Lung cancer remains the leading cause of cancer deaths in the United States, with more than half of all cases (57 percent) being diagnosed at a late stage with an average five-year survival rate of 22.6 percent.1. However, there are signs of progress, with the rate of new cases declining nationally by 9 percent and the five-year survival rate increasing by 13.1 percent over the past five years.2. This is probably due to lower smoking rates, increased radon testing, stricter air pollution regulations and improved treatment1. However, the implementation of screening for lung cancer to detect the deadly disease at an earlier stage has undoubtedly also played a role in this gain.
In 2011, the National Long Screening Trial reported a relative 20% reduction in lung cancer among adults who smoked heavily and received a low-dose CT (LDCT) annual examination, compared with those who received annual breast photographs.2. Based on this evidence, the United States Preventive Services (LSCT) Task Force for Preventive Services (LDCT) recommends high-risk adults (defined as 55- to 80-year-olds with a smoking history of more than 30 years). and ceased less than 15 years ago).
Insurance companies and Medicare / Medicaid started covering LCS in 2014-2015. Despite these guidelines and financial compensation, the patient and physician’s use of the guideline is slow. Less than 4 percent of eligible adults received selections in 2015, and the figure had a marginal increase to 5.7 percent in 20202. But even with the lingering adoption, early diagnosis rates have increased by 33 percent over the past five years2. Of all cases, 23 percent are caught at an early stage, which has a much higher five-year survival rate at 59 percent2.
Why did the rates for LCS with LDCT remain low? There are many possible factors at stake, such as healthcare providers not collecting sufficiently detailed smoking history to qualify patients; smokers are a demographic with a tendency to have less contact with primary care providers (PCPs), and PCPs do not recommend screening time and other priorities, lack of incentive of insurance, a high amount of false positive responses to MOL , perhaps even the perception that smoking is a lifestyle choice and that no resources should be spent on this population.
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As for the argument for the unacceptable number of false positives, there is indeed a 20 percent rate of overdiagnosis of lung cancer, which is consistent with the rate of overdiagnosis in breast cancer3. However, it also prevents one death for every 250 screens, which exceeds the number required to treat 2000 (NBT) for mammography screening4. According to one meta-analysis of the annual LCS with LDCT, mortality from all causes has not been significantly reduced, which is reassuring that the increased amount of screening and overdiagnosis of lung cancer has not increased other causes of mortality5.
What can we do to increase compliance with this useful screening tool? Many possible barriers can be targeted, such as the use of clinical navigators to help patients follow up appropriately, implement algorithms to better identify suitable patients using existing electronic healthcare data. There are two reports that try to augment it in two different ways, one more clinical, one involving more of the community.
In the first scenario, within the Kaiser Northern California system, in 2015 they implemented a reporting system that standardized radiological reports of pulmonary findings with labels. Markers indicating lung cancer were automatically forwarded to a coordinator who sent a list of cases to a triage doctor. The doctor then referred the matter to a multidisciplinary committee or the patient’s primary care physician (PCP) with recommendations on management.
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The committee was composed of a care coordinator, pulmonologist, breast surgeon and often a radiologist and oncologist. The group met weekly to discuss issues. They will then manage the case or send recommendations to the PCP. From the data collected before and after the implementation of nearly 100,000 patients, they found that early-stage lung cancer was detected 26 percent of the time before intervention and 30 percent of the time after surgery.
The intervention was accompanied by a 24 percent increase in the chance of early-stage lung cancer diagnosis within 120 days, with a faster time to surgery (46 days versus 41 days) without biopsies. It appears that the standardization of the radiological reporting together with the multidisciplinary committee has increased the detection rate of cancer in the early stages, which ultimately leads to long-term outcomes3.
The other case is the state of Kentucky which has one of the highest LCS rates in the country. Kentucky has expanded the Medicaid program, removing the need for pre-authorization for LCS. The government supports the case by committing the governor to reducing the risk of lung cancer. In 2013, the Kentucky Long Survivorship Collaborative for the Awareness of Lung Cancer Education was created and two LCS projects were implemented.
The first one taught hundreds of PCPs about the prevention, early detection, treatment and survival of lung cancer. The second project provided feedback to LCS programs on the best way to deliver screening and engage healthcare providers. As a result of this joint effort by the community with government support, Kentucky has the third highest screening percentage in the country, leading to more lung cancer survivors. They provided a framework for other countries with high lung cancer burdens to follow2.
As evidence continues to grow that LDCT is an effective tool for increasing lung cancer survival – and increasing public awareness – LCS rates are likely to rise in subsequent years. However, there is still much work to be done to achieve the rates that will benefit the most vulnerable population.
As shown by these two cases, there are issues that can be improved at every level of the system – teaching patients about the benefits of the annual LDCT, promoting the value of LCS for PCPs, standardizing lung cancer findings and – patterns within an electronic medical record. improved coordination of care, and further research on how to refine screening populations and screening modalities. With widespread acceptance by healthcare providers, this intervention will certainly improve longevity and quality of life for a greater number of individuals at risk of being diagnosed with lung cancer.
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References:
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Report on State of Lung Cancer 2020 (Rep.). (2020, November 17). Visit https://www.lung.org/getmedia/381ca407-a4e9-4069-b24b-195811f29a00/solc-2020-report-final.pdf
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Stacey A Fedewa, PhD, Ella A Kazerooni, MD, MS, Jamie L Studts, PhD, Robert A Smith, PhD, Priti Bandi, PhD, Ann Goding Sauer, MSPH, Megan Cotter, MPH, Helmneh M Sineshaw, MD, MPH, Ahmedin Jemal, DVM, PhD, Gerard A Silvestri, MD, MS, condition variation in low-dose computed tomography scan for lung cancer screening in the United States, JNCI: Journal of the National Cancer Institute, 2020;, djaa170, https: // doi .org / 10.1093 / jnci / djaa170
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Urbania, TH, Dusendang, JR, Herrinton, LJ, Alexeeff, S., Corley, DA, Ely, S.,. . . Sakoda, LC (2020). Standardized reporting and management of suspicious findings on chest imaging are associated with improved lung cancer diagnosis in an observational study. Bors, 158 (5), 2211-2220. doi: 10.1016 / j.chest.2020.05.595
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Gøtzsche, PC, & Nielsen, M. (2006). Screening for breast cancer with mammography. The Cochrane Database of Systematic Reviews, (4), CD001877. https://doi.org/10.1002/14651858.CD001877.pub2
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Ebell, MH, Bentivegna, M., & Hulme, C. (2020). Cancer-specific mortality, mortality from all causes and overdiagnosis in lung cancer Screening Trials: A meta-analysis. The Annals of Family Medicine, 18 (6), 545-552. doi: 10.1370 / afm.2582