Rural areas are disproportionately impacted by smoking and lung cancer

Improving Access to Care, Patient Costs, and Environmental Impact Through a Community Outreach Lung Cancer Rapid Assessment Clinic

PURPOSE

In Southeastern Ontario, increased patient distance from the regional lung cancer diagnostic assessment program (LDAP) is associated with a lower likelihood of patient care via LDAP while receiving care via LDAP is associated with improved survival. We implemented an LDAP outreach clinic to provide specialist assessment for patients with suspected lung cancer at a regional community hospital and assessed the impact on timeliness and accessibility of care.

MATERIALS AND METHODS

The Kingston Health Sciences Centre LDAP team engaged with community hospital partners to develop and launch the LDAP outreach clinic. We performed a retrospective chart review of LDAP patients (N = 1,070) before (August-November 2021; n = 234) and after implementation of the outreach clinic (November 2021-October 2022; n = 836). Descriptive data are reported as No. (%). Unpaired t tests and statistical process control charts assess for significance. A cost analysis of out-of-pocket patient costs related to travel and parking is presented in 2022 Canadian dollars (CAD).

RESULTS

Compared with a 3-month matched time period before (August-October 2021) and after outreach clinic (August-October 2022), the mean time from referral to assessment and time from referral to diagnosis decreased from 20.3 to 14.4 days (P = .0019) and 40.0 to 28.9 days (P = .0007), respectively. Over 12 months, the total patient travel was reduced by 8,856 km, which combined with parking cost-savings, resulted in patient out-of-pocket savings of CAD $5,755.60 (CAD $47.60/patient). Accounting for physician travel, the total travel saved was 5,688 km, corresponding to reduced CO2 emissions by 1.9 tCO2.

CONCLUSION

Implementation of a lung cancer outreach clinic led to improved timeliness of care, patient cost-savings, and reduced carbon footprint while serving patients in their community.

Disparities in Advance Directive Documentation for Rural-Dwelling Persons With Lung Cancer

Purpose: Advance directives (AD) are recommended for persons with lung cancer, yet few studies have investigated AD and healthcare power of attorney (HCPOA) documentation for this population in rural regions of the United States. The purpose of this study was to examine demographic and clinical factors associated with AD and HCPOA documentation for persons with lung cancer in rural eastern North Carolina (ENC). Methods: A cross-sectional retrospective chart review was conducted to collect demographic and clinical data from electronic health records from 2017 to 2021 at a tertiary cancer center and regional satellite sites in ENC. Descriptive statistics and Chi-Square Tests of Independence were used for data analysis. Findings: The sample's mean age was 69.5 years (n = 402, SD = 10.5, range = 28 - 92). Most participants were male (58%) and had a smoking history (93%). Consistent with regional population statistics, 32% of persons were black, and 52% lived in rural counties. Just 18.5% of the sample had a documented AD and 26% had a healthcare power of attorney. Black persons had significantly lower AD and HCPOA (P < .001) documentation than white persons. Rural-dwellers had significantly lower HCPOA documentation than urban-dwellers (P = .03). For all other variables, no significant differences were found. Conclusions: These findings suggest that AD and HCPOA documentation are low for persons with lung cancer in ENC, particularly for black persons and rural-dwellers. This disparity highlights the need for enhanced advance care planning (ACP) access to and outreach in the region.

A systematic review on the qualitative experiences of people living with lung cancer in rural areas

PURPOSE

To synthesize the qualitative literature exploring the experiences of people living with lung cancer in rural areas.

METHODS

Searches were performed in MEDLINE, CINAHL, and PsycINFO. Articles were screened independently by two reviewers against pre-determined eligibility criteria. Data were synthesized using Thomas and Harden's framework for the thematic synthesis of qualitative research. The CASP qualitative checklist was used for quality assessment and the review was reported in accordance with the ENTREQ and PRISMA checklists.

RESULTS

Nine articles were included, from which five themes were identified: (1) diagnosis and treatment pathways, (2) travel and financial burden, (3) communication and information, (4) experiences of interacting with healthcare professionals, (5) symptoms and health-seeking behaviors. Lung cancer diagnosis was unexpected for some with several reporting treatment delays and long wait times regarding diagnosis and treatment. Accessing treatment was perceived as challenging and time-consuming due to distance and financial stress. Inadequate communication of information from healthcare professionals was a common concern expressed by rural people living with lung cancer who also conveyed dissatisfaction with their healthcare professionals. Some were reluctant to seek help due to geographical distance and sociocultural factors whilst others found it challenging to identify symptoms due to comorbidities.

CONCLUSIONS

This review provides a deeper understanding of the challenges faced by people with lung cancer in rural settings, through which future researchers can begin to develop tailored support to address the existing disparities that affect this population.

Development of two novel treatments to promote smoking cessation: Savor and retrieval-extinction training pilot clinical trial findings

Despite decades of progress, cigarette smoking remains a significant contributor to disease burden. This effect is especially pronounced for specific priority populations, such as individuals who live in rural communities, in that the burden of tobacco smoking is greater among these groups than in urban areas and the general population. The present study aims to evaluate the feasibility and acceptability of two novel tobacco treatment interventions delivered through remote telehealth procedures to individuals who smoke in the state of South Carolina. Results also include exploratory analyses of smoking cessation outcomes. Study I evaluated savoring, a strategy based on mindfulness practices, alongside nicotine replacement therapy (NRT). Study II evaluated retrieval-extinction training (RET), a memory-modification paradigm alongside NRT. In Study I (savoring), recruitment and retention data showed high interest and engagement in the intervention components, and participants who received this intervention decreased cigarette smoking throughout the course of the treatment (ps < .05). In Study II (RET), results showed high interest and moderate engagement in treatment, although exploratory outcome analyses did not demonstrate significant treatment effects on smoking behaviors. Overall, both studies showed promise in generating interest among individuals who smoke in participating in remotely delivered, telehealth smoking cessation interventions with novel therapeutic targets. A brief savoring intervention appeared to have effects on cigarette smoking throughout treatment, whereas RET did not. Gaining insight from the present pilot study, future studies may improve the efficacy of these procedures and incorporate the treatment components into more robust available treatments. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Social and Biological Determinants in Lung Cancer Disparity

