Predictors of participant nonadherence in lung cancer screening programs: a systematic review and meta-analysis

Willingness to participate in combination screening for lung cancer, chronic obstructive pulmonary disease and cardiovascular disease in four European countries

OBJECTIVES

Lung cancer screening (LCS), using low-dose computed tomography (LDCT), can be more efficient by simultaneously screening for chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD), the Big-3 diseases. This study aimed to determine the willingness to participate in (combinations of) Big-3 screening in four European countries and the relative importance of amendable participation barriers.

METHODS

An online cross-sectional survey aimed at (former) smokers aged 50-75 years elicited the willingness of individuals to participate in Big-3 screening and used analytical hierarchy processing (AHP) to determine the importance of participation barriers.

RESULTS

Respondents were from France (n = 391), Germany (n = 338), Italy (n = 399), and the Netherlands (n = 342), and consisted of 51.2% men. The willingness to participate in screening was marginally influenced by the diseases screened for (maximum difference of 3.1%, for Big-3 screening (73.4%) vs. lung cancer and COPD screening (70.3%)) and by country (maximum difference of 3.7%, between France (68.5%) and the Netherlands (72.3%)). The largest effect on willingness to participate was personal perceived risk of lung cancer. The most important barriers were the missed cases during screening (weight 0.19) and frequency of screening (weight 0.14), while diseases screened for (weight 0.11) ranked low.

CONCLUSIONS

The difference in willingness to participate in LCS showed marginal increase with inclusion of more diseases and limited variation between countries. A marginal increase in participation might result in a marginal additional benefit of Big-3 screening. The amendable participation barriers are similar to previous studies, and the new criterion, diseases screened for, is relatively unimportant.

CLINICAL RELEVANCE STATEMENT

Adding diseases to combination screening modestly improves participation, driven by personal perceived risk. These findings guide program design and campaigns for lung cancer and Big-3 screening. Benefits of Big-3 screening lie in long-term health and economic impact, not participation increase.

KEY POINTS

• It is unknown whether or how combination screening might affect participation. • The addition of chronic obstructive pulmonary disease and cardiovascular disease to lung cancer screening resulted in a marginal increase in willingness to participate. • The primary determinant influencing individuals' engagement in such programs is their personal perceived risk of the disease.

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.

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.

Lung cancer screening adherence among people living with and without HIV: An analysis of an integrated health system in Florida, United States (2012-2021)

Although lung cancer is a leading cause of death among people living with HIV (PLWH), limited research exists characterizing real-world lung cancer screening adherence among PLWH. Our objective was to compare low-dose computed tomography (LDCT) adherence among PLWH to those without HIV treated at one integrated health system. Using the University of Florida's Health Integrated Data Repository (01/01/2012-10/31/2021), we identified PLWH with at least one LDCT procedure, using Current Procedural Terminology codes(S8032/G0297/71271). Lung cancer screening adherence was defined as a second LDCT based on the Lung Imaging Reporting and Data System (Lung-RADS®). Lung-RADS categories were extracted from radiology reports using a natural language processing system. PLWH were matched with 4 randomly selected HIV-negative patients based on (+/- 1 year) age, Lung-RADS category, and calendar year. Seventy-three PLWH and 292 matched HIV-negative adults with at least one LDCT were identified. PLWH were more likely to be male (66% vs.52%,p < 0.04), non-Hispanic Black (53% vs.23%,p < 0.001), and live in an area of high poverty (45% vs.31%,p < 0.001). PLWH were more likely to be diagnosed with lung cancer after first LDCT (8% vs.0%,p < 0.001). Seventeen percent of HIV-negative and 12% of PLWH were adherent to LDCT screenings. Only 25% of PLWH diagnosed with category 4A were adherent compared to 44% of HIV-negative. On multivariable analyses, those with older age (66-80 vs.50-64 years) and with either Medicaid, charity-based, or other government insurance (vs. Medicare) were less likely to be adherent to LDCT screenings. PLWH may have poorer adherence to LDCT compared to their HIV-negative counterparts.

Leveraging natural language processing to identify eligible lung cancer screening patients with the electronic health record

OBJECTIVE

To develop and validate an approach that identifies patients eligible for lung cancer screening (LCS) by combining structured and unstructured smoking data from the electronic health record (EHR).

METHODS

We identified patients aged 50-80 years who had at least one encounter in a primary care clinic at Vanderbilt University Medical Center (VUMC) between 2019 and 2022. We fine-tuned an existing natural language processing (NLP) tool to extract quantitative smoking information using clinical notes collected from VUMC. Then, we developed an approach to identify patients who are eligible for LCS by combining smoking information from structured data and clinical narratives. We compared this method with two approaches to identify LCS eligibility only using smoking information from structured EHR. We used 50 patients with a documented history of tobacco use for comparison and validation.

RESULTS

102,475 patients were included. The NLP-based approach achieved an F1-score of 0.909, and accuracy of 0.96. The baseline approach could identify 5,887 patients. Compared to the baseline approach, the number of identified patients using all structured data and the NLP-based algorithm was 7,194 (22.2 %) and 10,231 (73.8 %), respectively. The NLP-based approach identified 589 Black/African Americans, a significant increase of 119 %.

CONCLUSION

We present a feasible NLP-based approach to identify LCS eligible patients. It provides a technical basis for the development of clinical decision support tools to potentially improve the utilization of LCS and diminish healthcare disparities.

