PERSPECTIVES: Research in Context

Integration of Lung Cancer Screening Into Practice is Lacking

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he results of a recent study have demonstrated that the implementation of lung cancer screening guidelines is lacking among primary care physicians (Cancer Epidemiol Biomarkers Prev. 2015;24:664-670). The National Lung Screening Trial (NLST), which included more than 53,000 individuals at high risk of lung cancer, demonstrated a 20% reduction in lung cancer-specific mortality and an overall mortality reduction of 6.7% with annual low-dose computed tomography (LDCT) (N Engl J Med. 2011;365:395-407). Cancer screening guidelines from multiple organizations now include LDCT of the chest for the early detection of lung cancer in patients aged older than 55 years with a significant smoking history. Furthermore, Medicare now will provide coverage for the test. Researchers set out to investigate whether the lung cancer screening guidelines were integrated into practice and what the barriers might be to implementation. Researchers at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina surveyed primary care providers (PCPs) from their medical center between November 2013 and December 2013. In addition to demographic questions and practice type, the survey asked questions to assess a PCP’s lung cancer screening practices over the past 12 months, knowledge of screening recommendations, barriers to screening implementation, beliefs in cancer screening, and interest in further education. Approximately 60% of surveys were completed (212 surveys) and were included in the analysis.

The majority of providers were physicians (87%), had been in practice for 10 years or fewer (76%), and were from departments of internal medicine (76%). Knowledge of the guideline components was lacking: 53% knew fewer than 3 of the 6 components (screen annually, begin at age 50 or 55 years, end at age 75 or 80 years, 20-30 pack-year history, current and former smokers, not secondhand smoke only). Approximately 25% of PCPs did not know any of the components. Guideline knowledge was found to be the only significant predictor of ordering a screening LDCT or chest x-ray in a multivariate model adjusting for medical position and for having greater than 50% of patients covered by Medicare. Fewer than one-half of participants (42%) believed that LDCT lung cancer screening was very or moderately effective, 28% thought it was minimally or not effective, and 38% did not know the efficacy at all. Chest xrays were used more often than LDCT scans (21% vs 12%) for lung cancer screening. Screening tests for other cancers were perceived as very or moderately effective by more of the respondents: 93% for mammography, 99% for colonoscopy, and 96% for Papanicolaou testing versus 42% for LDCT. Prostate-specific antigen screening was the only test with a lower perceived effectiveness, at 27%. The most common perceived barriers to lung cancer screening with LDCT were patient cost (87%), potential harm from false-positive findings (83%), patient lack of awareness (81%), and lack of insurance coverage (80%).

KEY POINTS  Integration of lung cancer screening into practice has been lacking.  More education regarding the benefits of and guideline recommendations for lung cancer screening is needed.  Medicare now covers the cost of screening for lung cancer with computed tomography scans in individuals at high risk.

“In my observations, I find that one barrier to screening is simply lack of knowledge of PCPs about the benefits of LDCT screening for lung cancer,” says Therese Bevers, MD, director of the cancer prevention center at The University of Texas MD Anderson Cancer Center in Houston. “I do not believe that false-positives are the only issue as I don’t think they [PCPs] have a great deal of knowledge of either the benefits or harms. Previously, lack of reimbursement for the testing was the greatest barrier, leading to PCPs being less interested in learning more about the test as they didn’t feel they would recommend it to their patients.”

Implications Researchers found that 2 years after multiple screening guidelines included chest LDCT for lung cancer screening in high-risk individuals, most PCPs had not integrated it into their practice. Few knew the specifics of the guidelines or thought LDCT was an effective screening test. More complete

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guideline knowledge was associated with using LDCT, but so was ordering a chest x-ray for screening even though it is not recommended in the guidelines and has been shown in prior studies not to be an effective screening modality. “We have taken several steps to improve knowledge about LDCT screening among our primary care providers, including incorporating lung cancer screening into our residency educational curriculum, providing guideline pocket cards, and producing an online video about our lung cancer screening clinic,” says Jennifer Lewis, MD, lead author and chief medical resident at Wake Forest Baptist Medical Center. Providers considered that screening for lung cancer was less effective than screening tests for other cancers, such as those of the breast and colorectum. However, the authors point out that based on data from the NLST, the number of patients needed to screen to prevent 1 lung

cancer death is 320, and that the number of patients needed to screen for LDCT compares favorably with other cancer screening tests as well as common cardiovascular disease screening tests. Patient costs are now less of a barrier, because the Patient Protection and Affordable Care Act mandates that private insurance cover US Preventive Services Task Force recommendations and Medicare ruled in February 2015 that it will cover the test. “We expect that these coverage changes will greatly reduce the financial costs of screening and increase utilization of LDCT lung cancer screening,” says Dr. Lewis. The concerns regarding falsepositive findings and complications are founded. The NLST data estimate that approximately 30% of patients will have at least 1 falsepositive finding and approximately 3 of every 1000 patients will have a major complication from the followup procedure.

“In my opinion, before it became a covered service, PCPs were not motivated to gain an understanding about LDCT screening. I anticipate that will begin to change now that it is covered by Medicare and private payors. Additionally, I believe that the primary care community is not familiar with the follow-up recommendations for newly discovered lung nodules,” says Dr. Bevers. “There are criteria to follow and knowledge of the criteria can help minimize unneeded biopsies and complications.” “Bottom line, providers and patients need to recognize the sense of urgency regarding lung cancer care in the United States,” says Dr. Lewis. “Lung cancer kills more people than any other cancer, and even more than breast cancer, colorectal cancer, and prostate cancer combined. Currently, most patients are diagnosed with late-stage disease with poor survival, but if we can detect this disease early, we can increase survival rates with appropriate treatment.” doi: 10.3322/caac.21282

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Integration of lung cancer screening into practice is lacking.

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