Update on Lung Cancer Screening

Andrew R. Brownlee, MD; Jessica S. Donington, MD, MSCR


Semin Respir Crit Care Med. 2020;41(3):447-452. 

In This Article

Lung Cancer Screening Implementation

The wide spread implementation of LDCT screening for lung cancer has been slow. In the United States, it is estimated <5% of eligible individuals are currently screened.[35] This is due in part to the poor reception from the AAFP and many primary care clinicians being unaware of the eligibility criteria and requirements.[36] This results in a low–referral rates and/or referral of ineligible individuals. In a survey conducted of U.S. Federally Qualified Health Centers, only 3 out of the 110 clinics reported screening more than 10 patients per year.[37] The main barriers identified were accurate assessment of smoking history, lack of smoking cessation resources, limited access to specialty providers to evaluate and follow abnormal findings, lack of insurance, and out of pocket costs to patients.[19] Distrust, fear of finding cancer, inconvenience, and misconceptions about cancer risk are major barriers for patients to pursue screening, but a majority report that they would get screened if recommended by their doctor. Stigma, nihilism, and misconceptions about eligibility, shared decision making, and false positive rates are physician-based barriers in screening. In a 2019 report, only 18% of current smokers and 10.5% of former smokers discussed lung cancer screening with their providers in the past year.[38]

National Lung Cancer Roundtable

The National Lung Cancer Roundtable (NLCRT) is a coalition of public, private, and voluntary organizations dedicated to reducing the incidence and mortality from lung cancer.[39] It focuses on promoting increased awareness, prevention, early detection, and assurance of optimal therapy through public education, provider education, targeted research, and health policy initiatives. A major focus of the NLCRT is overcoming the significant challenges in the implementation of successful LDCT programs nationwide. There are specific task groups on screening implementation strategies, provider engagement, shared decision making, survivorship, stigma and nihilism, and tobacco treatment in the setting of lung cancer screening.

Similarly, the American College of Radiology (ACR) who publish the Lung-RADS system for reporting of screened nodules and maintain the only CME-approved registry for reporting LDCT screening have also put forth considerable resources to assist in implementation of lung cancer screening programs.[40]

Future Considerations and Challenges

Despite the promising results of the NELSON and the NSLT trials, endorsement by USPSTF, and reimbursement from CMS and many major private insurers, there remains very low adoption rates of lung cancer screening in the United States. As the evidence for a mortality benefit in lung cancer screening continues to mount, the hope is that there will be increased support from primary care providers and the AAFP. A further challenge is that the current screening criteria capture only one-third of individuals in the United States who develop lung cancer,[30] and poorly targets African Americans.[34] More information is needed to determine if altering or expanding eligibility criteria to include other known risk factors, as has been suggested by the NCCN group 2, or the use of risk calculators, such as those from the Prostate–Lung Colorectal and Ovarian (PLCO) or Tammemagi's risk could improve capture of patients with early-stage lung cancer.[41] Other potential advances include nodule characterization by three-dimensional volumetric measurements and the use of volume doubling times for improved nodule characterization. In one study, the use of nodule volumetry coupled with doubling time compared with nodule diameter alone reduced downstream testing from 22 to 8% in appropriately selected nodules.[42] Molecular testing from airway epithelial cells, peripheral blood, and exhaled breath are under investigation as novel tools to better refine populations for screening and for determination of cancer risk in screen-detected nodules.[43]