Diagnostic follow-up after positive lung cancer screening often falls short

Only about 60% of patients received guideline-concordant care after positive low-dose CT lung cancer screening, a study found.

The retrospective cohort study assessed diagnostic follow-up among Medicare beneficiaries by analyzing linked data from the American College of Radiology Lung Cancer Screening Registry and Medicare claims for 64,555 adults ages 65 years or older with a first positive CT screening result in 2015 to 2021. Positive results were categorized using Lung-RADS scores. The study was published Dec. 16 by Annals of Internal Medicine.

Overall, 59.7% of participants received guideline-concordant follow-up, 32.3% received less intensive care, and 7.9% received more intensive care than recommended. Concordance with recommendations increased with higher Lung-RADS scores. Within one year, 12.4% of participants were diagnosed with lung cancer, with rates rising alongside follow-up intensity.

Invasive procedures were performed in 16.2% of participants overall and in 7.3% of those without lung cancer, including 0.8% who underwent lung resection. Among patients with Lung-RADS scores of 3, less intensive follow-up was more likely in non-Hispanic Black (odds ratio [OR, 1.26; 95% CI, 1.12 to 1.41), Asian (OR, 1.66; 95% CI, 1.28 to 2.14), and Hispanic (OR, 1.56; 95% CI, 1.30 to 1.88) patients than non-Hispanic White patients; Hispanic patients with Lung-RADS scores of 3 were also more likely to receive more intensive follow-up (OR, 1.45; 95% CI, 1.10 to 1.91) than White patients.

The findings highlight gaps in adherence to follow-up guidelines and persistent racial disparities, suggesting a need for targeted interventions to improve timely and appropriate care and improve lung cancer screening outcomes, according to the study authors.

“Less intensive follow-up was associated with lower lung cancer risk through 1 and 2 years, but this still could have led to delays in diagnosis and a reduction in the mortality benefit from screening—although more research is needed to know to what extent, if any, this is occurring,” the authors wrote. “This finding clarifies that the main opportunity for improvement among U.S. [lung cancer screening] participants is ensuring timely and appropriate follow-up (therefore interventions to address the underuse problem), not addressing harms from overuse.”

Another study, also published by Annals on Dec. 16, found that using smoking duration rather than pack-years reduced gaps in screening among African American and Latino patients relative to White patients and improved lung cancer detection sensitivity across all races.

To evaluate the effect of alternative eligibility criteria for lung cancer screening, the study analyzed data for 105,261 adults ages 45 to 75 years in California and Hawaii who had a smoking history. Basing screening on a smoking duration of 30 years or more increased eligibility for screening among Black and Latino patients while maintaining similar overall eligibility, the study found. The study authors wrote that criteria based on smoking duration may offer a viable alternative to pack-year-based screening, while risk-based approaches may require refinement to ensure equity.