer Institute Smoking Cessation at Lung Examination Trials Brief Report: Baseline Characteristics and Comparison With the U.S. General Population of Lung Cancer Screening-Eligible Patients

Introduction

The National Cancer Institute Smoking Cessation at Lung Examination (SCALE) Collaboration includes eight clinical trials testing smoking cessation interventions delivered with lung cancer screening (LCS). This investigation compared pooled participant baseline demographic and smoking characteristics of seven SCALE trials to LCS-eligible smokers in three U.S. nationally representative surveys.

Methods

Baseline variables (age, sex, race, ethnicity, education, income, cigarettes per day, and time to the first cigarette) from 3614 smokers enrolled in SCALE trials as of September 2020 were compared with pooled data from the Tobacco Use Supplement-Current Population Survey (2018-2019), National Health Interview Survey (2017-2018), and Population Assessment of Tobacco and Health (wave 4, 2016-2017) using the U.S. Preventive Services Task Force 2013 (N = 4803) and 2021 (N = 8604) LCS eligibility criteria.

Results

SCALE participants have similar average age as the U.S. LCS-eligible smokers using the 2013 criteria but are 2.8 years older using the 2021 criteria (p < 0.001). SCALE has a lower proportion of men, a higher proportion of Blacks, and slightly higher education and income levels than national surveys (p < 0.001). SCALE participants smoke an average of 17.9 cigarettes per day (SD 9.2) compared with 22.4 (SD 9.3) using the 2013 criteria and 19.6 (SD 9.7) using the 2021 criteria (p < 0.001). The distribution of time to the first cigarette differs between SCALE and the national surveys (p < 0.001), but both indicate high levels of nicotine dependence.

Conclusions

SCALE participants smoke slightly less than the LCS-eligible smokers in the general population, perhaps related to socioeconomic status or race. Other demographic variables reveal small but statistically significant differences, likely of limited clinical relevance with respect to tobacco treatment outcomes. SCALE trial results should be applicable to LCS-eligible smokers from the U.S. population.

Cost-effectiveness of Low-Dose Computed Tomography With a Plasma-Based Biomarker for Lung Cancer Screening in China

IMPORTANCE

China, which has one-third of the worldwide smoking population, has a substantial cancer burden, with lung cancer being the leading cause of cancer-related death. The effectiveness of lung cancer screening for mortality reduction has been confirmed, but the cost-effectiveness of diverse screening modalities remains unclear.

OBJECTIVE

To compare the cost-effectiveness of low-dose computed tomography (LDCT) with a biomarker (micro-RNA signature classifier [MSC]) with that of LDCT alone by screening interval and cumulative smoking exposure.

DESIGN, SETTING, AND PARTICIPANTS

In this economic evaluation, a comparative cost-effectiveness analysis used Markov state transition models that simulated the 1947 to 1971 China birth cohort. Simulated individuals in 8 cohorts of 10 000 entered the study between ages 50 and 74 years and were followed up until death or age 79 years, corresponding to a study period from January 1, 2021, to December 31, 2050. The model was run with a cycle length of 1 year. All the transition probabilities were validated, and health utility values were extracted from published literature. Cost parameters were derived from the databases of local medical insurance bureaus.

MAIN OUTCOMES AND MEASURES

Primary outcomes included life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) with future costs and outcomes discounted by 5%. Screening strategies with a mean ICER less than Chinese yuan (CNY) 212 676 per QALY gained were deemed to be cost-effective. The cost-effectiveness of 7 alternative screening strategies with a screening starting age of 50 years, minimum cumulative smoking exposure of 20 vs 30 pack-years, and screening interval of annual vs 1 time was estimated, including the 2021 China guideline-recommended strategy (LDCT, annual, 30 pack-years) and the 2018 China guideline-recommended strategy (LDCT, annual, 20 pack-years).