Lung Cancer Screening Adherence Among People with HIV Treated at an Integrated Health System in Florida

We evaluated low-dose computed tomography (LDCT) adherence among people with HIV (PWH) treated at University of Florida (UF). From the UF Health Integrated Data Repository, we identified PWH who underwent at least one LDCT procedure (January 1, 2012-October 31, 2021). Lung cancer screening adherence was defined as having a second LDCT within recommended observation window, based on the Lung Imaging Reporting and Data System (Lung-RADS®). We identified 73 PWH with a history of at least one LDCT. PWH were mostly male (66%), non-Hispanic Black (53%), and living in urban (86%), high poverty (45%) areas. Almost 1 in 10 of PWH were diagnosed with lung cancer after their first LDCT. Overall, 48% and 41% of PWH were diagnosed with Lung-RADS categories 1 and 2, respectively. We observed that 12% of PWH were adherent to LDCT. Only 25% of PWH diagnosed with category 4A were adherent. PWH may have poor adherence to lung cancer screening.

Predictive value of serum SCCA and CYFRA21-1 levels on radiotherapy efficacy and prognosis in patients with non-small cell lung cancer

Monitoring changes in serum tumor marker concentrations can help in the early diagnosis of non-small cell lung cancer (NSCLC). However, there are few methods to monitor the efficacy and prognosis of radiotherapy in NSCLC patients. The present research aimed to explore the correlation between radiotherapy efficacy and squamous cell carcinoma antigen (SCCA) and cytokeratin 19 soluble fragment (CYFRA21-1) levels in NSCLC patients. Serum CYFRA21-1 and SCCA were detected with an automatic chemiluminescence immunoassay analyzer. Patients with NSCLC were followed up by telephone at regular intervals for 35 months. The χ² test was used to compare clinical characteristics such as age, gender, smoking history and other count data between groups. Predictive value of serum SCCA and CYFRA21-1 on the efficacy of radiotherapy was analyzed by Receiver Operating Characteristic (ROC) curves. The survival of the patients was analyzed by Kaplan-Meier method. The serum SCCA and CYFRA21-1 levels in the NSCLC group were apparently higher by comparison with control group. The SCCA and CYFRA21-1 concentration were both positive relevant to Tumor Node Metastasis (TNM) stage. The Area Under Curve (AUC) of serum SCCA and CYFRA21-1 were 0.732 and 0.721, respectively. In addition, high serum SCCA and CYFRA21-1 levels could predict poor radiotherapy outcomes. Patients with high serum concentration of SCCA and CYFRA21-1 have shorter survival times. High serum SCCA and CYFRA21-1 levels could predict poor prognosis and unfavorable efficacy of radiotherapy in invalids with NSCLC.

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.

Secondary prevention and treatment innovation of early stage non-small cell lung cancer: Impact on diagnostic-therapeutic pathway from a multidisciplinary perspective

Lung cancer (LC) is the leading cause of cancer-related death worldwide, mostly because the lack of a screening program so far. Although smoking cessation has a central role in LC primary prevention, several trials on LC screening through low-dose computed tomography (LDCT) in a high risk population showed a significant reduction of LC related mortality. Most trials showed heterogeneity in terms of selection criteria, comparator arm, detection nodule method, timing and intervals of screening and duration of the follow-up. LC screening programs currently active in Europe as well as around the world will lead to a higher number of early-stage Non Small Cell Lung Cancer (NSCLC) at the diagnosis. Innovative drugs have been recently transposed from the metastatic to the perioperative setting, leading to improvements in terms of resection rates and pathological responses after induction chemoimmunotherapy, and disease free survival with targeted agents and immune checkpoint inhibitors. The present review summarizes available evidence about LC screening, highlighting potential pitfalls and benefits and underlining the impact on the diagnostic therapeutic pathway of NSCLC from a multidisciplinary perspective. Future perspectives in terms of circulating biomarkers under evaluation for patients' risk stratification as well as a focus on recent clinical trials results and ongoing studies in the perioperative setting will be also presented.

Lung cancer in the emergency department

Background

Though decreasing in incidence and mortality in the USA, lung cancer remains the deadliest of all cancers. For a significant number of patients, the emergency department (ED) provides the first pivotal step in lung cancer prevention, diagnosis, and management. As screening recommendations and treatments advance, ED providers must stay up-to-date with the latest lung cancer recommendations. The purpose of this review is to identify the many ways that emergency providers may intersect with the disease spectrum of lung cancer and provide an updated array of knowledge regarding detection, management, complications, and interdisciplinary care.

Findings

Lung cancer, encompassing 10-12% of cancer-related emergency department visits and a 66% admission rate, is the most fatal malignancy in both men and women. Most patients presenting to the ED have not seen a primary care provider or undergone screening. Ultimately, half of those with a new lung cancer diagnosis in the ED die within 1 year. Incidental findings on computed tomography are mostly benign, but emergency staff must be aware of the factors that make them high risk. Radiologic presentations range from asymptomatic nodules to diffuse metastatic lesions with predominately pulmonary symptoms, and some may present with extra-thoracic manifestations including neurologic. The short-term prognosis for ED lung cancer patients is worse than that of other malignancies. Screening offers new hope through earlier diagnosis but is underutilized which may be due to racial and socioeconomic disparities. New treatments provide optimism but lead to new complications, some long-term. Multidisciplinary care is essential, and emergency medicine is responsible for the disposition of patients to the appropriate specialists at inpatient and outpatient centers.

