Lung Cancer Screening in the United States

Alexandra Potter, Simar bajaj, & Chi-Fu Jeffrey Yang

Abstract

Lung cancer is the deadliest cancer in the U.S., causing more deaths than breast, colon, and prostate cancer combined. The early detection of lung cancer through screening by low-dose computed tomography (CT) can identify up to 59% of lung cancers at the earliest stage of disease, leading to a 20-33% reduction in lung cancer mortality in high-risk populations. Despite the significant mortality reduction from lung cancer screening, only 5.7% of high-risk individuals are currently getting screened. Lung cancer has the potential to save thousands of lives every year; however, misconceptions and unfamiliarity with the lung cancer screening process among primary care providers and patients, little funding and public support, and the negative public perception of lung cancer prevent the widespread adoption of screening. Eliminating the stigma surrounding lung cancer and changing public perception of lung cancer is key to increasing lung cancer screening rates in the U.S. and saving lives.

“Lung cancer mortality reduction attributable to annual screening with low-dose CT imaging is the most profound advance in the war against cancer in a generation” - Dr. Douglas E. Wood, Chair of the Department of Surgery at the University of Washington

For decades, lung cancer has been the number one cause of cancer-related death in the United States. In 2020, it is estimated that 135,720 Americans will die from lung cancer, accounting for more deaths than breast, colon, and prostate cancer combined.¹ While the lung cancer mortality rate has declined every year since 1990, lung cancer deaths still cause 24% of all cancer deaths in the U.S.^2,3 Moreover, from 2015 to 2065, it is estimated that 4.4 million more Americans will die from lung cancer.⁴

The lung cancer mortality rate is exorbitantly high in large part because of the prevalence of lung cancers diagnosed at a late stage. In 2020, of the 228,820 Americans that will be diagnosed with lung cancer, 57% will be diagnosed at a distant stage where the cancer has metastasized to areas outside of the lungs, such as the bones, brain, or liver.^1,5 The five-year survival rate for a patient diagnosed with distant lung cancer is 6%; however, if diagnosed at an early, localized stage—before the cancer has spread—the five-year survival rate is 61%.⁵

Early detection of lung cancer is one of the most promising ways to reduce lung cancer mortality. Indeed, annual lung cancer screening using low-dose computed tomography (CT) scans detects up to 59% of lung cancers at Stage 1. For high-risk populations, as determined by patients’ age and smoking history, lung cancer screening has been shown to significantly reduce mortality from lung cancer. In 2011, the National Lung Screening Trial, a large randomized trial of over 50,000 high-risk individuals, reported a 20% reduction in mortality in participants screened for lung cancer using low-dose CT relative to chest x-ray.⁶ In February 2020, the NELSON (Nederlands–Leuvens Longkanker Screenings Onderzoek) trial further confirmed the life-saving benefit of lung cancer screening using low-dose CT, reporting a 24% reduction in mortality for men and a 33% reduction in mortality for women when compared to no screening.⁷

Despite the high incidence of and mortality from lung cancer as well as the significant reduction in lung cancer mortality from lung cancer screening, only 5.7% of high-risk individuals in the U.S. are currently getting screened by low-dose CT scans.⁸ Lung cancer has the potential to save thousands of lives every year, yet misconceptions and unfamiliarity with the lung cancer screening process among primary care providers and patients, minimal funding and public support, and negative public perception of lung cancer prevent the widespread adoption of screening.

While many primary care providers support lung cancer screening, their awareness and familiarity with the lung cancer screening process is suboptimal. To screen a patient for lung cancer, a primary care provider must determine the patient’s lung cancer screening eligibility, conduct a shared decision-making visit, and provide a written order for screening. In a study assessing primary care provider understanding of each of these steps, only 10% accurately identified all elements of the lung cancer screening process, and only 69% correctly assessed patient eligibility in three out of four scenarios.⁹ Moreover, a 2015 survey found that 53% of primary care providers were unaware that lung cancer screening was recommended by the United States Preventive Services Task Force.¹⁰ In addition to misconceptions about the lung cancer screening guidelines, primary care providers report significant challenges in conducting a shared-decision making visit, which requires primary care providers to outline the benefits and risks of lung cancer screening and to discuss the importance of smoking cessation or abstinence with the patient. While important, primary care providers report unfamiliarity with the shared decision-making process, insufficient time, and a lack of patient comprehension as barriers to the implementation of lung cancer screening.¹¹

