Evaluating Lung Cancer Screening Uptake, Outcomes, and Costs in the United States: Challenges With Existing Data and Recommendations for Improvement

Primary care patient interests in joining a planned multi-cancer early detection clinical trial

INTRODUCTION

Clinical trials are being conducted and are being planned to assess the safety and efficacy of multi-cancer early detection (MCED) tests for use in cancer screening. This study aimed to determine the feasibility of primary care patient outreach in recruiting participants to a planned MCED clinical trial, assess patient interest in trial participation, and measure decisional conflict related to participation.

METHODS

The research team used the electronic medical record of a large, urban health care system to identify primary care patients 50-80 years of age who were potentially eligible for a planned MCED trial. We mailed information about the planned MCED trial to identified patients and then contacted the patients by telephone to obtain consent and administer a baseline survey. Subsequently, we contacted consented patients to complete an interview to review the mailed information and elicit perceptions about trial participation. Finally, a research coordinator administered an endpoint telephone survey to assess patient interest in and decisional conflict related to joining the trial.

RESULTS

We randomly identified 1000 eligible patients and were able to make contact with 690 (69%) by telephone. Of the patients contacted, 217 (31%) completed the decision counseling session and 219 (32%) completed the endpoint survey. Among endpoint survey respondents, 177 (81%) expressed interest in joining the MCED trial and 162 (74%) reported low decisional conflict.

CONCLUSIONS

Most patients were contacted and about a quarter of those contacted expressed interest in and low decisional conflict about joining the planned MCED trial. Research is needed to determine how to optimize patient outreach and engage patients in shared decision-making about MCED trial participation.

Integrating primary care, shared decision making, and community engagement to facilitate equitable access to multi-cancer early detection clinical trials

Effective implementation of cancer screening programs can reduce disease-specific incidence and mortality. Screening is currently recommended for breast, cervical, colorectal and lung cancer. However, initial and repeat adherence to screening tests in accordance with current guidelines is sub-optimal, with the lowest rates observed in historically underserved groups. If used in concert with recommended cancer screening tests, new biospecimen-based multi-cancer early detection (MCED) tests could help to identify more cancers that may be amendable to effective treatment. Clinical trials designed to assess the safety and efficacy of MCED tests to assess their potential for reducing cancer mortality are needed and many are underway. In the conduct of MCED test trials, it is crucial that participant recruitment efforts successfully engage participants from diverse populations experiencing cancer disparities. Strategic partnerships involving health systems, clinical practices, and communities can increase the reach of MCED trial recruitment efforts among populations experiencing disparities. This goal can be achieved by developing health system-based learning communities that build understanding of and trust in biomedical research; and by applying innovative methods for identifying eligible trial patients, educating potential participants about research trials, and engaging eligible individuals in shared decision making (SDM) about trial participation. This article describes how a developing consortium of health systems has used this approach to encourage the uptake of cancer screening in a wide range of populations and how such a strategy can facilitate the enrollment of persons from diverse patient and community populations in MCED trials.

Liquid Biopsy as an Adjunct to Lung Screening Imaging

Current lung cancer screening protocols use low-dose computed tomography scans in selected high-risk individuals. Unfortunately, utilization is low, and the rate of false-positive screens is high. Peripheral biomarkers carry meaningful promise in diagnosing and monitoring cancer with added potential advantages reducing invasive procedures and improving turnaround time. Herein, the use of such blood-based assays is considered as an adjunct to further utilization and accuracy of lung cancer screening.

Interventions Designed to Increase the Uptake of Lung Cancer Screening: An Equity-Oriented Scoping Review

Introduction

Participation in lung cancer screening (LCS) is lower in populations with the highest burden of lung cancer risk (through the social patterning of smoking behavior) and lowest levels of health care utilization (through structurally inaccessible care) leading to a widening of health inequities.

Methods

We conducted a scoping review using the Arksey and O'Malley methodological framework to inform equitable access to LCS by illuminating knowledge and implementation gaps in interventions designed to increase the uptake of LCS. We comprehensively searched for LCS interventions (Ovid Medline, Excerpta Medica database, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Scopus from 2000 to June 22, 2021) and included peer-reviewed articles and gray literature published in the English language that describe an intervention designed to increase the uptake of LCS, charted data using our previously published tool and conduced a health equity analysis to determine the intended-unintended and positive-negative outcomes of the interventions for populations experiencing the greatest inequities.

