Most heavy smokers in the United States who are eligible for low-dose CT screening for lung cancer do not receive it, according to a cross-sectional study reported in a press briefing held before the annual meeting of the American Society of Clinical Oncology.
Results of the National Lung Screening Trial reported in 2011 showed a 20% reduction in lung cancer mortality with targeted low-dose CT (LDCT) screening, noted lead study author Danh C. Pham, MD, of the James Graham Brown Cancer Center at the University of Louisville (Ky.).
Since 2013, the U.S. Preventive Services Task Force has recommended this screening for people aged 55-80 years who are current or former heavy smokers, defined as having smoked at least 30 pack-years, he added. “More importantly, in 2015, the Centers for Medicare and Medicaid Services expanded Medicare coverage for LDCT for lung cancer screening,” he said.
However, results of the new study showed that nationally, only 1.9% of more than 7.6 million eligible current and former smokers underwent LDCT screening in 2016. By region, the South had one of the lowest rates, despite having the most accredited screening sites and the greatest number of eligible patients.
The findings are stark when juxtaposed with rates of screening for some other cancers, Dr. Pham maintained. For example, 65% of women aged 40 years or older underwent mammography for breast cancer screening in 2015.
Dr. Dahn C. Pham
“This ultimately begs the question as to the root of the disparity,” he said. “Are physicians not referring enough? Or perhaps, are eligible patients not wanting screening, even if they know a test is available? Unfortunately, controversy still exists among providers about costs and benefits of screening, while patients at risk for lung cancer also perhaps lack adequate awareness of the benefits of screening.”
It is also possible that the stigma attached to smoking, a modifiable risk factor, and thus to lung cancer screening may be a deterrent, Dr. Pham speculated. Specifically, patients may perceive screening-detected lung cancer as confirmation of a poor lifestyle choice.
“Regardless of the reason, this ultimately is a call to action on everyone’s part to increase this much-needed screening, whether that’s through creating awareness or conducting additional research, to urgently increase screening for the No. 1 cancer killer in America, as it has been now documented that effective screening can prevent nearly 12,000 premature lung cancer deaths per year,” he concluded.
Oncologists in the lung cancer field “would certainly like to be put out of business by an effective screening program,” commented ASCO President Bruce E. Johnson, MD, FASCO.
These new findings should be considered in light of the fact that the study period came only about a year after the change in reimbursement for LDCT, he noted. “So this is not a measure of the steady-state situation, but rather when this was first implemented.”
Nonetheless, it is “very disappointing” how little LDCT screening is being used, added Dr. Johnson, who is also a professor of medicine at the Dana-Farber Cancer Institute in Boston, and a leader of the center’s lung cancer program. “It should be saving 12,000 lives a year, and with this number, it’s about 250 lives. As correctly stated, there is a certain stigma whereby people who smoke feel as if they deserve it or that it’s sort of a self-punishment.”
He agreed that the findings represent a call to action. “We hope that the message will get out there, that people who fall into this risk pattern, folks who have smoked a pack of cigarettes daily for 30 years or longer, will get in and get themselves screened for lung cancer.”
What will it take?
Policy change would likely help increase uptake of LDCT lung cancer screening, according to Dr. Pham. “I think the most radical thing we could suggest based on our study so far would potentially be making lung cancer screening a national quality health measure, just the way that CMS made [mammograms for] breast cancer and colonoscopies [for colorectal cancer] national areas of improvement in 2008,” he elaborated.
“I agree that that could be an effective strategy, particularly since physicians are increasingly being required [to follow] our quality measures to optimize the reimbursement,” commented Richard L. Schilsky, MD, FACP, FASCO, chief medical officer of ASCO and press briefing moderator.
“Keep in mind that, generally speaking, screening of healthy or high-risk individuals for cancer is typically performed by primary care physicians, not by oncologists,” he further noted. “So one of the things that we also need to do is to be sure that primary care physicians are well aware of the screening data and the importance of referring the appropriate patients for screening, and are aware of screening centers available in their communities.”
Dr. Johnson said that the society has been active in that area. “ASCO is working with the American College of Physicians and some of the other primary care groups to try to get the message out about the screening,” as well as to educate them about the large potential impact of screening and treatment. “There are 15 million cancer survivors in the United States, and for the people who fit those criteria for smoking, [we need] to make certain they are getting screened.”
Study details
For the study, Dr. Pham and his colleagues used data from the American College of Radiology’s Lung Cancer Screening Registry, collecting total number of LDCTs performed in 2016 from all 1,796 accredited radiographic screening sites. They also used data from the 2015 National Health Interview Survey to estimate eligible smokers who could be screened based on the USPSTF recommendations.
Overall, 1.9% of 7,612,975 eligible current and former heavy smokers underwent LDCT, he reported. By census region, the rate was highest in the Northeast (3.5%) and lowest in the West (1.0%).
Notably, only 1.6% of eligible heavy smokers in the South underwent LDCT, even though that region had, by far, the most accredited screening sites (663) and the most eligible patients (3,072,095). The rate was highest in the Northeast, at 3.5%, even though that region had the second-lowest number of accredited screening sites (404) and the fewest eligible patients (1,152,141).
Dr. Pham disclosed no relevant conflicts of interest. The study received grant funding from the Bristol-Myers Squibb Foundation.
SOURCE: Pham DC et al. ASCO 2018. Abstract 6504.