Conclusion

ED providers are intimately involved in all aspects of lung cancer care. Risk factor modification and referral for lung cancer screening are opportunities to further enhance patient care. In addition, with the advent of newer cancer therapies, ED providers must stay vigilant and up-to-date with all aspects of lung cancer including disparities, staging, symptoms of disease, prognosis, treatment, and therapy-related complications.

Increasing pneumococcal vaccine uptake in older adults: a scoping review of interventions in high-income countries

BACKGROUND

There is low uptake of the pneumococcal vaccination in eligible older adults, even in high-income countries that offer routine and universal vaccination programs.

OBJECTIVE

To systematically characterize interventions aimed at improving pneumococcal vaccine uptake in older adults.

DESIGN

We conducted a scoping review following PRISMA-SCr guidelines of five interdisciplinary databases: Medline-Ovid, Embase, CINAHL, PsychInfo, and Cochrane Library. Databases were searched from January 2015 until April 2020. The interventions were summarized into three pillars according to the European Union Conceptional Framework for Action: information campaigns, prioritization of vaccination schemes, and primary care interventions.

RESULTS

Our scoping review included 39 studies that summarized interventions related to pneumococcal vaccine uptake for older adults, encompassing 2,481,887 study participants (945 healthcare providers and 2,480,942 older adults) across seven countries. Examples of interventions that were associated with increased pneumococcal vaccination rate included periodic health examinations, reminders and decision-making tools built into electronic medical records, inpatient vaccination protocols, preventative health checklists, and multimodal educational interventions. When comparing the three pillars, prioiritization of vaccination schemes had the highest evidence for improved rates of vaccination (n = 14 studies), followed by primary care interventions (n = 8 studies), then information campaigns (n = 5 studies).

CONCLUSION

Several promising interventions were associated with improved outcomes related to vaccine uptake, although controlled study designs are needed to determine which interventions are most effective.

Qualitative Findings From a Survey on Patient Experiences and Satisfaction with Lung Cancer Screening

BACKGROUND

To reveal successes and potential limitations of the lung cancer screening program, we conducted a survey that included both quantitative and open-ended questions to measure patient experiences and satisfaction with screening.

METHODS

We report on the five open-ended items related to barriers to returning for screening, experience with other cancer prevention screenings, positive and negative experiences, and suggestions for improving future appointments. The open-ended responses were analyzed using constant comparison method and inductive content analysis.

RESULTS

Respondents (182 patients, 86% response rate for open-ended questions) provided generally positive comments about their lung cancer screening experience. Negative comments were related to desire for more information about results, long wait times for results, and billing issues. Suggestions for improvements included: scheduling on-line appointments and text or email reminders, lower costs, and responding to uncertainty about eligibility criteria.

CONCLUSION

Findings provide insights about patient experiences and satisfaction with lung cancer screening which is important given low uptake. Ongoing patient-centered feedback may improve the lung cancer screening experience and increase follow-up screening rates.

Eligibility to lung cancer screening among staffs of a university hospital: A large cross-sectional survey

INTRODUCTION

Implementation of Lung cancer screening (LCS) programs is challenging. The ILYAD study objectives is to evaluate communication methods to improve participation rate among the Lyon University Hospital employees. In this first part of the study, we aimed to determinate the number of eligible individuals among our population of employees.

METHOD

In November 2020, we conducted a questionnaire based cross sectional survey among the Lyon University Hospital employees (N = 26,954). We evaluated the PLCO m2012 risk prediction model and the eligibility criteria recommended by French guidelines. We assessed the proportion of eligible individuals among the responders and calculated the total eligible individuals in our hospital.

RESULTS

Overall, 4,526 questionnaires were available for analysis. 16.0% were current smokers, and 28.2% were former smokers. Among the 50-75yo ever-smoker employees, 27% were eligible according to the French guidelines, 2.7% of all eversmokers according to a PLCO m2012 score ≥ 1.51%, and thus, 3.8% of the surveyed population were eligible to the combined criteria. The factors associated with higher eligibility among 50-75yo ever-smokers were educational level, feeling symptoms related to tobacco smoking, personal history of COPD and family history of lung cancer. Using the French guidelines criteria only, we estimated the total number of eligible individuals in the hospital at 838.

CONCLUSION

In this study, we determined a theoretical number of eligible employees to LCS in our institution and the factors associated to eligibility. Secondly, we will propose LCS to all eligible employees of Lyon University Hospital with incremented information actions.

Barriers and facilitators for low-dose computed tomography lung cancer screening in rural populations in the United States: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to identify barriers and facilitators for low-dose computed tomography lung cancer screening uptake and adherence among rural populations in the United States.

INTRODUCTION

Lung cancer is the leading cause of cancer-related death in the United States, and cancer patients from rural areas have poorer outcomes than those from metropolitan areas. Evidence exists that lung cancer screening by low-dose computed tomography significantly increases survival time but is also significantly underutilized.

