A pragmatic pre-post intervention trial to address adherence to lung cancer screening follow-up in community settings (the ACCELL trial): Study protocol.

When Will Enough Ever Be Enough?

10559 Background: Lung cancer is the leading cause of cancer death in the U.S, accounting for about 25% of all cancer mortality. The U.S Preventive Services Task Force has recommended annual screening for lung cancer using low-dose computed tomography (LDCT) scanning for individuals at higher risk (aged 55-80 years with a >30 pack-year smoking history). Early detection using LDCT scanning reduces lung cancer specific mortality by 20%. Despite its efficacy, the uptake of annual lung cancer screening among high-risk individuals remains low ( < 18%). The purpose of this study was to identify factors associated with the uptake of lung cancer screening in high-risk individuals in the U.S population. Methods: Data for this study were obtained from the 2017-2019 Behavioral Risk Factor Surveillance System (BRFSS), a population-based survey conducted annually by the Centers for Disease Control and Prevention (CDC) in collaboration with health departments in all 50 states, Washington, DC, and the U.S territories. We restricted our sample to high-risk individuals aged 55-80 years with a >30 pack-year smoking history. Only subjects with complete data on all predictor variables (age, gender, race/ethnicity, marital status, education, income, insurance, COPD, current smoking status, primary care provider) and the outcome variable (uptake of lung cancer screening) (n = 11, 714) were included in the final analysis. Chi-square tests were used to compare the uptake of lung cancer screening by demographic and socioeconomic factors. Multivariable logistic regression models were used to model the association between the predictors and the outcome variable. Results: Individuals with no health insurance (OR: 0.64; 95%CI: 0.46-0.90), no primary healthcare provider (OR: 0.40; 95%CI: 0.31-0.52), no chronic obstructive pulmonary disease (COPD) (OR: 0.35; 95%CI: 0.31-0.0.40) and who were females (OR: 0.86; 95%CI: 0.76-0.96) were less likely to participate in annual lung cancer screening. Individuals aged 65–69 years (OR: 1.65; 95%CI: 1.38-1.97), 70–74 years (OR: 1.77; 95%CI: 1.46-2.14) or 75–80 years (OR: 1.42; 95%CI: 1.16-1.76) were more likely to receive annual lung cancer screening compared with those aged 55-59 years. Race/ethnicity, level of education, level of income, marital status, and current smoking status had no significant association with the uptake of annual lung cancer screening. Conclusions: Our study identifies factors associated with lower uptake of annual lung cancer screening (no health insurance coverage, no primary healthcare provider, no COPD, and female gender). The findings from this study have important implications for the design of more effective interventions to target specific subgroups for the uptake of annual lung cancer screening.

6555 Background: Lung cancer (LC) is the leading cause of cancer death in the US in both men and women; causing 25% of all cancer deaths. Annual lung cancer screening (LCS) with a low-dose CT (LDCT) in high-risk individuals (aged 50-80 with a >20 pack-year smoking history) decreases LC deaths by 20% and is recommended by USPSTF. Despite the efficacy, uptake of LDCT remains low at 6% nationally, and 13% in Rhode Island. Patient (pt) and provider perceived barriers, along with racial, ethnic and socioeconomic disparities widen the gap. We evaluated the implementation of a LCS navigation program at an urban community health center (CHC) with a multiethnic, socioeconomically underserved population. Methods: A bilingual (English and Spanish speaking) pt navigator was integrated into routine clinic practice at a large primary care CHC group, across 4 sites, starting in January 2022. The navigator’s role was to assess pt and provider awareness of the LCS process, assess for systemic barriers, and provide navigational support for the LDCT process. Pts eligible for LCS at the CHC from 1/2022 to 12/2022 were retrospective examined; 50 to 80 years and a >20 pack-year smoking history. The navigator administered a questionnaire to assess barriers to LDCT and demographic variables. Results: A total of 360 eligible pts were seen across the CHC practice in 2022, of which 149 (41.4%) agreed to undergo LDCT after counseling and shared decision making and 28% of these (n 101) completed LDCTs. 153 of the eligible pts completed the survey questionnaire. Of these, 50% were females; 40% were Hispanic/Latinx, 40% were non-Hispanic/Latinx and 22% declined to answer. Majority, 61% were white, 10% African American/Black and 28% declined to answer. A sizeable proportion were non-English speaking (34%) and resided in cities with Rhode Island’s lowest per-capita incomes (Pawtucket 48%), Central Falls (32%) and North Providence/Providence (10%). In assessing barriers to LCS, 46% of pts were not aware of the LCS process and 44% were unaware that LCS was covered by health insurance; 58% of eligible pts did not recall their PCP discussing LCS. Of the LDCTs resulted available at the time of analysis, 84% were Lung RADS-1 and 16% Lung RADS-4 category. Conclusions: Our study highlights the unique barriers to LCS in an urban multiethnic community. While access to LCS remains an issue, pt awareness of the lung cancer screening process was the major barrier. A patient navigation program is critical to the success of LCS in a community, by providing education to patients and providers and the necessary logistical support needed in the LDCT process. With a community based navigational program, we demonstrate a significant increase in lung cancer screening rates in our population to 28% as compared to the state LCS rate of 13%. (Supported by the Robert A. Winn Diversity in Clinical Trials Career Development Award).