Lung cancer remains a leading cause of death in the United States and globally, despite progress in treatment and screening efforts. While mortality rates have decreased in recent years, long-term survival of patients with lung cancer continues to be a challenge. Notably, African American (AA) men experience significant disparities in lung cancer compared to European Americans (EA) in terms of incidence, treatment, and survival. Previous studies have explored factors such as smoking patterns and complex social determinants, including socioeconomic status, personal beliefs, and systemic racism, indicating their role in these disparities. In addition to social factors, emerging evidence points to variations in tumor biology, immunity, and comorbid conditions contributing to racial disparities in this disease. This review emphasizes differences in smoking patterns, screening, and early detection and the intricate interplay of social, biological, and environmental conditions that make African Americans more susceptible to developing lung cancer and experiencing poorer outcomes.

Education messages and strategies to inform the public, potential screening candidates and healthcare providers about lung cancer screening: A systematic review

International lung cancer screening (LCS) trials, using low-dose computed tomography, have demonstrated clinical effectiveness in reducing mortality from lung cancer. This systematic review aims to synthesise the key messages and strategies that could be successful in increasing awareness and knowledge of LCS, and ultimately increase uptake of screening. Studies were identified via relevant database searches up to January 2022. Two authors evaluated eligible studies, extracted and crosschecked data, and assessed quality. Results were synthesised narratively. Of 3205 titles identified, 116 full text articles were reviewed and 22 studies met the inclusion criteria. Twenty studies were conducted in the United States. While the study findings were heterogenous, key messages mentioned across multiple studies were about: provision of information on LCS and the recommendations for LCS (n = 8); benefits and harms of LCS (n = 6); cost of LCS and insurance coverage for participants (n = 6) and eligibility criteria (n = 5). To increase knowledge and awareness, evidence from awareness campaigns suggests that presenting information about eligibility and the benefits and harms of screening, may increase screening intention and uptake. Evidence from behavioural studies suggests that campaigns supporting engagement with platforms such as educational videos and digital awareness campaigns might be most effective. Group based learning appears to be most suited to increasing health professionals' knowledge. This systematic review found a lack of consistent evidence to demonstrate which strategies are most effective for increasing participant healthcare professional and community awareness and education about LCS.

Lung cancer screening in rural primary care practices in Colorado: time for a more team-based approach?

BACKGROUND

Despite lung cancer being a leading cause of death in the United States and lung cancer screening (LCS) being a recommended service, many patients eligible for screening do not receive it. Research is needed to understand the challenges with implementing LCS in different settings. This study investigated multiple practice members and patient perspectives impacting rural primary care practices related to LCS uptake by eligible patients.

METHODS

This qualitative study involved primary care practice members in multiple roles (clinicians n = 9, clinical staff n = 12 and administrators n = 5) and their patients (n = 19) from 9 practices including federally qualified and rural health centers (n = 3), health system owned (n = 4) and private practices (n = 2). Interviews were conducted regarding the importance of and ability to complete the steps that may result in a patient receiving LCS. Data were analyzed using a thematic analysis with immersion crystallization then organized using the RE-AIM implementation science framework to illuminate and organize implementation issues.

RESULTS

Although all groups endorsed the importance of LCS, all also struggled with implementation challenges. Since assessing smoking history is part of the process to identify eligibility for LCS, we asked about these processes. We found that smoking assessment and assistance (including referral to services) were routine in the practices, but other steps in the LCS portion of determining eligibility and offering LCS were not. Lack of knowledge about screening and coverage, patient stigma, and resistance and practical considerations such as distance to LCS testing facilities complicated completion of LCS compared to screening for other types of cancer.

CONCLUSIONS

Limited uptake of LCS results from a range of multiple interacting factors that cumulatively affect consistency and quality of implementation at the practice level. Future research should consider team-based approaches to conduct of LCS eligibility and shared decision making.

Rural Disparities in Lung Cancer-directed Surgery: A Medicare Cohort Study

OBJECTIVE

The primary objective of this study was to determine the influence of rural residence on access to and outcomes of lung cancer-directed surgery for Medicare beneficiaries.

SUMMARY OF BACKGROUND DATA

Lung cancer is the leading cause of cancerrelated death in the United States and rural patients have 20% higher mortality. Drivers of rural disparities along the continuum of lung cancercare delivery are poorly understood.

METHODS

Medicare claims (2015-2018) were used to identify 126,352 older adults with an incident diagnosis of nonmetastatic lung cancer. Rural Urban Commuting Area codes were used to define metropolitan, micropolitan, small town, and rural site of residence. Multivariable logistic regression models evaluated influence of place of residence on 1) receipt of cancer-directed surgery, 2) time from diagnosis to surgery, and 3) postoperative outcomes.

RESULTS

Metropolitan beneficiaries had higher rate of cancer-directed surgery (22.1%) than micropolitan (18.7%), small town (17.5%), and isolated rural (17.8%) (P < 0.001). Compared to patients from metropolitan areas, there were longer times from diagnosis to surgery for patients living in micropolitan, small, and rural communities. Multivariable models found nonmetropolitan residence to be associated with lower odds of receiving cancer-directed surgery and MIS. Nonmetropolitan residence was associated with higher odds of having postoperative emergency department visits.

CONCLUSIONS

Residence in nonmetropolitan areas is associated with lower probability of cancer-directed surgery, increased time to surgery, decreased use of MIS, and increased postoperative ED visits. Attention to timely access to surgery and coordination of postoperative care for nonmetropolitan patients could improve care delivery.

