Few people had lung cancer screening. Do the updated recommendations make a difference?

However, only a small proportion of Americans who meet the criteria set by the USPSTF guidelines are screened. Estimates of percentages vary, but range from 6% to 18%. The list of reasons is long: fear of radiation exposure, stigma of smokers, lack of insurance coverage, to name just a few. Apart from motivation, the eligibility criteria set by the USPSTF may have had some discriminatory implications. According to one study, the criteria would have excluded 67.8% of black smokers diagnosed with lung cancer, compared to 43.5% of white smokers.

In March 2021, the USPSTF updated its lung cancer recommendations in two important ways. We have reduced the age of screening from 55 to 50. We also reduced the number of “pack years” from 30 to 20. The pack year is a measure of how hard someone smoked and how long they smoked. For example, a person who smokes two packs of cigarettes a day for two years has a four-pack year of smoking history. According to some estimates, the new guidelines mean that an additional 6.4 million Americans, or a total of about 14.5 million, will be eligible for lung cancer screening, the number eligible under the 2013 recommendations. Increases by 80%.

Studies published in JAMA At the time the new guidelines were announced, we found that the percentage of black smokers screened increased from 16.3% in the old guidelines to 28.8% in the new guidelines.

For supporters of lung cancer screening, the challenge now is how to turn expanded eligibility into a more hands-on screening. John Balger DO, Chief Medical Officer of the Gaisinger Health Plan in Danville, Pennsylvania, states that the Health Plan implements a claim structure and has no cost sharing.

“The biggest challenge we see is disseminating information to our members and their doctors,” says Bulger. “In addition, we need a clinical facility to perform the tests. Geisinger’s clinical companies have streamlined processes set up to identify patients, test patients, close the results loop, and schedule further tests. I have. I need more programs like this. “

Reduction of false positives

However, some vigilance about lung cancer screening can be understood given its history. Chest x-rays and sputum cytology also looked promising, but were discontinued because more rigorous studies showed that lung cancer mortality did not decrease. This is one of the reasons why the National Cancer Institute conducted a $ 300 million randomized trial of low-dose CT scans. In 2011, the National Lung Screening Trial (NLST), which enrolled a total of approximately 53,000 research volunteers, was the “win” for lung cancer screening. They showed a 20% lower risk of lung cancer mortality among those randomized to be screened on low-dose CT scans compared to those screened on chest x-rays. Other studies have shown that lung cancer mortality benefits from low-dose CT scans.

Last year, the result was New England Journal of Medicine A large randomized trial conducted in the Netherlands and Belgium showed a 24% reduction in lung cancer mortality in the CT scan group compared to the unscreened control group, according to a NELSON study. ..

Adam Saltman, MD, Chief Medical Officer of Eko, a cardiopulmonary digital health company, said low-dose CT scans have revolutionized the field of lung cancer screening. “It detected many small early-stage cancers and facilitated the curative treatment of many who would not have appeared long after their illness,” he says.

Historically, 60% to 70% of lung cancer patients have stage 3 or 4 cancer, said Dr. Mark Dilevsky, MD, Head of General Thoracic Surgery at the Miami Cancer Institute in Baptist Health South Florida. Stated. “The number depends on the screening done by CT scans,” he says. “We are capturing more and more patients in the early stages (stage 1 and stage 2) where surgery can affect the healing of those patients.”

False positives are a drawback of low-dose CT scans for lung cancer screening, as is the case with many cancer screenings. In the NLST study, just under a quarter (23.3%) of scans had false positives. The scan detected a non-cancerous nodule (small growth in the lungs). A few years ago, a program standardizing lung cancer screening by the American College of Radiology and the American College of Radiology raised the threshold for positive nodule size from 4 mm (mm) to 6 mm. When reanalyzed using data from NLST with a threshold of 6 mm, the false positive rate decreased to 13% and subsequent readings to 5%. Saltmen notes the progress made in the follow-up tests.

“”[That low-dose CT scans] We have identified many non-cancerous lung lesions, which are a bit daunting, but using fine needle biopsies, PET / CT scans, electromagnetic navigation bronchoscopy, etc., the field is mature. “
He says.

Some people hesitate to be screened for radiation exposure, even if the false positive rate is zero. This is why it is called low-dose CT scan screening. Radiation is about one-fifth of the radiation a person receives during a diagnostic CT scan. However, as the recommendation is to be screened annually, there are concerns about cumulative exposure and whether it may increase the risk of cancer. A few years ago, Italian researchers calculated that profits far outweighed risks.For every 108 lung cancers detected by screening, one radiation-induced cancer can occur, they said. BMJ.. Nevertheless, it is a risk and can be increased by the new USPSTF recommendation to start screening at a younger age.

