This article is the fourth in a five-part Bulletin health equity series and examines challenges around lung cancer screening when identifying eligible populations in uninsured and underserved communities. The third article in the series, Screening at the Source: Mobile Health Units Deliver, was posted in October on acr.org/bulletin.
Efforts to eradicate disparities in delivering critical imaging services continue to gain momentum as systemic problems loom large over the house of medicine. Current healthcare inequities in radiology can result in lower quality of care, poor patient outcomes and higher costs to patients and providers.
Marginalized populations often face barriers to treatment — including education and outreach, access to healthcare services and a host of social determinants that plague underinsured and underserved communities. Initiatives that establish health equity partnerships and build from innovative institutional efforts to ensure equitable care on a united front are putting vital services within reach.
The ACR is part of the Radiology Health Equity Coalition (RHEC), a group of organizations that joined forces in 2021 to positively impact health equity for vulnerable outlier populations. To paint a picture of how radiologists and physicians from other specialties are moving the needle, the ACR Bulletin is interviewing changemakers who are striving to meet Coalition goals around advancing equitable care.
Cancer Mortality in Underserved Populations
In the northern and central parts of Florida, there are rural populations that do not have adequate access to efficient and effective medical care. Hispanic/Latino populations in the southern part of the state and Black populations in concentrated pockets of Florida also experience disproportionate poverty and distress, according to Mathew Ninan, MD, FACS, FRCS, FETCS, director of the thoracic surgery and lung nodule network at HCA Florida Healthcare (West Division).
“When you look at especially disadvantaged populations, you find that lung cancer is the number one cause of cancer mortality,” Ninan says. If lung cancer is caught before it spreads, the survival rate of five years or more is boosted to 80%. Low-dose CT scanning (LDCT) has been proven to reduce lung cancer deaths. “The best way to reduce deaths from lung cancer is to find it early when it is most treatable,” he says.
Among the three major screenings nationwide — breast, colon and lung — lung screening by far is the most underused. Breast screening is around 75%, colon at about 60%, and lung screening at just below 5% of eligible patients, according to the National Cancer Institute’s Cancer Trends Progress Report.
When reaching out to these populations, you should be careful not to say you want to do lung cancer screening. Instead, tell patients that you are checking to see how healthy their lungs are. That can make a big difference in a patient’s willingness to get screened.
As of March 9, 2021, the U.S. Preventive Services Task Force (USPSTF) recommends adults age 50 to 80 who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years screen for lung cancer with LDCT every year. One pack-year refers to smoking 20 cigarettes (one pack) per day for one year.
“Only 3% of eligible Floridians receive lung cancer screening, and I decided I had to do something to increase that rate in our state,” Ninan says. “My aim is to increase our rate from 3% to 30%.”
To help achieve that goal, Ninan earlier this year convened the Florida Lung Health Coalition (FLHC). The Coalition’s stated goal is to accelerate the uptake and adherence of lung cancer screening in Florida. Using a three-pronged approach, FLHC is focused on collaboration among public and private stakeholders, leveraging technology to increase screening and reduce unnecessary procedures and to strategically engage in community outreach. Coalition participants include hospital systems, outpatient radiology providers, surgical equipment manufacturers and national lung cancer foundations, among others.
The FLHC held its first major symposium in June, featuring a host of expert speakers on lung health. Topics included equity in cancer detection, patient perspectives, applying data analytics to mobile healthcare and building screening networks.
FLHC Symposium and a County Focus
Ninan hosted the symposium in part to secure funding for new pilot studies. “I have found industry partners to put money into the initial studies, which will focus on identifying screening challenges and increasing screening rates,” he says. One study will focus on St. Lucie and Martin counties on Florida’s east coast north of Palm Beach, which were chosen because of their demographics, hospital systems and access to radiology services. A second screening study will be conducted in Pasco County in western Florida, using the latest blood test-based screening.
“Other individuals and institutions have been successful in educating patients and moving the needle on lung cancer screening through mobile outreach at the community level, but we are approaching this problem by identifying larger geographic areas at the county level,” Ninan says. “The aim of the study, the endpoint, is plain and simple — to increase the rate of screening in eligible patients for lung cancer. We are getting more partners in place who have promised funding through private sources to see the studies through to completion.”
Ninan believes findings from the initial studies will show that lung cancer screening rates can be significantly increased in the selected counties — and that evidence-based data can influence policymakers’ decisions around current screening shortfalls. “We need to take something to policymakers and regulators that will shape better healthcare practices around this important screening.”