INCLUSION CRITERIA

Studies completed in the United States with adults who fit United States Preventive Services Task Force guidelines for lung cancer screening and who live in rural areas will be included. Studies published in English since 2013 that report on barriers and facilitators for low-dose computed tomography lung cancer screening uptake and adherence will be included in this review. Quantitative, qualitative, or mixed-methods studies will be included, along with opinion pieces published by government agencies or professional cancer-related organizations.

METHODS

The search strategy will locate published primary studies, reviews, and opinion papers, including those by government and nonprofit agencies focused on cancer. The databases to be searched include MEDLINE, CINAHL Complete, Embase, Web of Science, and Cochrane Library. Gray literature databases and sources of unpublished studies will also be searched. Independent reviewers will be used throughout the search and selection process.

Evidence of Racial Disparities in the Lung Cancer Screening Process: a Systematic Review and Meta-Analysis

BACKGROUND

Annual lung cancer screening (LCS) with low-dose chest computed tomography for high-risk individuals reduces lung cancer mortality, with greater reduction observed in Black participants in clinical trials. While racial disparities in lung cancer mortality exist, less is known about disparities in LCS participation. We conducted a systematic review to explore LCS participation in Black compared with White patients in the USA.

METHODS

A systematic review was conducted through a search of published studies in MEDLINE, PubMed, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied-Health Literature Database, from database inception through October 2020. We included studies that examined rates of LCS participation and compared rates by race. Studies were pooled using random-effects meta-analysis.

RESULTS

We screened 18,300 titles/abstracts; 229 studies were selected for full-text review, of which nine studies met inclusion criteria. Studies were categorized into 2 groups: studies that reported the screening rate among an LCS-eligible patient population, and studies that reported the screening rate among a patient population referred for LCS. Median LCS participation rates were 14.4% (range 1.7 to 62.6%) for eligible patient studies and 68.5% (range 62.6 to 88.8%) for referred patient studies. The meta-analyses showed screening rates were lower in the Black compared to White population among the LCS-eligible patient studies ([OR]=0.43, [95% CI: 0.25, 0.74]). However, screening rates were the same between Black and White patients in the referred patient studies (OR=0.94, [95% CI: 0.74, 1.19]).

DISCUSSION

Black LCS-eligible patients are being screened at a lower rate than White patients but have similar rates of participation once referred. Differences in referrals by providers may contribute to the racial disparity in LCS participation. More studies are needed to identify barriers to LCS referral and develop interventions to increase provider awareness of the importance of LCS in Black patients. Trial Registry PROSPERO; No.: CRD42020214213; URL: http://www.crd.york.ac.uk/PROSPERO.

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.

Facilitators and Barriers to Implementation of Lung Cancer Screening: A Framework-Driven Systematic Review

BACKGROUND

The purpose of this study is to undertake a comprehensive systematic review to describe multilevel factors (barriers and facilitators) that may influence the implementation of low-dose chest computed tomography for lung cancer screening in the United States.

METHODS

Systematic literature searches were performed using 6 online databases and citation indexes for peer-reviewed studies, for articles published from 2013 to 2021. Studies were classified into 3 perspectives, based on the study's unit of analysis: system, health-care provider, and patient. Barriers and facilitators identified for each study included in our final review were then coded and categorized using the Consolidate Framework for Implementation Research domains.

RESULTS

At the system level, the 2 most common constructs were external policy and incentives and executing the implementation process. At the provider level, the most common constructs were evidence strength and quality of the intervention characteristics, patient needs and resources, implementation climate, and an individual's knowledge and beliefs about the intervention. At the patient level, the most common constructs were patient needs and resources, individual's knowledge and beliefs about the intervention, and engaging in the implementation process. These constructs can act as facilitators or barriers to lung cancer screening implementation.

CONCLUSIONS

Applying the Consolidate Framework for Implementation Research domains and constructs to understand and specify factors facilitating uptake of lung cancer screening as well as cataloging the lessons learned from previous efforts helps inform the development and implementation processes of lung cancer screening programs in the community setting.

REGISTRATION

PROSPERO, CRD42021247677.

An Evaluation of Annual Adherence to Lung Cancer Screening in a Large National Cohort

INTRODUCTION

Lung cancer screening reduces mortality in large RCTs where adherence is high. Unfortunately, recently published adherence rates do not replicate those seen in trials. Previous publications support a centralized approach to ensure patient eligibility and improve adherence.

METHODS

Investigators reviewed a large, geographically diverse cohort of patients from 14 health systems, with 73 centers across the U.S. Lung cancer screening patients were screened from 2015 to 2019 and tracked utilizing a commercial system. Data were analyzed in 2019-2021. Demographics, eligibility, imaging results, and cancer diagnosis were collected. Overall return was calculated for 2 years (Time 0-Time 1 and Time 1-Time 2) on the basis of follow-up through March 31, 2020. Only U.S. Preventive Services Task Force-eligible patients with a normal or benign result (Lung-Reporting and Data System 1 or 2) at baseline (Time 0) were included in annual adherence calculations.

RESULTS

A total of 30,166 patients were screened; 50% were male, with a mean age of 65 years. Most individuals currently smoked (58.3%), with an average of 48.3 pack years. A total of 58% were White, 6% were Black, and 34% had race information unavailable. U.S. Preventive Services Task Force eligibility criteria were not met by 10.6%. Of the 26,958 patients eligible at baseline, 76% were Lung-Reporting and Data System 1 or 2. Annual adherence at Year 1 (Time 0-Time 1) was 48.4%. Adherence at Year 2 (Time 1-Time 2) was 44.4%. A total of 93 U.S. Preventive Services Task Force‒eligible patients were diagnosed with lung cancers, mostly during the first annual follow-up.

