Lung Cancer Screening: Why it Feels Like We Have More to Do

YPS: Early to Rise

The YPS is a community dedicated to representing and supporting early-career professionals — members under the age of 40 or within the first eight years of completion of training. The YPS Executive Committee works to develop valuable early-career member resources, amplify YPS issues and needs at the national level and provide a network of support to all members in this stage of their ACR and career journey. This new Bulletin series, proposed and authored by YPS members, shares their perspectives on challenges, opportunities and outcomes within an ever-evolving specialty.

The most recent 2021 U.S. Preventive Services Task Force guidelines significantly broadened eligibility for lung cancer screening with lower age and pack-year criteria, increasing the percentage of Americans who are eligible for screening by about 87%. However, a common source of frustration for radiologists is that while lung cancer screening is proven to work and is widely available, it’s still not universally used.

The Problem

The uncomfortable truth is that despite the evidence, national lung cancer screening uptake seems to have stalled around 16% of the eligible population. This means that most of the eligible population is either not aware, not referred or not participating.

Where are we going wrong? Barriers include provider and patient awareness gaps, logistic hurdles like insurance coverage, prior-authorization headaches in primary care physician offices, and delays between patients being referred and being able to be screened. A recent JACR^® article titled “A Multicomponent Behavior Change and Implementation Strategy to Increase Lung Cancer Screening in Primary Care Practices: The IBREATHE Study” by Lauren K. Groner, DO, MS, and coauthors is an updated and comprehensive snapshot of the types of barriers that primary care providers are facing. Not surprisingly, primary care physicians are already stretched too thin at annual visits, and it may not be feasible to include a discussion of lung cancer screening as well.

Meanwhile, radiologists are juggling incidental findings (e.g., thyroid nodules, etc.) and absorbing low-dose CTs (LDCTs) into the ever-expanding imaging volumes. It can often feel like our efforts to improve screening uptake are going unnoticed, particularly because we are not at the front lines translating the guidelines into practice.

Where Things Are Heading

Despite the aforementioned challenges, there are reasons to be optimistic:

• Artificial Intelligence: AI tools are getting better at nodule detection, risk stratification, and even helping with incidental findings and follow-up. The challenge is facilitating seamless integration into clinical practice.
  
• Expanded Efforts: Screening requires access to a center that offers LDCT, insurance coverage, a primary care office that can navigate the insurance-approval process, and further time and transportation to follow through with the scan. Historically underserved groups — who are often at higher risk — are increasingly being prioritized in outreach and education campaigns. A recent JACR article by Jordan M. Neil, PhD, and coauthors titled “Co-Development, Evaluation, and Dissemination of a Lung Cancer Screening Digital Outreach Intervention: A Multiphase Randomized Clinical Trial” used targeted and curated videos to successfully promote lung cancer screening among individuals from low-socioeconomic status communities. Direct-to-patient efforts may be a worthwhile endeavor for future efforts.
  
• Better Integration into Primary Care: Follow-up research from the IBREATHE pilot study and dissemination of resources such as LungCheck.org has the potential to streamline clinical workflows and help clinicians navigate tedious nuances.
  
• Continued Research and Advancements: A dedicated December special issue of the JACR will be highlighting all of the recent research and advancements in lung cancer screening.

A Call to Action

If you’re reading this, you are already in the choir. But the choir still needs to sing louder and on key. Encourage your institution to make lung cancer screening a part of the routine care pathways. Nudge primary care colleagues who don’t consistently refer patients and provide them with the resources they need to navigate the nuances. Advocacy doesn’t have a relative value unit conversion, but it has clinical value and can keep moving the needle in the right direction. And keep reminding patients that just because they don’t feel sick, it doesn’t mean their lungs are in the clear.

At the end of the day, lung cancer screening is a scan that can save a life. And yes, sometimes it feels like the challenges are insurmountable because of the diverse stakeholders, complex behaviors and opaque insurance processes. The challenge isn’t convincing us of the effectiveness — it’s in making the system work so that our patients can be screened.

By Madison K. Wulfeck, MD, MBA, CIIP, cardiothoracic radiologist with Radiology Partners-Florida, and ACR RFS/YPS Liaison