Study reveals gaps in lung cancer screening despite updated guidelines

Since 2021, when lung cancer screening guidelines began to include younger people and those with a lower smoking history, the number of screenings climbed, but significant gaps remain, especially among people with limited access to healthcare, according to a new study led by researchers at Sylvester Comprehensive Cancer Center, part of the University of Miami Miller School of Medicine.

"The updated guidelines substantially increased lung cancer screenings overall, even as cancer screenings declined during the COVID-19 pandemic," said Tracy E. Crane, Ph.D., R.D.N., associate professor and co-leader of the Cancer Control Research Program at Sylvester. "However, discrepancies for who is screened persist, underscoring the importance of addressing structural barriers in rural and underserved populations." Crane is senior author of the study, published in the March 20 issue of JAMA Oncology.

Lung cancer is the leading cause of cancer deaths in the United States for both men and women, and screenings can save lives by finding cancer early and making treatment more effective. Low-dose computed tomography (CT) is a relatively new screening tool for early-stage lung cancer.

The U.S. Preventive Services Task Force (USPSTF) issued its first lung cancer screening guidelines in 2013. These screens are quick and painless. In 2021, the USPSTF updated the guidelines to start screening at 50 instead of 55 and to include those with a lower smoking history (20 or more pack-years instead of 30 or more). A pack-year is calculated by multiplying the number of years an individual smoked by the number of packs smoked per day.

First author LaShae D. Rolle, M.P.H., C.PH., a Sylvester doctoral research fellow, used data on health-related risks and behaviors from a nationally representative CDC survey. The dataset is large, but habits and risks are self-reported. Participants may underestimate how much they've smoked or be ashamed to report their habits accurately.

Rolle found that, of the people classified as high-risk before the guidelines changed, only 15.43% were up to date on their lung cancer screenings. The year after the guidelines changed, this jumped to 47.08% of those eligible were up to date - better, but still less than half. The numbers were lower in uninsured patients, those without a primary care provider, and those who live in rural areas.

Many barriers to care

Because patients without a primary care provider were much less likely to get screened, one barrier may be the requirement for a referral. In other cases, the barrier may be knowledge - these patients may not even know they're eligible for screening.

Other barriers include the cost of care. Rolle found that health insurance pays for 97% of lung cancer screenings. Without insurance, a scan can cost hundreds of dollars, in addition to paying for a doctor's visit to obtain a referral.

There are often options to access free or low-cost scans. Many states and nonprofits have programs to defer costs and increase access.

But screening is not a one-time deal. Patients should get a scan annually, and results may require additional testing. The costs come not only from the scan but the follow-up."

Coral Olazagasti, M.D., study author, Sylvester assistant professor of clinical medical oncology

"A person may say - I don't have the money; I don't have insurance. But, no one thinks they have cancer," Rolle said. "I am a cancer survivor myself. I was diagnosed at 26. I understand how easy it is to brush off a screening, especially among those choosing between having food or getting screened."

In rural areas, screening facilities may be hundreds of miles apart, making travel a barrier for many. Mobile lung cancer screening units can bring access to rural areas but cost up to $2 million.

Ways to close the gap

At Sylvester, community outreach teams work to close the disparities in lung cancer screenings.

"We have been identifying the places in our catchment area where the highest-risk patients are not getting screened. We then head over in the Game Changer Bus and educate and counsel the public on lung cancer screenings," said study author Estelamari Rodriguez, M.D., M.P.H., Sylvester's associate director of community outreach for thoracic oncology.

Other ways to increase screening rates among minority populations include patient navigators who can help educate patients, schedule their scans and arrange transportation.

"Partnering with local community organizations, churches and health workers has proven effective in promoting lung cancer screening," study author Gilberto Lopes, M.D., Sylvester's chief of the division of medical oncology, said. "Trusted local figures can help overcome mistrust and fear while providing culturally tailored education."

The gaps in access to lung cancer screening are personal to Rolle. "I was lucky enough to catch my breast cancer early, and now I'm cancer-free. I would love for others to get screened so they can also catch cancer early, too," she said.