RESULTS

In a simulated population of 80 000 individuals, the conjunctive LDCT and MSC screening strategy was estimated to obtain an ICER of CNY -793 995.17 to 254 417.46 (minimum cumulative smoking exposure, 20-30 pack-years) per QALY gained compared with LDCT screening alone. China's 2021 guideline-recommended strategy was not cost-effective compared with the 2018 guideline-recommended strategy, with higher costs and fewer QALYs gained; the QALY loss ranged from 0.02 to 0.15 per person and the increase in cost ranged from CNY 945.89 to CNY 5131.29 per person. LDCT and MSC screening beginning at age 70 to 74 years in individuals with a 20 pack-year smoking history was the most cost-effective strategy, with an ICER of CNY -793 995.17 per QALY gained. Lowering the minimum cumulative smoking exposure for screening from 30 to 20 pack-years and maintaining annual screening were associated with greater cost savings regardless of the screening tool.

CONCLUSIONS AND RELEVANCE

This economic evaluation found that China's 2018 recommendation for lung cancer screening was more cost-effective than the 2021 recommendation. Moreover, the cost-effectiveness of lung cancer screening was improved when MSC was included with LDCT. These findings may be useful for the modification of guidelines for lung cancer screening.

Improving Lung Cancer Screening Rates Through an Evidence-Based Electronic Health Record Smoking History

BACKGROUND

Lung cancer is prevalent worldwide, with 2.1 million new cases and 1.8 million deaths in 2020. In the United States, an estimated 131 880 lung cancer deaths are expected to occur in 2021, with most detected in later stages. Smokers are 15 to 30 times more likely to develop or die from lung cancer.

LOCAL PROBLEM

Our community residents were more likely to be diagnosed with lung cancer in later stages (62%) compared with 56% nationally, resulting in an increased community mortality rate.

INTERVENTION

Evidence-based changes in an electronic health record system supported identification and referral of high-risk patients for low-dose computer tomography to improve early lung cancer detection rates.

RESULTS

Early-stage lung cancer detection increased 24%.

CONCLUSIONS

Interprofessional teams used technology to adopt evidence-based practice and improve health outcomes in their communities.

Impact of Joint Lung Cancer Screening and Cessation Interventions Under the New Recommendations of the U.S. Preventive Services Task Force

INTRODUCTION

In 2021, the U.S. Preventive Services Task Force (USPSTF) revised its lung cancer screening recommendations expanding its eligibility. As more smokers become eligible, cessation interventions at the point of screening could enhance the benefits. Here, we evaluate the effects of joint screening and cessation interventions under the new recommendations.

METHODS

A validated lung cancer natural history model was used to estimate lifetime number of low-dose computed tomography screens, percentage ever screened, lung cancer deaths, lung cancer deaths averted, and life-years gained for the 1960 U.S. birth cohort aged 45 to 90 years (4.5 million individuals). Screening occurred according to the USPSTF 2013 and 2021 recommendations with varying uptake (0%, 30%, 100%), with or without a cessation intervention at the point of screening with varying effectiveness (15%, 100%).

RESULTS

Screening 30% of the eligible population according to the 2021 criteria with no cessation intervention (USPSTF 2021, 30% uptake, without cessation intervention) was estimated to result in 6845 lung cancer deaths averted and 103,725 life-years gained. These represent 28% and 34% increases, respectively, relative to screening according to the 2013 guidelines (USPSTF 2013, 30% uptake, without cessation intervention). Adding a cessation intervention at the time of the first screen with 15% effectiveness (USPSTF 2021, 30% uptake, with cessation intervention with 15% effectiveness) was estimated to result in 2422 additional lung cancer deaths averted (9267 total, ∼73% increase versus USPSTF 2013, 30% uptake, without cessation intervention) and 322,785 life-years gained (∼318% increase). Screening 100% of the eligible according to the 2021 guidelines with no cessation intervention (USPSTF 2021, 100% uptake, without cessation intervention) was estimated to result in 23,444 lung cancer deaths averted (∼337% increase versus USPSTF 2013, 30% uptake, without cessation intervention) and 354,330 life-years gained (∼359% increase). Adding a cessation intervention with 15% effectiveness (USPSTF 2021, 100% uptake, with cessation intervention with 15% effectiveness) would result in 31,998 lung cancer deaths averted (∼497% increase versus USPSTF 2013, 30% uptake, without cessation intervention) and 1,086,840 life-years gained (∼1309% increase).

