Lung cancer remains the deadliest cancer in the United States. Health disparities and inequity place an even greater disease burden on certain populations with factors including race, gender, and socioeconomic status impacting both lung cancer incidence and death.

Living in a lower socioeconomic area increases a person’s 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 (Table 1).  Disparities also persist within race and gender. Black men are most likely to die of lung cancer, with a mortality rate nearly 20% higher than men from all other races in a study published in 2019 (Table 2).

Lung cancer survival rate depends heavily on stage at diagnosis. Patients diagnosed at early stages, when the lung cancer is still localized, have a five-year survival rate of nearly 57%. However, that rate drops to 31% for regional stages, and just 7% for distant stages.

We can’t over-rely on lung cancer screening

Lung cancer screening via low-dose CT (LDCT) offers a common pathway to early diagnosis. 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.

Screening rates may increase as nearly double the number of Americans are eligible for LDCT lung cancer screening thanks to revised guidelines released by the United States Preventive Services Task Force (USPSTF) in March 2021. The most dramatic increases are among populations with the highest lung cancer mortality and/or those at the highest risk for lung cancer at younger ages, that is, female, Black, and Hispanic patients.

However, a plethora of challenges keep screening rates low, from individual concerns like radiation exposure to societal barriers like the stigma that accompanies smoking.

Based on Advisory Board’s research, we believe the industry should absolutely continue pushing to increase screening rates. We understand that it will be extremely difficult to advance equity relying on screening alone. Fortunately, another approach exists that may bypass some of the common barriers to screening.

Enter incidental pulmonary nodule (IPN) findings

Incidental findings are abnormalities uncovered unintentionally and unrelated to the condition that prompted an exam. Pulmonary nodules are abnormal growths that form in a lung. They can be identified on imagining scans. Most pulmonary nodules are benign, but some indicate the presence of lung cancer.

As an example: a patient visits the emergency department (ED) after a fall where the ED provider orders a chest X-ray to check for fractured ribs. While reading the scan, the radiologist finds an IPN and informs the ordering provider, who in turn notifies the patient and helps coordinate follow-up care.

If managed correctly, incidental findings may allow more patients with lung cancer to be diagnosed at earlier stages, providing another opportunity to improve survival. For example, one organization found that of all patients with lung nodules, 80% of cases were detected incidentally versus 20% from routine lung cancer screenings. In other words, incidental findings resulted in the detection of four times as many patients with lung nodules than relying on screening alone. Of the total patients, about 15% were diagnosed with lung cancer with 94% of those cases being Stage I or II.

How can IPNs reduce disparities?

Effective finding and management of incidental pulmonary nodules can bypass some common barriers to lung cancer screening that contribute to health disparities.

This answer isn’t perfect.

IPN programs may help ease some barriers to lung cancer detection, but there are further challenges that contribute to disparities that this option does not address:

• Complications that come through follow-up including making an appointment, having nearby providers in your community, and transportation to appointments
• Costs of care for patients without adequate insurance coverage or financial means
• Trust in the health care system overall and in individual providers

Finally, IPN management requires additional resources, clinician education, and staff to ensure patients don’t slip through care gaps. Leaders may struggle to capture their executives’ attention or secure enough funding for a robust IPN program right away. However, there are steps you can take to get started in the right direction.

Advisory Board’s guidance and next steps

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