Men, younger patients less likely to be screened for lung cancer

From 2015 to 2019, most patients who were screened for lung cancer met 2013 U.S. Preventive Services Task Force criteria, but men, younger patients and those who previously smoked were less likely to be screened, a recent study found.

The now-outdated 2013 USPSTF guidance recommended annual lung cancer screening (LCS) with low-dose computed tomography (LDCT) for adults aged 55 to 80 years who had a 30-pack year smoking history and smoked or quit smoking within the last 15 years.

In 2021, the task force updated its guidance on annual LCS with LDCT, nearly doubling the number of patients who were eligible to be screened, according to Gerard Silvestri, MD, MS, a professor of medicine at the Medical University of South Carolina, and colleagues. This created “an opportune time to consider how the first wave of screening was implemented,” they wrote.

In addition, Silvestri and colleagues noted that CMS is no longer requiring facilities to enter LCS data into a registry for reimbursement, “making this the last time we might be able to analyze nationally representative data on LCS,” the researchers wrote.

For the study, Silvestri and colleagues examined data on patients who, from 2015 to 2019, received a baseline LCDT for LCS at 3,625 facilities that reported to the American College of Radiology’s Lung Cancer Screening Registry (LCSR). They then compared the demographics of patients in the screening registry with the general population and respondents from the 2015 National Health Interview Survey who met the 2013 criteria for LCS.

The researchers found that of the 1,159,092 patients screened, 90.8% (n = 1,052,591) met the 2013 USPSTF criteria. Among those who met the criteria and were included in further analysis, 51.8% were male, 50.3% were aged 65 to 80 years, and 61.4% currently smoked.

Compared with NLST participants (n = 1,257), patients in the LCSR who were screened for lung cancer were more likely to be:

• female (prevalence ratio [PR] = 1.15; 95% CI, 1.08-1.23);

• aged 65 to 74 years (PR = 1.29; 95% CI, 1.2-1.39); and

• a current smoker (PR = 1.17; 95% CI, 1.11-1.23).

Silvestri and colleagues wrote that the differences in those demographics could influence health outcomes.

“Older persons who smoke are at higher risk for cancer, and screening may be more effective, leading to higher lung cancer detection rates,” they wrote. “Conversely, older persons who smoke may have more comorbidities, may have more complications during follow-up evaluation, and may be at higher risk for death from competing causes.”

The researchers pointed out that more current smokers and fewer former smokers were screened than expected. They hypothesized that former smokers may be less likely to insert their smoking status into electronic health records and are thus not available for eligibility.

Silvestri and colleagues added that women have historically been more engaged with preventive health care services than men, resulting in them being screened more frequently.

The researchers reported several limitations to the study, including LCS being potentially underreported and follow-up adherence data not being collected by all centers. They also noted that Medicare managed plans, “which are more common among Medicare beneficiaries who are younger groups and groups of color,” may not have known that reporting LCS data to a registry was mandatory, so screening may be underestimated in these groups.

The researchers concluded that to improve LCS effectiveness, uptake and adherence, a coordinated policy health system — along with efforts from clinicians — are necessary.

“The primary care community should leverage this experience to ensure that LCS is delivered to the persons most likely to benefit, and with increased attention to the nearly doubling of the number of eligible persons with the 2021 update of the USPSTF criteria,” they wrote.

In a related editorial, Karina Davidson, PhD, MASc, advocated for clinicians to obtain a complete smoking history from all patients, “particularly men, former smokers, and younger eligible patients,” to improve lung cancer screening rates while lowering deaths.

Davidson additionally recommended clinicians to:

• ensure that patients who are not likely to benefit from screenings are not being referred;
• work within their health care systems to establish adequate annual follow-up screenings; and
• obtain smoking histories from historically underrepresented groups, including patients who are Black, American Indian or Alaska Native.

“The best way for primary care clinicians to prevent this devastating disease is to help patients avoid smoking and to help those who are currently smoking to quit,” she said.

References:

• Davidson K. Ann Intern Med. 2022;doi:10.7326/M22-2886.
• Moyer V, et al. Ann Intern Med. 2014;doi:160:330-338.
• Silvestri G, et al. Ann Intern Med. 2022;doi:10.7326/M22-1325.