Simplified criteria can be used to help identify eligibility for lung cancer screening

An estimated 9 million individuals in the United States are eligible for low-dose computed tomography (LDCT) lung cancer screening, according to researchers from the University of Washington (UW) Department of Medicine in Seattle.¹ Timely screening could prevent up to 12,000 deaths from lung cancer.² But efficiently and economically identifying these people can be challenging.

The UW researchers propose using a set of five criteria with information extractable from patients’ electronic health records (EHRs) to help improve screening referral. The team published their findings in the July 12, 2019, online edition of the Annals of the American Thoracic Society.

Led by Matthew Triplette, MD, UW assistant professor of pulmonary and critical care medicine, and a faculty member of the Fred Hutchinson Cancer Research Center, the team utilized data from the National Health and Nutrition Examination Survey (NHANES) from the years 2011 through 2016. The annual survey of approximately 5,000 U.S. residents collects demographic, socioeconomic, dietary, and health-related data.

The study cohort consisted of 17,830 subjects over age 18 who had completed the smoking segment of the survey. The researchers then used NHANES weighting criteria to create a nationally representative cohort of 235.5 million people, and then applied lung cancer screening eligibility criteria recommended by the U.S. Preventive Services Task Force (USPSTF) and the Centers for Medicare and Medicaid Services (CMS). These criteria include those aged 55-77 with 30 pack-years of smoking history who either were current smokers or had quit within the previous 15 years.

The authors estimated 3.8% of the study cohort, or nearly 9 million individuals, would be eligible for lung cancer screening.  They also determined that using smoking status and age alone can predict CMS and USPSTF screening eligibility with high a high degree of accuracy, aiding health systems in targeting those who would benefit from testing. Accuracy would further increase if smoking intensity (packs a day and pack-years) and quit data were also recorded in a patient’s her, the researchers found.

The authors also evaluated the impact of gender, racial/ethnic group, education and income level, and insurance status on the predictive value of these criteria. They found wide differences in eligibility based on these data, while the predictive value of the simplified criteria remained high. The authors cautioned, however, that “current smoking is becoming increasingly concentrated in certain minority groups and those of lower socioeconomic status.”

“Even at present, our results suggest that those in the lowest education and income status are twice as likely to be eligible for lung cancer screening than those in the highest,” they wrote. “It is important to note that eligibility for screening may not equitably reflect actual lung cancer risks across groups, which has been demonstrated for black Americans.” The authors also noted that individual life expectancy and co-morbidity should be factored into any recommendation for lung cancer screening.

However, even the simplest extrapolation of data from patients’ EHRs can create a pre-screening tool that could alert healthcare professionals to patients who may be eligible for lung cancer screening, and could improve participation in screening programs. Although clinical trials have proven the value of LDCT screening in high-risk individuals, fewer than 5% are having low-dose CT screenings.³

“The low uptake of screening is a cause for concern, and we want to be particularly careful that we aren’t creating disparities in screening referral,” Dr. Triplette told Applied Radiology. “EHR-based alerts informed by simplified criteria as a pre-screening tool may improve equitable identification of potentially eligible patients in a health system.”

REFERENCES

1. Triplette M, Donovan LM, Crothers K, et al. Prediction of lung cancer screening eligibility using simplified criteria. Ann Am Thorac Soc. Published online July 12, 2019. doi: 10.1513/AnnalsATS.201903-239OC.
2. Ma J, Ward EM, Smith R, et al. Annual number of lung cancer deaths potentially avertable by screening in the United States. Cancer. 2013;119:1381-1385.
3. Triplette M, Thayer JH, Pipavath SN, et al. Poor Uptake of Lung Cancer Screening: Opportunities for Improvement. J Am Coll Radiol. 2019;16(4-PartA):446-450.