CONCLUSIONS

In this large cohort screened and managed primarily using a commercial tracking platform, most patients were U.S. Preventive Services Task Force eligible. However, annual adherence was poor despite this resource, suggesting that additional interventions are needed to recognize the full mortality benefit from screening programs.

New Implications of Patients’ Sex in Today’s Lung Cancer Management

Simple Summary

We aim to raise awareness that sex is an important factor to take into account in modern-day thoracic oncology practice. Summarized, women should be specifically targeted in smoking cessation campaigns and sex-specific barriers should be addressed. Women present more often with adenocarcinoma histology and EGFR/ALK alterations, as lung cancer in never-smokers is more common in women compared to men. Lung cancer in female patients may show a poorer response to immune checkpoint inhibition; therefore, the addition of chemotherapy should be considered. On the other hand, women experience more benefits from targeted therapy against EGFR. In general, prognosis for women is better compared to that in men. Lung cancer screening trials report that women derive more benefit from screening, although they have not been designed for women. Future trial designs should take this into account and encourage participation of women.

Abstract

This paper describes where and how sex matters in today’s management of lung cancer. We consecutively describe the differences between males and females in lung cancer demographics; sex-based differences in the immune system (including the poorer outcomes in women who are treated with immunotherapy but no chemotherapy); the presence of oncogenic drivers and the response to targeted therapies according to sex; the greater benefit women derive from lung cancer screening and why they get screened less; and finally, the barriers to smoking cessation that women experience. We conclude that sex is an important but often overlooked factor in modern-day thoracic oncology practice.

Low-dose computed tomography lung cancer screening: Clinical evidence and implementation research

Lung cancer causes more deaths than breast, cervical, and colorectal cancer combined. Nevertheless, population-based lung cancer screening is still not considered standard practice in most countries worldwide. Early lung cancer detection leads to better survival outcomes: patients diagnosed with stage 1A lung cancer have a >75% 5-year survival rate, compared to <5% at stage 4. Low-dose computed tomography (LDCT) thorax imaging for the secondary prevention of lung cancer has been studied at length, and has been shown to significantly reduce lung cancer mortality in high-risk populations. The US National Lung Screening Trial reported a 20% overall reduction in lung cancer mortality when comparing LDCT to chest X-ray, and the Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON) trial more recently reported a 24% reduction when comparing LDCT to no screening. Hence, the focus has now shifted to implementation research. Consequently, the 4-IN-THE-LUNG-RUN consortium based in five European countries, has set up a large-scale multicenter implementation trial. Successful implementation of and accessibility to LDCT lung cancer screening are dependent on many factors, not limited to population selection, recruitment strategy, computed tomography screening frequency, lung-nodule management, participant compliance, and cost effectiveness. This review provides an overview of current evidence for LDCT lung cancer screening, and draws attention to major factors that need to be addressed to successfully implement standardized, effective, and accessible screening throughout Europe. Evidence shows that through the appropriate use of risk-prediction models and a more personalized approach to screening, efficacy could be improved. Furthermore, extending the screening interval for low-risk individuals to reduce costs and associated harms is a possibility, and through the use of volumetric-based measurement and follow-up, false positive results can be greatly reduced. Finally, smoking cessation programs could be a valuable addition to screening programs and artificial intelligence could offer a solution to the added workload pressures radiologists are facing.

Patient Adherence to Lung CT Screening Reporting & Data System-Recommended Screening Intervals in the United States: A Systematic Review and Meta-Analysis

Lung cancer screening (LCS) is effective in reducing mortality, particularly when patients adhere to follow-up recommendations standardized by the Lung CT Screening Reporting & Data System (Lung-RADS). Nevertheless, patient adherence to recommended intervals varies, potentially diminishing benefit from screening. We conducted a systematic review and meta-analysis of patient adherence to Lung-RADS-recommended screening intervals. We systematically searched MEDLINE, EMBASE, Web of Science, the Cochrane Central Register of Controlled Trials, and major radiology and oncology conference archives between April 28, 2014, and December 17, 2020. Eligible studies mentioned patient adherence to the recommendations of Lung-RADS. The review protocol was registered with PROSPERO (CRD42020189326). We identified 24 eligible studies for qualitative summary, of which 21 were suitable for meta-analysis. The pooled adherence rate was 57% (95% confidence interval: 46%-69%) for defined adherence (e.g., an annual incidence screen was performed within 15 mo) among 6689 patients and 65% (95% confidence interval: 55%-75%) for anytime adherence among 5085 patients. Large heterogeneity in adherence rates between studies was observed (I² = 99% for defined adherence, I² = 98% for anytime adherence). Heterogeneous adherence rates were associated with Lung-RADS scores, with significantly higher adherence rates among Lung-RADS 3 to 4 than Lung-RADS 1 to 2 (p < 0.05). Patient adherence to Lung-RADS-recommended screening intervals is suboptimal across clinical LCS programs in the United States, especially among patients with results of Lung-RADS categories 1 to 2. To improve adherence rates, future research may focus on implementing tailored interventions after identifying barriers to LCS. We also propose a minimum standardized set of data elements for future pooled analyses of LCS adherence on the basis of our findings.