CONCLUSIONS

Joint screening and cessation interventions would result in considerable lung cancer deaths averted and life-years gained. Adding a one-time cessation intervention of modest effectiveness (15%) results in comparable life-years gained as increasing screening uptake from 30% to 100% because while cessation decreases mortality from many causes, screening only reduces lung cancer mortality. This simulation indicates that incorporating cessation programs into screening practice should be a priority as it can maximize overall benefits.

Low Rates of Lung Cancer Screening Referrals in Patients With Human Immunodeficiency Virus: A Correlational Study

People living with HIV (PLWH) have an increased risk of lung cancer compared to the general population. In 2013, the United States Preventive Services Task Force (USPSTF) released their lung cancer screening (LCS) guidelines. However, the impact of these guidelines has not been well established in PLWH. The objective of this retrospective descriptive study is to evaluate the frequency of lung cancer screening referrals and factors associated with LCS referrals using the 2013 USPSTF screening guidelines in at-risk PLWH. We collected demographic and clinical information on PLWH from electronic medical records from July 2016 to July 2018. Descriptive statistics, chi-square tests, t-tests, Wilcoxon rank sum tests, and Fisher’s exact tests were used for analysis. Only 14% of patients who met 2013 USPSTF screening guidelines were referred for screening. Patients who received a referral were more likely to have received tobacco cessation counseling. Patients who received and completed a referral were more likely to have hepatitis C infection. Quality improvement strategies are needed to improve rates of LCS in PLWH.

Cost-effectiveness Evaluation of the 2021 US Preventive Services Task Force Recommendation for Lung Cancer Screening

IMPORTANCE

The US Preventive Services Task Force (USPSTF) issued its 2021 recommendation on lung cancer screening, which lowered the starting age for screening from 55 to 50 years and the minimum cumulative smoking exposure from 30 to 20 pack-years relative to its 2013 recommendation. Although costs are expected to increase because of the expanded screening eligibility criteria, it is unknown whether the new guidelines for lung cancer screening are cost-effective.

OBJECTIVE

To evaluate the cost-effectiveness of the 2021 USPSTF recommendation for lung cancer screening compared with the 2013 recommendation and to explore the cost-effectiveness of 6 alternative screening strategies that maintained a minimum cumulative smoking exposure of 20 pack-years and an ending age for screening of 80 years but varied the starting ages for screening (50 or 55 years) and the number of years since smoking cessation (≤15, ≤20, or ≤25).

DESIGN, SETTING, AND PARTICIPANTS

A comparative cost-effectiveness analysis using 4 independently developed microsimulation models that shared common inputs to assess the population-level health benefits and costs of the 2021 recommended screening strategy and 6 alternative screening strategies compared with the 2013 recommended screening strategy. The models simulated a 1960 US birth cohort. Simulated individuals entered the study at age 45 years and were followed up until death or age 90 years, corresponding to a study period from January 1, 2005, to December 31, 2050.

EXPOSURES

Low-dose computed tomography in lung cancer screening programs with a minimum cumulative smoking exposure of 20 pack-years.

MAIN OUTCOMES AND MEASURES

Incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) of the 2021 vs 2013 USPSTF lung cancer screening recommendations as well as 6 alternative screening strategies vs the 2013 USPSTF screening strategy. Strategies with a mean ICER lower than $100 000 per QALY were deemed cost-effective.

