Lung cancer is the leading cause of death in the U.S. and highly treatable when caught early. But less than 15% of people at high risk for lung cancer receive potentially life-saving screening.
If you’ve been considering setting up a lung cancer screening program in your office, new screening recommendations, better shared decision-making approaches, and stronger follow-up guidelines make getting started easier than ever.
Matthew Triplette, MD, MPH, is a pulmonologist, lung cancer screening expert and medical director of the Seattle Cancer Care Alliance (SCCA) and University of Washington Medicine (UW) Lung Cancer Screening Program. SCCA was among the first programs in the U.S. to receive the designation as a Screening Center of Excellence by the Lung Cancer Alliance. At SCCA, Dr. Triplette studies how to tailor lung cancer screening to save the most lives and make this an effective service for eligible patients.
Dr. Triplette sheds light on the fundamentals of lung cancer screening, including:
- The evidence behind lung cancer screening
- Current recommendations for screening
- Real world strategies for putting a screening program in place
Clinical Trials Provide Evidence for Lung Cancer Screening
Lung cancer screening is a quick, simple scan that uses low-dose CT. Two landmark trials established that low-dose CT is an effective tool to reduce lung cancer mortality in high-risk patients. They are:
- National Lung Screening Trial (NLST): This study, published in 2011, included 53,454 patients. It found that low-dose CT screening lowered lung cancer deaths by 20% compared with chest X-ray screening.
- Dutch-Belgian Lung Cancer Screening Trial (NELSON): This more recent study, published in 2020, included 15,792 patients (84% male). Lung cancer screening resulted in a 24% reduction in lung cancer mortality in men, compared with routine care that did not include screening. A 33% reduction in mortality was also seen in women, though this finding was not statistically significant.
Updated Lung Cancer Screening Guidelines Increase Access and Insurance Coverage
Recently, national lung cancer screening guidelines have been updated to reflect advances in clinical trial research and the epidemiology of lung cancer. This change impacts who should be screened and expands insurance coverage for screening tests.
U.S. Public Service Task Force (USPSTF) guidelines expand eligibility
In a 2021 update to their national guidelines, the USPSTF recommended annual lung cancer screening using low-dose CT for patients who:
- Are between 50 and 80 years of age
- Have a smoking history of at least 20 pack years
- Smoke currently or quit within the past 15 years
Providers should not offer screening if patients have not smoked for 15 years, have a life-limiting health problem or are unable or unwilling to have curative lung surgery. The strength of this USPSTF recommendation is grade B, which means there is moderate certainty the benefit is moderate to substantial.
This update expands the number of people who may be eligible for screening from the 2013 guidelines by lowering the minimum screening age to 50 from 55 years old and pack year smoking history to 20 from 30 pack years. “These changes are especially important for improving early detection among Black men who are at higher risk of lung cancer despite lower smoking histories,” says Dr. Triplette.
Centers for Medicare & Medicaid Services (CMS) follows USPSTF lead
In February 2022, CMS updated their lung cancer screening eligibility criteria to align more closely with the USPSTF recommendations. However, the CMS guidelines recommend an age range of 50 to 77 years old, compared to 50 to 80 years old.
CMS also requires a visit prior to the first lung cancer screening that documents shared decision-making between the patient and provider.
Eligibility criteria and insurance coverage
Expanded USPSTF and CMS eligibility criteria translate to insurance benefits for more patients, says Dr. Triplette.
The Affordable Care Act requires private insurances to cover USPSTF-recommended screening modalities with a grade A or B at no cost sharing to the patient. Patients who are eligible for lung cancer screening and are covered by Medicare, Washington State Medicaid or private insurance can access lung cancer screening with no cost sharing.
Best Practices for a Successful Lung Cancer Screening Program
When establishing a lung cancer screening program, it’s essential to consider clinician behavior and system-wide processes. Four key considerations include:
Smoking history is critical
Identifying patients who are eligible for lung cancer screening can be challenging. This is because providers do not always record smoking history.
Dr. Triplette recommends documenting smoking history as you would a vital sign. This will provide updated data on smoking status, quit dates and pack years so providers can recommend lung cancer screening, as appropriate.
Shared decision-making is mandatory
CMS requires a counseling and shared decision-making visit prior to lung cancer screening. This visit should include determination of eligibility. It's also required to use a decision aid, such as Should I Screen, and provide counseling on the following topics:
- Importance of annual screening
- Impact of comorbidities
- Patient’s ability and willingness to undergo therapy
- Tobacco cessation
Some EMR systems have built-in decision aids to guide and document the visit.
Explain the benefits and challenges of lung cancer screening
“Once you determine a patient is eligible for screening, counseling them can be tricky,” says Dr. Triplette. “It’s important to clearly explain the benefits and risks of screening.”
Lung cancer screening benefits include:
- Lives saved: Screening can save an estimated 12,000 to 15,000 American lives annually.
- Reduced lung cancer mortality: Screening decreases the risk of death from lung cancer by 20% compared to a chest X-ray or usual care.
- Smoking cessation: Screening gives providers an opportunity to discuss smoking cessation with patients, a critical conversation that can have life-saving consequences.
The risks of lung cancer screening include:
- Anxiety risk: The false positive rate of lung cancer screening is about 2.2 false positives for each patient over their lifetime of screening. Most patients will eventually have a false positive result. There is also a risk of incidental findings outside the lungs. Studies show that the fear of undue anxiety related to these risks should not dissuade providers from screening patients.
- Complication risk: The NLST study found that the risk of complications among patients who needed a diagnostic test was 1.4%. However, most patients who experienced complications had lung cancer.
- Financial risk: Screening is usually a covered service. But patients may be subject to cost sharing for follow-up testing if the screening identifies abnormalities.
- Overdiagnosis risk: The risk of finding lung cancer that is clinically insignificant is 11% to 18%. For patients, this means the majority of lung cancers detected in the early stage advance to a later stage if they aren't detected, evaluated and treated.
- Radiation risk: A low dose CT scan delivers about one-sixth the radiation of a routine CT and less than half the radiation that the average person receives during a year at sea level.
Providing smoking cessation assistance
Smoking cessation counseling is an important component of lung cancer screening. But not all providers feel comfortable having these conversations with patients. Strategies Dr. Triplette recommends for smoking cessation counseling include:
- Discussing a patient’s tobacco use at every visit
- Identifying a counseling strategy that works for you and practicing it until you are confident
- Knowing the literature on nicotine replacement and medications, such as varenicline
- Letting patients know they can reduce their risk of lung cancer mortality by nearly 40% with persistent smoking cessation and routine screening
Manage follow-up using the latest tools
The ACR Lung Reporting and Data System (Lung-RADS) provides a useful tool for managing lung nodules found during lung cancer screening, especially in the lower categories. For higher grade findings, Dr. Triplette recommends referral to a pulmonologist or multidisciplinary clinic for management.
Follow-up also includes putting systems into place to remind patients of their annual screening. Dr. Triplette recommends using the ACR registry, which is compatible with many EHR systems and can assist with patient tracking and reminders.
Lung Cancer Screening at Scca
SCCA is accredited by the American College of Radiology. Together, Seattle Cancer Care Alliance (SCCA) and UW Medicine offer screening for people at high risk for lung cancer at six locations through Puget Sound.