Understanding patient factors to increase uptake of cancer screening: a review

Early detection of cancer through organized screening is a central component of population-level strategies to reduce cancer mortality. For screening programs to be effective, it is important that those invited to screening participate. However, uptake rates are suboptimal in many populations and vary between screening programs, indicating a complex combination of patient factors that require elucidation to develop evidence-based strategies to increase participation. In this review, the authors summarize individual-level (sociodemographic and psychosocial) factors associated with cancer screening uptake and evidence for the effectiveness of behavioral interventions to increase uptake. The authors reflect on current trends and future directions for behavioral cancer screening research to overcome challenges and address unmet needs in reducing cancer mortality.

Guideline-Recommended Lung Cancer Screening Adherence Is Superior With a Centralized Approach

BACKGROUND

To recognize fully the benefit of lung cancer screening (LCS), annual adherence must approach the high levels seen in the National Lung Screening Trial. Emerging data suggest that annual adherence is poor and that a centralized approach to screening improves adherence.

RESEARCH QUESTIONS

Do differences in adherence exist between a centralized and decentralized approach to LCS within a hybrid program and what are predictors of adherence?

STUDY DESIGN

A retrospective evaluation of a single-center hybrid LCS program was conducted to compare outcomes including patient eligibility and adherence between the centralized and decentralized approaches.

METHODS

Patient demographics and outcomes were compared between those screened with a centralized and decentralized approach and between adherent and nonadherent patients using two-sample t tests, χ ² tests, or analyses of variance, as appropriate. Annual adherence analysis was conducted using data from patients who remained eligible for screening with a baseline Lung CT Screening Reporting and Data System (Lung-RADS) score of 1 or 2. Logistic regression was used to estimate the association between adherence and the primary exposure, adjusting for potential confounders.

RESULTS

A cohort of 1,117 patients underwent baseline low-dose CT imaging. Two hundred eleven patients (19%) were ineligible by United States Preventative Services Task Force criteria and most (90%) were screened with the decentralized approach. After exclusions, 765 patients with Lung-RADS score of 1 or 2 remained eligible for annual screening. Overall adherence was 56%; however, adherence in the centralized program was 70%, compared with 41% with the decentralized approach (P < .001). Individuals screened in a decentralized approach were 73% less likely to be adherent (OR, 0.27; 95% CI, 0.19-0.37). A greater proportion of patients with three or more comorbidities were screened outside the centralized program.

INTERPRETATION

Those screened using a centralized approach were more likely to meet eligibility criteria for LCS and more likely to return for annual screening than those screened using a decentralized approach.

Racial Differences in Adherence to Lung Cancer Screening Follow-Up: A Systematic Review and Meta-Analysis

BACKGROUND

In 2013 the United States Preventive Services Taskforce (USPSTF) instituted recommendations for annual lung cancer screening (LCS) with low dose chest computed tomography for high-risk individuals. LCS reduces lung cancer mortality, with greater reduction observed in Black participants in clinical trials. While racial disparities in lung cancer mortality have been well documented, less is known about disparities in LCS participation and adherence to follow-up in clinical practice.

RESEARCH QUESTION

What is the association between race and adherence to LCS follow-up?

STUDY DESIGN & METHODS

A systematic review was conducted through a search of published studies in MEDLINE, PubMed, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health Literature Database, from database inception through October 2020. We included studies that examined rates of adherence to LCS follow-up and compared rates by race. Studies were pooled using random-effects meta-analysis.

RESULTS

We screened 18,300 titles/abstracts and 229 studies were selected for full-text review. Nine studies met inclusion criteria; seven were included in the meta-analysis. Median adherent follow-up rate was 37% (range 16-82%). Notable differences among the studies included the proportion of the Black population (range 4-47%) and the structure of the LCS programs. The meta-analyses showed lower adherence to LCS follow-up in the Black population (Odds Ratio [OR]=0.67, [95% CI: 0.55, 0.80]). This disparity persisted across all malignancy risk levels determined by initial screening results.

INTERPRETATION

There is lower adherence to LCS follow-up in Black compared to White patients despite the higher potential lung cancer mortality benefit. Literature specifically addressing race-related barriers to LCS adherence is still limited. To ensure equity in LCS benefits, greater outreach to eligible Black patients should be implemented through increased physician education and utilization of screening program coordinators to focus on this patient population.

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

OBJECTIVE

Lung cancer screening (LCS) efficacy is highly dependent on adherence to annual screening, but little is known about real-world adherence determinants. We used insurance claims data to examine associations between LCS annual adherence and demographic, comorbidity, health care usage, and geographic factors.

MATERIALS AND METHODS

Insurance claims data for all individuals with an LCS low-dose CT scan were obtained from the Colorado All Payer Claims Dataset. Adherence was defined as a second claim for a screening CT 10 to 18 months after the index claim. Cox proportional hazards regression was used to define the relationship between annual adherence and age, gender, insurance type, residence location, outpatient health care usage, and comorbidity burden.