RESULTS

The 2021 USPSTF recommendation was estimated to be cost-effective compared with the 2013 recommendation, with a mean ICER of $72 564 (range across 4 models, $59 493-$85 837) per QALY gained. The 2021 recommendation was not cost-effective compared with 6 alternative strategies that used the 20 pack-year criterion. Strategies associated with the most cost-effectiveness included those that expanded screening eligibility to include a greater number of former smokers who had not smoked for a longer duration (ie, ≤20 years and ≤25 years since smoking cessation vs ≤15 years since smoking cessation). In particular, the strategy that screened former smokers who quit within the past 25 years and began screening at age 55 years was associated with screening coverage closest to that of the 2021 USPSTF recommendation yet yielded greater cost-effectiveness, with a mean ICER of $66 533 (range across 4 models, $55 693-$80 539).

CONCLUSIONS AND RELEVANCE

This economic evaluation found that the 2021 USPSTF recommendation for lung cancer screening was cost-effective; however, alternative screening strategies that maintained a minimum cumulative smoking exposure of 20 pack-years but included individuals who quit smoking within the past 25 years may be more cost-effective and warrant further evaluation.

Change in amount smoked and readiness to quit among patients undergoing lung cancer screening

Background

There is mixed evidence regarding whether undergoing computed tomography lung cancer screening (LCS) can serve as a "teachable moment" that impacts smoking behavior and attitudes. The study aim was to assess whether the standard procedures of undergoing LCS and receiving free and low-cost evidence-based cessation resources impacted short-term smoking-related outcomes.

Methods

Participants were smokers (N=87) who were registered to undergo lung screening and were enrolled in a cessation intervention trial. We conducted two phone interviews, both preceding trial randomization: the first interview was conducted prior to lung screening, and the second interview followed lung screening (median =12.5 days post-screening) and participants' receipt of their screening results. The interviews assessed demographic characteristics, interest in evidence-based cessation intervention methods, and tobacco-related characteristics, including cigarettes per day and readiness to quit. Participants received minimal evidence-based cessation resources following the pre-lung screening interview.

Results

Participants were 60.3 years old, 56.3% female, and reported a median of 40 pack-years. Participants were interested in using several evidence-based strategies, including counseling from a healthcare provider (76.7%) and receiving nicotine replacement therapy (69.8%). Pre-lung screening, 25.3% smoked ≤10 cigarettes per day, and 29.9% were ready to quit in the next 30 days. We conducted two McNemar binomial distribution tests to assess change from pre- to post-screening. At the post-lung screening assessment, approximately three-quarters reported no change on these variables. However, 23.3% reported smoking fewer cigarettes per day, whereas 4.7% reported smoking more cigarettes per day (McNemar P=0.002), and 17.2% reported increased readiness to quit, whereas 6.9% reported decreased readiness to quit (McNemar P=0.078).

Conclusions

Following receipt of cessation resources and completion of lung screening, most participants reported no change in smoking outcomes. However, there was a significant reduction in cigarettes per day, and there was a trend for increased readiness to quit. This setting may provide a potential "teachable moment" and an opportunity to assist smokers with quitting. However, more proactive and intensive interventions will be necessary to capitalize on these changes and to support abstinence in the long-term.

Tobacco use disorder and the lungs

This narrative review provides a summary of the impact of tobacco smoking on the respiratory system and the benefits of smoking cessation. Tobacco smoking is one of the leading preventable causes of death world-wide and a major risk factor for lung cancer and chronic obstructive pulmonary disease. Smoking is also associated with an increased risk of respiratory infections and appears to be related to poorer outcomes among those with COVID-19. Non-smokers with second-hand smoke exposure also experience significant adverse respiratory effects. Smoking imposes enormous health- and non-health-related costs to societies. The benefits of smoking cessation, in both prevention and management of respiratory disease, have been known for decades and, to this day, cessation support remains one of the most important cost-effective interventions that health professionals can provide to people who smoke. Cessation at any age confers substantial health benefits, even in smokers with established morbidities. As other treatments for chronic respiratory disease advance and survival rates increase, smoking cessation treatment will become even more relevant. While smoking cessation interventions are available, the offer of these by clinicians and uptake by patients remain limited.