Results

Our search yielded 3572 peer-reviewed articles and 54,292 pieces of gray literature. Ultimately, we included 35 peer-reviewed articles and one gray literature. The interventions occurred in the United States, United Kingdom, Japan, and Italy, focusing on shared decision-making, the use of electronic health records as reminders, patient navigation, community-based campaigns, and mobile computed tomography scanners. We developed an equity-oriented LCS framework and mapped the dimensions and outcomes of the interventions on access to LCS on the basis of approachability, acceptability, availability, affordability, and appropriateness of the intervention. No intervention was mapped across all five dimensions. Most notably, knowledge and implementation gaps were identified in dimensions of acceptability, availability, and affordability.

Conclusions

Interventions that were most effective in improving access to LCS targeted priority populations, raised community-level awareness, tailored materials for sociocultural acceptability, did not depend on prior patient engagement/registration with the health care system, proactively considered costs related to participation, and enhanced utilization through informed decision-making.

Outreach to primary care patients in lung cancer screening: A randomized controlled trial

Current guidelines recommend annual lung cancer screening (LCS), but rates are low. The current study evaluated strategies to increase LCS. This study was a randomized controlled trial designed to evaluate the effects of patient outreach and shared decision making (SDM) about LCS among patients in four primary care practices. Patients 50 to 80 years of age and at high risk for lung cancer were randomized to Outreach Contact plus Decision Counseling (OC-DC, n = 314), Outreach Contact alone (OC, n = 314), or usual care (UC, n = 1748). LCS was significantly higher in the combined OC/OC-DC group versus UC controls (5.5% vs. 1.8%; hazard ratio, HR = 3.28; 95% confidence interval, CI: 1.98 to 5.41; p = 0.001). LCS was higher in the OC-DC group than in the OC group, although not significantly so (7% vs. 4%, respectively; HR = 1.75; 95% CI: 0.86 to 3.55; p = 0.123). LCS referral/scheduling was also significantly higher in the OC/OC-DC group compared to controls (11% v. 5%; odds ratio, OR = 2.02; p = 0.001). We observed a similar trend for appointment keeping, but the effect was not statistically significant (86% v. 76%; OR = 1.93; p = 0.351). Outreach contacts significantly increased LCS among primary care patients. Research is needed to assess the additional value of SDM on screening uptake.

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.

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.

Lung cancer screening: targeting the hard to reach-a review

Lung cancer (LC) is the leading cause of cancer death in the USA for both men and women, and also worldwide, it is the commonest cause of cancer death. The five-year survival rate for LC depends on the stage at which it is diagnosed. It is over 50% for cases detected in a localized stage but when the disease has spread to other organs, the five-year survival rate is only 5%. Unfortunately, only 16% of LC cases are diagnosed at an early stage. In 2013, the US Preventive Services Task Force (USPSTF) recommended annual LC screening with low dose chest computed tomography (CT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years, based on the evidence from the National Lung Screening Trial (NLST) in the USA. When it comes to recruiting the target group for lung cancer screening (LCS), there are several barriers to overcome, such as whom exactly to include, where to find the target group, how to convince the target to participate or how to attract participants from all socioeconomic groups. The aim of this review is to find out what is already known about how the target group for LCS can be contacted and how participation can be improved, since uptake is a key issue in every (cancer) screening program. A review of the literature was conducted using ‘lung cancer screening and participation and uptake’ as search string. We searched in Web of Science and PubMed for reviews, systematic reviews and articles, published between 2015 and 2020. Compared to the target groups for screening in the long-running cancer screening programs of breast, cervical and colorectal cancer, there are several additional obstacles regarding defining, locating and recruiting of the target group for LCS. Shared decision-making is crucial when we want to reach the hard to reach for LCS and it should be improved, by educating primary care practitioners about LCS guidelines and providing them with the necessary tools, such as decision aids, to facilitate their job in this respect. Moreover, the information materials should be more tailored to specific groups who participate least.