Overcome barriers

In the United States and many other countries, smoking is now more common behavior in disadvantaged people, those with poverty, disability, or behavioral health problems, or a combination of the three. However, a 2018 review of 14 studies on lung cancer screening programs found that participants tended to have a relatively high socio-economic status. The review, including studies of programs in other countries, also found that former smokers were more likely to be screened than current smokers. This difference may partially reflect the stigma associated with smoking.

In the United States, lack of health insurance is part of the barrier. The USPSTF gives low-dose CT scan lung cancer screening a B rating, and the ACA requires most health insurance to cover preventive services with A or B rated USPSTF services. However, these requirements do not necessarily apply to those who are eligible for Medicaid. Screening was not covered by Medicaid’s service pricing program in 12 states, according to a report from the American Lung Association. This report is based on information collected a few years ago and may have changed coverage in some states.

In addition, managed Medicaid plans may cover screening in states not covered by the service pricing program. Anyway, the coverage of Medicaid is sparse, and the smoking rates of people covered by Medicaid are higher than those covered by Medicare or commercial insurance. Medicare finalized a national coverage decision for low-dose CT scans in February 2015. However, Medicare also has some hurdles. One is that the program needs to send data to the CMS registry. Second, CMS has formal shared decision-making requirements for low-dose CT scans, which in theory may facilitate screening, but in practice can be an obstacle.

Karen Winkfield, MD, Secretary-General of the Meharry Vanderbilt Alliance, a partnership between Meharry Medical College and Vanderbilt University Medical Center in Nashville, Tennessee, said most insurance plans and Medicare cover low doses. However, a CT scan of lung cancer screening said, “Because Stinger is a Medicaid, it does not require coverage, leaving a small gap in a particular community. Part of the challenge is that many individuals in Medicaid are the same individual. Yes, it has a low socio-economic status and tends to have a high incidence of lung cancer. “

Winkfield says more cancer screenings will occur in states that have expanded Medicaid. “But if there are findings on the scan, lung cancer can be a very diverse way of diagnosing, so we are still struggling with what happens after screening patients. People follow-up care. You need to be able to access it. It shouldn’t be just during the show. ”

In a review published last year Chest Oncology JournalJacob Sands, MD and his colleagues, a lung cancer specialist at the Dana-Farber Cancer Institute in Boston, who is the lead author, found that lung cancer screening programs using low-dose CT scans include program navigators, a reliable database for patients, and Nodule monitoring and interdisciplinary committee. Sands and his colleagues also mention the need to work with primary care physicians, partnerships with community leaders and organizations, and standardization of radiation reports as an important aspect of screening programs.

Race difference

Winkfield, who addresses the issue of health inequalities and the differences in access to health and health care between racial and ethnic groups, said the 2013 USPSTF Recommendation excluded many African Americans. “Smoking intensity” (pack years) tends to be lower for black Americans than for white Americans, but black Americans develop lung cancer at a young age. There is some evidence that black smokers are at higher risk of developing lung cancer at relatively low levels of smoking than white smokers. Black smokers are more likely to smoke menthol cigarettes than white smokers, and some explanations for the differences in lung cancer at the same level of smoking may indicate higher exposure to nicotine and carcinogens per cigarette than other cigarettes. Mensole cigarettes are cited for proof of sex.

If the new USPSTF recommendation could narrow the eligibility gap between black and white smokers, but still means that black (and Hispanic) smokers are underestimated in the screened population. there is. Some studies have shown that adding ratings to those recommendations to identify “high-margin” individuals fills the gap and perhaps eliminates it.

Screening for lung cancer may be particularly important for black men. Lung cancer incidence and mortality are higher in black men than in white men. The opposite is true for black and white women. Differences may be related to smoking prevalence. According to the American Cancer Society, smoking rates were higher in black men than in white men (19% vs. 17%) in 2017, but lower in black women than in white women (12% vs. 15%). ..

“Looking at the data related to the number of new cases associated with lung cancer, blacks showed a much higher incidence a few years ago, but nowadays the numbers are even.” I will. It can be seen that the incidence of lung cancer is higher than that of white men, and that black men die with a much higher rate of lung cancer. “

That’s why it’s so important to prioritize the African-American community for screening, Winkfield says. She is also thinking about other groups. “Some of the challenges of the screening program are to recognize and inform individuals that they are aware of the recommended health promotion,” she says. “We need to think about our poorly serviced communities, whether it’s our black and brown individuals, local communities or LGBT plus communities.” Many who do not are disproportionately uninsured and do not have a primary care provider. These providers play an important role in uptake screening because they provide advice and referrals to patients. Winfield said the widespread use of lung cancer screening could also be an opportunity for patients who are currently smoking to participate in smoking cessation programs. “Cancer will soon be the number one murderer in the United States,” she says. “We need to take every opportunity to discuss risk reduction with individuals.

Keith Lollia, Frequent contributors to Managed Healthcare Executive® are freelance writers in the Washington, DC region.