Participation in lung cancer screening programs: are there gender and social differences? A systematic review

Women are Underrepresented in Non-small Cell Lung Cancer Clinical Trials: A Systematic Review

PURPOSE

To perform a systematic review of clinical trials examining non-small cell lung cancer (NSCLC) to better understand the equity afforded to women in the study of lung cancer.

METHODS

An electronic search was conducted for all NSCLC clinical trials published between 2010 and 2020 with included words "carcinoma, non-small cell, lung" and "non-small cell lung cancer." Studies from PubMed, Cochrane, and SCOPUS were included and were uploaded into Covidence to assist with systematic review. All articles were screened by two separate individuals and reviewed for location, study type, cancer stage, field of study of the research team, and percentage of females included. Student's t-test was used to compare the means of males and females.

RESULTS

Across the 269 studies that met inclusion criteria, fewer females than males were enrolled (38.7% vs. 61.1%; p < 0.0001). Compared with studies from 2010 to 2015, those from 2016 to 2020 had greater representation of females (36.7% vs. 41.4%, p = 0.0091, respectively). Both nonsurgical and surgical studies enrolled fewer female than male patients (38.1% vs. 61.7%, p < 0.0001; 43.1% vs. 57.2%, p = 0.0002, respectively). Clinical trials from the USA had the least difference between sexes with an average of 46.7% females enrolled. Less females compared with males were enrolled in early-stage NSCLC (37.6% female vs. 62.6% male, p < 0.0001) and late-stage NSCLC trials (37.6% female vs. 62.0% male, p < 0.0001).

CONCLUSIONS

Despite recent improvement, there continues to be significant underrepresentation of females compared with males in NSCLC clinical trials.

Demographics and socioeconomic determinants of health predict continued participation in a CT lung cancer screening program

PURPOSE

We developed machine learning (ML) models to assess demographic and socioeconomic status (SES) variables' value in predicting continued participation in a low-dose CT lung cancer screening (LCS) program.

MATERIALS AND METHODS

480 LCS subjects were retrospectively examined for the following outcomes: (#1) no follow-up (single LCS scan) vs. multiple follow-ups (220 and 260 subjects respectively) and (#2) absent or delayed (>1 month past the due date) follow-up vs timely follow-up (356 and 124 subjects respectively). We quantified the contributions of 14 socioeconomic, demographic, and clinical predictors to LCS adherence, and validated and compared prediction performances of multivariate logistic regression (MLR), support vector machine (SVM) and shallow neural network (NN) models.

RESULTS

For outcome #1, age, sex, race, insurance status, personal cancer history, and median household income were found to be associated with returning for follow-ups. For outcome #2, age, sex, race, and insurance status were significant predictor of absent/delayed LCS follow-up. Across 5-fold cross-validation, the MLR model achieved an average AUC of 0.732 (95% CI, 0.661-0.803) for outcome #1 and 0.633 (95% CI, 0.602-0.664) for outcome #2 and is the model with best predictive performance overall, whereas NN and SVM tended to overfit training data and fell short on testing data performance for either outcome.

CONCLUSIONS

We identified significant predictors of LCS adherence, and our ML models can predict which subjects are at higher risk of receiving no or delayed LCS follow-ups. Our results could inform data-driven interventions to engage vulnerable populations and extend the benefits of LCS.

Yorkshire Lung Screening Trial (YLST) pathway navigation study: a protocol for a nested randomised controlled trial to evaluate the effect of a pathway navigation intervention on lung cancer screening uptake

INTRODUCTION

Lung cancer is the most common cause of cancer death globally. In 2022 the UK National Screening Committee recommended the implementation of a national targeted lung cancer screening programme, aiming to improve early diagnosis and survival rates. Research studies and services internationally consistently observe socioeconomic and smoking-related inequalities in screening uptake. Pathway navigation (PN) is a process through which a trained pathway navigator guides people to overcome barriers to accessing healthcare services, including screening. This nested randomised controlled trial aims to determine whether a PN intervention results in more individuals participating in lung cancer screening compared with the usual written invitation within a previous non-responder population as part of the Yorkshire Lung Screening Trial (YLST).

METHODS AND ANALYSIS

A two-arm randomised controlled trial and process evaluation nested within the YLST. Participants aged 55-80 (inclusive) who have not responded to previous postal invitations to screening will be randomised by household to receive PN or usual care (a further postal invitation to contact the screening service for a lung health check) between March 2023 and October 2024. The PN intervention includes a postal appointment notification and prearranged telephone appointment, during which a pathway navigator telephones the participant, following a four-step protocol to introduce the offer and conduct an initial risk assessment. If eligible, participants are invited to book a low-dose CT (LDCT) lung cancer screening scan. All pathway navigators receive training from behavioural psychologists on motivational interviewing and communication techniques to elicit barriers to screening attendance and offer solutions.

COPRIMARY OUTCOMES

The number undergoing initial telephone assessment of lung cancer risk. The number undergoing an LDCT screening scan.Secondary outcomes include demographic, clinical and risk parameters of people undergoing telephone risk assessment; the number of people eligible for screening following telephone risk assessment; the number of screen-detected cancers diagnosed; costs and a mixed-methods process evaluation.Descriptive analyses will be used to present numbers, proportions and quantitative components of the process evaluation. Primary comparisons of differences between groups will be made using logistic regression. Applied thematic analysis will be used to interpret qualitative data within a conceptual framework based on the COM-B framework. A health economic analysis of the PN intervention will also be conducted.

ETHICS AND DISSEMINATION

The study is approved by the Greater Manchester West Research Ethics Committee (18-NW-0012) and the Health Research Authority following the Confidentiality Advisory Group review. Results will be shared through peer-reviewed scientific journals, conference presentations and on the YLST website.

TRIAL REGISTRATION NUMBERS

ISRCTN42704678 and NCT03750110.

Optimising recruitment to a lung cancer screening trial: A comparison of general practitioner and community-based recruitment

OBJECTIVES

Pre-trial focus groups of the Early detection of Cancer of the Lung Scotland (ECLS) trial indicated that those at high risk of lung cancer are more likely to engage with community-based recruitment methods. The current study aimed to understand if general practitioner (GP) and community-based recruitment might attract different groups of people, and to quantitatively explore the demographic and psychosocial differences between people responding to GP or community-based recruitment.

DESIGN

Secondary data analysis of ECLS trial baseline data.