Cost-Effectiveness of Smoking Cessation Interventions in the Lung Cancer Screening Setting: A Simulation Study

BACKGROUND

Guidelines recommend offering cessation interventions to smokers eligible for lung cancer screening, but there is little data comparing specific cessation approaches in this setting. We compared the benefits and costs of different smoking cessation interventions to help screening programs select specific cessation approaches.

METHODS

We conducted a societal-perspective cost-effectiveness analysis using a Cancer Intervention and Surveillance Modeling Network model simulating individuals born in 1960 over their lifetimes. Model inputs were derived from Medicare, national cancer registries, published studies, and micro-costing of cessation interventions. We modeled annual lung cancer screening following 2014 US Preventive Services Task Force guidelines plus cessation interventions offered to current smokers at first screen, including pharmacotherapy only or pharmacotherapy with electronic and/or web-based, telephone, individual, or group counseling. Outcomes included lung cancer cases and deaths, life-years saved, quality-adjusted life-years (QALYs) saved, costs, and incremental cost-effectiveness ratios.

RESULTS

Compared with screening alone, all cessation interventions decreased cases of and deaths from lung cancer. Compared incrementally, efficient cessation strategies included pharmacotherapy with either web-based cessation ($555 per QALY), telephone counseling ($7562 per QALY), or individual counseling ($35 531 per QALY). Cessation interventions continued to have costs per QALY well below accepted willingness to pay thresholds even with the lowest intervention effects and was more cost-effective in cohorts with higher smoking prevalence.

CONCLUSION

All smoking cessation interventions delivered with lung cancer screening are likely to provide benefits at reasonable costs. Because the differences between approaches were small, the choice of intervention should be guided by practical concerns such as staff training and availability.

Predictors of Enrollment of Older Smokers in Six Smoking Cessation Trials in the Lung Cancer Screening Setting: The Smoking Cessation at Lung Examination (SCALE) Collaboration

SIGNIFICANCE

Increased rates of smoking cessation will be essential to maximize the population benefit of low-dose CT screening for lung cancer. The NCI's Smoking Cessation at Lung Examination (SCALE) Collaboration includes eight randomized trials, each assessing evidence-based interventions among smokers undergoing lung cancer screening (LCS). We examined predictors of trial enrollment to improve future outreach efforts for cessation interventions offered to older smokers in this and other clinical settings.

METHODS

We included the six SCALE trials that randomized individual participants. We assessed demographics, intervention modalities, LCS site and trial administration characteristics, and reasons for declining.

RESULTS

Of 6,285 trial- and LCS-eligible individuals, 3,897 (62%) declined and 2,388 (38%) enrolled. In multivariable logistic regression analyses, Blacks had higher enrollment rates (OR 1.5, 95% CI 1.2,1.8) compared to Whites. Compared to 'NRT Only' trials, those approached for 'NRT+prescription medication' trials had higher odds of enrollment (OR 6.1, 95% CI 4.7,7.9). Regarding enrollment methods, trials using 'Phone+In Person' methods had higher odds of enrollment (OR 1.6, 95% CI 1.2,1.9) compared to trials using 'Phone Only' methods. Some of the reasons for declining enrollment included 'too busy' (36.6%), 'not ready to quit' (8.2%), 'not interested in research' (7.7%), and 'not interested in the intervention offered' (6.2%).

CONCLUSION

Enrolling smokers in cessation interventions in the LCS setting is a major priority that requires multiple enrollment and intervention modalities. Barriers to enrollment provide insights that can be addressed and applied to future cessation interventions to improve implementation in LCS and other clinical settings with older smokers.

IMPLICATIONS

We explored enrollment rates and reasons for declining across six smoking cessation trials in the lung cancer screening setting. Offering multiple accrual methods and pharmacotherapy options predicted increased enrollment across trials. Enrollment rates were also greater among Blacks compared to Whites. The findings offer practical information for the implementation of cessation trials and interventions in the lung cancer screening context and other clinical settings, regarding intervention modalities that may be most appealing to older, long-term smokers.

