USPSTF Expands Criteria for Lung Cancer Screening

Roxanne Nelson, RN, BSN

March 09, 2021

The US Preventive Services Task Force (USPSTF) has expanded the criteria for lung cancer screening. The updated final recommendations have lowered the age at which screening starts from 55 to 50 years and have reduced the criterion regarding smoking history from 30 to 20 pack-years.

"This is great news because it means that nearly twice as many people are eligible to be screened, which we hope will allow clinicians to save more lives and help people remain healthy longer," commented John Wong, MD, chief science officer, vice chair for clinical affairs, and chief of the Division of Clinical Decision Making at the Task Force.

The updated final recommendations were published online on March 9 in JAMA.

The Task Force recommends annual screening with low-dose CT for adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years.

This updates guidance issued in 2013, which recommended annual screening for lung cancer for adults aged 55 to 80 years who had a 30 pack-year smoking history and who were either current smokers or had quit within the past 15 years.

The move will nearly double the number of people are now eligible for screening, up to 14.5 million individuals ― an increase of 81% (6.4 million adults) from the 2013 recommendations.

The expanded criteria may help in increase screening among Black individuals and women. Data show that both groups tend to smoke fewer cigarettes than White men and that Black persons are at higher risk for lung cancer than White persons. In addition, research has shown that about one third of Black patients with lung cancer were diagnosed before the age of 55 years, which means they would not have been recommended for screening under the previous guidelines.

Uptake Has Been Limited

To date, uptake of lung cancer screening has been very limited, from 6% to 18% of individuals who meet the eligibility criteria.

The new recommendations will open up screening to many more people, but challenges to implementation remain.

"The science is clear that lung cancer screening has the potential to save lives," Wong told Medscape Medical News. "We recognize that there are existing barriers to screening everyone who is eligible, but clinicians and patients both deserve to know that screening can detect lung cancer early, when treatment has the best chance of being beneficial."

He added that the hope is that these recommendations will encourage clinicians to examine the barriers to effective lung cancer screening in their communities and to do what they can to improve implementation. "We also hope to encourage patients to have conversations with their clinicians about whether they are eligible for screening and to discuss smoking cessation treatments if they are still smoking," Wong added.

In an accompanying editorial, Louise M. Henderson, PhD, M. Patricia Rivera, MD, and Ethan Basch, MD, all from the University of North Carolina at Chapel Hill, address some of the current challenges in implementation.

They note that reimbursement for lung cancer screening by Medicare requires submission of data to a Centers for Medicare & Medicaid Services–approved registry, and this can present problems for facilities serving less affluent communities or that have limited resources.

Medicaid coverage is also uneven: as of September 2020, lung cancer screening was covered by 38 Medicaid programs, but not by nine; for three programs, data on coverage were not available.

"With the new recommendations lowering the screening-eligible age to 50 years, many eligible individuals who are uninsured or who are receiving Medicaid and living in states that do not cover screening will have financial barriers to undergo screening," they write.

In addition, many individuals in at-risk populations lack adequate geographic access to comprehensive lung cancer screening programs.

Expanding eligibility criteria is important, the editorialists point out, but barriers to screening, which include lack of insurance coverage and limited physical access to high-quality screening programs, highlight the complex problems with implementation that need to be addressed.

"A concerted effort to increase the reach of lung cancer screening is needed," they write. "The 2021 USPSTF recommendation statement represents a leap forward in evidence and offers promise to prevent more cancer deaths and address screening disparities. But the greatest work lies ahead to ensure this promise is actualized."

Advocacy Needed

Approached for comment, Jianjun Zhang, MD, PhD, from the Department of Thoracic/Head and Neck Medical Oncology, the University of Texas MD Anderson Cancer Center, Houston, Texas, noted that he supports the new guidelines and that they will lower mortality. "The data are pretty strong overall," he said in an interview.

Although the uptake of screening is currently very low, he pointed out even if uptake remains the same, more lives will be saved because eligibility has been expanded. "More people will be getting screened, so it's a start," he said.

Aside from factors such as insurance and access, another problem involves primary care. "Time is very limited in primary care," he said. "You have about 15 minutes, and it can be really hard to fit everything into a visit. Screening may get left out or may only get a brief mention."

Advocacy is needed, Zhang pointed out. "Breast cancer has strong voices and advocacy, and people are more aware of mammography," he said. "The information is disseminated out into the community. We need the same for lung cancer."

Zhang emphasized that even with the expanded criteria, many individuals will still be missed. "There are other risk factors besides smoking," he said. "About 10% of lung cancers occur in never-smokers."

Other risk factors include a family history of lung cancer, exposure to certain materials and chemicals, working in the mining industry, and genetics.

"We will move on to more personalized screening at some point," he said. "But right now, we can't make it too complicated for patients and doctors. We need to concentrate on increasing screening rates within these current criteria."

The updated guidelines have been given a B recommendation, meaning that the Task Force recommends that clinicians provide the service to eligible patients and that there is at least fair evidence that this service improves important health outcomes and that benefits outweigh harms.

The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF. All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings. The original article lists relevant financial relationships of Task Force members. Zhang has received grants from Merck and Johnson & Johnson and adversary/consulting/hornoraria fees from Bristol-Myers Squibb, AstraZeneca, GenePlus, Innovent, OrigMed, and Roche.

JAMA. Published online March 9, 2021. Full text, Editorial

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