METHODS

Adults (n = 11,164) aged 50 to 75 years completed a baseline questionnaire as part of their participation in the ECLS trial. The questionnaire assessed smoking behaviour, health state, health anxiety and illness perception. Alongside demographic characteristics, how participants were made aware of the study/participant recruitment method (GP recruitment/community recruitment) was also obtained via trial records.

RESULTS

The likelihood of being recruited via community-based methods increased as deprivation level decreased. Those recruited via the community had higher levels of perceived personal control of developing lung cancer and were more likely to understand their own risk of developing lung cancer, compared to those who were recruited to the trial via their GP. Health state and health anxiety did not predict recruitment methods in multivariable analysis.

CONCLUSIONS

Community and opportunistic screening invitations were associated with uptake in people from less-deprived backgrounds, and therefore might not be the optimal method to reach those at high risk of lung cancer and living in more deprived areas.

Increasing health inequality among Inuit in Greenland from 1993 to 2018: Different patterns for household assets, urbanization and a sociocultural index as indicators of social position

Income inequality affects population health and wellbeing negatively. In Greenland, health inequality has been shown to exist among social groups, regionally and according to urbanization, and between Inuit and migrants from Denmark. The purpose of the study was to compare the changes in health inequality from 1993 to 2018 according to three measures of social position, i.e. a socioeconomic measure (household assets), a measure of urbanization and a composite sociocultural index. We hypothesized that social inequality in health increased parallel to the increasing economic inequality in Greenland. The sample was based on four population health surveys conducted among the Inuit in Greenland in 1993, 2005-2010, 2014 and 2018. The total number of interviews was 9024 and the total number of individuals interviewed was 5829, as participants were invited to several surveys as part of a cohort. As statistical measure of social disparity we used the slope index of inequality (SII) adjusted for age and sex. Analyses were performed with daily smoking, suicidal thoughts and obesity as health outcomes. Daily smoking was most prevalent among participants with low social position whereas obesity was most prevalent among participants with high social position. With household assets as indicator of social position, the results showed high and increasing social inequality for both daily smoking and obesity. Social inequality for daily smoking increased over time also for urbanization and the sociocultural index. The hypothesis that social inequality increased over time was thus confirmed for daily smoking and obesity but not for suicidal thoughts. With the results from the present study there is solid evidence to guide prevention and health care towards social equality in health.

The Gap of Health Inequalities Amongst Lung Cancer Patients of Different Socioeconomic Status: A Brief Reference to the Greek Reality

Lung cancer treatment and patient care are constantly improving, but it remains doubtful whether this applies equally to all socioeconomic groups. It is nowadays well established that there are socioeconomic inequalities regarding lung cancer incidence, screening, effective treatment, overall survival, and prognosis. One of the key contributing factors to low socioeconomic status is low education. Low educational level is correlated with several factors, such as smoking habits, bad lifestyle behaviors, lower paid and unhealthier occupations, polluted neighborhoods, and genetic-familial risk, that lead to increased lung cancer incidence. The disparities regarding lung cancer care are further enhanced by stigma. On this basis and inspired by the gap in health equality among the Greek population, the Greek Society of Lung Cancer initiated a campaign, "MIND THE GAP", to help increase awareness and minimize the gap associated with lung cancer, both in Greece and across Europe. The aim of this review is to explore the gap of health inequalities regarding lung cancer incidence and prognosis between patients of different SES and its root of causality. Key pivotal actions towards bridging this gap are reviewed as well.

Co-designing a recruitment strategy for lung cancer screening in high-risk individuals: protocol for a mixed-methods study

Background

Lung cancer is a significant cause of cancer-related mortality globally, with early detection through screening critical to improving patient outcomes. However, recruiting high-risk individuals, particularly in deprived populations, for screening remains a considerable challenge. This study aims to co-design a targeted recruitment strategy for lung cancer screening, tailored to the specific needs and experiences of high-risk individuals, in collaboration with a Patient and Public Involvement (PPI) panel and expert stakeholders in Ireland.

Methods

We will employ a mixed-methods design guided by the Medical Research Council (MRC) framework for developing complex interventions. Our approach will integrate systematic review findings on screening participation interventions, evaluation of the recruitment strategy's feasibility in an Irish context, and the application of behavioural science frameworks. The target population includes individuals over 55 years, either current smokers or those who quit within the last year, who reside in highly deprived areas.

Conclusion

This co-designed recruitment strategy will combine evidence-based research, local context understanding, and stakeholder input to develop a solution that is both scientifically robust and tailored to the target population's needs. This patient-centred approach aims to increase the potential for successful implementation of lung cancer screening programs, thereby improving early detection and patient outcomes.

Recruitment strategies and interventions to increase participation in lung cancer screening programmes: a systematic review protocol

INTRODUCTION

Despite strong evidence for the efficacy of low-radiation dose CT (LDCT) in reducing lung cancer (LC) mortality, implementing LC screening (LCS) programmes remains a challenge. We aim to systematically review the evidence on the strategies used to recruit the adult population at risk of LC to LDCT within LCS programmes and to estimate the effectiveness of interventions identified, used to reach the potentially eligible population, increase participation and informed choice, and ensure equitable access.

METHODS AND ANALYSIS

This sequential systematic literature review will consist of three steps: (1) a scoping review of existing strategies and organisational models for LCS; (2) selecting papers reporting relevant outcomes (test coverage, screening participation and informed choice) and comparing results among different models; (3) a systematic review of interventions implemented to increase participation in LCS programmes. Each step will follow the methodological guidelines provided by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data sources include electronic databases such as Medline (PubMed version), Embase, CINAHL (Ebsco version), Scopus and Cochrane CENTRAL. The search will be limited to studies published from January 2000 to March 2023 in English, Italian, French, Spanish, Serbian and Croatian language. Findings will be synthesised quantitatively and qualitatively as appropriate. Risk of bias assessment will be only applied to studies selected in the second and third steps. The quality of evidence will be summarised for each outcome using the Grading Recommendation Assessment, Development and Evaluation methodology.

ETHICS AND DISSEMINATION

Given that this is a review of existing literature, ethics approval is not required. The results will be published in peer-reviewed scientific journals and presented at relevant conferences. The findings of this review will help guide health authorities in organising LCS programmes and developing recommendations, policies, and actions at national and regional levels.

PROSPERO REGISTRATION NUMBER

CRD42023408357.

