Planning and Implementation of Low-dose Computed Tomography Lung Cancer Screening Programs in the United States

Rebecca Qiu, BSN, RN; Amy Copeland, MPH; Erica Sercy, MSPH; Nancy R. Porter, MS; Karen Kane McDonnell, PhD, RN, OCN; Jan Marie Eberth, PhD


Clin J Oncol Nurs. 2016;20(1):52-58. 

In This Article


LDCT lung cancer screening centers are gaining ground in the medical community and among the public. The average time from startup to implementation of a screening program was reported to be less than six months, and almost half (n = 30) of centers have less than four years of screening experience, which can be explained largely by the results of the NLST (Siegel et al., 2013). Despite lung cancer's high mortality rate, many institutions (n = 28) have screened fewer than 50 patients since the inception of their programs. Many factors have influenced this low number, including the fact that LDCT lung cancer screening is a relatively new innovation and is not routine, as well as numerous barriers that have hindered LDCT use.

The biggest challenge to implementing LDCT screening was attracting patients. Many interviewees attributed this challenge to few physician referrals. Although some organizations support annual screening for patients at high risk for lung cancer (ACR, 2013; American Lung Association, 2015; CMS, 2015; Jaklitsch et al., 2012), the American Academy of Family Physicians (2013) has concluded that the evidence is insufficient to warrant recommendation of annual LDCT screening in any group of patients. The lack of physician endorsement may have contributed to low referral rates.

Insurance reimbursement issues were another critical barrier. Some interviewees complained that lack of insurance coverage deterred patients from getting screened. In addition, the lack of support from some professional organizations (American Academy of Family Physicians, 2013) likely has affected the overall use of LDCT screening for lung cancer. However, CMS issued a final decision in February 2015 to cover and support annual LDCT lung cancer screening for high-risk individuals aged 55–77 years, a slimmer age range than recommended by the USPSTF (CMS, 2015). Private insurers are required to cover LDCT lung cancer screening for high-risk patients starting in their 2015 plan year, as stipulated by the Affordable Care Act, which states that full coverage be provided to services graded an A or B by the USPSTF (American Lung Association, 2013; U.S. Department of Health and Human Services, 2010; USPSTF, 2015). Codes to bill for lung cancer screening and the shared decision-making visit that should precede screening also were recently announced by CMS, paving the way for institutions to handle billing more efficiently (ACR, 2015a). Finally, a lack of patient and physician knowledge about screening continues to be a barrier, although a growing number of resources are available for the public and medical community to learn about lung cancer and the screening process (see Table 4).

Although the current study was vital in identifying barriers to the implementation of LDCT lung cancer screening programs, some limitations also must be noted. First, the interviews and survey focused solely on members of LCA Screening Centers of Excellence; therefore, this sample is not truly representative of all active screening programs. Second, the interviews were conducted with 13 LCA participants, which is too small of a cohort to generalize information relative to all Screening Centers of Excellence or screening programs in the United States. Third, both assessment methods (interview and survey) were voluntary, meaning that members whose programs were not as well developed may have been more reluctant to respond.