Screening for Lung Cancer — 10 States, 2017

Thomas B. Richards, MD; Ashwini Soman, MBBS; Cheryll C. Thomas, MSPH; Brenna VanFrank, MD; S. Jane Henley, MSPH; M. Shayne Gallaway, PhD; Lisa C. Richardson, MD

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(8):201-206. 

In This Article

Abstract and Introduction

Introduction

Lung cancer is the leading cause of cancer death in the United States; 148,869 lung cancer-associated deaths occurred in 2016.[1] Mortality might be reduced by identifying lung cancer at an early stage when treatment can be more effective.[2] In 2013, the U.S. Preventive Services Task Force (USPSTF) recommended annual screening for lung cancer with low-dose computed tomography (CT) for adults aged 55–80 years who have a 30 pack-year* smoking history and currently smoke or have quit within the past 15 years.[2] This was a Grade B recommendation, which required health insurance plans to cover lung cancer screening as a preventive service.§ To assess the prevalence of lung cancer screening by state, CDC used Behavioral Risk Factor Surveillance System (BRFSS) data collected in 2017 by 10 states.** Overall, 12.7% adults aged 55–80 years met the USPSTF criteria for lung cancer screening. Among those meeting USPSTF criteria, 12.5% reported they had received a CT scan to check for lung cancer in the last 12 months. Efforts to educate health care providers and provide decision support tools might increase recommended lung cancer screening.

BRFSS is a random-digit–dialed landline and cellular telephone survey of the noninstitutionalized U.S. adult population aged ≥18 years conducted by state health departments in conjunction with CDC.†† In 2017, for the first time, an optional module added questions on lung cancer screening. In combination with core BRFSS questions on age and cigarette smoking status, three questions§§ from the lung cancer screening module enabled calculation of cigarette pack-years smoked. A fourth question asked about receipt of CT scans in the last 12 months with the following possible responses: "Yes, to check for lung cancer"; "No (did not have a CT scan)"; and "Had a CT scan, but for some other reason."

Ten states administered this module to 85,514 respondents¶¶ during January 2017–December 2017.*** Weighted estimates were derived by following BRFSS recommendations for optional modules.[3] and using SAS-callable SUDAAN (version 11.0; RTI International) to account for the BRFSS stratified, complex sampling design. Current, former, and never cigarette smoking status††† and smoking pack-year categories§§§ were defined for adults aged 55–80 years¶¶¶ (33,137). Weighted prevalences of smoking status and pack-year categories among adults aged 55–80 years were estimated for each state. Weighted populations for smoking status and pack-year categories were derived by multiplying the state population of persons aged 55–80 years by the weighted percentage of adults in the corresponding smoking status and pack-year category.

Weighted estimates were calculated for self-reported receipt of lung cancer screening among current and former cigarette smokers (hereafter referred to as smokers) aged 55–80 years (14,585) who did and did not meet USPSTF criteria for lung cancer screening.**** The weighted prevalence of lung cancer screening was calculated by age group, smoking status, sex, race/ethnicity, education, general health status, health care coverage, routine checkup in the past year, and diagnosed chronic obstructive pulmonary disease (COPD), emphysema, or bronchitis.†††† Logistic regression was used to calculate prevalence ratios (PRs) with 95% confidence intervals, with reported lung cancer screening as the outcome, adjusted for all other variables.

Overall, 12.7% of adults aged 55–80 years met USPSTF criteria for lung cancer screening, with nearly one half (5.6%) being former smokers (Table 1). The percentage of adults meeting USPSTF screening criteria by state ranged from 8.9% (Maryland) to 17.0% (Oklahoma). The population size meeting USPSTF criteria ranged from 16,200 (Vermont) to 610,000 (Florida) (Supplementary Table 1, https://stacks.cdc.gov/view/cdc/85167).

Lung cancer screening was reported by 12.5% of smokers who met USPSTF criteria and ranged from 9.7% (Oklahoma) to 16.0% (Florida) (Table 2). Differences between states ranged from –3.8% (Oklahoma versus Vermont) to 6.3% (Florida versus Oklahoma) (Supplementary Table 2, https://stacks.cdc.gov/view/cdc/85168). Lung cancer screening was reported by 7.9% of smokers aged 55–80 years who did not meet USPSTF criteria and ranged from 4.3% (Maryland) to 9.4% (Oklahoma and Florida) (Table 2). Differences between states ranged from –5.1% (Maryland versus Oklahoma) to 5.2% (Florida versus Maryland) (Supplementary Table 2, https://stacks.cdc.gov/view/cdc/85168).