Artificial Intelligence in Lung Cancer Screening: The Future Is Now

Lung cancer has one of the worst morbidity and fatality rates of any malignant tumour. Most lung cancers are discovered in the middle and late stages of the disease, when treatment choices are limited, and patients' survival rate is low. The aim of lung cancer screening is the identification of lung malignancies in the early stage of the disease, when more options for effective treatments are available, to improve the patients' outcomes. The desire to improve the efficacy and efficiency of clinical care continues to drive multiple innovations into practice for better patient management, and in this context, artificial intelligence (AI) plays a key role. AI may have a role in each process of the lung cancer screening workflow. First, in the acquisition of low-dose computed tomography for screening programs, AI-based reconstruction allows a further dose reduction, while still maintaining an optimal image quality. AI can help the personalization of screening programs through risk stratification based on the collection and analysis of a huge amount of imaging and clinical data. A computer-aided detection (CAD) system provides automatic detection of potential lung nodules with high sensitivity, working as a concurrent or second reader and reducing the time needed for image interpretation. Once a nodule has been detected, it should be characterized as benign or malignant. Two AI-based approaches are available to perform this task: the first one is represented by automatic segmentation with a consequent assessment of the lesion size, volume, and densitometric features; the second consists of segmentation first, followed by radiomic features extraction to characterize the whole abnormalities providing the so-called "virtual biopsy". This narrative review aims to provide an overview of all possible AI applications in lung cancer screening.

Circulating noncoding RNAs: promising biomarkers in liquid biopsy for the diagnosis, prognosis, and therapy of NSCLC

As the second most common malignant tumor in the world, lung cancer is a great threat to human health. In the past several decades, the role and mechanism of ncRNAs in lung cancer as a class of regulatory RNAs have been studied intensively. In particular, ncRNAs in body fluids have attracted increasing attention as biomarkers for lung cancer diagnosis and prognosis and for the evaluation of lung cancer treatment due to their low invasiveness and accessibility. As emerging tumor biomarkers in lung cancer, circulating ncRNAs are easy to obtain, independent of tissue specimens, and can well reflect the occurrence and progression of tumors due to their correlation with some biological processes in tumors. Circulating ncRNAs have a very high potential to serve as biomarkers and hold promise for the development of ncRNA-based therapeutics. In the current study, there has been extensive evidence that circulating ncRNA has clinical significance and value as a biomarker. In this review, we summarize how ncRNAs are generated and enter the circulation, remaining stable for subsequent detection. The feasibility of circulating ncRNAs as biomarkers in the diagnosis and prognosis of non-small cell lung cancer is also summarized. In the current systematic treatment of non-small cell lung cancer, circulating ncRNAs can also predict drug resistance, adverse reactions, and other events in targeted therapy, chemotherapy, immunotherapy, and radiotherapy and have promising potential to guide the systematic treatment of non-small cell lung cancer.

Research Priorities for Interventions to Address Health Disparities in Lung Nodule Management: An Official American Thoracic Society Research Statement

Background: Lung nodules are common incidental findings, and timely evaluation is critical to ensure diagnosis of localized-stage and potentially curable lung cancers. Rates of guideline-concordant lung nodule evaluation are low, and the risk of delayed evaluation is higher for minoritized groups. Objectives: To summarize the existing evidence, identify knowledge gaps, and prioritize research questions related to interventions to reduce disparities in lung nodule evaluation. Methods: A multidisciplinary committee was convened to review the evidence and identify key knowledge gaps in four domains: 1) research methodology, 2) patient-level interventions, 3) clinician-level interventions, and 4) health system-level interventions. A modified Delphi approach was used to identify research priorities. Results: Key knowledge gaps included 1) a lack of standardized approaches to identify factors associated with lung nodule management disparities, 2) limited data evaluating the role of social determinants of health on disparities in lung nodule management, 3) a lack of certainty regarding the optimal strategy to improve patient-clinician communication and information transmission and/or retention, and 4) a paucity of information on the impact of patient navigators and culturally trained multidisciplinary teams. Conclusions: This statement outlines a research agenda intended to stimulate high-impact studies of interventions to mitigate disparities in lung nodule evaluation. Research questions were prioritized around the following domains: 1) need for methodologic guidelines for conducting research related to disparities in nodule management, 2) evaluating how social determinants of health influence lung nodule evaluation, 3) studying approaches to improve patient-clinician communication, and 4) evaluating the utility of patient navigators and culturally enriched multidisciplinary teams to reduce disparities.

Lung Cancer Screening Penetration in an Urban Underserved County

PURPOSE

To compare residential geography, sex, socioeconomic status (SES), and race/ethnicity of patients screened at Montefiore's Lung Cancer Screening Program with those of patients diagnosed with lung cancer, assessing whether screening efforts are appropriately focused.

METHODS

This retrospective cohort study involved patients within a multisite urban medical center undergoing lung cancer screening or diagnosed with lung cancer from January 1, 2015 to December 31, 2019. Inclusion criteria were residence within the Bronx, NY and age between 55 and 80 years. Institutional review board approval was obtained. Data were analyzed using the Wilcoxon two-sample t test and χ².

RESULTS

The cohorts comprised 1568 (50.3%) women and 1551 (49.7%) men (mean age 65.6 ± 6.16). The Southeast Bronx had the most diagnosed lung cancers (29.96%) and screenings (31.22%). Sex did not significantly differ (p = 0.053). Cancer and screening cohorts were from impoverished neighborhoods with mean SES of - 3.11 ± 2.78 and - 3.44 ± 2.80 (p < 0.01). The lower tier SES neighborhoods demonstrated more patients in the screening cohort than cancer cohort (p = 0.01). Both cohorts included a majority of Hispanic patients, although race/ethnicity differed significantly (p = 0.01). Lower SES neighborhoods showed no significant difference in race/ethnicity between cancer and screening cohorts (p = 0.262).

CONCLUSION

Though statistically significant differences were found between cohorts, likely due to sample size, few clinically meaningful differences were found, implying our lung cancer screening program was effective in reaching the desired population. Demographics-based programs should be considered in global efforts to screen vulnerable populations.

