Each year, we lose 127,000 Americans to lung cancer. That’s nearly the equivalent of a commercial airliner packed with passengers falling out of the sky every other day, making lung cancer “by far the leading cause of cancer death in the U.S.,” according to the American Cancer Society. For perspective, in people older than 50, we lose more friends, family members, and loved ones to lung cancer annually than we do to colon cancer, breast cancer, and prostate cancer combined.
Lung cancer screening can help detect cancers early. For patients at high risk of lung cancer, an annual low-dose chest CT can reduce the risk of dying from lung cancer by 20%. Yet, even though we have an effective screening process to identify lung cancer in early stages, only 5.8% of eligible people have undergone screening. Of those few patients who underwent screening, only 20% came back for the necessary second round of screening.
Why are we under-utilizing such a valuable resource in lung cancer care? It’s an urgent question, and the answer we give could save lives. Like all weighty questions, this one is complicated.
First and foremost, not enough people know about lung cancer screening. Though most people are aware of breast, colon, and prostate cancer screening, far fewer know about lung cancer screening and how to obtain it.
Next, available guidelines have conflicting recommendations that are difficult for patients and providers to follow. Several societies recommend lung cancer screening, but their recommendations may differ. Take for example the recently updated screening guidelines from the American Cancer Society. While expanding screening eligibility to an additional 5 million people, the updated guidelines are distinct from the U.S. Preventive Services Task Force (USPSTF) recommendations.
So, which recommendations are best practice? Perhaps both. It’s clear we’re not screening everyone who is high risk for lung cancer. Though the American Cancer Society and USPSTF recommendations advance our ability to find lung cancers early, some patients would benefit from screening but don’t meet established criteria. For example, a younger patient with a family history of lung cancer, heavy smoking history, and prior work around asbestos may benefit from screening but may not meet age criteria for screening.
Insurance requirements and reimbursement (which are generally based on USPSTF guidelines) can also be barriers to lung cancer screening. Though most insurance policies cover baseline lung cancer screening, specific documentation is required for reimbursement, and follow-up testing is not always covered. The result: it is more difficult than it should be for patients to find, obtain, and pay for lung cancer screening.
Unfortunately, the challenges don’t stop there. Another big hurdle is the way we talk about lung cancer. Many patients who smoke (or used to smoke) feel stigmatized and are reluctant to ask for help; they’ve been conditioned to being criticized or shamed about their history, leading to delayed or skipped screening. We can improve screening rates by recognizing the stigma and changing the way we talk about lung cancer.
Finally, we’re not offering lung cancer screening equitably. Black Americans, for example, are less likely to (1) be eligible for lung cancer screening, (2) undergo lung cancer screening, and (3) have lung cancers diagnosed in early stages. As a result, lung cancer survival is shorter in Black Americans compared with their white neighbors.
What can we do to improve lung cancer screening challenges?
- More federal and state resources are needed: awareness campaigns, consistent insurance coverage, and efforts to improve racial and ethnic disparities.
- Let’s open the dialogue with increased awareness and better communication. Honest, open, and non-judgmental discussions with physicians, family, and friends would be a big step toward reducing stigma.
- More individualized care is essential. Our system should revisit the way we think about lung cancer screening. Determining an individual’s risk gives more insight into the benefit from screening. This straightforward and personalized approach will pose some organizational challenges. But, if implemented, such a system would make for a much more strategic — and accurate — approach to detecting lung cancer early.
These recommendations don’t require as much of an overhaul as it might seem. Our system is already changing for the better. The USPSTF first issued recommendations for lung cancer screening in 2013. In 2021, the guidelines were updated to include more patients and address the racial disparities mentioned above. We’re moving in the right direction.
It’s high time we took America’s deadliest cancer for what it is — not a stigmatized condition related to prior lifestyle choices, but rather a challenge for each one of us to grapple with personally. Our friends, family, and patients are depending on us. We have no time to lose.
Brett Bade, MD, is a pulmonologist with Northwell Health. Subroto Paul, MD, MPH, is the chief of thoracic surgery at Northwell Health’s Lenox Hill Hospital.
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