Lung Cancer Screening Policy in Alaska and Occupational Therapy

Lung cancer claims more lives than any other cancer in the world and remains difficult to diagnose in the early stages. This article examines the current state of lung cancer detection and screening via low-dose computed tomography (LDCT) in Alaska and considers potential opportunities for occupational therapy practitioners in primary care settings. Medicare requires at least one documented shared decision-making encounter between provider and patient before LDCT lung cancer screening occurs. As a result of time constraints, documentation requirements, and the plethora of preventive health services they provide, primary care physicians often lack the time and training to conduct this essential service. This provides an opportunity for occupational therapy practitioners to perform these services as part of their practice and to play a role in this area as patient educators and prevention specialists in primary care settings. What This Article Adds: This article explores the national health crisis of lung cancer and describes how occupational therapists can participate in providing care in primary care settings.

The Intersection of Rural Residence and Minority Race/Ethnicity in Cancer Disparities in the United States

One in every twenty-five persons in America is a racial/ethnic minority who lives in a rural area. Our objective was to summarize how racism and, subsequently, the social determinants of health disproportionately affect rural racial/ethnic minority populations, provide a review of the cancer disparities experienced by rural racial/ethnic minority groups, and recommend policy, research, and intervention approaches to reduce these disparities. We found that rural Black and American Indian/Alaska Native populations experience greater poverty and lack of access to care, which expose them to greater risk of developing cancer and experiencing poorer cancer outcomes in treatment and ultimately survival. There is a critical need for additional research to understand the disparities experienced by all rural racial/ethnic minority populations. We propose that policies aim to increase access to care and healthcare resources for these communities. Further, that observational and interventional research should more effectively address the intersections of rurality and race/ethnicity through reduced structural and interpersonal biases in cancer care, increased data access, more research on newer cancer screening and treatment modalities, and continued intervention and implementation research to understand how evidence-based practices can most effectively reduce disparities among these populations.

Radiomics: an overview in lung cancer management-a narrative review

Radiomics is a novel approach for optimizing the analysis massive data from medical images to provide auxiliary guidance in clinical issues. Quantitative feature extraction is one of the critical steps of radiomics. The association between radiomics features and the clinicopathological information of diseases can be identified by several statistics methods. For instance, although significant progress has been made in the field of lung cancer, too many questions remain, especially for the individualized decisions. Radiomics offers a new tool to encode the characteristics of lung cancer which is the leading cause of cancer-related deaths worldwide. Here, we reviewed the workflow and clinical utility of radiomics in lung cancer management, including pulmonary nodules detection, classification, histopathology and genetics evaluation, clinical staging, therapy response, and prognosis prediction. Most of these studies showed positive results, indicating the potential value of radiomics in clinical practice. The implementation of radiomics is both feasible and invaluable, and has aided clinicians in ascertaining the nature of a disease with greater precision. However, it should be noted that radiomics in its current state cannot completely replace the work of therapists or tissue examination. The potential future trends of this modality were also remarked. More efforts are needed to overcome the limitations identified above in order to facilitate the widespread application of radiomics in the reasonably near future.

Rates of positive lung cancer screening examinations in academic versus community practice

The benefits and harms of lung cancer screening reported in the National Lung Screening Trial (NLST) likely differ from those observed in academic and community settings. High rates of positive screening findings in the NLST led to the development of the Lung CT Screening Reporting and Data System (Lung-RADS) to standardize interpretation and reporting. We conducted a prospective observational study of lung cancer screening data from four lung cancer screening sites in North Carolina to compare prospective use of Lung-RADS in a real-world screened population versus Lung-RADS retrospectively applied to the NLST, and to determine if Lung-RADS assessment use differs in academic versus community settings. We included 4,037 screening examinations from 11/2014 to 12/2018 in academic and community sites and 75,126 NLST LDCT screening exams. On baseline screening exams, the proportion of positive LDCT exams was higher in community versus academic sites or the NLST (17.7% vs. 11.4% and 13.6%, P value <0.01). On subsequent screens, the proportion of positive exams was lowest in the NLST and higher in community and academic sites (5.9% vs. 12.7% and 11.6%, P value <0.01). After adjusting for age, race, sex, and smoking status, patients screened at academic versus community sites were 34% less likely to have a positive screen at baseline [adjusted odds ratio (aOR) =0.66; 95% confidence interval (95% CI): 0.51-0.86] but on subsequent examinations, there was no difference in academic versus community sites (aOR =0.91; 95% CI: 0.58-1.43). Our findings may be due to differences in radiologists' training or experiences or the availability of prior images for comparison.