Assessment of Barriers and Challenges to Screening, Diagnosis, and Biomarker Testing in Early-Stage Lung Cancer

Management of lung cancer has transformed over the past decade and is no longer considered a singular disease as it now has multiple sub-classifications based on molecular markers. The current treatment paradigm requires a multidisciplinary approach. One of the most important facets of lung cancer outcomes however relies on early detection. Early detection has become crucial, and recent effects have shown success in lung cancer screening programs and early detection. In this narrative review, we evaluate low-dose computed tomography (LDCT) screening and how this screening modality may be underutilized. The barriers to broader implementation of LDCT screening is also explored as well as approaches to address these barriers. Current developments in diagnosis, biomarkers, and molecular testing in early-stage lung cancer are evaluated as well. Improving approaches to screening and early detection can ultimately lead to improved outcomes for patients with lung cancer.

Economic impact of using risk models for eligibility selection to the International lung screening Trial

OBJECTIVES

Using risk models as eligibility criteria for lung screening can reduce race and sex-based disparities. We used data from the International Lung Screening Trial(ILST; NCT02871856) to compare the economic impact of using the PLCOm2012 risk model or the US Preventative Services' categorical age-smoking history-based criteria (USPSTF-2013).

MATERIALS AND METHODS

The cost-effectiveness of using PLCOm2012 versus USPSTF-2013 was evaluated with a decision analytic model based on the ILST and other screening trials. The primary outcomes were costs in 2020 International Dollars ($), quality-adjusted life-years (QALY) and incremental net benefit (INB, in $ per QALY). Secondary outcomes were selection characteristics and cancer detection rates (CDR).

RESULTS

Compared with the USPSTF-2013 criteria, the PLCOm2012 risk model resulted in $355 of cost savings per 0.2 QALYs gained (INB=$4294 at a willingness-to-pay threshold of $20 000/QALY (95 %CI: $4205-$4383). Using the risk model was more cost-effective in females at both a 1.5 % and 1.7 % 6-year risk threshold (INB=$6616 and $6112, respectively), compared with males ($5221 and $695). The PLCOm2012 model selected more females, more individuals with fewer years of formal education, and more people with other respiratory illnesses in the ILST. The CDR with the risk model was higher in females compared with the USPSTF-2013 criteria (Risk Ratio = 7.67, 95 % CI: 1.87-31.38).

CONCLUSION

The PLCOm2012 model saved costs, increased QALYs and mitigated socioeconomic and sex-based disparities in access to screening.

Uptake of invitations to a lung health check offering low-dose CT lung cancer screening among an ethnically and socioeconomically diverse population at risk of lung cancer in the UK (SUMMIT): a prospective, longitudinal cohort study

BACKGROUND

Lung cancer screening with low-dose CT reduces lung cancer mortality, but screening requires equitable uptake from candidates at high risk of lung cancer across ethnic and socioeconomic groups that are under-represented in clinical studies. We aimed to assess the uptake of invitations to a lung health check offering low-dose CT lung cancer screening in an ethnically and socioeconomically diverse cohort at high risk of lung cancer.

METHODS

In this multicentre, prospective, longitudinal cohort study (SUMMIT), individuals aged 55-77 years with a history of smoking in the past 20 years were identified via National Health Service England primary care records at practices in northeast and north-central London, UK, using electronic searches. Eligible individuals were invited by letter to a lung health check offering lung cancer screening at one of four hospital sites, with non-responders re-invited after 4 months. Individuals were excluded if they had dementia or metastatic cancer, were receiving palliative care or were housebound, or declined research participation. The proportion of individuals invited who responded to the lung health check invitation by telephone was used to measure uptake. We used univariable and multivariable logistic regression analyses to estimate associations between uptake of a lung health check invitation and re-invitation of non-responders, adjusted for sex, age, ethnicity, smoking, and deprivation score. This study was registered prospectively with ClinicalTrials.gov, NCT03934866.

FINDINGS

Between March 20 and Dec 12, 2019, the records of 2 333 488 individuals from 251 primary care practices across northeast and north-central London were screened for eligibility; 1 974 919 (84·6%) individuals were outside the eligible age range, 7578 (2·1%) had pre-existing medical conditions, and 11 962 (3·3%) had opted out of particpation in research and thus were not invited. 95 297 individuals were eligible for invitation, of whom 29 545 (31·0%) responded. Due to the COVID-19 pandemic, re-invitation letters were sent to only a subsample of 4594 non-responders, of whom 642 (14·0%) responded. Overall, uptake was lower among men than among women (odds ratio [OR] 0·91 [95% CI 0·88-0·94]; p<0·0001), and higher among older age groups (1·48 [1·42-1·54] among those aged 65-69 years vs those aged 55-59 years; p<0·0001), groups with less deprivation (1·89 [1·76-2·04] for the most vs the least deprived areas; p<0·0001), individuals of Asian ethnicity (1·14 [1·09-1·20] vs White ethnicity; p<0·0001), and individuals who were former smokers (1·89 [1·83-1·95] vs current smokers; p<0·0001). When ethnicity was subdivided into 16 groups, uptake was lower among individuals of other White ethnicity than among those with White British ethnicity (0·86 [0·83-0·90]), whereas uptake was higher among Chinese, Indian, and other Asian ethnicities than among those with White British ethnicity (1·33 [1·13-1·56] for Chinese ethnicity; 1·29 [1·19-1·40] for Indian ethnicity; and 1·19 [1·08-1·31] for other Asian ethnicity).

INTERPRETATION

Inviting eligible adults for lung health checks in areas of socioeconomic and ethnic diversity should achieve favourable participation in lung cancer screening overall, but inequalities by smoking, deprivation, and ethnicity persist. Reminder and re-invitation strategies should be used to increase uptake and the equity of response.

FUNDING

GRAIL.

Use of digital technologies to support cancer screening in community health promotion interventions: scoping review

The scoping review investigated how digital technologies have helped to increase cancer screening uptake in communities including adolescents, adults and elderly people during the COVID-19 outbreak between January 2020 and June 2021. Thirteen studies were identified as being relevant, mostly addressing underserved or minority communities with the purpose to increase screening uptake, delivering health education or investigating social and cultural barriers to cancer screening. The interventions effectively used digital technologies such as mobile apps and messengers mobile apps, messaging and Web platforms. The limitations imposed by COVID-19 on social interaction can be supported with digital solutions to ensure the continuity of cancer screening programs. However, more research is needed to clarify the exact nature of effectiveness, especially in large-scale interventions.