Association of type 2 diabetes mellitus with lung cancer in patients with chronic obstructive pulmonary disease

Background

Patients with chronic obstructive pulmonary disease (COPD) have an increased risk of developing lung cancer. Some studies have also suggested that diabetes mellitus (DM) may increase the risk of developing lung cancer. This study aimed to investigate whether type 2 DM (T2DM) is associated with an increased risk of lung cancer in patients with COPD.

Materials and methods

We conducted a retrospective analysis on two cohorts: the National Health Insurance Service-National Sample Cohort (NHIS-NSC) of Korea and the Common Data Model (CDM) database of a university hospital. Among patients newly diagnosed with COPD in each cohort, those with a lung cancer diagnosis were included, and a control group was selected through propensity score matching. We used the Kaplan-Meier analysis and Cox proportional hazard models to compare lung cancer incidence between patients with COPD and T2DM and those without T2DM.

Results

In the NHIS-NSC and CDM cohorts, we enrolled 3,474 and 858 patients with COPD, respectively. In both cohorts, T2DM was associated with an increased risk of lung cancer [NHIS-NSC: adjusted hazard ratio (aHR), 1.20; 95% confidence interval (CI), 1.02-1.41; and CDM: aHR, 1.45; 95% CI, 1.02-2.07). Furthermore, in the NHIS-NSC, among patients with COPD and T2DM, the risk of lung cancer was higher in current smokers than in never-smokers (aHR, 1.45; 95% CI, 1.09-1.91); in smokers with ≥30 pack-years than in never-smokers (aHR, 1.82; 95% CI, 1.49-2.25); and in rural residents than in metropolitan residents (aHR, 1.33; 95% CI, 1.06-1.68).

Conclusion

Our findings suggest that patients with COPD and T2DM may have an increased risk of developing lung cancer compared to those without T2DM.

Characterizing Regional Variability in Lung Cancer Outcomes across Ontario-A Population-Based Analysis

Background: Lung cancer (LC) is the leading cause of cancer-related mortality. In Ontario, Canada, there are significant survival differences for patients with newly diagnosed LC across the 14 provincial regions. Methods: A population-based retrospective cohort study using ICES databases from 01/2007-12/2017 identified patients with newly diagnosed LC through the Ontario Cancer Registry and those with LC as the cause of death. Descriptive data included patient, disease, and system characteristics. The primary outcome was 5-year survival by region. Results: 178,202 patient records were identified; 101,263 met inclusion criteria. LC incidence varied by region (5.6-14.6/10,000), as did histologic subtype (adenocarcinoma: 27.3-46.1%). Five-year cancer-specific survival was impacted by age, rurality, pathologic subtype, stage at diagnosis, and income quintile. Timely care was inversely related to survival (fastest quintile: HR 3.22, p < 0.0001). Adjusted 5-year cancer-specific survival varied across regions (24.1%, HR 1.12; 34.0%, HR 0.89, p < 0.001). Conclusions: When adjusting for confounders, differences in survival by health region persisted, suggesting a complex interplay between patient, disease, and system factors. A single approach to improving patient care is likely to be ineffective across different systems. Quality improvement initiatives to improve patient outcomes require different approaches amongst health regions to address local disparities in care.

Impact of Low-dose Chest CT Screening on the Association Between Rurality and Lung Cancer Outcomes

INTRODUCTION

Lung cancer mortality is higher among rural United States populations compared with nonrural ones. Little is known about screening low-dose chest computed tomography (LDCT) outcomes in rural settings.

MATERIALS AND METHODS

This retrospective cohort study examined all patients (n=1805) who underwent screening LDCT in a prospective registry from March 1, 2015, through December 31, 2019, in a majority-rural health care system. We assessed the proportion of early-stage lung cancers (American Joint Committee on Cancer stage I-II) diagnosed among LDCT-screened patients, and analyzed overall survival after early-stage lung cancer diagnosis according to residency location.

RESULTS

The screening cohort had a median age of 63 and median 40-pack-year smoking history; 62.4% had a rural residence, 51.2% were female, and 62.7% completed only 1 LDCT scan. Thirty-eight patients were diagnosed with lung cancer (2.1% of the cohort), of which 65.8% were early-stage. On multivariable analysis, rural (vs nonrural) residency was not associated with a lung cancer diagnosis (adjusted hazard ratio 1.59; 95% CI, 0.74-3.40; P =0.24). At a median follow-up of 37.1 months (range, 3.3 to 67.2 months), 88.2% of rural versus 87.5% of nonrural patients with screen-diagnosed early-stage lung cancer were alive ( P =0.93).

CONCLUSIONS

In a majority-rural United States population undergoing LDCT, most screen-detected lung cancers were early-stage. There were no significant differences observed between rural and nonrural patients in lung cancer diagnosis rate or early-stage lung cancer survival. Increased implementation of LDCT might blunt the historical association between rural United States populations and worse lung cancer outcomes.

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.

The effectiveness of smoking cessation interventions in rural and remote populations: Systematic review and meta-analyses

BACKGROUND

Rural and remote residents are more likely to smoke tobacco than those in major cities. However, they may experience unique systemic, provider, and individual barriers to accessing smoking cessation treatments, including distance and limited resources. Understanding the effectiveness of smoking cessation interventions in this population is important due to higher smoking-related disease burden and death compared to those in major cities.