RESULTS

After exclusions, the final data set consisted of 9,056 records with 3,072 adherent, 3,570 nonadherent, and 2,414 censored (unclassifiable) individuals. Less adherence was associated with ages 55 to 59 (hazard ratio [HR] = 0.80, 99% confidence interval [CI] = 0.67-0.94), 60 to 64 (HR = 0.83, 99% CI = 0.71-0.97), and 75 to 79 (HR = 0.79, 99% CI = 0.65-0.97); rural residence (HR = 0.56, 99% CI = 0.43-0.73); Medicare fee-for-service (HR = 0.45, 99% CI = 0.39-0.51), and Medicaid (HR = 0.50, 99% CI = 0.40-0.62). A significant interaction between outpatient health care usage and comorbidity was also observed. Increased outpatient usage was associated with increased adherence and was most pronounced for individuals without comorbidities.

CONCLUSIONS

This population-based description of LCS adherence determinants provides insight into populations that might benefit from specific interventions targeted toward improving adherence and maximizing LCS benefit. Quantifying population-based adherence rates and understanding factors associated with annual adherence are critical to improving screening adherence and reducing lung cancer death.

Radiologists' Increasing Role in Population Health Management: AJR Expert Panel Narrative Review

Population health management (PHM) is the holistic process of improving health outcomes of groups of individuals through the support of appropriate financial and care models. Radiologists' presence at the intersection of many aspects of healthcare, including screening, diagnostic imaging, and image-guided therapies, provides significant opportunity for increased radiologist engagement in PHM. Further, innovations in artificial intelligence and imaging informatics will serve as critical tools to improve value in healthcare through evidence-based and equitable approaches. Given radiologists' limited engagement in PHM to date, it is imperative to define the specialty's PHM priorities so that the radiologists' full value in improving population health is realized. In this expert review, we explore programs and future directions for radiology in PHM.

Examining lung cancer screening utilization with public-use data: Opportunities and challenges

Lung cancer screening with low-dose computed tomography is recommended for high-risk smokers who meet specific eligibility criteria. Current guidelines suggest that eligible adults with a heavy smoking history will benefit from annual low dose computed tomography but due to several associated risks (e.g., false-positives, radiation exposure, overdiagnosis) a shared decision-making consultation is required by the Centers for Medicare & Medicaid Services, and endorsed by the United States Preventive Services Task Force. In order to examine potential for tracking LCS uptake, adherence, and patient-provider communication at a national level, we reviewed four regularly publicly available national surveys (National Health Interview Survey [NHIS], Behavioral Risk Factor Surveillance System [BRFSS], National Health and Nutrition Examination Survey [NHANES], and Health Information National Trends Survey [HINTS]) to assess available data; an overview of 37 publications using these sources is also provided. The results show that none of the surveys include items that fully assess current LCS guidelines. Implications for future research-including the potential to examine factors associated with LCS uptake and patient-provider communication-are addressed.

Patient Adherence in an Academic Medical Center's Low-dose Computed Tomography Screening Program

OBJECTIVES

Low-dose computed tomography (LDCT) screening is an important tool for reducing lung cancer mortality. This study describes a single center's experience with LDCT and attempts to identify any barriers to compliance with standard guidelines.

MATERIALS AND METHODS

This is a retrospective review of a single university-based hospital system from 2015 to 2019. All individuals who met eligibility for lung cancer screening were entered into a database. The definition of adherence with the screening program was determined by the recommended timeline for the follow-up LDCT. Cohorts were split by adherence and demographics were compared.

RESULTS

A total of 203 LDCTs were performed in 121 patients who met eligibility for LDCT and had appropriate surveillance from 2015 to 2019. The average age was 64 years old. The overall adherence rate for prescribed LDCTs was 59.1%. Patients with Lung-RADS score 2 had 2.43 times higher odds of adherence relative to patients with Lung-RADS score 1 (odds ratio [OR]=2.43; 95% confidence interval [CI]: 1.23-4.83; P=0.011). African American patients had 42% lower odds of adherence relative to white patients (OR=0.58; 95% CI: 0.32-1.06; P=0.076). Patients with non-District of Columbia zip codes had 57% higher odds of adherence relative to those with District of Columbia zip codes, although this did not reach statistical significance (OR=1.57; 95% CI: 0.87-2.82; P=0.136).

CONCLUSIONS

Despite the implementation of a multidisciplinary, academic LDCT screening program, overall adherence rate to prescribed follow-up scans was suboptimal. Socioeconomic disparities and African American race may negatively affect adherence to lung cancer screening LDCT guidelines. Patients with concerning findings on initial LDCT had a higher association of adherence to guidelines.

Barriers and facilitators for cervical cancer screening among adolescents and young people: a systematic review

BACKGROUND

Though cervical cancer is one of the leading causes of cancer-related death globally, its incidence is nearly entirely preventable. Young people have been an international priority for screening as this population has historically been under-screened. However, in both high-income and low-income countries, young people have not been screened appropriately according to country-specific guidelines. The aim of this systematic review was to systematically characterize the existing literature on barriers and facilitators for cervical cancer screening (CCS) among adolescents and young people globally.

METHODS

We conducted a systematic review following PRISMA guidelines of three key databases: Medline-OVID, EMBASE, and CINAHL. Supplementary searches were done through ClinicialTrials.Gov and Scopus. Databases were examined from 1946 until the date of our literature searches on March 12th 2020. We only examined original, peer-reviewed literature. Articles were excluded if they did not specifically discuss CCS, were not specific to individuals under the age of 35, or did not report outcomes or evaluation. All screening, extraction, and synthesis was completed in duplicate with two independent reviewers. Outcomes were summarized descriptively. Risk of bias for individual studies was graded using an adapted rating scale based on the Risk of Bias Instrument for Cross-Sectional Surveys of Attitudes and Practices.