A Cross-Sectional Study on the Acceptability of Implementing a Lung Cancer Screening Program in Belgium

Lung cancer is the most common and deadliest cancer in the world, and its incidence is expected to grow. Nonetheless, this growth can be contained through smoking cessation programs and effective lung cancer screening programs. In 2018, Belgium had the seventh highest incidence of lung cancer in the world, with lung cancer incidence accounting for 11.8% of all cancers diagnosed and 23.8% of all cancer-related deaths that same year. The aims of this study were to determine the overall acceptability of a lung cancer screening program in the Flemish population and to determine the main factors that would influence the overall acceptability of such a program. A questionnaire-based cross-sectional study was performed in the Flemish population and distributed online and on paper. The results are presented with the variables of interest and the main outcome, i.e., the acceptability of participating in such a program if implemented. Odds ratios were used to compare acceptability between subgroups. A multivariate regression model was used to determine the key factors that would have the largest impact on the level of acceptability and, thus, on the possible efficiency of such a program. This study estimated that acceptability of participating in a lung cancer screening program was 92%. Irrespective of the smoking status, levels of acceptability were higher than 89%. The key factors which could significantly influence the acceptability of a lung cancer screening program were individuals with low education, low protective factor knowledge and total knowledge, and lung cancer screening reimbursement, which were significantly associated with acceptability (0.01, 0.001, 0.01, and 0.05 respectively). Low protective factor knowledge decreased the log odds of acceptability 3.08-fold. In conclusion, the acceptability of implementing a lung cancer screening program in Flanders seems to be extremely high and would be well received by all. When implementing such a program, policymakers should aim for it to be reimbursed, campaigns should be gender-specific, focused on those with lower educational and socioeconomic status, and there should be investment in increasing total knowledge about lung cancer and knowledge about protective factors.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

Barriers and facilitators to uptake of lung cancer screening: A mixed methods systematic review

Numerous factors contribute to the low adherence to lung cancer screening (LCS) programs. A theory-informed approach to identifying the obstacles and facilitators to LCS uptake is required. This study aimed to identify, assess, and synthesize the available literature at the individual and healthcare provider (HCP) levels based on a social-ecological model and identify gaps to improve practice and policy decision-making. Systematic searches were conducted in nine electronic databases from inception to December 31, 2020. We also searched Google Scholar and manually examined the reference lists of systematic reviews to include relevant articles. Primary studies were scored for quality assessment. Among 3938 potentially relevant articles, 36 studies, including 25 quantitative and 11 qualitative studies, were identified for inclusion in the review. Fifteen common factors were extracted from 34 studies, including nine barriers and six facilitators. The barriers included individual factors (n = 5), health system factors (n = 3), and social/environmental factors (n = 1). The facilitators included only individual factors (n = 6). However, two factors, age and screening harm, remain mixed. This systematic review identified and combined barriers and facilitators to LCS uptake at the individual and HCP levels. The interaction mechanisms among these factors should be further explored, which will allow the construction of tailored LCS recommendations or interventions for the Chinese context.

Association of area-level socioeconomic status and non-small cell lung cancer stage by race/ethnicity and health care-level factors: Analysis of the National Cancer Database

BACKGROUND

This study examined whether the association of socioeconomic status (SES) and non-small cell lung cancer (NSCLC) stage varied by race/ethnicity and health care access measures.

METHODS

This study used data from the 2004-2016 National Cancer Database for patients aged 18-89 years who had been diagnosed with Stage 0-IV NSCLC. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated for the associations of area-level SES with an advanced stage at diagnosis via multilevel, multivariable logistic regression. The stage at diagnosis was dichotomized into early (0-II) and advanced (III-IV) stages, and area-level SES was categorized on the basis of the patient's zip code level: (1) the proportion of adults aged ≥25 years without a high school degree and (2) the median household income. The models were stratified by race/ethnicity (non-Hispanic [NH] White, NH Black, Hispanic, Asian, American Indian/Alaskan Native, and Native Hawaiian/Pacific Islander), insurance status (none, government, and private), and health care facility type (community, comprehensive community, academic/research, and integrated network).

RESULTS

The study population included 1,329,972 patients. Although only 17% of the NH White patients were in the lowest income quartile, 50% of the NH Black patients were in this group. Lower area-level education and income were associated with higher odds of an advanced-stage diagnosis (aOR for education, 1.12; 95% CI, 1.10-1.13; aOR for income, 1.13; 95% CI, 1.11-1.14). These associations persisted among NH White, NH Black, Hispanic, and Asian patients; among those with government and private insurance (but not the uninsured); and among those treated at each facility type.

CONCLUSIONS

Area-level income and education are strongly associated with an advanced NSCLC diagnosis regardless of the facility type and among those with government and private insurance.

Low Rates of Lung and Colorectal Cancer Screening Uptake Among a Safety-net Emergency Department Population

INTRODUCTION

A suspected diagnosis of cancer through an emergency department (ED) visit is associated with poor clinical outcomes. The purpose of this study was to explore the rate at which ED patients attend cancer screenings for lung, colorectal (CRC), and breast cancers based on national guidelines set forth by the United States Preventive Services Task Force (USPSTF).

METHODS

This was a prospective cohort study. Patients were randomly approached in the Eskenazi Hospital ED between August 2019-February 2020 and were surveyed to determine whether they would be eligible and had attended lung, CRC, and breast cancer screenings, as well as their awareness of lung cancer screening with low-dose computed tomography (LDCT). Patients who were English-speaking and ≥18 years old, and who were not critically ill or intoxicated or being seen for acute decompensated psychiatric illness were offered enrollment. Enrolled subjects were surveyed to determine eligibility for lung, colorectal, and breast cancer screenings based on guidelines set by the USPSTF. No cancer screenings were actually done during the ED visit.

RESULTS

A total of 500 patients were enrolled in this study. More participants were female (54.4%), and a majority were Black (53.0%). Most participants had both insurance (80.2%) and access to primary care (62.8%). Among the entire cohort, 63.0% identified as smokers, and 62.2% (140/225) of the 50- to 80-year-old participants qualified for lung cancer screening. No patients were screened for lung cancer in this cohort (0/225). Only 0.6% (3/500) were aware that LDCT was the preferred method for screening. Based on pack years, 35.5% (32/90) of the patients who were 40-49 years old and 6.7% (6/90) of those 30-39 years old would eventually qualify for screening. Regarding CRC screening, 43.6% (218/500) of the entire cohort was eligible. However, of those patients only 54% (118/218) had been screened. Comparatively, 77.7% (87/112) of the eligible females had been screened for breast cancer, but only 54.5% (61/112) had been screened in the prior two years.