Attitudes toward tobacco cessation and lung cancer screening in two South African communities

Among men in South Africa, the prevalence of tobacco smoking is as high as 33%. Although smoking is responsible for most lung cancer in South Africa, occupational and environmental exposures contribute greatly to risk. We conducted a tobacco and lung cancer screening needs assessment and administered surveys to adults who smoked >100 cigarettes in their lifetime in Johannesburg (urban) and Kimberley (rural). We compared tobacco use, risk exposure, attitudes toward and knowledge of, and receptivity to cessation and screening, by site. Of 324 smokers, nearly 85% of current smokers had a <30 pack-year history of smoking; 58.7% had tried to stop smoking ≥1 time, and 78.9% wanted to quit. Kimberley smokers more often reported being advised by a healthcare provider to stop smoking (56.5% vs. 37.3%, p=0.001) than smokers in Johannesburg but smokers in Johannesburg were more willing to stop smoking if advised by their doctor (72.9% vs. 41.7%, p<0.001). Findings indicate that tobacco smokers in two geographic areas of South Africa are motivated to stop smoking but receive no healthcare support to do so. Developing high risk criteria for lung cancer screening and creating tobacco cessation infrastructure may reduce tobacco use and decrease lung cancer mortality in South Africa.

Evaluating Lung Cancer Screening Across Diverse Healthcare Systems: A Process Model from the Lung PROSPR Consortium

Numerous organizations, including the United States Preventive Services Task Force, recommend annual lung cancer screening (LCS) with low-dose CT for high risk adults who meet specific criteria. Despite recommendations and national coverage for screening eligible adults through the Centers for Medicare and Medicaid Services, LCS uptake in the United States remains low (<4%). In recognition of the need to improve and understand LCS across the population, as part of the larger Population-based Research to Optimize the Screening PRocess (PROSPR) consortium, the NCI (Bethesda, MD) funded the Lung PROSPR Research Consortium consisting of five diverse healthcare systems in Colorado, Hawaii, Michigan, Pennsylvania, and Wisconsin. Using various methods and data sources, the center aims to examine utilization and outcomes of LCS across diverse populations, and assess how variations in the implementation of LCS programs shape outcomes across the screening process. This commentary presents the PROSPR LCS process model, which outlines the interrelated steps needed to complete the screening process from risk assessment to treatment. In addition to guiding planned projects within the Lung PROSPR Research Consortium, this model provides insights on the complex steps needed to implement, evaluate, and improve LCS outcomes in community practice.

Challenges of using nationally representative, population-based surveys to assess rural cancer disparities

Population-based surveys provide important information about cancer-related health behaviors across the cancer care continuum, from prevention to survivorship, to inform cancer control efforts. These surveys can illuminate cancer disparities among specific populations, including rural communities. However, due to small rural sample sizes, varying sampling methods, and/or other study design or analytical concerns, there are challenges in using population-based surveys for rural cancer control research and practice. Our objective is three-fold. First, we examined the characterization of "rural" in four, population-based surveys commonly referenced in the literature: 1) Health Information National Trends Survey (HINTS); 2) National Health Interview Survey (NHIS); 3) Behavioral Risk Factor Surveillance System (BRFSS); and 4) Medical Expenditures Panel Survey (MEPS). Second, we identified and described the challenges of using these surveys in rural cancer studies. Third, we proposed solutions to address these challenges. We found that these surveys varied in use of rural-urban classifications, sampling methodology, and available cancer-related variables. Further, we found that accessibility of these data to non-federal researchers has changed over time. Survey data have become restricted based on small numbers (i.e., BRFSS) and have made rural-urban measures only available for analysis at Research Data Centers (i.e., NHIS and MEPS). Additionally, studies that used these surveys reported varying proportions of rural participants with noted limitations in sufficient representation of rural minorities and/or cancer survivors. In order to mitigate these challenges, we propose two solutions: 1) make rural-urban measures more accessible to non-federal researchers and 2) implement sampling approaches to oversample rural populations.