His message to those with the authority to expand lung cancer screening coverage: A small expense on the front end to identify people in an underserved patient population will save untold amounts of money down the road. “Who is going to pay for the care of lung cancer patients?” he asks. “How will they cover the cost of immunotherapies, for example? As a thoracic surgeon, I see patients coming in with tubes and wires and wonder how many of them could have avoided their current state if only they had been screened.”
Policy Barriers to Lung Cancer Screening
Existing coverage policies and their eligibility requirements for lung cancer screening are as responsible for low screening numbers as geographic and socioeconomic barriers, Ninan says. “We need to get rid of shared decision-making visits and stop delays to follow-up scans because of prior authorization. These are two big problems with lung screening uptake.”
CMS defines a lung cancer screening shared decision-making visit as one to determine eligibility and provide information about potential benefits or harms of screening — including counseling on the importance of adherence to screening recommendations and tobacco abstinence. This is intended to result in a shared decision — to screen or not — by the clinician and patient. While the mandate may accomplish an information exchange, such a visit may not take into account a patient’s values or preferences — which compromises the best patient-centered care.
“Shared decision-making visits with primary care providers (PCPs) were put in place initially because Medicare thought there could be a lot of patients with findings that could lead to unnecessary biopsy procedures,” Ninan says. “In addition, the incentive to screen is minimal, as Medicare does not reimburse well, and PCPs may not take the time to order lung screening even if a patient may be eligible.”
There is no Medicare requirement of PCPs to offer lung cancer screening to their patients, Ninan says. “If multiple visits are necessary and it takes them up to 45 minutes to hold one, how much shared decision-making are they going to do?
“I think the entry point to screening is not through the PCPs, but by going directly to the patient,” Ninan says. “When reaching out to these populations, you should be careful not to say you want to do lung cancer screening. Instead, tell patients that you are checking to see how healthy their lungs are. That can make a big difference in a patient’s willingness to get screened.”
If a patient does get screened and something is detected, prior authorization — getting approval in advance from a health plan to cover a service before it can be provided — should not be a hurdle. “If a lung mass or nodule is detected on lung screening, further downstream investigations of the finding should not require prior authorization,” Ninan says.
Those patients need to be treated efficiently, Ninan says. “We don’t want to wait six months and allow a cancer to grow into real trouble.” Changes to both shared decision-making and prior authorization rules would have a positive response from the general population, he says.
“This is always the case,” Ninan says. “If you look at breast cancer screening, for example, a woman needing a mammogram can go out and get one virtually on request. In Florida, about 80% of eligible women in the state have had a mammogram in the last two years. That is not happening with lung screening.”
Partnering and Tapping Expertise
Ninan is confident lung cancer screening numbers will improve through the work of the FLHC and by producing conclusive data when identifying underserved counties. “We have established the coalition, have commissioned a pilot study and are building a broader network to advocate for equitable lung cancer screening coverage,” he says. “To do anything less would be ridiculous.”
It is critical to build a network and form partnerships with like-minded groups that are dedicated to fair and equitable patient care, Ninan says. Prior to and throughout the launch of the FLHC and the first symposium, Ninan reached out to the ACR, the Radiology Health Equity Coalition (RHEC), the Florida Radiological Society and others to garner support and resources.
“I have also become familiar with some of the outpatient radiology providers in the state and other industry stakeholders involved in the treatment of lung cancer — including Big Pharma, surgical equipment manufacturers, multiple physician groups and medical oncologists,” Ninan says.
Ninan even reached out to a consultant radiologist for the National Health Service in the UK to learn more about the mechanics of how that organization has accomplished similar goals in preventive screening. He is also working with lung health program leaders in other states for insight into their processes, successes and lessons learned.
“At some point, we will need the ability to store and retrieve a massive number of scans,” Ninan says. “That is one thing I am talking to program leaders about, and we believe this can be done using outpatient radiology providers in the state.”
The idea is to pick the brains of as many experts as possible on growing lung cancer screening rates, Ninan says. Securing more private investments is also on the radar. “We would like to extend our approach to at least five other counties,” he adds. “There is a real need in these underserved areas, and it is time to focus and get things done.”
National Lung Cancer Screening Day 2023
In November 2022, almost 400 screening centers opened their doors and participated in the first-ever National Lung Cancer Screening Day. Building on its success, the second annual National Lung Cancer Screening Day will be held on Saturday, Nov. 11, which is also Veterans Day. Celebrate and save lives — register now to participate.