CONCLUSION

Many ED patients are not screened for lung/colorectal/breast cancers even though many are eligible and have reported access to primary care. This study demonstrates an opportunity and a need to address cancer screening in the ED.

Barriers and facilitators to lung cancer screening and follow-up

Two randomized trials have shown that lung cancer screening (LCS) with low dose computed tomography (LDCT) reduces lung cancer mortality in patients at high-risk for lung malignancy by identifying early-stage cancers, when local cure and control is achievable. The implementation of LCS in the United States has revealed multiple barriers to preventive cancer care. Rates of LCS are disappointingly low with estimates between 5%-18% of eligible patients screened. Equally concerning, follow-up after baseline screening is far lower than that of clinical trials (44-66% v >90%). To optimize the benefits of LCS, programs must identify and address factors related to LCS participation and follow-up while concurrently recognizing and mitigating barriers. As a relatively new screening test, the most effective processes for LCS are uncertain. Therefore, LCS programs have adopted a wide range of approaches without clearly established best practices to guide them, particularly in rural and resource-limited settings. In this narrative review, we identify barriers and facilitators to LCS, focusing on those studies in non-clinical trial settings - reflecting "real world" challenges. Our goal is to identify effective and scalable LCS practices that will increase LCS participation, improve adherence to follow-up, inform strategies for quality improvement, and support new research approaches.

Increasing uptake to a lung cancer screening programme: building with communities through co-design

Background

Lung cancer is the most common cause of cancer death in the UK. Low-dose computed tomography (LDCT) screening has been shown to identify lung cancer at an earlier stage. A risk stratified approach to LDCT referral is recommended. Those at higher risk of developing lung cancer (aged 55 + , smoker, deprived area) are least likely to participate in such a programme and, therefore, it is necessary to understand the barriers they face and to develop pathways for implementation in order to increase uptake.

Methods

A 2-phased co-design process was employed to identify ways to further increase opportunity for uptake of a lung cancer screening programme, using a risk indicator for LDCT referral, amongst people who could benefit most. Participants were members of the public at high risk from developing lung cancer and professionals who may provide or signpost to a future lung cancer screening programme. Phase 1: interviews and focus groups, considering barriers, facilitators and pathways for provision. Phase 2: interactive offline booklet and online surveys with professionals. Qualitative data was analysed thematically, while descriptive statistics were conducted for quantitative data.

Results

In total, ten barriers and eight facilitators to uptake of a lung cancer screening programme using a biomarker blood test for LDCT referral were identified. An additional four barriers and four facilitators to provision of such a programme were identified. These covered wider themes of acceptability, awareness, reminders and endorsement, convenience and accessibility. Various pathway options were evidenced, with choice being a key facilitator for uptake. There was a preference (19/23) for the provision of home test kits but 7 of the 19 would like an option for assistance, e.g. nurse, pharmacist or friend. TV was the preferred means of communicating about the programme and fear was the most dominant barrier perceived by members of the public.

Conclusion

Co-design has provided a fuller understanding of the barriers, facilitators and pathways for the provision of a future lung cancer screening programme, with a focus on the potential of biomarker blood tests for the identification of at-risk individuals. It has also identified possible solutions and future developments to enhance uptake, e.g. Embedding the service in communities, Effective communication, Overcoming barriers with options. Continuing the process to develop these solutions in a collaborative way helps to encourage the personalised approach to delivery that is likely to improve uptake amongst groups that could benefit most.

Barriers and facilitators of lung cancer screening uptake: protocol of a mixed methods systematic review

INTRODUCTION

The global uptake rates of lung cancer screening (LCS) with low-dose CT remain low. Since numerous factors contribute to the underuse of LCS, a theory-informed approach to identify and address the uptake of LCS barriers and facilitators is required. This study aims to document the methods which were used to identify, appraise, and synthesise the available qualitative, quantitative, and mixed methods evidence, addressing the barriers and facilitators at the individual and healthcare provider level, according to the social-ecological model, before identifying gaps to aid future practices and policies.

METHODS AND ANALYSIS

The following databases will be searched: PubMed, Ovid (Journals @ Ovid Full Text and Ovid MEDLINE), EMBASE, CINAHL, PsycINFO, Cochrane Library, Chinese Biomedical Database, Chinese National Knowledge Infrastructure, and Wanfang database, from their creation up to 31 December 2020. Two reviewers will be involved in independently screening, reviewing, and synthesising the data; and calibration exercises will be conducted at each stage. Disagreements between the two reviewers will be resolved by arbitration by a third reviewer. The Critical Appraisal Checklist for Studies Reporting Prevalence Data from the Joanna Briggs Institute, the Critical Appraisal Skills Programme criteria adapted for qualitative studies, and the 16-item Quality Assessment Tool (QATSDD) will be used in the quality assessment of primary studies. We will perform data synthesis using the Review Manager software, V.5.3.

ETHICS AND DISSEMINATION

This study is a review of published data and therefore needs no ethical approval. The findings of this systematic review will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

CRD42020162802.

Biomarker-Based Lung Cancer Screening Eligibility: Implementation Considerations

With the convergence of promising biomarkers for lung cancer risk stratifications, and the increasing need for better eligibility assessment for lung cancer low-dose CT (LDCT) screening, the elephant in the room now is whether and how the implementation of biomarker-based lung cancer screening eligibility can be successfully achieved. This brief commentary provides an outline of key considerations for biomarker implementations for LDCT eligibility assessment and possible mitigation strategies. See related article by Jacobsen et al., p. 758.

Socio-Economic Inequalities in Lung Cancer Outcomes: An Overview of Systematic Reviews

In the past decade, evidence has accumulated about socio-economic inequalities in very diverse lung cancer outcomes. To better understand the global effects of socio-economic factors in lung cancer, we conducted an overview of systematic reviews. Four databases were searched for systematic reviews reporting on the relationship between measures of socio-economic status (SES) (individual or area-based) and diverse lung cancer outcomes, including epidemiological indicators and diagnosis- and treatment-related variables. AMSTAR-2 was used to assess the quality of the selected systematic reviews. Eight systematic reviews based on 220 original studies and 8 different indicators were identified. Compared to people with a high SES, people with a lower SES appear to be more likely to develop and die from lung cancer. People with lower SES also have lower cancer survival, most likely due to the lower likelihood of receiving both traditional and next-generation treatments, higher rates of comorbidities, and the higher likelihood of being admitted as emergency. People with a lower SES are generally not diagnosed at later stages, but this may change after broader implementation of lung cancer screening, as early evidence suggests that there may be socio-economic inequalities in its use.