ImportanceLung cancer is the second most common cancer and the leading cause of cancer death in the US. In 2020, an estimated 228 820 persons were diagnosed with lung cancer, and 135 720 persons died of the disease. The most important risk factor for lung cancer is smoking. Increasing age is also a risk factor for lung cancer. Lung cancer has a generally poor prognosis, with an overall 5-year survival rate of 20.5%. However, early-stage lung cancer has a better prognosis and is more amenable to treatment.ObjectiveTo update its 2013 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review on the accuracy of screening for lung cancer with low-dose computed tomography (LDCT) and on the benefits and harms of screening for lung cancer and commissioned a collaborative modeling study to provide information about the optimum age at which to begin and end screening, the optimal screening interval, and the relative benefits and harms of different screening strategies compared with modified versions of multivariate risk prediction models.PopulationThis recommendation statement applies to adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years.Evidence AssessmentThe USPSTF concludes with moderate certainty that annual screening for lung cancer with LDCT has a moderate net benefit in persons at high risk of lung cancer based on age, total cumulative exposure to tobacco smoke, and years since quitting smoking.RecommendationThe USPSTF recommends annual screening for lung cancer with LDCT in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. (B recommendation) This recommendation replaces the 2013 USPSTF statement that recommended annual screening for lung cancer with LDCT in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years.

Lung cancer screening using low-dose computed tomography for high risk populations: Investigating effectiveness and screening program implementation considerations: An Evidence Check rapid review brokered by the Sax Institute (www.saxinstitute.org.au) for the Cancer Institute NSW

Aim: Lung cancer is the most common cause of cancer death in Portugal. The Dutch-Belgian lung cancer screening (LCS) study (NELSON), the biggest European LCS study, showed a lung cancer mortality reduction in a high-risk population when being screened. In this study, the cost-effectiveness of LCS, based on the NELSON study protocol and outcomes, was evaluated compared with no screening in Portugal. Methods: The present study modified an established decision tree by incorporating a state-transition Markov model to evaluate the health-related advantages and economic implications of low-dose computed tomography (LDCT) LCS from the healthcare standpoint in Portugal. The analysis compared screening versus no screening for a high-risk population aged 50-75 with a smoking history. Various metrics, including clinical outcomes, costs, quality-adjusted life years (QALYs), life-years (LYs) and the incremental cost-effectiveness ratio (ICER), were calculated to measure the impact of LDCT LCS. Furthermore, scenario and sensitivity analyses were executed to assess the robustness of the obtained results. Results: Annual LCS with volume-based LDCT resulted in €558million additional costs and 86,678 additional QALYs resulting in an ICER of €6440 per QALY for one screening group and a lifetime horizon. In total, 13,217 premature lung cancer deaths could be averted, leading to 1.41 additional QALYs gained per individual diagnosed with lung cancer. Results are robust based on the sensitivity analyses. Conclusion: This study showed that annual LDCT LCS for a high-risk population could be cost-effective in Portugal based on a willingness to pay a threshold of one-time the GDP (€19,290 per QALY gained).

Incidental Lymphadenopathy at CT Lung Cancer Screening.

