This March the US Preventive Services Taskforce (USPSTF) released highly anticipated lung cancer screening recommendations. This is the first update since 2013 when the Task Force initially recommended annual low dose CT (LDCT) lung cancer screening exams for a small group of high-risk patients.

The new guidelines nearly double the number of Americans eligible for the highly effective screening exam. In particularly good news, the most dramatic increases are among populations disproportionately affected by lung cancer and those with the highest lung cancer mortality, that is, female, Black, and Hispanic patients.

Lung Cancer Screening Recommendations Table

Source: (US Preventive Services Task Force, 2021)

Notes:

1. The USPSTF is comprised of a panel of independent, volunteer clinicians and scientific experts who review evidence to recommend preventive services. The Task Force assigns a letter grade (A, B, C, D, or I) to preventive services to indicate recommendations. Under the Patient Protection and Affordable Care Act (ACA), private payers are required to cover services rated as "A" or "B" at no cost to their beneficiaries.
2. A pack-year the equivalent of smoking one pack of cigarettes per day for a full year.

How will lung cancer screening guidelines change?

The screening recommendation of annual LDCT exams remains, but who is eligible for those exams expand in two important ways:

• To younger patients; eligibility will begin age 50, down from age 55.
• To those with a shorter history of smoking, dropping the number of pack years from 30 down to 20.

Taken together, this increases the eligible population by 6.4 million people or by nearly 90%. The new guidelines have a notable impact on both racial minorities and women. Eligibility increased by 107% in Black adults and 112% in Hispanic adults compared to 78% for white adults, as well as 95% in women compared to 80% in men.

Table title: 2013 versus 2021 Lung Cancer Screening Guidelines

Lung cancer is the deadliest cancer in the US, accounting for nearly 25% of all cancer deaths. This is partially because most patients with lung cancer remain asymptomatic until late stages. LDCT screening has been an incredibly effective tool to identify more cancers at earlier stages, increasing five-year survival rates of this fatal disease.

This increase in eligibility has the potential to dramatically improve lung cancer outcomes. Modeled across a lifetime of screening, these guidelines could reduce lung cancer mortality by 13.0%, as well as avoid 503 lung cancer deaths and contribute to 6,918 life-years gained per 100,000 people.

The harsh reality of lung cancer detection today

Expanded eligibility for lung cancer screening is unquestionably good news. But an increase in eligibility does not necessarily mean an increase in screening volumes. To meaningful improve early stage detection, leaders must consider the broader context of lung cancer screening.

Lung cancer screening rates remain dramatically low

LDCT screening has demonstrated profound results, reducing lung cancer mortality by 20% in high-risk patients who received annual screenings. Despite this, only 8-14% of eligible patients receive the recommended screening exam – compared to 66% for breast cancer screenings and 61% for colorectal cancer screenings.

Why are screening rates so low? Here are just a few of the most common reasons:

• Patients, and even some referring providers, are unaware of the screening exam, eligibility, and clinical benefits
• 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 must cover screening costs out-of-pocket, as only private payers and Medicare are required to cover the exam

• Health disparities persist in lung cancer

  Disparities[1] in lung cancer screening and, subsequently, cancer outcomes persist. Lung cancer mortality is highest among Black men, and five-times higher among the least educated men compared to the highest educated men. Women also have a higher incidence of lung cancer than men.

  Screening disparities can primarily be attributed to eligibility criteria that fails to account for differences in risk related to race, SES, or gender. For example, Black Americans, women, and low SES populations were more likely to be ineligible for screening, not meeting minimum age or smoking history criteria, despite demonstrating an overall increased risk for lung cancer.

  USPSTF's 2021 recommendation helps address some race and gender disparities. However, these new guidelines will likely have a limited impact on low SES populations due to differences between which insurance providers actually cover the cost of LDCT screening.

  Insurance coverage doesn't capture critical populations

  USPSTF recommendations must be covered by private health plans, and Medicare almost always follows suit. However, Medicaid coverage for preventive services varies from state to state. In fact, only 38 Medicaid fee-for-service programs covered preventive lung cancer screening in 2020.

  This leaves out two critically important, and often lowest income, populations: those that rely on Medicaid plans and those who are uninsured. This is especially important because belonging to a racial minority, low SES, and poor literacy all increase the likelihood of someone being uninsured. Even more, low SES is correlated with heavier use of cigarettes, making this population particularly important to target for early lung cancer detection.

  Put simply, many patients that would benefit most from no-cost LDCT screenings will remain unable to access this potentially life-saving service.

  Screening is only one piece of a comprehensive lung cancer detection program

  As many as 70% of lung cancers currently diagnosed are initially found outside of screening. While smoking remains the highest risk factor for lung cancer, about 18% of diagnoses are in patients with no smoking history.

  Many of these cases are identified incidentally, when a pulmonary nodule is detected outside the primary purpose of the scan. In one cancer center, the ratio of nodules detected incidentally versus through screening is 5:1.

  As such, any comprehensive lung cancer program must involve two parts: screening and nodule management. To be successful, it is critical that nodule management programs be highly organized with clear and appropriate care pathways for patients with lung nodules.

  This approach enables programs to both reduce existing barriers to lung cancer screening and address health disparities by identifying patients outside of screening, such as through the emergency room.

  Advisory Board guidance and next steps: How to grow a comprehensive lung cancer early detection program

  1. Improve identification of patients eligible for screening.
     1. How can you determine how many more patients are eligible in your community based on the updated guidelines?
     2. Do you have a marketing plan to communicate changes to your target community?
  2. Inform providers on early detection pathways.
     1. Are providers accurately capturing patient smoking history?
     2. Do providers know where to send patients who meet eligibility criteria?
     3. How will you educate referring physicians on the updated guidelines?
  3. Increase accessibility of screening program.
     1. What data are you tracking to monitor health equity?
     2. How will you overcome lung cancer screening disparities in your community? Consider: education level, language, socioeconomic status, cultural, and racial barriers.
     3. Who is responsible for navigating patients through the nodule and screening programs? Do you have enough navigation staff?
  4. Hardwire pulmonary nodule management.
     1. What happens when radiologists identify pulmonary nodules incidentally?
     2. How are patients and their referring providers (if they have one) notified of the IPN?
     3. What guidelines do you follow for IPN referrals and triage?

  References

  Artiga, S., Orgera, K., & Pham, O. (2020, March 4). Disparities in Health and Health Care: Five Key Questions and Answers. Retrieved from Kaiser Family Foundation: https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/

  Centers for Disease Control and Prevention. (2021, March 2). Nation Center for Health Statistics. Retrieved from Data Finder: https://www.cdc.gov/nchs/hus/contents2019.htm

  Grady, D. (2021, March 9). Yearly Lung Cancer Scans Are Advised for People 50 and Over With Shorter Smoking Histories. Retrieved from New York Times: https://www.nytimes.com/2021/03/09/health/lung-cancer-smoking-screenings-black-women-younger-adults.html?action=click&module=Top%20Stories&pgtype=Homepage

  US Preventive Services Task Force. (2021, March 9). Recommendation: Lung Cancer: Screening. Retrieved from U.S. Preventive Services Task Force: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening

  US Preventive Services Task Force. (2021). Screening for Lung Cancer. Journal of the American Medical Association, 962-70.

   

  
  

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  [1] Health disparities are defined as the higher burden of illness, injury, disability, or mortality experienced by one population relative to another. These differences are based on unnecessary, avoidable, or unjust socially determined factors including geographic location, race, ethnicity, gender, socioeconomic status (SES), and literacy.