Decreased Rates of Lung Cancer Screening Highlight Need for Greater Awareness

More focus is needed on increasing lung cancer screening for patients, especially in those who are eligible for it according to their smoking history.

Lung cancer screening may not be performed as often as needed to identify patients at low or high risk for the disease, but increasing awareness to both patients and health care professionals may help increase the rate.

Approximately 5% of people who are eligible for lung cancer screening actually get screened, according to a presentation during the CURE® Educated Patient® Lung Cancer Summit. Due to a number of barriers like fear of stigma and criteria specifications, this low percentage prevents doctors and patients from deciphering who is at a low or high risk for lung cancer.

“There really hasn't been a big focus to tackle this, meaning there have been wonderful, educational campaigns by different lung cancer patient advocacy groups, but there really hasn't been an effort for most health systems to tackle this because it really involves not just educating patients, but educating providers,coordinating all of this having a system where patients are easily identified,” Dr. Dan Raz, director of lung cancer screening and associate professor of surgery at City of Hope in California, explained in an interview with CURE® after his presentation. Here, he speaks more on the topic.

CURE®: What is the difference between a low-dose computed tomography (CT) and a chest X-ray?

Raz: That's a really important question because a lot of primary care physicians will still screen patients with annual chest X-rays. That's been studied many times in the past, and it's never really panned out to show a decrease in lung cancer deaths. So there may be some benefit in selected patients, but overall, it hasn't been shown to be effective in studies, whereas low-dose CT is a lot more sensitive. It picks up very, very small nodules compared to X-ray, and that's probably the reason why it has been shown to decrease death from lung cancer in people who used to smoke or currently smoke.

You said in your presentation that low-dose CTs aren’t frequently used by primary care doctors. Why is that?

The estimates currently are that less than 5% of people who are eligible for lung cancer screening actually get screened. And there's a variety of barriers to utilization of lung cancer screening, and we typically separate barriers … to system barriers, physician barriers and patient barriers. We’ve actually worked and studied all three of them. … (With system barriers, one of the issues is that unlike other cancer screening, where it's very simple like age, sex (and) it's very clear what the recommendations are. Lung cancer screening depends on knowing the patient's smoking history. And so most health systems and primary care physicians don't collect that information in enough detail where patients can easily be identified. So (it) really relies on either a doctor thinking about it in the back of their head, “Okay, how much did you smoke? How many packs a day? How many years,” asking those kinds of questions, or a patient knowing that they're eligible and asking their doctor for a scan. So that's one of the big reasons (why it’s underutilized).

Amongst primary care doctors, we did surveys — which they're a few years old now — but still about half of primary care doctors don't know the recommendations for lung cancer screening. So there's a really big opportunity to educate primary care doctors about this.

What are the requirements to be eligible for a lung cancer screening?

Right now, it's age 50 to 80, and someone who has smoked at least 20 pack-years. Pack-year is you multiply the number of packs per day that someone smoked times the number of years that they smoked. So usually, some people have smoked a range of cigarettes. We usually just use like the highest amount they smoke, so if they smoked one pack a day at the most, we use that. … And if someone smoked for 30 years, one pack per day, then that would give them a 30 pack-year history. If someone smoked half a pack per day for 40 years, that gives them a 20-pack year history. So right now, the guidelines are for people who have at least a 20-pack-year history of smoking, and one more complicating factor — if they quit smoking, that they should have quit within 15 years. So someone who's quit 20 years ago but smoked very heavily would not be eligible. Although if they went and smoked a cigarette yesterday, then they would be eligible. So it's a little bit of a weird criteria.

Does this extend to all tobacco products like cigarillos or hookah?

It’s really just cigarettes, but you're absolutely right. I mean, people who smoke (other things) heavily probably have the same amount of exposure.

How do we make lung cancer screening better known and more accessible?

I think education is probably the most important thing. And I think there needs to be some kind of involvement of different health systems to make it a priority for patients. That means improving systems to identify patients that are eligible for screening, keeping track of how frequently primary care physicians are ordering scans for patients who are eligible. That's something that's commonly done for other preventative health measures like colorectal screening, mammography, diabetes care where that's a quality metric. And so that really kind of lights a fire under the primary care physician to make sure that they do those things for eligible patients. And I think having something like that for lung cancer screening would probably be very helpful.

One thing that we're really interested in is expanding the role of smoking cessation. A lot of people are referred for smoking cessation either at individual hospitals or through quit lines, and there's a big opportunity to identify people who are eligible for screening who are current smokers and to encourage them to get screened, to educate them, to coordinate their screening.

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