METHODS

Medline, EMBASE, Scopus, PsychINFO, and Cochrane Library were searched until 19-02/2021. Inclusion criteria were randomised controlled trials (RCTs), cluster RCTs, randomised trials, or cluster randomised trials investigating behavioural interventions and pharmacotherapies for smoking cessation in rural and remote populations compared with a control or another smoking cessation treatment; and published in English. Given there is no internationally-standardised rurality index, definitions of 'rural' and 'remote' used by authors of studies were applied to reflect their country. Exclusion criteria were studies of non-combustible smoking cessation; and studies with urban participants in the sample. Two reviewers independently screened records for eligibility, extracted data from studies utilising a modified Cochrane Effective Practice and Organisation of Care Group form, and rated methodological quality using the Quality Assessment Tool for Quantitative Studies.

RESULTS

Sixteen studies were included. Meta-analysis revealed a statistically significant treatment effect of individual face-to-face counselling on smoking cessation (RR 2.35, 95% CI 1.16-4.76, I²=0%) in rural and remote populations. There was no statistically significant treatment effect for nicotine replacement therapy (RR 2.97, 95% CI 0.84-10.53, I²=47%), telephone-counselling (RR 1.69, 95% CI 0.56-5.06, I²=62%), and community-based multiple-interventions (RR:1.57, 95% CI 0.89-2.78, I²=85%). Certainty of evidence was rated very low for each meta-analysis.

CONCLUSION

Despite limited resources in rural and remote settings, individual face-to-face counselling for smoking cessation appears promising. Given the limited number of studies, further research about the effectiveness of smoking cessation interventions in rural and remote populations is warranted.

A Heart Healthy Intervention Improved Tobacco Screening Rates and Cessation Support in Primary Care Practices

We examined whether an evidence-based cardiovascular disease risk reduction intervention (Heart Health Now) would improve rates for tobacco cessation screening and counseling in small primary care practices in North Carolina. Heart Health Now was a stepped wedge, stratified, cluster randomized trial for primary care practices that were staffed by 10 or fewer clinicians and had an electronic health record. The Heart Health Now intervention consisted of education tools, onsite practice facilitation for one year, and a practice-specific cardiovascular population management dashboard that included monthly, measure-specific run charts to help guide quality improvement. Our primary outcomes were practice-level rates of tobacco screening and tobacco cessation support-extracted from practices' electronic health records-and measured at pre-intervention and 6 months post-intervention. The 28 practices included in our analyses represented 78,120 patients and 17,687 smokers. Significant change occurred in practices' tobacco screening rates and cessation support rates over time. From pre- to post-intervention, screening rates significantly increased from 82.7 to 96.2% (p < 0.001). Similarly, cessation support rates significantly increased from 44.3 to 50.1% (p = 0.03). Several practice-level factors were associated with improvement including being in an academic health center or faculty practice, having more clinicians, and having a lower percentage of White patients. In conclusion, a multi-component intervention focused on multiple cardiovascular disease risk reduction in multiple small primary care practices successfully improved rates of tobacco screening and cessation support.

Rural-Urban Differences in Common Mental Disorders, Functional Limitation and Social Support among Adults with Cancer: A Population-Based Study in Spain

The psychological, physical and social well-being components may differ for cancer patients living in urban vs. rural zones. This study aimed to examine the common mental disorders (CMDs), functional limitation (FL) and perceived social support (PSS) of rural and urban Spanish cancer patients from 2006 to 2017, to compare sociodemographic variables, health-related determinants and use of healthcare resources and to identify which sociodemographic and health-related factors were related to CMDs, FL and PSS. We performed a cross-sectional study among cancer patients using data from the Spanish National Health Surveys (2006, 2011 and 2017). A total of 698 of the subjects resided in rural areas and 1824 in urban areas. Binary logistic and multiple linear regressions were performed to determine the factors related to CMDs, FL and PSS. Rural residents visited their general practitioners more frequently than the city dwellers (61.03% vs. 56.63%, p = 0.04). A decreased prevalence of CMDs was observed among urban individuals over time (2006: 39.13%, 2011: 38.87%, 2017: 34.30%; p for trend = 0.04). Among rural residents, FL was associated with age, educational level and self-perceived health status, while among city dwellers, PSS was linked to marital status, nationality, having chronic conditions and self-perceived health status.

A Multilevel Approach to Investigate Relationships Between Health Care Resources and Lung Cancer

BACKGROUND

Screening for lung cancer is evidence-based but an underutilized measure to reduce the burden of lung cancer mortality. Lack of adequate data on geographic availability of lung cancer screening inhibits the ability of health care providers to help patients with decision-making and impedes equity-focused implementation of screening-supportive services.

OBJECTIVES

This analysis used data from 2012-2016 Surveillance, Epidemiology, and End Results Program (SEER), The Behavioral Risk Factor Surveillance System, and County Health Ranking to examine: (a) which cancer resources and county-level factors are associated with late-stage lung cancer at diagnosis; and (b) associations between county rurality and lung cancer incidence/mortality rates.

METHODS

Using New York state SEER data, we identified 68,990 lung cancer patients aged 20 to 112; 48.3% had late-stage lung cancers, and the average lung cancer incidence and mortality rates were 70.7 and 46.2 per 100,000, respectively. There were 144 American College of Radiology designated lung cancer screening centers and 376 Federally Qualified Health Centers identified in New York state. County rurality was associated with a higher proportion of late-stage lung cancers and higher lung cancer mortality rates.

DISCUSSION

Visual geomapping showed the scarcity of rural counties' health care resources. County rurality is a significant factor in differences in lung cancer screening resources and patient outcomes. Use of publicly available data with geospatial methods provides ways to identify areas for improvement, populations at risk, and additional infrastructure needs.