Amongst patients, on the other hand, unfamiliarity with the lung cancer screening process and the stigma surrounding lung cancer make it challenging to increase screening rates. Patients who smoke may hold fatalistic beliefs, deny their risk for lung cancer, or have a fear of screening itself.¹² Anxiety and confusion about the outcome also prevent patients from pursuing lung cancer screening. Additionally, although most insurances cover lung cancer screening without cost-sharing, many patients are unaware of this and report concerns about the cost of screening.¹³

Currently, there are only a negligible number of programs in place to address these barriers that primary care providers and patients face. Many state health departments receive funding from the federal government to support breast, colon, and cervical cancer screening and education but not for lung cancer.¹⁴ Similarly, city health departments provide educational resources for most cancer screenings yet not for lung cancer screening. Awareness for lung cancer and lung cancer screening amongst policymakers as well as state and city officials is paltry in comparison to other cancers, and, as a result, there is little federal, state, or community support in place.

This disparity in funding, support, and awareness for lung cancer may be a result of the stigma associated with lung cancer and smoking. The stigma surrounding lung cancer not only affects patients, but it is ingrained in the way society views lung cancer. If someone says they were diagnosed with cancer, the initial response is sympathy; if someone says they were diagnosed with lung cancer, the initial response is often something along the lines of “Oh, I didn’t know you smoked.” This stigma may result in the belief that a patient who gets lung cancer “deserves” the disease, and this stigma manifests in society as a lack of initiative to raise awareness for lung cancer and lung cancer screening. In a survey of a random cross-section of 1,000 American adults, 59% said that lung cancer patients were at least partly to blame for their illness.¹⁵ Only 18% of participants said they were likely to donate money or volunteer time to support lung cancer, compared to 29% of participants who said they would for breast cancer. The stigma surrounding lung cancer directly influences public perception of lung cancer, and results in a lack of funding, awareness, and initiative to implement lung cancer screening programs.

The disturbingly low lung cancer screening rate is a problem that will only be resolved with systematic change. Burdened by the stigma surrounding lung cancer, there is little initiative to widely implement lung cancer screening programs in the U.S. Stigma is at the crux of this problem, and eliminating it is the foundation of its solution. We need awareness campaigns and widespread education about lung cancer screening for primary care providers and the general public. Shifting the public perception of lung cancer is the key to increasing the lung cancer screening rate. Breast cancer was once highly stigmatized like lung cancer, but, in 1974, after former first lady Betty Ford was diagnosed with breast cancer and started openly discussing it, public perception began to shift. Nearly fifty years later, breast cancer is the most funded cancer and has extensive awareness and education campaigns. The impact of this shift in public perception is evident; nearly 70% of at-risk individuals are screened for breast cancer in the U.S.² While breast cancer is more common than lung cancer, it is far less deadly.

Awareness, education, and advocacy is the solution to increasing lung cancer screening rates and decreasing lung cancer mortality. The American Lung Cancer Screening Initiative (ALCSI) is a 501(c)3 nonprofit working to initiate a paradigm shift in lung cancer screening in the U.S. Through awareness campaigns, educational webinars, and political advocacy, ALCSI is initiating the change that will increase lung cancer screening rates and decrease lung cancer mortality. The barriers we face in the implementation of lung cancer screening are extensive; however, if we work together to overcome them, lung cancer screening will realize its potential to save millions of lives.

About the Authors

Alexandra Potter is an undergraduate at UC Berkeley majoring in Bioengineering and is the Program Director of the American Lung Cancer Screening Initiative, apotter1@berkeley.edu.

Simar Bajaj is an undergraduate at Harvard University majoring in History of Science and is a co-leader of the American Lung Cancer Screening Initiative, simarbajaj@college.harvard.edu.

Dr. Chi-Fu Jeffrey Yang, MD, is a thoracic surgeon at Massachusetts General Hospital and a member of the faculty at Harvard Medical School. He is on the Board of Advisors for the American Lung Cancer Screening Initiative and is a member of the editorial board of the Journal of Thoracic and Cardiovascular Surgery, cjyang@mgh.harvard.edu.

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