Updated Review of Major Cancer Risk Factors and Screening Test Use in the United States in 2018 and 2019, with a Focus on Smoking Cessation

Cancer prevention and early detection efforts are central to reducing cancer burden. Herein, we present estimates of cancer risk factors and screening tests in 2018 and 2019 among US adults, with a focus on smoking cessation. Cigarette smoking reached a historic low in 2019 (14.2%) partly because 61.7% (54.9 million) of all persons who had ever smoked had quit. Yet, the quit ratio was <45% among lower-income, uninsured, and Medicaid-insured persons, and was <55% among Black, American Indian/Alaska Native, lower-educated, lesbian, gay or bisexual, and recent immigrant persons, and in 12 of 17 Southern states. Obesity levels remain high (2017-2018: 42.4%) and were disproportionately higher among Black (56.9%) and Hispanic (43.7%) women. HPV vaccination in adolescents 13 to 17 years remains underutilized and over 40% were not up-to-date in 2019. Cancer screening prevalence was suboptimal in 2018 (colorectal cancer ≥50 years: 65.6%; breast ≥45 years: 63.2%; cervical 21-65 years: 83.7%), especially among uninsured adults (colorectal: 29.8%; breast: 31.1%). This snapshot of cancer prevention and early detection measures was mixed, and substantial racial/ethnic and socioeconomic disparities persisted. However, gains could be accelerated with targeted interventions to increase smoking cessation in under-resourced populations, stem the obesity epidemic, and improve screening and HPV vaccination coverage.

Personalising lung cancer screening: An overview of risk-stratification opportunities and challenges

Randomised clinical trials have shown the efficacy of computed tomography lung cancer screening, initiating discussions on whether and how to implement population‐based screening programs. Due to smoking behaviour being the primary risk‐factor for lung cancer and part of the criteria for determining screening eligibility, lung cancer screening is inherently risk‐based. In fact, the selection of high‐risk individuals has been shown to be essential in implementing lung cancer screening in a cost‐effective manner. Furthermore, studies have shown that further risk‐stratification may improve screening efficiency, allow personalisation of the screening interval and reduce health disparities. However, implementing risk‐based lung cancer screening programs also requires overcoming a number of challenges. There are indications that risk‐based approaches can negatively influence the trade‐off between individual benefits and harms if not applied thoughtfully. Large‐scale implementation of targeted, risk‐based screening programs has been limited thus far. Consequently, questions remain on how to efficiently identify and invite high‐risk individuals from the general population. Finally, while risk‐based approaches may increase screening program efficiency, efficiency should be balanced with the overall impact of the screening program. In this review, we will address the opportunities and challenges in applying risk‐stratification in different aspects of lung cancer screening programs, as well as the balance between screening program efficiency and impact.

Quantitative Emphysema on Low-Dose CT Imaging of the Chest and Risk of Lung Cancer and Airflow Obstruction: An Analysis of the National Lung Screening Trial

BACKGROUND

Lung cancer risk prediction models do not routinely incorporate imaging metrics available on low-dose CT (LDCT) imaging of the chest ordered for lung cancer screening.

RESEARCH QUESTION

What is the association between quantitative emphysema measured on LDCT imaging and lung cancer incidence and mortality, all-cause mortality, and airflow obstruction in individuals who currently or formerly smoked and are undergoing lung cancer screening?

STUDY DESIGN AND METHODS

In 7,262 participants in the CT arm of the National Lung Screening Trial, percent low attenuation area (%LAA) was defined as the percentage of lung volume with voxels less than -950 Hounsfield units on the baseline examination. Multivariable Cox proportional hazards models, adjusting for competing risks where appropriate, were built to test for association between %LAA and lung cancer incidence, lung cancer mortality, and all-cause mortality with censoring at 6 years. In addition, multivariable logistic regression models were built to test the cross-sectional association between %LAA and airflow obstruction on spirometry, which was available in 2,700 participants.