Preliminary Evaluation of a Citizen Scientist Educational Curriculum Aimed at Engaging Black Men in Lung Cancer Early Detection Screening

This article describes an educational program to engage African American men as citizen scientists (CSs) and future research partners in a lung cancer screening project. We provide an overview of the curriculum used, the structure and format of the educational sessions, and associated educational outcomes. Furthermore, we describe lessons learned in the engagement of African American men as CS in community-based lung-health equity research. The CS educational program included five group-based sessions delivered through zoom. The educational curriculum was adapted from the University of Florida Citizen Scientist program and tailored to address lung health and the contextual experiences of African American men. Each session lasted 90 minutes. Pre- and post-test measures were collected to examine changes in knowledge, comfort, health literacy, research interests, and medical mistrust. Eight African American men completed the CS educational program. Attendance rates were high for each session (100%). Seven participants completed additional human subject research certification. Improvements were observed from pre- to post-test in participants' level of knowledge, comfort, and health literacy but not medical mistrust. CS reported the most interest in participating in research aimed to identify important community strengths and problems. Study findings suggest that it was feasible to deliver an online citizen scientist educational program designed to prepare participants to serve as partners in a lung cancer screening intervention for African American men. Results suggest the educational program has the potential to improve key outcomes including completion of regulatory training and increased research-related knowledge, comfort, and health literacy.

Implementation and Uptake of Rural Lung Cancer Screening

OBJECTIVE

Given the higher rates of tobacco use along with increased mortality specific to lung cancer in rural settings, low-dose CT (LDCT)-based lung cancer screening could be particularly beneficial to such populations. However, limited radiology facilities and increased geographical distance, combined with lower income and education along with reduced patient engagement, present heightened barriers to screening initiation and adherence.

METHODS

In collaboration with community leaders and stakeholders, we developed and implemented a community-based lung cancer screening program, including telephone-based navigation and tobacco cessation counseling support, serving 18 North Texas counties. Funding was available to support clinical services costs where needed. We collected data on LDCT referrals, orders, and completion.

RESULTS

To raise awareness for lung cancer screening, we leveraged our established collaborative network of more than 700 community partners. In the first year of operation, 107 medical providers referred 570 patients for lung cancer screening, of whom 488 (86%) were eligible for LDCT. The most common reasons for ineligibility were age (43%) and insufficient tobacco history (20%). Of 381 ordered LDCTs, 334 (88%) were completed. Among screened patients, 61% were current smokers and 36% had insurance coverage for the procedure. The program cost per patient was $430.

DISCUSSION

Implementation, uptake, and completion of LDCT-based lung cancer screening is feasible in rural settings. Community outreach, health promotion, and algorithm-based navigation may support such efforts. Given low lung cancer screening rates nationally and heightened lung cancer risk in rural populations, similar programs in other regions may be particularly impactful.

Challenges Faced by Rural Primary Care Providers When Caring for COPD Patients in the Western United States

RATIONALE

Rural chronic obstructive pulmonary disease (COPD) patients have worse outcomes and higher mortality compared with urban patients. Reasons for these disparities likely include challenges to delivery of care that have not been explored.

OBJECTIVE

To determine challenges faced by rural primary care providers when caring for COPD patients.

METHODS

Rural primary care providers in 7 primarily western states were asked about barriers they experienced when caring for COPD patients.

RESULTS

A total of 71 rural primary care medical providers completed the survey, of which 51% were physicians and 49% were advanced practice providers (APPs). A total of 61% used Global Initiative for Chronic Obstructive Lung Disease or American Thoracic Society/European Respiratory Society guidelines as an assessment and treatment resource. The presence of multiple chronic conditions and patient failure to recognize and report symptoms were the greatest barriers to diagnose COPD. A total of 89% of providers used spirometry to diagnose COPD, but only 62% were satisfied with access to spirometry. Despite recommendations, 41% of providers never test for alpha-1 antitrypsin deficiency. A total of 87% were comfortable with their ability to assess symptoms, but only 11% used a guideline-recommended assessment tool. Although most providers were satisfied with their ability to treat symptoms and exacerbations, only 66% were content with their ability to prevent exacerbations. Fewer providers were happy with their access to pulmonologists (55%) or pulmonary rehabilitation (37%). Subgroup analyses revealed differences based on provider type (APP versus physician) and location (Colorado and Kansas versus other states), but not on population or practice size.

CONCLUSIONS

Rural providers face significant challenges when caring for COPD patients that should be targeted in future interventions to improve COPD outcomes.

Promoting Community Awareness of Lung Cancer Screening Among Disparate Populations: Results of the cancer-Community Awareness Access Research and Education Project

BACKGROUND

Lung cancer is the no. 1 cause of cancer death in the United States. Racial/ethnic minority and medically underserved populations suffer higher mortality than whites. Early detection through uptake of low-dose computed tomography (LDCT) among screening-eligible adults may mitigate high mortality. However, nearly 5 years since the publication of the US Preventive Services Task Force lung cancer screening guideline, population awareness of LDCT is low, and only 4% of screening-eligible adults have undergone screening.

OBJECTIVE

This project used an education intervention to change participants' knowledge, attitudes, and beliefs about cancer risk factors and lung cancer and to connect eligible individuals to LDCT screening and tobacco cessation services.

INTERVENTIONS/METHODS

Community-engaged strategies were used to deliver a 4-week educational program in 13 community sites. Trained community health workers delivered the intervention. The intervention was guided by the Health Belief Model. Data were collected by survey to 481 participants; 93% were African American, the majority was female (73.1%), mean age was 58.3 (SD, 10.9) years.

RESULTS

There were knowledge increase regarding lung cancer screening (P = .001), a significant decrease in Perceived Severity and Perceived Barriers subscales (P = .001), and an overall increase in response to Perceived Benefits of lung cancer screening and Self-efficacy (P = .001). Fifty-four percent of tobacco users engaged in cessation; 38% of screening-eligible participants underwent LDCT screening.

CONCLUSIONS

Community health workers are effective in increasing awareness of lung cancer screening and affecting behavior change among disparate populations.

IMPLICATIONS FOR PRACTICE

Community health workers may have a clinical role in LDCT shared decision making.

