Article

CT Screening in the U.S. South for Lung Cancer: A Clear Need

Lung cancer is the biggest cause of cancer-related deaths in the United States.1 But appropriate lung cancer screening with low-dose CT scan can detect disease early and improve mortality rates and the success of treatment. Access to such screening programs, however, is not universal, and this lack of access impacts some regions and communities more heavily than others.

Studies to understand where lung cancer screening programs are located and what percentage of people access such screening programs are underway, and the results are showing that there are some significant disparities between rural and urban areas and within certain geographic areas of the United States.2

Rural Areas Have Higher Need For, Less Access to Screening

Rural areas have significantly higher smoking rates, lung cancer incidence and mortality compared to urban regions, indicating a high need for CT lung cancer screening in these areas. Yet rural smokers live significantly farther from a screening facility than those who live in more populated areas, according to a study published in January 2019 the Journal of the American College of Radiology.3

There are more smokers who are eligible for CT scan based screening in rural areas compared to urban regions, according to a recent study published in the Journal of the American College of Radiology.4 The study analyzed data from the 2015 National Health Interview Study. Even though there is a greater need for screening facilities in rural areas, most CT lung cancer screening programs are found in metropolitan areas. And regardless of access, both rural and urban residents have low participation rates in lung CT screening programs: only about 4 percent of those eligible for early screening actually get a CT scan.4

Geography plays a role as well: some 40 percent of smokers who met criteria for receiving lung cancer screening lived in the South, the authors found, while southern states had only half the number of screening centers per capita compared to northeastern states. Rural and urban disparities are especially stark in the South, which has the highest rates of lung cancer, smoking, and poverty in the nation.4

Can Low-Dose CT Screening Reduce Rural Disparities?

The authors of the JACR study propose that annual low-dose CT screening among high-risk smokers and former smokers can detect lung nodules at early stages, which can allow for better treatment options and better prognosis. Early detection is crucial for improving lung cancer survival rates.4

Yet rural regions present unique challenges and barriers to implementing low-dose CT screening programs for high-risk individuals. Geographic access is one significant challenge, as rural areas simply may not have the number of radiologists needed to screen all eligible individuals. The “inverse care law” is a principle that states that the availability of high-quality medical care inversely differs from the needs of the population. In other words, where the need is greatest, access is lowest. This law appears to be at play when it comes to lung cancer CT screening programs.4

The authors also identify provider-patient communication as a key predictor of screening uptake. Physicians must be knowledgeable about low-dose CT screening guidelines and the risks and benefits as well as insurance reimbursement policies. Screening costs have been identified as a key barrier to screening uptake.4

The development and use of appropriate decision-making tools and decision aids may be helpful in communicating with patients. A shared decision-making process is required by Medicare for reimbursement.5 Providers must discuss both benefits and risks of screening and tobacco cessation if patients are current smokers. Developing decision aids in collaboration with patients will ensure that they are the most helpful, appropriate, and effective for educating patients about both the risks and benefits of screening.4

Decision aids have yet to be tested in rural populations, and overall, more data is needed to determine the best predictors of screening uptake and to help develop the most effective decision-making tools. But providers can discuss benefits, risks, and options for screening with eligible patients to ensure that they are able to make informed decisions about their care.4

Sources

1. Lung Cancer Alliance Screening Facts and Figures. https://lungcanceralliance.org/risk-early-detection/screening-facts-figures/   Last accessed July 30, 2019.

2. A Geospatial Analysis of Factors Affecting Access to CT Facilities: Implications for Lung Cancer Screening. Journal of the American College of Radiology. https://www.jacr.org/article/S1546-1440(19)30751-3/fulltext Last accessed July 30, 2019.

3. Geographic Access to CT for Lung Cancer Screening: A Census Tract-Level Analysis of Cigarette Smoking in the United States and Driving Distance to a CT Facility. Journal of the American College of Radiology. https://www.jacr.org/article/S1546-1440(18)30850-0/fulltext Last accessed July 30, 2019.

4. Challenges and Opportunities for Lung Cancer Screening in Rural America. Journal of the American College of Radiology. https://www.jacr.org/article/S1546-1440(19)30018-3/fulltext Last accessed July 30, 2019.

5. Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439N) https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274 Last accessed July 30, 2019.