“The fact that nearly half of all patients with abnormal findings in our study experienced delays in following up is alarming,” said the study’s presenting author, Alwiya Ahmed, MD, MPH, internal medicine resident at the University of Washington School of Medicine and physician-scientist at the Seattle Cancer Care Alliance and Fred Hutchinson Cancer Research Center, in a release. Although skin cancer, breast cancer (in women), and prostate cancer (in men) are more common than lung cancer, lung cancer causes more deaths than any other type of cancer. It’s estimated that 130,180 Americans will die from lung cancer in 2022, which accounts for about 25 percent of all cancer deaths, according to the American Cancer Society.
Current Smokers More Likely to Delay Follow-Ups Than Former Smokers
To evaluate follow-up for people whose initial lung cancer screening indicated they were high risk for lung cancer, researchers looked at patients enrolled in a Seattle-based CT lung cancer screening program who underwent baseline or annual screening between 2012 and January 2021. CT findings were given one of four classifications based on a standardized assessment tool established by the American College of Radiology: Lung-RADS 3, 4A, 4B, and 4X, from low to high risk. Recommended follow-up care consisted of a second CT scan, other appropriate imaging, or specialty consultation or procedure. Delay time was considered more than 30 days past the recommended follow-up, and 30 days for patients in the 2 highest risk categories with very suspicious findings. Researchers found a total of 397 people with 464 exams had high-risk findings, and 59 (15 percent) of those people were ultimately diagnosed with lung cancer. In 47 percent of high-risk exams, there was a delay in follow-up. The median delay time was 91 days, although the people in the highest two risk categories had shorter delays — 32 days. Current smokers had longer delays in follow-up than former smokers, a finding that researchers called “concerning” given the high risk of lung cancer in this group. Previous studies have shown that participation in lung cancer screening is low relative to other types of screening, such as mammography and colorectal cancer screening, but part of that might be because lung cancer screening is relatively new, said Dr. Ahmed. “Nonetheless, it is disconcerting to see that among those screened who have abnormal findings, there is a significant delay in recommended follow-up. This could ultimately result in delayed diagnosis of lung cancer,” he said.
Screening Programs Use Reminders and Navigators to Improve Follow-Up Adherence
These findings emphasize the importance of a structured screening program with patient reminders to facilitate adherence to follow-up, says Christina Bellinger, MD, associate professor and director of the Lung Cancer Screening Program at Atrium Health Wake Forest Baptist in Winston Salem, North Carolina. Dr. Bellinger authored research published in November 2020 in the Southern Medical Journal that found similar results. Only 48 percent of the population studied received the recommended follow-up after an abnormal CT lung screening. Although Bellinger’s study took place pre-pandemic, and this current study did not specifically look at any changes that occurred during the pandemic, screening and follow-ups likely worsened during this time, says Caroline Chiles, MD, professor of radiology at Atrium Health Wake Forest Baptist. “We definitely experienced patients delaying their lung screening CTs and also their follow-up of positive screens during the pandemic surges in 2020 and 2021. After the vaccines became available and once patients became aware that they could get these examinations done safely, the numbers came back up,” says Dr. Chiles. At Atrium Health Wake Forest Baptist, the lung cancer screening program closely monitors enrolled patients and sends reminders to help ensure timely follow-up, says Bellinger. They’ve also added a dedicated navigator to their staff to improve adherence to follow-up, she says.
Recommendations and Risks of Screening for Lung Cancer
The lung cancer screenings performed in these studies — low-dose computerized tomography, also called a low-dose CT scan, or LDCT — is the only recommended screening test for lung cancer, according to the CDC. During an LDCT scan, the patient lies on a table and an X-ray machine uses a low dose of radiation to make detailed images of the lungs. The U.S. Preventive Services Task Force (USPSTF) recommends this yearly lung cancer screening for the following people:
Have a 20 pack-year or more smoking history, andSmoke now or have quit within the past 15 years, andAre between 50 and 80 years old
A “pack-year” is smoking an average of one pack of cigarettes per day for one year. For example, a person could have a 20 pack-year history by smoking one pack a day for 20 years or two packs a day for 10 years. There are a few risks to lung cancer screenings. There is a low radiation exposure and there is about a 12 to 14 percent incidence of false positives, according to the American Lung Association. Because cigarette smoking is the number one cause of lung cancer, the best way to reduce your risk of lung cancer is to not smoke and to avoid secondhand smoke. However, it is possible to get lung cancer even if you’ve never smoked. It’s estimated that about 10 to 20 percent of lung cancer in the United States occurs in people who have either never smoked or smoked less than 100 cigarettes in their lifetime, per the CDC.