Lung cancer screening implementation: Complexities and priorities

Lung cancer is the number one cause of cancer death worldwide. The benefits of lung cancer screening to reduce mortality and detect early-stage disease are no longer in any doubt based on the results of two landmark trials using LDCT. Lung cancer screening has been implemented in the US and South Korea and is under consideration by other communities. Successful translation of demonstrated research outcomes into the routine clinical setting requires careful implementation and co-ordinated input from multiple stakeholders. Implementation aspects may be specific to different healthcare settings. Important knowledge gaps remain, which must be addressed in order to optimize screening benefits and minimize screening harms. Lung cancer screening differs from all other cancer screening programmes as lung cancer risk is driven by smoking, a highly stigmatized behaviour. Stigma, along with other factors, can impact smokers' engagement with screening, meaning that smokers are generally 'hard to reach'. This review considers critical points along the patient journey. The first steps include selecting a risk threshold at which to screen, successfully engaging the target population and maximizing screening uptake. We review barriers to smoker engagement in lung and other cancer screening programmes. Recruitment strategies used in trials and real-world (clinical) programmes and associated screening uptake are reviewed. To aid cross-study comparisons, we propose a standardized nomenclature for recording and calculating recruitment outcomes. Once participants have engaged with the screening programme, we discuss programme components that are critical to maximize net benefit. A whole-of-programme approach is required including a standardized and multidisciplinary approach to pulmonary nodule management, incorporating probabilistic nodule risk assessment and longitudinal volumetric analysis, to reduce unnecessary downstream investigations and surgery; the integration of smoking cessation; and identification and intervention for other tobacco related diseases, such as coronary artery calcification and chronic obstructive pulmonary disease. National support, integrated with tobacco control programmes, and with appropriate funding, accreditation, data collection, quality assurance and reporting mechanisms will enhance lung cancer screening programme success and reduce the risks associated with opportunistic, ad hoc screening. Finally, implementation research must play a greater role in informing policy change about targeted LDCT screening programmes.

Rural barriers to early lung cancer detection: Exploring access to lung cancer screening programs in New Hampshire and Vermont

BACKGROUND

Rural populations face many health disadvantages compared to urban areas. There is a critical need to better understand the current lung cancer screening landscape in these communities to identify targeted areas to improve the impact of this proven tool.

METHODS

Data from the County Health Rankings of New Hampshire and Vermont was reviewed for population density, distribution of adult smokers, and level of education compared to the distribution of Lung Cancer Screening Facilities throughout these two states.

RESULTS

Screening programs in southern counties of Vermont with lower levels of education have decreased access. In New Hampshire, there are no programs within 30 miles of the areas with the largest distribution of smokers, and decreased access in some areas with the lowest levels of education.

CONCLUSIONS

Improving equitable access to high-quality screening services in rural regions and the creation of targeted interventions to address decreased access in areas of high tobacco use and low education is vital to decreasing the incidence of latestage presentations of lung cancer within these populations.

Health Disparities in Environmental and Occupational Lung Disease

Pulmonary health disparities disproportionately impact disadvantaged and vulnerable populations. This article focuses on disparities in disease prevalence, morbidity, and mortality for asthma, chronic obstructive pulmonary disease, pneumoconiosis, and lung cancer. Disparities are categorized by race, age, sex, socioeconomic status, and geographic region. Each category highlights differences in risk factors for the development and severity of lung disease. Risk factors include social, behavioral, economic, and biologic determinants of health (occupational/environmental exposures, psychosocial stressors, smoking, health literacy, health care provider bias, and health care access). Many of these risk factors are complex and inter-related; strategies proposed to decrease disparities require multilevel approaches.

Addressing Disparities in Lung Cancer Screening Eligibility and Healthcare Access. An Official American Thoracic Society Statement

Background: There are well-documented disparities in lung cancer outcomes across populations. Lung cancer screening (LCS) has the potential to reduce lung cancer mortality, but for this benefit to be realized by all high-risk groups, there must be careful attention to ensuring equitable access to this lifesaving preventive health measure.Objectives: To outline current knowledge on disparities in eligibility criteria for, access to, and implementation of LCS, and to develop an official American Thoracic Society statement to propose strategies to optimize current screening guidelines and resource allocation for equitable LCS implementation and dissemination.Methods: A multidisciplinary panel with expertise in LCS, implementation science, primary care, pulmonology, health behavior, smoking cessation, epidemiology, and disparities research was convened. Participants reviewed available literature on historical disparities in cancer screening and emerging evidence of disparities in LCS.Results: Existing LCS guidelines do not consider racial, ethnic, socioeconomic, and sex-based differences in smoking behaviors or lung cancer risk. Multiple barriers, including access to screening and cost, further contribute to the inequities in implementation and dissemination of LCS.Conclusions: This statement identifies the impact of LCS eligibility criteria on vulnerable populations who are at increased risk of lung cancer but do not meet eligibility criteria for screening, as well as multiple barriers that contribute to disparities in LCS implementation. Strategies to improve the selection and dissemination of LCS in vulnerable groups are described.

Promoting Clinical Conversations about Lung Cancer Screening: Exploring the Role of Perceived Online Social Support

The perceived availability of online social support may contribute to patient-provider conversations about lung cancer screening. This study examines how the perceived availability of instrumental and emotional online social support is associated with patient-provider communication about lung cancer screening among adults who meet U.S. Preventive Services Taskforce (USPSTF) eligibility criteria and live with a COPD diagnosis. In April 2018, 575 adults completed an online survey after being recruited from a large southeastern academic medical center's broad research registry and website listing. Nearly half of the participants were 55-to-80 years old (41%), a current or former smoker who had quit smoking within the past 15 years (42%), and reported a smoking prevalence of 30 pack years or more (PPY; 41%). Results demonstrate that having a COPD diagnosis, identifying as male, and being a current or former tobacco smoker resulted in greater odds of having a clinical conversation about lung cancer screening. Conversely, meeting the 30 PPY smoking and 55-to-80 age thresholds lowered the odds of having these conversations. A high degree of instrumental and emotional online social support was associated with a greater incidence of annual patient-provider conversations about screening. This combination of perceived online social support was especially useful for patients with COPD.

