Fewer than 6% of high-risk smokers undergo an annual lung cancer screening test as is recommended by health authorities, even though the test can detect early lung cancer when it is still curable, according to a new report from the American Lung Association.
It begs the question: Why are the screening rates so dismally low?
“There are a lot of reasons why,” the report’s lead author, Zach Jump, MA, of the American Lung Association in Chicago, told Medscape Medical News.
First, despite it now being nearly 10 years since the initial recommendation by the US Preventive Services Task Force (USPSTF), it takes time to prod people into action, Jump suggested. “Even for long-standing cancer screening programs such as mammograms, the rates of screening are much lower than we would like, so our best hope is still less than we’d like.”
Importantly, in March 2021, the USPSTF expanded the screening recommendations to include a larger age range and more current and former smokers than were originally recommended for screening. “That recommendation almost doubled the number of people eligible to be screened, meaning that suddenly, our denominator almost doubled,” Jump observed. In other words, proportionately fewer people are now being screened because the pool of eligible people is almost twice what it was before the USPSTF made its original recommendation.
A lot of work and “buy-in” also has to take place before any screening program can be established. For example, in a recent briefing, practicing pulmonologists pointed out to the American Lung Association just how difficult it can be to get a screening program established to make it successful. Not only does administration have to see the value (and the cost-benefit) of offering a lung cancer screening program, but there needs to be an advocate for the program and a willing number of staff who have to provide the actual services themselves and see the value of the program too.
In its defense, the American Lung Association has established multiple outreach efforts aimed at educating providers on the benefits of screening. They have also launched multi-pronged educational efforts at the public — for example, placing material in waiting rooms so that patients and their family members might be better informed of the advantages of annual lung cancer screening. They also have a large online presence in the form of the “Saved by the Scan” campaign.
“This campaign has been very broad-reaching and it encourages people to go to the website to see if they are eligible for screening and, if so, find a local screening center or at least talk to their provider about their risk,” Jump explained.
The American Lung Association has also made major inroads into getting Medicaid coverage for people who want to be screened for lung cancer — in one year alone, the association convinced six states to cover screening through Medicaid — to the point where now, very few states do not offer coverage.
And there is progress: despite a major setback in 2020 because of the disruption from the COVID-19 pandemic on all healthcare services, “lung cancer screening has been consistently increasing nationally, so overall we are seeing increases in the numbers although even the best of states has a lot of room for improvement,” Jump acknowledged.
Perhaps the hardest aspect to getting more high-risk patients screened is the “fatalist” attitude that most smokers have about smoking. When screening was first recommended, the American Lung Association carried out a multitude of focus groups, and in talking to smokers and panel groups they heard a lot about this fatalistic attitude. “There is a huge amount of stigma around smoking which we really want to combat,” Jump commented.
Typically, smokers blame themselves for smoking (and subsequently blame themselves if they develop smoking-related diseases including lung cancer), he elaborated. Moreover, “tobacco is incredibly addictive and there are a lot of influences out there from the tobacco industry that got people started and keep them going,” Jump added. The fact that the diagnosis of lung cancer used to be synonymous with death — and clearly one that patients did not want to hear — didn’t exactly incentivize smokers to go get tested for it.
But with screening, a diagnosis of lung cancer is no longer a death sentence — it’s a whole new world. “We are talking about something that we can detect early, patients can have it cut it out and then live the rest of their life, and [instead] worry about all the other diseases we all worry about,” Jump said.
Furthermore, treatment for lung cancer, and the advent of immunotherapy and targeted therapies, has significantly improved its prognosis, even the prognosis of metastatic lung cancer. “So we are trying to get that message across and change the national expectation from one of a ‘death sentence’ to a message of hope,” Jump said.
Coming back to the annual report, Jump said: “We started this report [5 years ago] when screening became a thing and our hope was to really get the message out there that screening is effective and helpful. But we also want to be able to show the effectiveness of screening going forward — not only that a clinical trial has shown screening is effective, but here are the real-world data and here’s what happening now. Here are real lives saved, here is increased early detection of lung cancer, and here is increased survival.
“So it’s important that we have something that is accessible to the everyday person, but also have a lot on which we can advocate for what we know can save lives.”
5th Annual “State of Lung Cancer” Report. Published online November 15, 2022