World Lung Cancer Day: Multiple Barriers Result in Low Lung Cancer Screening Rates

Peter Baik, DO, FACOS, FACS

Peter Baik, DO, FACOS, FACS, is a board-certified and fellowship-trained thoracic surgeon at Cancer Treatment Centers of America® (CTCA).

On February 2, 2022, the United States President Joe Biden reignited the Cancer Moonshot, setting a goal of reducing the cancer death rate by at least 50% over the next 25 years.¹ However, since the United States Preventive Services Task Force (USPSTF) recommended low-dose CT (LDCT) in 2013, the screening rate among eligible individuals is less than 6% nationally as of 2020.^2,3 Interestingly, the United States Department of Health and Human Services Healthy People 2030 Target for lung cancer screening is only 7.5%.⁴ This seems like a poor outlook on adoption of LDCT for lung cancer screening (LCS), especially after eligible age for LDCT was decreased to 50 years with risk factors. A major hurdle in LCS is the social inequalities that are seen, especially in the at-risk lung cancer population.

There was significant increase in adoption of breast and colon cancer screenings after Medicare began covering those screening exams. Medicare first began covering mammography screenings in 1991 and colonoscopy in non–high-risk individuals in 2001.^5,6 According to the National Cancer Institute, the percentage of women aged 50 to 74 years who had mammography within 2 years in 1987 was 30.2%, which increased to 60.7% in 1992.⁷ The percentage of adults aged 50 to 75 years who had sigmoidoscopy within 5 years or colonoscopy within 10 years in 2000 was 28.3%, 36.1% in 2003, and 49.4% in 2008.⁸

The reason for the low screening rate in lung cancer is multifactorial, including barriers perceived by physicians such as lack of insurance coverage, lack of benefit, failure of electronic medical record to notify providers of eligible patients, patient refusal, among others.^9,10 Many of these factors apply to other types of screening programs. However, there are 2 eligibility criteria for LDCT in lung cancer that may contribute significantly to the poor adoption: tobacco smoking history and the need for the documentation of Shared Decision-Making (SDM) prior to LDCT.

Tobacco smoking prevalence is significantly higher in both men and women with incomes below the federal poverty level.¹¹ Many of these patients reside in medically underserved areas. Although LCS is covered under Medicaid, only 39 states have adopted the Medicaid expansion.¹² Because Medicaid is administered by each state individually, with different eligibility criteria and reimbursement, the coverage of LCS is variable. There are disparities seen in implementation of and access to LCS in between different socioeconomic groups.¹³ Due to the combination of lack of coverage and access to LCS, current or former smokers in the medically underserved have difficulty participating in the program.

Additionally, SDM is a crucial component of any screening program. An important part of SDM is effectively discussing the benefits, potential harm from false positive tests and over diagnosis, and exposure to radiation and smoking cessation.¹⁴ However, the major issue with SDM is the difficulty in implementing high-quality SDM visits. The quality of SDM varies, more often counseled on benefits than harms.¹⁵ A survey of key practitioners and managers involved in implementing SDM for LCS programs by Tabriz et al in 2020 showed that time constraint is a major factor in balancing the access level and the quality of SDM visits.¹⁶ SDM visits are reimbursable by Medicare with a separate Current Procedural Terminology code for SDM visit (G0296), although the code is reimbursed at a level equivalent to a 15-minute visit.¹⁷ To adequately inform and counsel patients regarding LDCT, a visit longer than 15 minutes is needed. In medically underserved areas, having an increased burden of SDM increases the inequality of LCS access.

One of the solutions to the challenges of low adoption of LCS in high-risk individuals, as well as to increase the quality of SDM, is utilizing patient navigators. The rate of screening, compliance with follow-up, rapid initiation of therapy, and patient satisfaction increase when patient navigators are utilized.¹⁸ Though, many of these studies were based on breast and colon cancer screening programs.

There are multiple different models and methods to try to understand the issues and improve the adoption. Utilizing the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, Veterans Affairs New England Health Care Network has begun a study of barriers to SDM for LCS at each of the socio-economic levels, evaluating the implementation outcomes.^19,20 Pragmatic Robust Implementation and Sustainability Model (PRISM) is a model being used to clarify the issues of implementation planning, and guides evaluation of SDM and decision aids.²⁰ The effect of these models and programs are to be yet determined.

The adoption of LDCT for LCS has been very slow, especially when compared with breast and colon cancer screenings. Due to the multifactorial nature of the low adoption, improvement can be difficult. Many are attempting to tackle the issues, but the forecast for LCS is still low. With the significant improvement of 5-year survival in locally advanced and metastatic lung cancer, President Biden Cancer Moonshot for lung cancer could only be met if the screening inequalities of LCS are decreased.