Closing the gap: Contribution of surgical best practices to outcome differences between high- and low-volume centers for lung cancer resection

Background

Clinical outcomes for resected early‐stage non‐small cell lung cancer (NSCLC) are superior at high‐volume facilities, but reasons for these differences remain unclear. Understanding these differences and optimizing outcomes across institutions are critical to the management of the increasing incidence of these cases. We evaluated the extent to which surgical best practices account for resected early‐stage NSCLC outcome differences between facilities according to case volume.

Methods

We performed a retrospective cohort study for clinical stage 1 or 2 NSCLC undergoing surgical resection from 2004 to 2013 using the National Cancer Database (NCDB). Surgical best practices (negative surgical margins, lobar or greater resection, lymph node (LN) dissection, and examination of > 10 LNs) were compared between the highest and lowest quartile volumes.

Results

A total of 150,179 patients were included in the cohort (89% white, 53% female, median age 68 years). In a multivariate model, superior overall survival (OS) was observed at highest volume centers compared to lowest volume centers (hazard ratio (HR) = 0.89; 95% CI, 0.82‐0.96; P = .002). After matching for surgical best practices, there was no significant OS difference (HR = 0.95; 95% CI, 0.87‐1.05; P = .32). Propensity score‐adjusted HR estimates indicated that surgical best practices accounted for 54% of the numerical OS difference between low‐volume and high‐volume centers. Each surgical best practice was independently associated with improved OS (all P ≤ .001).

Conclusion

Quantifiable and potentially modifiable surgical best practices largely account for resected early‐stage NSCLC outcome differences observed between low‐ and high‐volume centers. Adherence to these guidelines may reduce and potentially eliminate these differences.

A stepped-wedge randomized trial protocol of a community intervention for increasing lung screening through engaging primary care providers (I-STEP)

Lung cancer screening with low-dose computed tomography (LDCT) reduces lung cancer mortality, yet few eligible high-risk patients receive it annually. This protocol describes a community-partnered intervention (Toolkit) designed to support primary care practices in making referrals for lung screening and guiding patients into appropriate screening pathways. This study uses a stepped-wedge implementation design. Screening centers are randomized by readiness level to enter the intervention phase in three-month "steps" with pre-intervention data serving as the control. The primary outcome is whether delivery of the Toolkit to primary care practices results in a monthly increase in number of initial LDCT screenings. Six participating centers will identify 10 practices and reach 2-3 providers per practice to train them to use the Toolkit. The Toolkit will address known barriers to screening and referral at the patient and provider levels and provide support for required elements of screening. Toolkit components include adaptable evidence-based interventions to maximize compatibility with workflows. We hypothesize that after nine months of intervention delivery, the number of initial screening per center will double. Involving 60 practices achieves 80% power at 5% level of significance. Implementation outcomes such as adoption, acceptability, feasibility, adaptation, and sustainability will be assessed through field-notes and activity logs. LDCT for lung cancer screening currently reaches a small fraction of eligible adults. To reach the full potential to reduce mortality, primary care practices are an important venue for increasing appropriate referrals. This multidisciplinary trial will encourage acceptability and sustainability by using local knowledge and promoting partnership between providers and patients. Trial registration: ClinicalTrials.gov, NCT03958253.

Annual report to the nation on the status of cancer, part II: Progress toward Healthy People 2020 objectives for 4 common cancers

BACKGROUND

The Centers for Disease Control and Prevention, the American Cancer Society, the National Cancer Institute, and the North American Association of Central Cancer Registries collaborate to provide annual updates on cancer occurrence and trends in the United States and to address a special topic of interest. Part I of this report focuses on national cancer statistics, and part 2 characterizes progress in achieving select Healthy People 2020 cancer objectives.

METHODS

For this report, the authors selected objectives-including death rates, cancer screening, and major risk factors-related to 4 common cancers (lung, colorectal, female breast, and prostate). Baseline values, recent values, and the percentage change from baseline to recent values were examined overall and by select sociodemographic characteristics. Data from national surveillance systems were obtained from the Healthy People 2020 website.

RESULTS

Targets for death rates were met overall and in most sociodemographic groups, but not among males, blacks, or individuals in rural areas, although these groups did experience larger decreases in rates compared with other groups. During 2007 through 2017, cancer death rates decreased 15% overall, ranging from -4% (rural) to -22% (metropolitan). Targets for breast and colorectal cancer screening were not yet met overall or in any sociodemographic groups except those with the highest educational attainment, whereas lung cancer screening was generally low (<10%). Targets were not yet met overall for cigarette smoking, recent smoking cessation, excessive alcohol use, or obesity but were met for secondhand smoke exposure and physical activity. Some sociodemographic groups did not meet targets or had less improvement than others toward reaching objectives.

CONCLUSIONS

Monitoring trends in cancer risk factors, screening test use, and mortality can help assess the progress made toward decreasing the cancer burden in the United States. Although many interventions to reduce cancer risk factors and promote healthy behaviors are proven to work, they may not be equitably applied or work well in every community. Implementing cancer prevention and control interventions that are sustainable, focused, and culturally appropriate may boost success in communities with the greatest need, ensuring that all Americans can access a path to long, healthy, cancer-free lives.