Background The European position on lung cancer screening (LCS) recommends planning for implementation of low-dose computer tomography (LDCT) screening for lung cancer (LC) to start. The Manchester LCS pilot is one of the first NHS screening implementation programmes to take place and publish results. In this abstract we share results from the first incidence round of screening. Methods Details of the baseline round of the Manchester LCS pilot have been previously published.1 In brief, ever smokers, aged 55–74, from deprived areas were invited to a free ‘Lung Health Check’ (LHC) in mobile units located at their local shopping centres. The PLCOm2012 LC risk model was incorporated into the LHCs and those at high risk (PLCOm2012 ≥1.51%) were invited for annual screening starting with an immediate LDCT in a co-located mobile scanner. At baseline, 1384 individuals were screened and 3% had LC diagnosed (80% early stage, I-II). In the second round of screening, the first incidence round, all individuals screened at baseline with no subsequent diagnosis of LC (screening or non-screening) were invited back for an annual LDCT at the same community location. Exclusion included death, other malignancies and CT thorax within 3 months of due screening date. National and GP registries were checked for interval LC diagnosis. Results A total of 1,194 LDCT scans were performed as part of the second round of screening. 29 (2.4%) individuals received a positive scan result of which 19 (1.6%) were diagnosed with LC. 79% of LCs were early stage (I-II). The false positive rate was 0.8% of the screened population and 35% of those with a positive scan result. There were no interval LCs diagnosed at one year. Overall, 61 individuals (4.4%) have been diagnosed with LC (80% early stage) in the first 12 months of the Manchester LCS programme. Conclusion Annual LDCT screening of high risk individuals in this real world LCS implementation pilot continues to identify a significant number of early stage lung cancers amenable to curative treatment. No interval lung cancers were diagnosed between rounds suggesting the baseline selection criteria for screening was appropriate. Reference Crosbie PA, Balata H, et al. Implementing lung cancer screening: Baseline results from a community-based ‘Lung Health Check’ pilot in deprived areas of Manchester. Thorax2018.

BackgroundA 2011 report from the National Lung Screening Trial indicates that three annual low-dose computed tomography (LDCT) screenings for lung cancer reduced lung cancer mortality by 20% compared to chest X-ray among older individuals at high risk for lung cancer. Discussion has shifted from clinical proof to financial feasibility. The goal of this study was to determine whether LDCT screening for lung cancer in a commercially-insured population (aged 50–64) at high risk for lung cancer is cost-effective and to quantify the additional benefits of incorporating smoking cessation interventions in a lung cancer screening program.Methods and FindingsThe current study builds upon a previous simulation model to estimate the cost-utility of annual, repeated LDCT screenings over 15 years in a high risk hypothetical cohort of 18 million adults between age 50 and 64 with 30+ pack-years of smoking history. In the base case, the lung cancer screening intervention cost $27.8 billion over 15 years and yielded 985,284 quality-adjusted life years (QALYs) gained for a cost-utility ratio of $28,240 per QALY gained. Adding smoking cessation to these annual screenings resulted in increases in both the costs and QALYs saved, reflected in cost-utility ratios ranging from $16,198 per QALY gained to $23,185 per QALY gained. Annual LDCT lung cancer screening in this high risk population remained cost-effective across all sensitivity analyses.ConclusionsThe findings of this study indicate that repeat annual lung cancer screening in a high risk cohort of adults aged 50–64 is highly cost-effective. Offering smoking cessation interventions with the annual screening program improved the cost-effectiveness of lung cancer screening between 20% and 45%. The cost-utility ratios estimated in this study were in line with other accepted cancer screening interventions and support inclusion of annual LDCT screening for lung cancer in a high risk population in clinical recommendations.

