Missed Opportunities? An Observational Analysis of Lung Cancer Screening Utilization Amongst Patients With Lung Cancer

Impaired lung function and lung cancer risk in 461 183 healthy individuals: a cohort study

BACKGROUND

It has been known that smoking and various lung diseases including lung cancer can cause lung function impairment. However, the impact of different types of lung function impairments, such as preserved ratio impaired spirometry (PRISm) and airflow obstruction (AO), on the incidence and mortality of lung cancer in both general and never-smoker populations remains unclear. We wished to examine the effect of lung function impairments on lung cancer risks.

METHODS

This was a retrospective cohort study (1 January 1994 to 31 December 2017) of individuals from a health surveillance programme in Taiwan who underwent baseline spirometry tests at the entry point. PRISm was defined as an FEV1/FVC (forced expiratory volume in 1 s/forced vital capacity) ratio >0.7 and FEV1 <0.8, while AO was defined as an FEV1/FVC ratio <0.7. Cox proportional hazards models and cubic spline curves were used to examine the associations between lung function impairments and lung cancer risks.

RESULTS

The study included 461,183 individuals, of whom 14.3% had PRISm and 7.9% had AO. A total of 4038 cases of lung cancer and 3314 lung cancer-related deaths were identified during the 23 years of follow-up. Individuals with PRISm and AO exhibited a higher risk of lung cancer incidence and mortality compared with those with normal lung function. The adjusted HRs and 95% CIs were 1.14 (1.03 to 1.26) and 1.23 (1.10 to 1.37) in the overall cohort, and 1.08 (0.93 to 1.24), and 1.23 (1.05 to 1.45) in the never-smoker cohort. The risks of both developing and dying of lung cancer increased with the severity levels of lung function impairments and lower FEV1 values.

CONCLUSION

Impaired lung function is associated with increased risks of developing lung cancer and subsequent mortality. The study highlights the importance of considering lung function in lung cancer screening for better candidate selection.

Pathways to lung cancer diagnosis among individuals who did not receive lung cancer screening: a qualitative study

BACKGROUND

Although early detection of lung cancer through screening is associated with better prognosis, most lung cancers are diagnosed among unscreened individuals. We therefore sought to characterize pathways to lung cancer diagnosis among unscreened individuals.

METHODS

Participants were individuals with lung cancer who did not undergo asymptomatic lung cancer screening (n = 13) and healthcare providers who may be involved in the pathway to lung cancer diagnosis (n = 13). We conducted semi-structured interviews to identify themes in lung cancer patients' narratives of their cancer diagnoses and providers' personal and/or professional experiences of various pathways to lung cancer diagnoses, to identify delays in diagnosis. We audio-recorded, transcribed, and coded interviews in two stages. First, we conducted deductive coding using three time-period intervals from the Models of Pathways to Treatment framework: appraisal, help-seeking, and diagnostic (i.e., excluding pre-treatment). Second, we conducted inductive coding to identify themes within each time-period interval, and classified these themes as either barriers or facilitators to diagnosis. Coding and thematic summarization were completed independently by two separate analysts who discussed for consensus.

RESULTS

Eight of the patient participants had formerly smoked, and five had never smoked. We identified eight barrier/facilitator themes within the three time-period intervals. Within the appraisal interval, the barrier theme was (1) minimization or misattribution of symptoms, and the facilitator theme was (2) acknowledgment of symptoms. Within the help-seeking interval, the barrier theme was (3) hesitancy to seek care, and the facilitator theme was (4) routine care. Within the diagnosis interval, barrier themes were (5) health system challenges, and (6) social determinants of health; and facilitator themes were (7) severe symptoms and known risk factors, and (8) self-advocacy. Many themes were interrelated, including minimization or misattribution of symptoms and hesitancy to seek care, which may collectively contribute to care and imaging delays.

CONCLUSIONS

Interventions to reduce hesitancy to seek care may facilitate timely lung cancer diagnoses. More prompt referral to imaging-especially computed tomography (CT)-among symptomatic patients, along with patient self-advocacy for imaging, may reduce delays in diagnosis.

One size does not fit all: Evaluating disparities in lung cancer screening eligibility amongst the Hispanic population

Lung cancer (LC) is the leading cause of cancer death among Hispanic men. We assessed the tendencies for screening eligibility amongst Hispanic prior to LC diagnosis according to the NCCN and The USPSTF guidelines available at the time of diagnosis. We conducted an observational study in patients diagnosed with LC from 2016 to 2019. Charts were reviewed to assess their screening eligibility prior to LC. The chi-square test was used to examine the association between race and ethnicity with each screening criteria. A total of 530 subjects were reviewed, of which 432 were included in the analysis. One hundred fifty-three and 245 subjects were ineligible for screening under NCCN and USPSTF criteria prior to their LC diagnosis. Twenty-eight of the subjects who did not fulfill NCCN criteria identified as AA and 12 as Hispanics. Forty and 20 of the USPSTF screening ineligible subjects identified as AA and Hispanics. There was a significant association between screening eligibility criteria in Hispanics, with 52% Hispanic subjects meeting NCCN criteria compared to only 20% who met USPSTF (p=0.0184). There was also a significant association between ethnicity and USPSTF eligibility criteria (p=0.0166), as 80% of Hispanic subjects were screening ineligible under USPSTF criteria compared to 56% of non-Hispanic or other. In our study, Hispanics had significantly lower tendencies of meeting the USPSTF LC screening eligibility criteria than non-Hispanics or other. Interestingly, a proportionally higher number of Hispanics who were ineligible under USPSTF criteria met NCCN criteria. These findings suggest that leniency in the screening criteria can possibly lead to earlier detection of LC in high-risk individuals. Recently, USPSTF has modified their criteria which may benefit more of these individuals. To improve rates of screening and overall mortality of minorities, organizations should continue to re-evaluate and liberalize their screening guidelines.

Access to Care Limits Lung Cancer Screening Eligibility in an Urban Safety Net Hospital

PURPOSE

Lung cancer screening (LCS) results in earlier detection of malignancy and decreases mortality but requires access to care to benefit. We assessed factors associated with timing of lung cancer diagnosis in the absence of systematic LCS in an urban safety net hospital.

PATIENTS AND METHODS

Retrospective chart review was performed of patients with pathologic diagnosis and/or staging of lung cancer at our institution between 2015 and 2018. Patient socio-demographics, disease characteristics, factors associated with access to medical care, and time point and process by which the patient accessed care were collected and analyzed.

RESULTS

In total, 223 patients were identified with median age of 63 years and 57.8% male predominance. Racial distribution was 22.9%, 20.2%, 17.1%, and 9.4% for Black, White, Asian, and Hispanic, respectively. Stage at diagnosis was 8.1%, 4.5%, 17.0%, and 60.5% for stages I, II, III, and IV, respectively. Medicaid (59.6%) and Medicare/Medicaid (17.1%) were the most common insurance types, while 16.1% had no insurance. A majority (54.3%) had no established primary care provider (PCP), and only 17.9% had an in-network PCP. Patients without PCPs were more likely to have diagnostic evaluation initiated from Emergency Department or Urgent Care settings (95.0% vs 50.1%, P < .01) and present with later stage disease (92.7% vs 77.8%, P < .01). Of the 83 patients that met age and smoking history LCS criteria, only 33.7% (12.6% of total) also had an in-network PCP.

CONCLUSION

Absence of established PCPs is associated with later stage presentation of lung cancer and may limit system- level benefits of LCS implementation.