RESULTS

The median %LAA was 0.8% (interquartile range, 0.2%-2.7%). Every 1% increase in %LAA was independently associated with higher hazards of lung cancer incidence (hazard ratio [HR], 1.02; 95% CI, 1.01-1.03; P = .004), lung cancer mortality (HR, 1.02; 95% CI, 1.00-1.05; P = .045), and all-cause mortality (HR, 1.01; 95% CI, 1.00-1.03; P = .042). Among participants with spirometry, 892 had airflow obstruction. The likelihood of airflow obstruction increased with every 1% increase in %LAA (odds ratio, 1.07; 95% CI, 1.06-1.09; P < .001). A %LAA cutoff of 1% had the best discriminative accuracy for airflow obstruction in participants aged > 65 years.

INTERPRETATION

Quantitative emphysema measured on LDCT imaging of the chest can be leveraged to improve lung cancer risk prediction and help diagnose COPD in individuals who currently or formerly smoked and are undergoing lung cancer screening.

Provision of Smoking Cessation Resources in the Context of In-Person Shared Decision-Making for Lung Cancer Screening

BACKGROUND

Lung cancer screening (LCS) is effective at reducing mortality for high-risk smokers. Mortality benefits go beyond early cancer detection, because shared decision-making (SDM) may present a "teachable moment" to reinforce cessation and provide resources.

RESEARCH QUESTION

How well is smoking cessation performed during LCS SDM encounters, and what patient and provider characteristics are associated with smoking cessation assistance?

STUDY DESIGN AND METHODS

This is a retrospective cohort study of current smokers participating in initial LCS SDM through a multisite program in Seattle, Washington, between 2015-2018. The LCS tracking database and electronic health record were reviewed for demographics, comorbidity data, and clinical encounter information. The primary outcome was provision of a smoking cessation resource, defined as referral to cessation resources, recommendation for nicotine replacement, or prescription for cessation medication. Participant and provider factor associations with the outcome were evaluated using χ² testing and multivariable logistic regression.

RESULTS

Most of the 423 study participants were men (70%), with a median age of 61 (IQR, 58-66) years and median of 50 (41-72) pack-years of smoking. Only 26% of encounters had documentation consistent with SDM. Thirty-nine percent of participants received at least one smoking cessation resource, and only 5% received both counseling referrals and medication. In a multivariable model, the provision of any smoking cessation resource was half as likely in participants with higher levels of comorbidity (Charlson Index >2; OR, 0.53; 95% CI, 0.31-0.81), and half as likely if the ordering provider was not the patient's PCP or their specialist (OR, 0.55; 95% CI, 0.32-0.96).

INTERPRETATION

Overall provision of smoking cessation resources was moderate during SDM encounters for LCS, and lower in patients with more comorbidities and when not performed by the patient's PCP or specialist. Interventions are needed to improve smoking cessation counseling and resource utilization at the time of LCS encounters.

Evaluation of the Benefits and Harms of Lung Cancer Screening With Low-Dose Computed Tomography: Modeling Study for the US Preventive Services Task Force

IMPORTANCE

The US Preventive Services Task Force (USPSTF) is updating its 2013 lung cancer screening guidelines, which recommend annual screening for adults aged 55 through 80 years who have a smoking history of at least 30 pack-years and currently smoke or have quit within the past 15 years.

OBJECTIVE

To inform the USPSTF guidelines by estimating the benefits and harms associated with various low-dose computed tomography (LDCT) screening strategies.

DESIGN, SETTING, AND PARTICIPANTS

Comparative simulation modeling with 4 lung cancer natural history models for individuals from the 1950 and 1960 US birth cohorts who were followed up from aged 45 through 90 years.

EXPOSURES

Screening with varying starting ages, stopping ages, and screening frequency. Eligibility criteria based on age, cumulative pack-years, and years since quitting smoking (risk factor-based) or on age and individual lung cancer risk estimation using risk prediction models with varying eligibility thresholds (risk model-based). A total of 1092 LDCT screening strategies were modeled. Full uptake and adherence were assumed for all scenarios.