The Impact of Social Determinants of Health on Lung Cancer Screening Utilization

PURPOSE

The purpose of this study was to understand how social determinants of health might influence lung cancer screening (LCS) adherence.

METHODS

All LCS low-dose CT appointments scheduled at an urban, tertiary care academic medical center in the New England region between January 1, 2015, and December 31, 2018, were included. Demographics, insurance type, information on social determinants of health, and appointment status were obtained from the electronic medical records. Multivariate logistic regression was performed to evaluate the associations between the appointment status and the explanatory variables.

RESULTS

During the study period, 2,797 patients had 4,747 scheduled LCS appointments. Forty-one percent of patients had at least one missed appointment, and 32.7% of all scheduled appointments were missed. The retention rate of patients after the baseline examination was approximately 50%. Self-reported Black race was independently associated with 1.5 times the odds of missing appointments compared with White race (P = .012). Patients with Medicaid had 6.1 times the odds of missing appointments compared with patients with private insurance and 4.6 times the odds of missing appointments compared with patients with Medicare (P < .0001). Housing insecurity was a risk factor for failing to follow up after the baseline examination, with an odds ratio of 5.3 (P = .0013).

CONCLUSIONS

The high rate of missed LCS appointments underscores the need to improve screening compliance. The identification of specific social determinants of health that contribute to disparities in access to LCS could empower policymakers, hospital systems, and providers to use targeted interventions to promote more equitable access.

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

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

Factors Associated With Obtaining Lung Cancer Screening Among Persons Who Smoke

Background. Screening with low-dose computed tomography scans can reduce lung cancer deaths but uptake remains low. This study examines psychosocial factors associated with obtaining lung cancer screening (LCS) among individuals. Methods. This is a secondary analysis of a randomized clinical trial conducted with 13 state quitlines’ clients. Participants who met age and smoking history criteria were enrolled and followed-up for 6 months. Only participants randomized to the intervention group (a patient decision aid) were included in this analysis. A logistic regression was performed to identify determinants of obtaining LCS 6 months after the intervention. Results. There were 204 participants included in this study. Regarding individual attitudes, high and moderate levels of concern about overdiagnosis were associated with a decreased likelihood of obtaining LCS compared with lower levels of concern (high levels of concern, odds ratio [OR] 0.17, 95% confidence interval [CI] 0.04–0.65; moderate levels of concern, OR 0.15, 95% CI 0.05–0.53). In contrast, higher levels of anticipated regret about not obtaining LCS and later being diagnosed with lung cancer were associated with an increased likelihood of being screened compared with lower levels of anticipated regret (OR 5.59, 95% CI 1.72–18.10). Other potential harms related to LCS were not significant. Limitations. Follow-up may not have been long enough for all individuals who wished to be screened to complete the scan. Additionally, participants may have been more health motivated due to recruitment via tobacco quitlines. Conclusions. Anticipated regret about not obtaining screening is associated with screening behavior, whereas concern about overdiagnosis is associated with decreased likelihood of LCS. Implications. Decision support research may benefit from further examining anticipated regret in screening decisions. Additional training and information may be helpful to address concerns regarding overdiagnosis.

A Web-Based Intervention to Increase Smokers' Intentions to Participate in a Cessation Study Offered at the Point of Lung Screening: Factorial Randomized Trial

BACKGROUND

Screen ASSIST is a cessation trial offered to current smokers at the point of lung cancer screening. Because of the unique position of promoting a prevention behavior (smoking cessation) within the context of a detection behavior (lung cancer screening), this study employed prospect theory to design and formatively evaluate a targeted recruitment video prior to trial launch.

OBJECTIVE

The aim of this study was to identify which message frames were most effective at promoting intent to participate in a smoking cessation study.

METHODS

Participants were recruited from a proprietary opt-in online panel company and randomized to a 2 (benefits of quitting vs risks of continuing to smoke at the time of lung screening; BvR) × 2 (gains of participating vs losses of not participating in a cessation study; GvL) message design experiment (N=314). The primary outcome was self-assessed intent to participate in a smoking cessation study. Message effectiveness and lung cancer risk perception measures were also collected. Analysis of variance examined the main effect of the 2 message factors and a least absolute shrinkage and selection operator (LASSO) approach identified predictors of intent to participate in a multivariable model. A mediation analysis was conducted to determine the direct and indirect effects of message factors on intent to participate in a cessation study.

RESULTS

A total of 296 participants completed the intervention. There were no significant differences in intent to participate in a smoking cessation study between message frames (P=.12 and P=.61). In the multivariable model, quit importance (P<.001), perceived message relevance (P<.001), and affective risk response (ie, worry about developing lung cancer; P<.001) were significant predictors of intent to participate. The benefits of quitting frame significantly increased affective risk response (Meanbenefits 2.60 vs Meanrisk 2.40; P=.03), which mediated the relationship between message frame and intent to participate (b=0.24; 95% CI 0.01-0.47; P=.03).

CONCLUSIONS

This study provides theoretical and practical guidance on how to design and evaluate proactive recruitment messages for a cessation trial. Based on our findings, we conclude that heavy smokers are more responsive to recruitment messages that frame the benefits of quitting as it increased affective risk response, which predicted greater intention to participate in a smoking cessation study.

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.

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

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

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.

Implementation of lung cancer screening: what are the main issues?

Two large-scale RCTs have shown computed tomography (CT) lung cancer screening to be efficacious in reducing lung cancer mortality (8–24% in men, 26–59% in women). However, lung cancer screening implicitly means personalised and risk-based approaches. Health care systems’ implementation of personalised screening and prevention is still sparse, and likely to be of variable quality, because of important remaining uncertainties, which have been incompletely addressed or not at all so far. Further optimisation of lung cancer screening programs is expected to reduce harms and maintain or enhance benefit for eligible European citizens, whilst significantly reducing health care costs. Some main uncertainties (e.g., Risk-based eligibility, Risk-based screening intervals, Volume CT screening, Smoking Cessation, Gender and Sex differences, Cost-Effectiveness) are discussed in this review. 4-IN-THE-LUNG-RUN (acronym for: Towards INdividually tailored INvitations, screening INtervals and INtegrated co-morbidity reducing strategies in lung cancer screening) is the first multi-centred implementation trial on volume CT lung cancer screening amongst 24,000 males and females, at high risk for developing lung cancer, across five European countries, started in January 2020. Through providing answers to the remaining questions with this trial, many EU citizens will swiftly benefit from this high-quality screening technology, others will face less harms than previously anticipated, and health care costs will be substantially reduced. Implementing a new cancer screening programme is a major task, with many stakeholders and many possible facilitators but also barriers and obstacle.