191 Background: In response to the National Lung Screening Trial’s findings, numerous professional organizations have published guidelines recommending annual lung cancer (LC) screening with low dose computed tomography (LDCT) for eligible patients. In the wake of these guidelines, we sought to assess LC screening practices and beliefs among providers at a large academic medical center. Methods: In 2015, we surveyed 54 physicians and 9 residents in pulmonology (27% response rate) and 86 physicians and 100 residents in family/internal medicine (39% response rate). The 23 question Qualtrics survey focused on beliefs and knowledge about LC screening recommendations, guidelines, and practices. Results: Survey respondents in both groups were mostly White non-Hispanic clinicians with a mean age of 40 (range 28-67). Pulmonology respondents were mostly male (69%) and family/internal medicine respondents were mostly female (53%). The pulmonology group was more likely than family/internal medicine to believe that LC screening is beneficial for patients (p < 0.0001) and cost effective (p = 0.02). Over 76% of the pulmonology group reported ordering a LDCT for an asymptomatic patient in the past 12 months compared to 41% in the family/internal medicine group (p = 0.012). Additionally, 76% in pulmonology were aware of the American College of Chest Physicians recommendations versus 38% in family/internal medicine (p = 0.02). The majority of both groups agreed that an electronic prompt would increase the likelihood of referring a patient for LC screening. While both groups agreed that a LC screening registry would benefit the quality of patient care (100% pulmonology; 65% family/internal medicine; p = 0.02) and make them more likely to refer patients to a LC screening program (88%; 54%; p = 0.04), a significantly larger majority of the pulmonology group held these beliefs. Conclusions: Pulmonology respondents had more knowledge of guidelines and more favorable opinions of LC screening than family/internal medicine respondents. Our findings suggest future studies should focus on educating providers about recommendations and understanding why the family/internal medicine group is less likely to refer patients for LC screening.

Mediastinal Lymphadenopathy in Lung Cancer Screening: A Red Flag.

Lung cancer screening.

Expansion of Guideline-Recommended Lung Cancer Screening Eligibility: Implications for Health Equity of Joint Screening and Cessation Interventions

In 2021, the US Preventive Services Task Force (USPSTF) called for increased efforts at tobacco control, smoking-cessation treatments, and annual lung cancer screening with low-dose computed tomography (LDCT), targeted at high-risk populations. In January 2024, the American Cancer Society (ACS) published an update on the previous 2013 lung cancer screening guidelines and recommends annual lung cancer screening with lung LDCT for individuals aged 50-80 years who are asymptomatic but who currently smoke or have previously smoked. Although rates of tobacco smoking have been falling in some countries, the incidence of lung cancer in individuals who have never smoked now represents the 7th most common cancer and the 5th leading cause of cancer-related death. Because there is evidence that lung cancer screening with LDCT reduces lung cancer mortality in individuals with a substantial smoking history, there is now increasing interest in evaluating LDCT for lung cancer screening in those who have never smoked. In 2024, the International Association for the Study of Lung Cancer (IASLC) published a five-year (2023-2027) roadmap for the global use of LDCT in screening for lung cancer. This editorial aims to highlight some recent guidelines and current approaches to lung cancer screening in smokers and non-smokers.

e19177 Background: Lung cancer is the leading cause of cancer deaths in the United States with only 15% alive 5 years after diagnosis. In 2013, USPSTF recommended annual screening for LDCT in high risk individuals. Studies had shown a 20% lower mortality (NELSON trial showed significantly lower lung cancer mortality) with LDCT screening. We aimed to assess the extent to which the guideline for lung cancer screening is being adopted in a community clinic. Methods: A retrospective review of electronic medical record of patients aged 55-80 years with no history of lung cancer who visited a primary care provider in a community clinic in New Jersey from October 2014- December 2019 was done. All records with any form of documentation of smoking were identified electronically. The records of those meeting the criteria (30 pack-year smoking history and currently smoking or have quit within the past 15 years) were reviewed manually to check 1) whether they are eligible for screening, 2) if eligible whether low dose CT has been recommended by the provider and 3) once recommended has it been done and followed by the patients. Results: 359 individuals with documented smoking history were identified. Of those 38.8 % (139/359) had a proper documentation (includes both PPD and number of years of smoking) of smoking history based on which high risk individuals could be identified. Of those 37 individuals met the criteria for lung cancer screening. 62% (23/37) had CT chest ordered at some point of time (16.2% for a different indication and the rest for lung cancer screening). Only 52.2% (12/23) of the patients followed the recommendations and got a LDCT done. Among those 50% (6/12) had follow up CT, 50 % (3/6) of those did it on a regular annual basis while the rest 50% (3/6) did it irregularly. 3 patients followed the annual CT screening for lung cancer. Conclusions: Based on these we note that almost half a decade since the recommendation has been established only a small proportion received the care and a still smaller minority followed it. It reflects the dearth of information regarding the guideline among providers and the lack of awareness of the need to follow among patients. This puts forward need for further interventions for implementation of the guidelines at all levels of care for lung cancer prevention. Measures include analyzing the areas of deficiency through questionnaires for patients and providers. Creating awareness on the need for accurate documentation of smoking history and the impact it can have on care delivered. Educating patients about the benefits in health outcome by following the recommendations.