Experts pinpoint low-dose CT lung cancer screening fixes: ‘Radiologists must be creative and proactive’

Low-dose lung cancer screening has been a hot topic in the news lately, with U.S. lawmakers recently pushing for greater efforts to expand use of this lifesaving clinical tool. Radiology researchers, meanwhile, have pinpointed predictors that patients will receive and stick with their cancer screening plan.

Just this week, the House Appropriations Committee advanced a 2021 spending bill for Health and Human Services that specifically calls out ongoing struggles with early detection.

“The committee remains concerned about the high morbidity and mortality of lung cancer,” lawmakers noted in the 384-page appropriations bill. “Early detection and treatment of lung cancer translates into higher survival rates, but only 16 percent of lung cancer cases are diagnosed early when the disease is most treatable,” lawmakers added, urging the Centers for Disease Control and Prevention to bolster promotion of such screenings as part of its anti-tobacco campaigns.

This problem has been well-documented in the news and medical literature as of late. Back in February, the CDC found in a wide-reaching survey that more than 87% of those recommended for such scans never actually received them. Another analysis published in June noted myriad barriers preventing widespread adoption, including lack of payment, time crunches and technology.

Multiple radiology researchers have added to this body of literature this week. Here is a quick look at three new studies exploring predictors that patients will receive their LDCT screenings, and solutions to address these low adherence rates:

Health status, insurance both predictors of screening

Having a related health condition, such as a different cancer or respiratory issue, along with health insurance status are both predictors of LDCT uptake.

That’s according to a new analysis published Thursday in JACR. Experts reached such conclusions by conducting a population-based survey over the phone across 10 states.

In particular, the team from the universities of Colorado and South Carolina noted that the uninsured were less likely to receive a low-dose CT screen. Uptake was higher, however, among those with chronic respiratory conditions, divorcees, widowers, cancer patients, and individuals between the ages of 65-74.

“Clinicians should increase discussions with LDCT-eligible patients through shared decision making and education visits to increase preference-sensitive lung cancer screening decisions,” advised first author Anja Zgodic, with the Rural and Minority Health Research Center at the University of South Carolina, and colleagues. “Interventions also are needed to improve access to and utilization of screening among those without insurance and to improve utilization among those without histories of cancer or chronic respiratory comorbid conditions,” they added later.

‘Crucial’ to focus on negative exams, current smokers

Another analysis published Wednesday in the American Journal of Roentgenology similarly explores screening predictors, and pinpoints negative exams and current smokers as targets.

To reach their conclusions, scientists with the University of Pennsylvania retrospectively identified patients who underwent at least two lung cancer screening exams between 2014 and 2019. They also analyzed related factors such as demographics, smoking history and Lung-RADS category.

All told, 260 individuals returned for a follow-up LDCT during the study period, with 16.5% testing positive for the disease. Overall adherence to follow-up was about 43% but increased progressively with higher Lung-RADS category. Adherence was also higher among former smokers when compared to current smokers (50% versus 36.2%).

“When devising interventions to augment [lung cancer screening] adherence, it is crucial to focus on negative exams and on current smokers,” advised first author and radiologist Eduardo Mortani Barbosa Jr., MD, and colleagues. “Radiologists must be creative and proactive in implementing solutions.”

Such creativity could include an automated electronic medical record tracking system to detect patients who have missed their screening appointment, or offering financial incentives for continued participation, including premium reductions. Multimodal communication—including in-person conversations, letters and electronic reminders—also warrant investigation, Barbosa added.

“Such communications should emphasize that a negative LCS exam does not confer immunity to future lung cancer development, and that continued participation in LCS, combined with smoking cessation, is essential to accrue the maximum benefits of mortality reduction amongst persons with [a] substantial smoking history.”

Get on the bus

Transportation and distance can also hinder adherence to such screenings, and experts in a third analysis are attempting to alleviate that barrier with the use of a high-tech “lung bus.”

Scientists in Tennessee have built the intervention from scratch, with a mobile LDCT fueled by an independent power source, in a controlled climate that still keeps the patient comfortable.

Researchers began testing out the bus back in early 2018 and highlighted their early learnings Monday in the Annals of Thoracic Surgery. During the first year, Breathe Easy, as it’s called, traveled to more than 100 sites and screened 548 patients, with a mean age of 62 and mean smoking pack years of 41.

They pinpointed significant pulmonary findings in about 9% of patients, including five lung cancers. Four of those, or roughly 80%, were of the early stage variety.

Financially, the team was able to exceed the break-even point of 428 annual scans by 28% in the first year. Insurance payments were collected, where possible, while screenings were free-of-charge for those who could not afford the $150 price tag. They estimated that the bus cost about $650,000 to build and they believe a commercially produced replica would run about $850,000.

"This study shows that if you bring it, they will come. People across the country have not been traveling to medical centers to get scans that they don't know they need," said Rob Headrick, MD, MBA, with CHI Memorial’s Chest and Lung Cancer Center in Chattanooga, Tennessee.

"This bus has provided us with the opportunity to help advance lung cancer screening," he added later. "It's only through conversations and efforts such as the Breathe Easy program that we are going to erase the stigma surrounding lung cancer and change the survival rates."