Lung Cancer Screening Rates Lag Among Those Eligible

Low uptake of lung cancer screening (LCS) among patients who are eligible according to the 2013 U.S. Preventive Services Task Force (USPSTF) recommendations suggests the need for more optimized screening strategies, a cross-sectional study using data from the 2019 Behavioral Risk Factor Surveillance System (BRFSS) survey suggested.

Among 5,750 survey respondents who met all three screening eligibility criteria (ages 55 to 80 years, at least a 30 pack-year smoking history, and current smokers or former smokers who had quit within the past 15 years), only 807 (12.8%) were actually screened for lung cancer, reported Ya-Chen Tina Shih, PhD, of the University of Texas MD Anderson Cancer Center in Houston, and colleagues.

Of the 3,374 respondents who underwent low-dose CT (LDCT) screening, only 20.9% met all three screening eligibility criteria, and 20.1% failed to meet any of these criteria, they noted in JAMA Network Open.

“The low rate of LCS reported here is concerning,” Shih and team wrote. “Although the rate has increased over time, it remains lower than 20%, even after more than 5 years since the USPSTF released its LCS recommendations in 2013 and 4 years after the Centers for Medicare & Medicaid Services began to cover LCS with low-dose CT.”

“Future research is needed to better understand the personal and clinical factors underpinning the underuse of CT screening among the screening-eligible population and its overuse among screening-ineligible individuals to optimize resources allocation for LCS,” they added.

If the March 2021 USPSTF recommendations, which extended the screening recommendation to include adults ages 50 to 80 years with a 20 pack-year smoking history, were used, the weighted proportion of patients screened who met all three criteria increased to 31%, while the proportion of patients who did not meet any of the criteria fell to 15%.

“It is, however, important not to label everyone who underwent CT screening but did not meet the USPSTF screening eligibility criteria as receiving inappropriate care,” Shih and team noted.

In an analysis of respondents who did not meet any eligibility criteria, those with a history of stroke, chronic obstructive pulmonary disease (COPD), kidney disease, and diabetes were found to be more likely to undergo lung cancer screening than those without a history of these conditions.

“Research has found an association of these comorbidities, especially COPD, with increased risk of lung cancer,” the authors wrote. “These comorbidities, however, were not significantly associated with LCS among the screening-eligible individuals, suggesting that physicians may use comorbidity profiles to make screening recommendations for those who did not meet any eligibility criteria.”

In a commentary accompanying the study, Dejana Braithwaite, PhD, MSc, of the University of Florida in Gainesville, and Michael K. Gould, MD, MS, of the Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena, California, called the study “unique in pointing to the dual conundrum, principally, how do we reach a target population that is most likely to benefit from screening while minimizing screening among those who are unlikely to benefit?”

They suggested that at the individual patient level, if a patient doesn’t meet eligibility criteria and has been adequately informed about the potential benefits and harms of screening, the patient is not necessarily being inappropriately screened.

“The real problem with screening individuals who do not meet criteria manifests at the population level,” they wrote. “If we accept the results of the analysis … of BRFSS data at face value, then more than three-quarters of screening LDCT scans are being performed in individuals who are unlikely to derive benefit, which is a wasteful and inefficient use of resources in a healthcare system that is struggling to improve quality and affordability.”

This cross-sectional study included 96,097 survey respondents who answered questions related to lung cancer screening, 33,809 of whom did not meet any screening eligibility criteria. Over 50% of respondents were under 50 years of age, and 33.8% were between the ages of 55 and 79. Half of the respondents were women.

Shih and colleagues acknowledged that the BRFSS did not capture all of the factors associated with risk of lung cancer, including family history, symptoms, and exposure to hazardous chemicals such as asbestos.