Individualized assessment may help to improve screening and detection rates, especially among black patients, according to the investigators of a retrospective analysis published in JAMA Oncology.8 Other research has demonstrated higher sensitivity and specificity with the use of individual risk assessments vs USPSTF criteria to guide selection for lung cancer screening.9 Approximately 20 such risk prediction models have been developed thus far, with the prostate, lung, colorectal, and ovarian (PLCO[m2012]) model showing the best performance (area under the receiver operating curve values, 0.77).9

In addition, a prospective observational cohort study published in August 2019 observed that “patients with lung cancer who quit 15 or more years before diagnosis and those who are up to 5 years younger than the age cutoff recommended for screening, but otherwise meet USPSTF criteria, have a similar risk of death to those individuals who meet all USPSTF criteria,” wrote the investigators.10 These findings suggest that “expansion of USPSTF screening criteria to include these subgroups could enable earlier detection of lung cancer and improved survival outcomes.”

Pulmonology Advisor spoke further with Dr Cooke to learn more about disparities in lung cancer screening.

Pulmonology Advisor: What are some of the main disparities in lung cancer screening  and the reasons for these, if known?


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Dr Cooke: Although lung cancer screening by LDCT is considered an essential health benefit by the Affordable Care Act and is covered, often with no copay by private insurance and Medicare, only 2% of eligible Americans have been screened.5

The American Lung Association performed a survey of more than 1000 men and women and found that only 15% of respondents were aware that lung cancer screening is an essential health benefit and is covered by most healthcare plans with no or minimal costs.11 The top reason why high-risk patients are not screened is that their doctors never recommended it. And only 3% of women cite lung cancer as a relevant health issue, even though lung cancer kills more women than breast and colon cancer combined.

Disparities exist for our black patients. Black Americans are more likely to die from lung cancer than white Americans but are screened less often. However, blacks may have a higher incidence of positive screening exams and exhibit the same survival advantage in low-stage detection as their white counterparts.7,8

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Pulmonology Advisor: What are potential solutions to these issues?

Dr Cooke: Physician education is key to ensure screening of patients who fit the USPSTF criteria. Patient empowerment and education are also important. Patients who fit the criteria for screening should visit their primary care provider and ask for LDCT for lung cancer screening.

Pulmonology Advisor: What are the remaining research needs regarding this topic?

Dr Cooke: While 80% of lung cancer is caused by smoking, 20% of cases are due to other causes such as genetics and the environment — specifically, air quality.12 There is research underway to identify those individuals who do not fit the current recommendations for screening but may be at high risk of developing lung cancer. 

Note: Dr Cooke participated in a panel discussion regarding lung cancer screening at the 2018 annual meeting of the Society of Thoracic Surgeons; the video may be viewed here.

References

1.      Lerner L, Winn R, Hulbert A. Lung cancer early detection and health disparities: the intersection of epigenetics and ethnicity. J Thorac Dis. 2018;10(4):2498-2507.

2.      American Cancer Society. Key statistics for lung cancer. www.cancer.org/cancer/lung-cancer/about/key-statistics.html Accessed December 16, 2019.

3.      Lemjabbar-Alaoui H, Hassan OU, Yang YW, Buchanan P. Lung cancer: Biology and treatment options. Biochim Biophys Acta. 2015;1856(2):189-210.

4.      Li J, Chung S, Wei EK, Luft HS. New recommendation and coverage of low-dose computed tomography for lung cancer screening: uptake has increased but is still low. BMC Health Serv Res. 2018;18(1):525.

5.      Pham D, Bhandari S, Pinkston C, Oechsil M, Kloecker G. Lung cancer screening registry reveals low-dose CT screening remains heavily underutilized [published online September 26, 2019]. Clin Lung Cancer. doi:10.1016/j.cllc.2019.09.002

6.      Martin AN, Hassinger TE, Kozower BD, Camacho F, Anderson RT, Yao N. Disparities in lung cancer screening availability: lessons from Southwest Virginia. Ann Thorac Surg. 2019;108(2):412-416.

7.      Japuntich SJ, Krieger NH, Salvas AL, Carey MP. Racial disparities in lung cancer screening: an exploratory investigation. J Natl Med Assoc. 2018;110(5):424-427.

8.      Pasquinelli MM, Kovitz KL, Koshy M, et al. Outcomes from a minority-based lung cancer screening program vs the National Lung Screening Trial. JAMA Oncol. 2018;4(9):1291-1293.   

9.      O’Dowd EL, Baldwin DR. Lung cancer screening-low dose CT for lung cancer screening: recent trial results and next steps. Br J Radiol. 2018;91(1090):20170460.

10.  Luo YH, Luo L, Wampfler JA, et al. 5-year overall survival in patients with lung cancer eligible or ineligible for screening according to US Preventive Services Task Force criteria: a prospective, observational cohort study. Lancet Oncol. 2019;20(8):1098-1108.

11.  American Lung Association. Lung health barometer. www.lung.org/our-initiatives/lung-force/lung-health-barometer/ Accessed December 16, 2019.

12.  American Cancer Society. Lung cancer risks for non-smokers. www.cancer.org/latest-news/why-lung-cancer-strikes-nonsmokers.html Accessed December 16, 2019.