Barriers, Facilitators, and Suggested Interventions for Lung Cancer Screening Among a Rural Screening-Eligible Population

Introduction: Rural areas are disproportionally affected by lung cancer late-stage incidence and mortality. Lung cancer screening (LCS) is recommended to find lung cancer early and reduce mortality, yet uptake is low. The purpose of this study was to elucidate the barriers to, facilitators of, and suggested interventions for increasing LCS among a rural screening-eligible population using a mixed methods concurrent embedded design study. Methods: Qualitative and quantitative data were collected from rural-residing adults who met the eligibility criteria for LCS but who were not up-to-date with LCS recommendations. Study participants (n = 23) took part in 1 of 5 focus groups and completed a survey. Focus group discussions were recorded, transcribed, and coded through a mixed deductive and inductive approach. Survey data were used to enhance and clarify focus group results; these data were integrated in the design and during analysis, in accordance with the mixed methods concurrent embedded design approach. Results: Several key barriers to LCS were identified, including an overall lack of knowledge about LCS, not receiving information or recommendation from a health care provider, and lack of transportation. Key facilitators were receiving a provider recommendation and high motivation to know the screening results. Participants suggested that LCS uptake could be increased by addressing provider understanding and recommendation of LCS and conducting community outreach to promote LCS awareness and access. Conclusion: The results suggest that the rural screening-eligible population is generally receptive to LCS. Patient-level factors important to getting this population screened include knowledge, transportation, motivation to know their screening results, and receiving information or recommendation from a provider. Addressing these factors may be important to increase rural LCS uptake.

NSCLC patient "migration" for treatment: A retrospective analysis of patient characteristics, travel patterns, and survival differences

PURPOSE

Every year a significant population exists of those diagnosed with nonsmall cell lung cancer (NSCLC) who do not receive initial treatment upon diagnosis and then "migrate" to additional hospital before ultimately getting treatment. Migration to different hospitals may play a role in the decision to treat or not-to-treat, and we aimed to evaluate the potential factors that lead to treatment.

METHODS

A retrospective review of 6212 patients with NSCLC from 29 Kentucky hospital registries from 2012 to 2014 was performed. Variables collected included hospital accreditation status, age at diagnosis, stage, overall survival (OS), and insurance status. Hospital records were matched to Kentucky Cancer Registry records to determine the number of hospitals visited for treatment.

RESULTS

Most patients were treated at their initial hospital (73%). Of the remaining patients, 36% migrated to a different hospital where most received treatment (93%). Migrating to another hospital was associated with Stage I-III disease, younger age (66.4 vs 72.2 years), and longer OS (561 vs 157 days). Notably, migration was also associated with private insurance status and missing treatment modalities at the initial hospital. Treatment after migrating was associated with Stage I-II disease, younger age (65.8 vs 72.8 years), and longer OS (595 vs 153 days). After adjusting for confounders, treated migrating patients lived longer than initially treated patients (591 vs 505 days), especially among those with stage III (563 vs 495 days) and IV (379 vs 300 days) disease.

CONCLUSION

This analysis demonstrates a survival benefit for initially untreated patients with advanced disease who migrate to another hospital for treatment. Migration was associated with having private insurance, thus making it noteworthy of the relationship between NSCLC survival benefit and insurance status.

Timeliness of lung cancer diagnosis and treatment: a single-center experience

Background

Lung cancer is the number one cause of cancer death in America. Timely and appropriate care is critical in the management of lung cancer. We retrospectively reviewed our experience at the University of Kentucky to determine whether there were delays from initial presentation to diagnosis and from diagnosis to treatment. Furthermore, if delays existed, whether they affected overall survival and what factors contributed to these holdups in patient care.

Methods

This was a retrospective review of all patients who were diagnosed with lung cancer at the University of Kentucky between 2014 and 2017, including only those newly diagnosed at our institution and excluding patients who were diagnosed at other hospitals as well as patients with cancer recurrence. Out of a cohort of 3588 patients, only 517 were included.

Results

The average time between presentation and diagnosis was 43 days, and 86.7% of patients were diagnosed within 60 days. The average time to treatment from diagnosis was 27.5 days with 77.7% of patients being treated with either surgery, chemotherapy, and/or radiation within 42 days.

Conclusion

The majority of our patients were diagnosed and treated within the recommended time. The 13.3% and 22.3% of patients who did not fall within this timeframe were delayed due to personal reasons, comorbidities, and/or “watchful waiting”. Mortality seemed to be unaffected by any delays in diagnosis or treatment. This analysis is the first step in understanding the challenges in patient care, and can be a tool to institute programs to help patients obtain necessary care.

Association Between Rurality and Lung Cancer Treatment Characteristics and Timeliness

BACKGROUND

Lung cancer is the leading cause of cancer-related mortality in the United States, and rural states bear a greater burden of disease.

METHODS

We analyzed tumor registry data to examine relationships between rurality and lung cancer stage at diagnosis and treatment. Cases were from the Maine Cancer Registry from 2012 to 2015, and rurality was defined using rural-urban commuting areas. Multivariable models were used to examine the relationships between rurality and treatment, adjusting for age, sex, poverty, education, insurance status, and cancer stage.

RESULTS

We identified 5,338 adults with incident lung cancer; 3,429 (64.2%) were diagnosed at a late stage (III or IV). Rurality was not associated with stage at diagnosis. For patients with early-stage disease (I or II), rurality was not associated with receipt of treatment. However, for patients with late-stage disease, residents of large rural areas received more surgery (10%) compared with metropolitan (9%) or small/isolated rural areas (6%), P = .01. In multivariable analyses, patients in large rural areas received more chemotherapy (OR 1.48; 95% CI: 1.08-2.02) than those in metropolitan areas. Patients with early-stage disease residing in small/ isolated rural areas had delays in treatment (median time to first treatment = 43 days, interquartile range [IQR] 22-68) compared with large rural (34 days, IQR 17-55) and metropolitan areas (35 days, IQR 17-60), P = .0009.

CONCLUSION

Rurality is associated with differences in receipt of specific lung cancer treatments and in timeliness of treatment.