Effectiveness of Lung Cancer Screening Implementation in the Community Setting in the United States

Abstract

Purpose: The National Lung Screening Trial demonstrated a 20% relative reduction in lung cancer mortality with low-dose computed tomography screening, leading to implementation of lung cancer screening across the United States. The Centers for Medicare and Medicaid Services approved coverage, but questions remained about effectiveness of community-based screening. To assess screening implementation during the first full year of CMS coverage, we surveyed a nationwide network of lung cancer screening centers, comparing results from academic and nonacademic centers.

Methods: One hundred sixty-five lung cancer screening centers that have been designated Screening Centers of Excellence responded to a survey about their 2016 program data and practices. The survey included 21 pretested, closed- and open-ended quantitative and qualitative questions covering implementation, workflow, numbers of screening tests completed, and cancers diagnosed.

Results: Centers were predominantly community based (62%), with broad geographic distribution. In both community and academic centers, more than half of lung cancers were diagnosed at stage I or limited stage, demonstrating a clear stage shift compared with historical data. Lung-RADS results were also comparable. There are wide variations in the ways centers address Centers for Medicare and Medicaid Services requirements. The most significant barriers to screening implementation were insurance and billing issues, lack of provider referral, lack of patient awareness, and internal workflow challenges.

Conclusion: These data validate that responsible screening can take place in a community setting and that lung cancers detected by low-dose computed tomography screening are often diagnosed at an early, more treatable stage. Lung cancer screening programs have developed different ways to address requirements, but many implementation challenges remain.

Fig 1.

A snapshot of lung cancer screening in the United States, 2016. (A) Geographic distribution of the 165 Screening Centers of Excellence survey respondents. (B) Screening Centers of Excellence reported if they had an academic or university affiliation. (C) Time of initiation of each screening program and relationship to US Preventive Services Task Force (USPSTF) recommendation and Centers for Medicare and Medicaid Services (CMS) national coverage determination.

Fig 2.

Implementation of Centers for Medicare and Medicaid Services (CMS) requirements. (A) Provider who performs shared decision-making counseling. (B) Smoking cessation resources provided to current smokers. Centers could choose multiple responses if applicable. (C) Information on whether screening centers follow up with current smokers after cessation counseling. PCP, primary care physician.

Fig 3.

Lung cancer screening results. (A) Lung Imaging Reporting and Data System (Lung-RADS) score distribution category from more than 40,000 low-dose computed tomography scans (n = 24,249 nonacademic centers; n = 16,186 academic-affiliated centers). (B) Percentage of each stage and type of lung cancer diagnosed at nonacademic centers (n = 272 cancer diagnoses at baseline screen; n = 59 diagnoses at annual screen) compared with academic-affiliated centers (n = 151 cancer diagnoses at baseline; n = 47 cancer diagnoses at annual screen). NSCLC, non–small cell lung cancer; SCLC, small-cell lung cancer.