Lung Cancer Screening in 10 States, 2017: Only 1 in 8 Eligible Adults Screened

Lung cancer is the leading cause of cancer death in the United States — 148,869 deaths in 2016. Finding it early, when treatment works better, could save lives.

Image from the Centers for Disease Control and Prevention

The recommendation

In 2013, the U.S. Preventive Services Task Force (USPSTF) recommended yearly low-dose computed tomography (CT) screening for adults 55–80 who have a 30 pack-year smoking history and still smoke or quit within the past 15 years. (Pack-years are the average number of 20-cigarette packs smoked a day times the years smoked.) As a Grade B recommendation, it requires health plans to cover screening as a preventive service without cost-sharing, under the Affordable Care Act; Medicare began covering it for beneficiaries 55–77 in 2015.

The survey

In 2017, the Behavioral Risk Factor Surveillance System (BRFSS) telephone survey added an optional module on lung cancer screening for the first time. Ten states used it — Florida, Georgia, Kansas, Maine, Maryland, Missouri, Nevada, Oklahoma, Vermont and Wyoming — reaching 85,514 people. Questions on when people started and stopped smoking and how much they smoked gave pack-years; another asked whether they had had a CT scan in the past 12 months to check for lung cancer.

Findings

• Who is eligible: 12.7% of adults 55–80 met USPSTF criteria — nearly half of them (5.6%) former smokers. By state, from 8.9% (Maryland) to 17.0% (Oklahoma); in numbers, from about 16,200 people (Vermont) to 610,000 (Florida).
• Who was screened: only 12.5% of eligible smokers — about one in eight — had been screened in the past year, from 9.7% (Oklahoma) to 16.0% (Florida).
• Screening outside the guidelines: 7.9% of smokers 55–80 who did not meet the criteria reported screening, from 4.3% (Maryland) to 9.4% (Oklahoma and Florida).

What went with screening:

Smoking is the leading cause of COPD in the United States. How severe patients' COPD was is unknown — and the USPSTF does not recommend screening for people whose health problems would sharply limit life expectancy or rule out curative lung surgery.

What it means

• Education and decision tools: teaching patients and providers, and giving providers decision-support tools for proper screening triage, along with evidence-based approaches from The Community Guide — such as provider reminders, informed decision-making, reducing structural barriers and out-of-pocket costs.
• States can use the estimates to see where more screening is needed, study barriers, and track their programs.
• Prevention first: screening is secondary prevention. The most effective steps against lung cancer are never starting to smoke and quitting as soon as possible — with advice, counseling, medicines and resources such as 1-800-QUIT-NOW. The National Cancer Institute and the Veterans Health Administration are testing quit-smoking strategies for people being screened.
• Staying within the criteria avoids harms such as overdiagnosis and overtreatment.

Limitations

1. Smoking and screening were self-reported, open to recall and social desirability bias; some people may not know what test they had or why.
2. The module did not ask whether smokers were offered cessation help.
3. It could not capture local differences in resources, such as where accredited screening facilities are.
4. Comparisons with other surveys need care: this survey's 12.5% was higher than the 4.4% in the 2015 National Health Interview Survey — partly a real rise, but also different methods and questions.

Sources

Based on "Screening for Lung Cancer — 10 States, 2017," by Thomas B. Richards, Ashwini Soman, Cheryll C. Thomas, Brenna VanFrank, S. Jane Henley, M. Shayne Gallaway and Lisa C. Richardson, Morbidity and Mortality Weekly Report 69(8), Centers for Disease Control and Prevention; a work of the United States government in the public domain.