Among smokers who met USPSTF criteria, higher prevalence of lung cancer screening was associated with diagnosed COPD (PR = 3.01) and lower prevalence of screening with no routine checkup in the past year (PR = 0.54) (Table 3). Among smokers who did not meet USPSTF criteria, higher prevalence of screening was associated with diagnosed COPD (PR = 2.34) and lower prevalences of screening with being a former smoker (PR = 0.63) and fair or poor general health status (PR = 0.68).

*Pack-years (PYs) are the average of number of 20-cigarette packs smoked per day multiplied by the number of years smoked.
USPSTF is currently conducting a review and update of this recommendation.
§Under Section 2713 of the Patient Protection and Affordable Care Act (ACA), individual and group health insurance plans must provide coverage of evidence-based screening services that have a rating of A or B in the current USPSTF recommendations and may not impose cost-sharing (such as copayments, deductibles, or co-insurance) on patients receiving these services. In addition, starting in 2015, the Centers for Medicare and Medicaid Services covered lung cancer screening for Medicare beneficiaries aged 55–77 years who met the USPSTF smoking criteria.
https://www.cdc.gov/brfss/questionnaires/pdf-ques/2017_BRFSS_Pub_Ques_508_tagged.pdf.
**Florida, Georgia, Kansas, Maine, Maryland, Missouri, Nevada, Oklahoma, Vermont, and Wyoming.
†† https://www.cdc.gov/brfss/about/index.htm.
§§"You've told us that you have smoked in the past or are currently smoking. The next questions are about screening for lung cancer. Q1. How old were you when you first started to smoke cigarettes regularly? (enter: age in years). Q2. How old were you when you last smoked cigarettes regularly? (enter: age in years). Q3. On average, when you {smoke/smoked} regularly, about how many cigarettes {do/did} you usually smoke each day? (enter: number of cigarettes)."
¶¶2017 BRFSS combined landline and cellular telephone cooperation and response rates. https://www.cdc.gov/brfss/annual_data/2017/pdf/2017-response-rates-table-508.pdf.
***All 10 states asked all respondents (including never smokers) Question (Q) 1 to Q3 on pack-years. Six states (Florida, Georgia, Maine, Maryland, Vermont, and Wyoming) asked all respondents (including never smokers) Q4 on lung cancer screening, and four states (Kansas, Missouri, Nevada, and Oklahoma) only asked current or former smokers (excluding never smokers) to respond to Q4.
†††Respondents were categorized as never smokers if they had smoked fewer than 100 cigarettes in their lifetime. Former smokers had smoked at least 100 cigarettes but now smoked cigarettes "not at all." Current smokers had smoked at least 100 cigarettes and now smoked cigarettes "every day" or "some days."
§§§For current and former cigarette smokers who met USPSTF criteria for lung cancer screening, PY categories were 1) current smokers ≥30 PY and 2) former smokers ≥30 PY who had quit smoking <15 years ago. For current and former smokers who did not meet USPSTF criteria, the smoking PY categories were 1) current smokers 20–29 PY; 2) current smokers <20 PY; 3) former smokers >30 PY who quit smoking ≥15 years ago; 4) former smokers 20–29 PY; and 5) former smokers <20 PY.
¶¶¶A restricted file with single-year age was used to determine years that smokers quit smoking for former smokers and to determine respondents aged 80 years. The public-use BRFSS combines persons aged ≥81 years with those aged 80 years into a single category aged ≥80 years.
****The following categories and number of respondents were excluded: history of any cancer or missing smoking PY data (18,267); never smokers (41,537); age <55 years (9,661); and age >80 years (1,464).
††††Diagnosed COPD was determined by a "yes" response to the question "Has a doctor, nurse, or other health professional ever told you that you had chronic obstructive pulmonary disease or COPD, emphysema, or chronic bronchitis?"

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