Despite significant changes in recent years, including highly anticipated revisions to lung cancer screening recommendations, lung cancer remains the deadliest cancer in the U.S. Lung cancer screening via low-dose CT (LDCT) offers a common pathway to early diagnosis. And in high-risk patients receiving LDCT screenings, clinical trials have demonstrated that annual screenings can reduce lung cancer mortality by 20%.

Unfortunately, lung cancer screening rates remain significantly lower compared to other cancer screenings. An estimated 14% of eligible patients received the recommended LDCT screening exam versus 66% for breast cancer screenings and 69% for colorectal cancer screenings.

Why are screening rates so low? A few of the most common reasons Advisory Board researchers hear from provider leaders are:

• Patients, and even some referring providers, are unaware of the screening exam, eligibility, and clinical benefits, and/or have concerns about radiation exposure, overdiagnosis and false-positive scans
• Referring providers and screening programs struggle to track accurate smoking history
• Some patients are hesitant to receive the exam due to stigma around smoking and perceive lung cancer as a personal failure
• Due to geographic spread, some patients are unable to access lung cancer screenings
• Some high-risk and often lower income patients may struggle to cover screening costs out-of-pocket, as only private payers and Medicare are required to cover the exam

Factors impacting false positives in screening exams

One way to build confidence in lung cancer screening exams is to reduce false positive rates. False positives in lung cancer screening lead to unnecessary interventions, causing higher costs and emotional strife for patients. In a recently published retrospective study, researchers found that two of the major factors affecting false positive rates include radiologist experience and median income by zip code.

Unsurprisingly, more experienced radiologists had lower rates of false positives. Patients living in higher income zip codes also had lower rates of false positive scans, the authors believe more research is required to understand why.

This second factor is especially concerning as living in a lower socioeconomic area is correlated with a greater likelihood of having lung cancer. Lung cancer incidence is more than 30% higher in rural counties where at least 20% of the population lives below poverty compared to similar counties with less than 10% of the population below poverty according to a study published in 2018.

To sum it up, the communities with higher instances of lung cancer are also the communities most likely to experience higher false positive rates. Building trust in these communities is imperative to increasing screening rates and, in turn, reducing lung cancer mortality.

Advisory Board guidance and next steps

Organizations have an opportunity to grow their comprehensive lung cancer programs and reduce instances of false positive exams. Some next steps to consider are:

Build the clinical workflow around the patient

A lung cancer diagnosis can be scary for patients. To reduce the chance of a false positive, centralize services and clinicians involved in lung cancer detection, staging, and treatment decisions. This approach allows clinicians to lean on each other's experience to make the best possible decision for the patient.

Collect, analyze, and leverage data to uncover disparities

We know disparities exist in lung cancer screening. Robust data collection and management can help identify care gaps, allows organizations to continuously improve practices, and highlights disparities in performance.

Continue to cultivate lung cancer awareness

Although false positives are possible, it's still incredibly important to grow screening rates.

1. Improve identification of patients eligible for screening.
   • Determine how many more patients are eligible in your community based on the updated guidelines.
   • Create a marketing plan to communicate changes to your target community.
   • Work with community trust brokers to raise screening awareness.
   • Build engagement around the patient.
2. Inform providers on early detection pathways.
   • Identify challenges related to accurately capturing and sharing smoking history
   • Ensure providers can easily and consistently refer eligible patients to your screening program.
   • Educate referring physicians on the updated guidelines.
3. Increase accessibility of screening program.
   • Identify data needed to advance health equity
   • Work to overcome lung cancer screening disparities in your community. Consider education level, language, socioeconomic status, cultural, and racial barriers.
   • Ensure you have appropriate staff and models to help patients navigate through the nodule and screening programs.
4. Hardwire pulmonary nodule management.
   • Establish a plan for what happens when radiologists identify pulmonary nodules incidentally.
   • Determine how patients and their referring providers (if they have one) are notified of the incidental pulmonary nodule (IPN).