_References:

_{1. Fact sheet: President Biden reignites Cancer Moonshot to end cancer as we know it. White House. Accessed July 6, 2022. https://bit.ly/3PoEPFc}

_{2. Lung cancer: screening. United States Preventive Services Taskforce. Published March 9, 2021. Accessed July 6, 2022. https://bit.ly/3B6jMmQ}

_{3. Lung cancer key findings. American Lung Association. Accessed July 6, 2022. https://bit.ly/3RNb02V}

_{4.Cancer trends progress report: lung cancer screening. National Cancer Institute. Accessed July 6, 2022. https://bit.ly/3yWt022}

_{5. Salloum RG, Jensen GA, Biddle AK. The "Welcome to Medicare" visit: a missed opportunity for cancer screening among women? J Womens Health (Larchmt). 2013;22(1):19-25. doi:10.1089/jwh.2012.3777}

_{6. Billing and coding: colorectal cancer screening – medical policy article. Centers for Medicare and Medicaid Services. Updated January 19, 2021. Accessed July 20, 2022. https://go.cms.gov/3aWjLqU}

_{7. Cancer trends progress report: breast cancer screening. National Cancer Institute. Accessed July 6, 2022. https://bit.ly/3IQdNnK}

_{8. Cancer trends progress report: colorectal cancer screening. National Cancer Institute. Accessed July 6, 2022. https://bit.ly/3PDjN5y}

_{9. Raz DJ, Wu GX, Consunji M, et al. Perceptions and Utilization of Lung Cancer Screening Among Primary Care Physicians. J Thorac Oncol. 2016;11(11):1856-1862. doi:10.1016/j.jtho.2016.06.010}

_{10. Coughlin JM, Zang Y, Terranella S, et al. Understanding barriers to lung cancer screening in primary care. J Thorac Dis. 2020;12(5):2536-2544. doi:10.21037/jtd.2020.03.66}

_{11. Garrett BE, Martell BN, Caraballo RS, King BA. Socioeconomic Differences in Cigarette Smoking Among Sociodemographic Groups. Prev Chronic Dis. 2019;16:E74. doi:10.5888/pcd16.180553}

_{12. Status of state Medicaid expansion decisions: interactive map. KFF. Published June 29, 2022. Accessed July 7, 2022. https://bit.ly/2EBAHjT}

_{13. Rivera MP, Katki HA, Tanner NT, et al. Addressing disparities in lung cancer screening eligibility and healthcare access. An official American Thoracic Society statement. Am J Respir Crit Care Med. 2020;202(7):e95-112. doi:10.1164/rccm.202008-3053ST}

_{14. Lowenstein LM, Deyter GMR, Nishi S, Wang T, Volk RJ. Shared decision-making conversations and smoking cessation interventions: critical components of low-dose CT lung cancer screening programs. Transl Lung Cancer Res. 2018;7(3):254-271. doi:10.21037/tlcr.2018.05.10}

_{15. Nishi SPE, Lowenstein LM, Mendoza TR, et al. Shared Decision-Making for Lung Cancer Screening: How Well Are We "Sharing"?. Chest. 2021;160(1):330-340. doi:10.1016/j.chest.2021.01.041}

_{16. Alishahi Tabriz A, Neslund-Dudas C, Turner K, Rivera MP, Reuland DS, Elston Lafata J. How Health-Care Organizations Implement Shared Decision-making When It Is Required for Reimbursement: The Case of Lung Cancer Screening. Chest. 2021;159(1):413-425. doi:10.1016/j.chest.2020.07.078}

_{17. Pulmonary physicians can order lung cancer screening/provide shared decision-making service. American Thoracic Society. Accessed July 20, 2022. https://bit.ly/3Pq8vSr}

_{18. Shusted CS, Barta JA, Lake M, et al. The case for patient navigation in lung cancer screening in vulnerable populations: a systematic review. Popul Health Manag. 2019;22(4):347-361. doi:10.1089/pop.2018.0128}

_{19. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322-1327. doi:10.2105/ajph.89.9.1322}

_{20. Khanna A, Fix GM, McCullough MB, et al. Implementing shared decision-making for lung cancer screening across a veterans health administration hospital network: a hybrid effectiveness-implementation study protocol. Ann Am Thorac Soc. 2022;19(3):476-483. doi:10.1513/AnnalsATS.202105-620SD}

_{21. Matlock DD, Fukunaga MI, Tan A, et al. Enhancing success of Medicare's shared decision making mandates using implementation science: examples applying the Pragmatic Robust Implementation and Sustainability Model (PRISM). MDM Policy Pract. 2020;5(2):2381468320963070. doi:10.1177/2381468320963070}