January 28, 2019
4 min read

Better adherence needed to ensure benefits, cost-effectiveness of lung cancer screening

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Paul Brasher, MD
Paul B. Brasher Jr.

Adherence to annual lung cancer screening appeared low among U.S. veterans at high risk for the malignancy who had negative findings on baseline scan, according to results of a retrospective observational cohort study presented at CHEST Annual Meeting.

The results highlight the need for strategies to improve adherence to ensure screening provides the maximum possible benefit, Paul B. Brasher Jr., MD, pulmonary/critical care fellow at Medical University of South Carolina, and colleagues concluded.

In 2015, CMS started covering annual low-dose CT lung cancer screening for Medicare beneficiaries aged 55 to 77 years who have a 30 pack-year smoking history and either currently smoke or have quit within the past 15 years. CMS based its decision on results of the National Lung Screening Trial, which showed screening with low-dose CT reduced lung cancer mortality by 16% among high-risk individuals.

Brasher and colleagues assessed adherence to annual screening among individuals within the Veterans Health Administration Lung Cancer Screening Demonstration Project. All members of the cohort were aged 55 to 80 years who met lung cancer screening risk criteria based on their smoking history.

The analysis included 2,106 veterans who underwent baseline scans with low-dose CT.

Sixty percent (n = 1,269) had scans that were negative for nodules at least 4 mm in size but received recommendations for repeat annual low-dose CT screening. Of this group, 149 subsequently were considered no longer eligible for screening due to one of several factors, including receipt of a lung cancer diagnosis or evaluation for cancer, no longer meeting age or smoking history criteria, or development of another life-limiting disease.

This left 1,120 veterans eligible for repeat annual screening with low-dose CT, of whom 870 (77.6%) underwent a follow-up scan.

“Our study demonstrates that, even within the context of a well-designed and guideline-adherent low-dose computed tomography screening program, adherence is not optimal and does not reach the reported 95% of the National Lung Screening Trial when the baseline scan is negative,” Brasher said in a press release. “Both mortality benefit and cost-efficacy are likely to suffer without better adherence.”

HemOnc Today spoke with Brasher about the potential explanations for poor adherence, the steps that can be taken to increase adherence among screening-eligible individuals, why high adherence is necessary to maximize the potential benefit of lung cancer screening, and whether the results observed in the VA cohort can be extrapolated to the general population.



Question: Can you explain the study rationale?

A nswer : Screening for lung cancer has been introduced nationwide since the findings of the National Lung Screening Trial were published in 2011. Several professional organizations published guidelines for appropriate implementation of low-dose CT screening. The VA initiated a demonstration project to assess its ability to implement the findings of the NLST. Although this program was successful, certain long-term outcomes were not assessed — continued adherence to recommended annual screening being one of them. Unless an early-stage cancer is discovered on the initial screen, patients will not benefit if they fail to return for annual follow-up screening. Within the National Lung Screening Trial cohort, adherence rates throughout the course of the trial were extremely high — approaching 95%. However, adherence rates of commonly screened for cancers such as breast or colon cancers are between 40% and 65% in the community. We undertook this study to assess adherence to lung cancer screening during a 3-year period in the VA demonstration project.


Q: How did you conduct the study and what did you find ?

A: We looked at the VA lung cancer screening demonstration project conducted between July 2013 and June 2015. The study included about 93,000 primary care patients who were assessed for screening criteria. We compared patients with nodules vs. no nodules and, for this study, we started with individuals who had no nodules. We assessed the baseline scan and follow-up scan at 9 months to 15 months, and we found adherence was far short of what was seen in the National Lung Screening Trial. All we can say for now is that adherence is not optimal. We will continue to look at these data to see if adherence is worse for patients who have a nodule than those who do not, and to see what happens with adherence over time.


Q: What are the clinical implications of the se findings?

A: The main takeaway is the potential loss of mortality benefit of screening if individuals are not adherent. The idea is to catch lung cancer at an early stage when it is potentially curable.


Q: Can the se results be extrapolated to the general population?

A: I believe so, but my fear is that adherence may be even worse in the general population. We conducted this trial in a VA hospital, where staff goes above and beyond what one may experience in the general community. If a patient at the VA has an appointment scheduled, they receive several reminder phone calls. If there is no response, letters are sent out at least three times. Our support staff do quite a bit to get patients to return for follow-up visits. If adherence is poor even though we are taking these types of measures, what does this say about what happens in the general community? We expect adherence to be even worse outside of the academic centers.



Q: Is there anything else that you would like to mention?

A: Once we see how adherence plays out, we wish to explore the factors that affected nonadherence in this cohort. We then can hopefully come up with a plan to target these individuals and improve their adherence to annual screening. – by Jennifer Southall


Reference s :

Brasher, PB et al. Presented at: CHEST Annual Meeting. Oct. 6-10, 2018; San Antonio.

Gatsonis CA, et al. Radiology. 2011;doi:10.1148/radiol.10091808.

National Lung Screening Trial Research Team. N Engl J. Med. 2011;doi:10.1056/NEJMoa1102873.


For more information:

Paul B. Brasher Jr. , MD, can be reached at Medical University of South Carolina, 171 Ashley Ave., Charleston, SC 29425; email: bradbrasher@gmail.com.


Disclosure : Brasher reports no relevant financial disclosures.