MAIN OUTCOMES AND MEASURES

Estimated lung cancer deaths averted and life-years gained (benefits) compared with no screening. Estimated lifetime number of LDCT screenings, false-positive results, biopsies, overdiagnosed cases, and radiation-related lung cancer deaths (harms).

RESULTS

Efficient screening programs estimated to yield the most benefits for a given number of screenings were identified. Most of the efficient risk factor-based strategies started screening at aged 50 or 55 years and stopped at aged 80 years. The 2013 USPSTF-recommended criteria were not among the efficient strategies for the 1960 US birth cohort. Annual strategies with a minimum criterion of 20 pack-years of smoking were efficient and, compared with the 2013 USPSTF-recommended criteria, were estimated to increase screening eligibility (20.6%-23.6% vs 14.1% of the population ever eligible), lung cancer deaths averted (469-558 per 100 000 vs 381 per 100 000), and life-years gained (6018-7596 per 100 000 vs 4882 per 100 000). However, these strategies were estimated to result in more false-positive test results (1.9-2.5 per person screened vs 1.9 per person screened with the USPSTF strategy), overdiagnosed lung cancer cases (83-94 per 100 000 vs 69 per 100 000), and radiation-related lung cancer deaths (29.0-42.5 per 100 000 vs 20.6 per 100 000). Risk model-based vs risk factor-based strategies were estimated to be associated with more benefits and fewer radiation-related deaths but more overdiagnosed cases.

CONCLUSIONS AND RELEVANCE

Microsimulation modeling studies suggested that LDCT screening for lung cancer compared with no screening may increase lung cancer deaths averted and life-years gained when optimally targeted and implemented. Screening individuals at aged 50 or 55 years through aged 80 years with 20 pack-years or more of smoking exposure was estimated to result in more benefits than the 2013 USPSTF-recommended criteria and less disparity in screening eligibility by sex and race/ethnicity.

Lung cancer screening and smoking cessation efforts

Randomized-controlled trials have confirmed substantial reductions in lung cancer mortality with low-dose computed tomography (LDCT) screening. Evidence on how to integrate smoking cessation support in lung cancer screening is however scarce. This represents a significant gap in the literature, as a combined strategy of lung cancer screening and smoking cessation greatly reduces the mortality risk due to lung cancer and other related comorbidities. In this review, a literature search in MEDLINE, Embase, Web of Science, the Cochrane Central Register of Controlled Trials and Google Scholar was performed to identify randomized-controlled and observational studies investigating the effect of lung cancer screening trials and integrated cessation interventions on smoking cessation. Of the 236 identified records, we included 32 original publications. Smoking cessation rates in lung cancer screening trials are promising. Especially findings suspicious for lung cancer and referral to a physician might function as a teachable moment to motivate smoking abstinence in current smokers or recent quitters. More intensive, personalized and multi-modality smoking cessation interventions delivered by a clinician appear to be the most successful in influencing smoking behavior. While it is evident that smoking cessation should be incorporated in lung cancer screening, further research is required to ascertain the optimal treatment type, modality, timing, and content of communication including the incorporation of CT results to motivate health behavior change.

[Smoking cessation and lung cancer screening]

Several studies have shown that lung cancer screening, using annual low-dose computed tomography (CT) scan in a targeted population of smokers and ex-smokers reduces overall and lung cancer specific mortality rates. This form of screening strategy is not currently established for use in France by the French High Authority for Health. Quitting smoking is the most important measure in reducing mortality from lung cancer. The maximum benefit in reducing mortality from lung cancer should be seen through an effective combination of smoking cessation intervention and chest CT screening to identify early, curable disease. However, current data to guide clinicians in the choice of smoking cessation interventions in this specific context are limited due to the small number of randomized studies that have been carried out. The optimal approach to smoking cessation during lung cancer screening needs to be clarified by new studies comparing different motivation strategies, establishing the ideal moment to propose stopping smoking and the most effective therapies to use.