Participation in lung cancer screening

Although there is now strong evidence for the efficacy of low-radiation dose computed tomography in reducing lung cancer mortality, the challenge is to establish screening programmes that have the maximum impact on the disease. In screening programmes, participation rates are a major determinant of the success of the programme. Informed uptake, participation, and adherence (to successive screening rounds) determine the overall impact of the intervention by ensuring the maximum number of people at risk of the disease are screened regularly and therefore have the most chance of benefiting. Existing cancer screening programmes have taught us a great deal about methods that improve participation. Although evidence is emerging for the efficacy of some of those methods in lung cancer screening, there is still much work to do in the specific demographic that is most at risk of lung cancer. This demographic, characterised by higher levels of socioeconomic deprivation, may be less willing to engage with healthcare interventions and present a particular challenge in the process of ensuring informed choice. In this article we review the evidence for improving participation and describe the challenges that need to be addressed to ensure the successful implementation of CT screening programmes.

Lung Screening Benefits and Challenges: A Review of The Data and Outline for Implementation

Lung cancer is the leading cause of cancer-related deaths worldwide, accounting for almost a fifth of all cancer-related deaths. Annual computed tomographic lung cancer screening (CTLS) detects lung cancer at earlier stages and reduces lung cancer-related mortality among high-risk individuals. Many medical organizations, including the U.S. Preventive Services Task Force, recommend annual CTLS in high-risk populations. However, fewer than 5% of individuals worldwide at high risk for lung cancer have undergone screening. In large part, this is owing to delayed implementation of CTLS in many countries throughout the world. Factors contributing to low uptake in countries with longstanding CTLS endorsement, such as the United States, include lack of patient and clinician awareness of current recommendations in favor of CTLS and clinician concerns about CTLS-related radiation exposure, false-positive results, overdiagnosis, and cost. This review of the literature serves to address these concerns by evaluating the potential risks and benefits of CTLS. Review of key components of a lung screening program, along with an updated shared decision aid, provides guidance for program development and optimization. Review of studies evaluating the population considered "high-risk" is included as this may affect future guidelines within the United States and other countries considering lung screening implementation.

Primary and Secondary Prevention of Lung Cancer: Tobacco Treatment

Tobacco dependence is the most consequential target to reduce the burden of lung cancer worldwide. Quitting after a cancer diagnosis can improve cancer prognosis, overall health, and quality of life. Several oncology professional organizations have issued guidelines stressing the importance of tobacco treatment for patients with cancer. Providing tobacco treatment in the context of lung cancer screening is another opportunity to further reduce death from lung cancer. In this review, the authors describe the current state of tobacco dependence treatment focusing on new paradigms and approaches and their particular relevance for persons at risk or on treatment for lung cancer.

Lung cancer screening patient-provider discussion: Where do we stand and what are the associated factors?

OBJECTIVE

The primary objective of this study was to estimate the percentage of individuals possibly eligible for lung cancer screening that report having discussed screening with a health care provider. The secondary objective was to investigate the associated factors of having patient-provider lung cancer screening discussion.

METHODS

Data from the Health Information National Trends Survey 2017 were used (n = 3217). Lung cancer screening eligibility was based on the criteria utilized by the Centers for Medicare and Medicaid Services. Gender, race, educational attainment, health insurance coverage, and usual source of health care were covariates. Current or former smokers ages 55-77 (n = 706) were considered potentially eligible for lung cancer screening (dependent variable).

RESULTS

Only 12.24% of individuals potentially eligible for lung cancer screening report prior discussion regarding lung cancer screening with a health care provider. Being eligible for lung cancer screening based on Centers for Medicare and Medicaid Services eligibility criteria was positively associated with the odds of a patient-provider lung cancer screening discussion (odds ratio = 3.95, 95% confidence interval = 2.48-6.30). Unlike gender, race, education, or insurance coverage, a usual source of health care was positively associated with a patient-provider screening discussion (odds ratio = 2.48, 95% confidence interval = 1.31-4.70).

CONCLUSION

Individuals potentially eligible for lung cancer screening are more likely to have screening discussions with a health care provider. Having a usual source of health care may increase the odds of such a discussion, while patients are not discriminated based on race, gender, education, and insurance coverage. However, the relatively low rate (12.24%) of reported patient-provider lung cancer screening discussion indicates that significant barriers still remain.

Study protocol for a telephone-based smoking cessation randomized controlled trial in the lung cancer screening setting: The lung screening, tobacco, and health trial

Lung cancer mortality can be reduced by 20% via low dose CT lung cancer screening (LCS) and treatment of early-stage disease. Providing tobacco use treatment to high risk cigarette smokers in the LCS setting may result in health benefits beyond the impact of LCS. As one of the nine trials in the National Cancer Institute's Smoking Cessation at Lung Examination (SCALE) collaboration, the goal of the Lung Screening, Tobacco, and Health (LSTH) trial is to develop a scalable and cost-effective cessation intervention for subsequent implementation by LCS programs. Guided by the RE-AIM Framework, the LSTH trial is a two-arm RCT (N = 1330) enrolling English- and Spanish-speaking smokers registered for LCS at one of seven collaborating sites. Participants are randomly assigned to Usual Care (UC; three proactive telephone counseling sessions/two weeks of nicotine patches) vs. Intensive Telephone Counseling (ITC; eight proactive sessions/eight weeks of nicotine patches, plus discussion of the LCS results to increase motivation to quit). Telephone counseling is provided by tobacco treatment specialists. To increase continuity of care, referring physicians are notified of participant enrollment and smoking status following the intervention. Outcomes include: 1) self-reported 7-day, 30-day, and sustained abstinence, and biochemically-verified at 3-, 6-, and 12-months post-randomization, 2) reach and engagement of the interventions, and 3) cost-effectiveness of the interventions. The Cancer Intervention and Surveillance Modeling Network (CISNET) will model long-term impacts of six SCALE trials on the cost per life year saved, quality-adjusted life years saved, lung cancer mortality reduction, and population mortality. CLINICAL TRIALS REGISTRATION: The trial is registered at clinical trials.gov: NCT03200236.