RESULTS

Of the 2177 original database citations, we included 36 studies that met inclusion criteria. The 36 studies included a total of 14,362 participants, and around half (17/36, 47.2%) of studies specifically targeted students. The majority of studies (31/36, 86.1%) discussed barriers and facilitators to Pap testing specifically, while one study analyzed self-sampling (1/36, 2.8%), one study targeted HPV DNA testing (1/36, 2.8%), and the remainder (4/36, 11.1%) were not specified. Our systematic review found that there are three large categories of barriers for young people: lack of knowledge/awareness, negative perceptions of the test, and systemic barriers to testing. Facilitators included stronger relationships with healthcare providers, social norms, support from family, and self-efficacy.

CONCLUSION

There are unique barriers and facilitators that affect CCS rates in adolescents and young people. Health systems and healthcare providers worldwide should address the challenges for this unique population.

Access to Lung Cancer Screening in the Veterans Health Administration: Does Geographic Distribution Match Need in the Population?

BACKGROUND

Studies show uneven access to Medicare-approved lung cancer screening (LCS) programs across the United States. The Veterans Health Administration (VA), the largest national US integrated health system, is potentially well positioned to coordinate LCS services across regional units to ensure that access matches distribution of need nationally.

RESEARCH QUESTION

To what extent does LCS access (considering both VA and partner sites) and use match the distribution of eligible Veterans at state and regional levels?

METHODS

In this retrospective analysis, we identified LCS examinations in VA facilities between 2013 and 2019 from the VA Corporate Data Warehouse and plotted VA facilities with LCS geographically. We compared estimated LCS rates (unique Veterans screened per LCS-eligible population) across states and VA regional units. Finally, we assessed whether the VA's new partnership with the GO₂ Foundation for Lung Cancer (which includes more than 750 LCS centers) closes geographic gaps in LCS access.

RESULTS

We identified 71,898 LCS examinations in 96 of 139 (69.1%) VA facilities in 44 states between 2013 and 2019, with substantial variation across states (0-8 VA LCS facilities per state). Screening rates among eligible Veterans in the population varied more than 30-fold across regional networks (rate ratio, 33.6; 95% CI, 30.8-36.7 for VA New England vs Veterans Integrated Service Network 4), with weak correlation between eligible populations and LCS rates (coefficient, -0.30). Partnering with the GO₂ Foundation for Lung Cancer expands capacity and access (eg, all states now have ≥ 1 VA or partner LCS site), but 9 of the 12 states with the highest proportions of rural Veterans still have ≤ 3 total LCS facilities.

INTERPRETATION

Disparities in LCS access exist based on where Veterans live, particularly for rural Veterans, even after partnering with the GO₂ Foundation for Lung Cancer. The nationally integrated VA system has an opportunity to leverage regional resources to distribute and coordinate LCS services better to ensure equitable access.

Patient Adherence to Screening for Lung Cancer in the US: A Systematic Review and Meta-analysis

Importance

To be effective in reducing deaths from lung cancer among high-risk current and former smokers, screening with low-dose computed tomography must be performed periodically.

Objective

To examine lung cancer screening (LCS) adherence rates reported in the US, patient characteristics associated with adherence, and diagnostic testing rates after screening.

Data Sources

Five electronic databases (MEDLINE, Embase, Scopus, CINAHL, and Web of Science) were searched for articles published in the English language from January 1, 2011, through February 28, 2020.

Study Selection

Two reviewers independently selected prospective and retrospective cohort studies from 95 potentially relevant studies reporting patient LCS adherence.

Data Extraction and Synthesis

Quality appraisal and data extraction were performed independently by 2 reviewers using the Newcastle-Ottawa Scale for quality assessment. A random-effects model meta-analysis was conducted when at least 2 studies reported on the same outcome. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guideline.

Main Outcomes and Measures

The primary outcome was LCS adherence after a baseline screening. Secondary measures were the patient characteristics associated with adherence and the rate of diagnostic testing after screening.

Results

Fifteen studies with a total of 16 863 individuals were included in this systematic review and meta-analysis. The pooled LCS adherence rate across all follow-up periods (range, 12-36 months) was 55% (95% CI, 44%-66%). Regarding patient characteristics associated with adherence rates, current smokers were less likely to adhere to LCS than former smokers (odds ratio [OR], 0.70; 95% CI, 0.62-0.80); White patients were more likely to adhere to LCS than patients of races other than White (OR, 2.0; 95% CI, 1.6-2.6); people 65 to 73 years of age were more likely to adhere to LCS than people 50 to 64 years of age (OR, 1.4; 95% CI, 1.0-1.9); and completion of 4 or more years of college was also associated with increased adherence compared with people not completing college (OR, 1.5; 95% CI, 1.1-2.1). Evidence was insufficient to evaluate diagnostic testing rates after abnormal screening scan results. The main source of variation was attributable to the eligibility criteria for screening used across studies.

Conclusions and Relevance

In this study, the pooled LCS adherence rate after a baseline screening was far lower than those observed in large randomized clinical trials of screening. Interventions to promote adherence to screening should prioritize current smokers and smokers from minority populations.