Early Detection Can Save Lives, but Many Face Barriers to Lung Cancer Screening: Sora Ely, MD

In the second and final part of her interview with The American Journal of Managed Care^®, Sora Ely, MD, a thoracic surgeon at GW Cancer Center, discussed the barriers preventing eligible patients from undergoing lung cancer screening and highlighted the populations most affected.

She also explained the differences in survival between early- and late-stage non–small cell lung cancer (NSCLC) and outlined strategies that providers and health systems can implement to improve screening rates, helping to detect more cases in their early stages.

Read part 1 to learn why lung cancer screening awareness is critical during National Cancer Prevention Month and beyond.

This transcript has been lightly edited for clarity.

AJMC: What are the biggest barriers preventing eligible patients from receiving low-dose CT scans, and which populations remain most under-screened?

Ely: An important barrier and difference with lung cancer screening compared with other cancer screenings is that the eligibility criteria are not really complex, but they are certainly less simple than just having to be a certain age. I think there's a lack of awareness even among providers about the current guidelines. So, they're not getting recognized at the point of care to be referred in the same way that they are for breast or colon cancer screening.

I think there's also a big lack of awareness among patients. I think pretty much everyone nowadays knows that you need to go get a colonoscopy at some point, and you need to get a mammogram at some point if you're a woman, but tons of people that I speak to aren't aware that there is a screening test for lung cancer. I think it's really important we get that word out.

Another significant barrier is that there have been a lot of national quality metrics that have been implemented for breast and colon cancer screening. Through CMS, and specifically through the Healthcare Effectiveness Data and Information Set (HEDIS), there are several active metrics for both of those cancer screenings, and there are none for lung cancer screening.

I think that having those metrics is really important both to assess where we are, how we're doing now, and to really increase systemic and provider awareness about attaining those metric goals. There was a movement by HEDIS to create a lung cancer screening metric recently that was stalled, much to the disappointment of myself and others who are big advocates of lung cancer screening.

We see that the lack of uptake is accentuated in underserved groups. Unfortunately, it's not surprising that we see that our minoritized race patients and also women are even more underscreened than our overall population.

AJMC: How do treatment approaches and survival outcomes differ between early- and late-stage NSCLC?

Ely: There have been a lot of advances on both sides, thankfully. There's a lot of optimism and certainly a lot of improvements, and we've started to see movement in the overall survival for lung cancer as a result. In the early stage, we really focus on curative intent treatment, and the cornerstone is still surgical resection, which is where I come in.

Some of those advances mean that even early-stage patients are now getting additional therapies. There are some new, much more effective, and also well-tolerated therapies that we use, sometimes before surgery and sometimes after surgery, even for relatively early-stage patients. The fantastic thing is, with screening, we hope to catch these in a very early stage. With the early stages now, like, for instance, 1A1, survival can be around 90%, so early-stage survival can be quite good.

What’s also exciting is that late-stage survival has made significant strides in the last several years. Both groups are benefiting from the advent of immunotherapy, which leverages the body's immune system to help fight the cancer, regardless of the cancer type or the specifics of the tumor, and targeted therapies, which require us to test the tumor for specific mutations or alterations. Then, these drugs target those exact mutations. Particularly targeted therapies, because they are focused on the tumor, can be really well-tolerated and may even be given as a pill instead of an infusion.

AJMC: From a provider and health system perspective, what strategies can meaningfully improve screening and early detection rates?

Ely: One of the first things, and hopefully one of the easier things, is that we could get the word out. I always ask my patients, or when I do community outreach, even people who are not patients, to really get the word out. I think it's become normalized that people will talk about health maintenance, like going to the doctor, getting cancer screening for some of the other cancers that we mentioned, and people may even advocate for their loved ones or their parents to get screened.

But I think there are two layers to that. One is that, like I said, a lot of people don't know that there's a screening test for lung cancer, so I always urge people I talk to to please bring that up. Now that you know that there's a screening test for lung cancer, next time you're having a conversation and it seems appropriate, say, “Hey, I learned something the other day. Did you know that there's a screening test for lung cancer? Tons of people who are eligible are not getting screened.”

I think just getting the word out, both for providers and for the public, so people are aware and can advocate for themselves as well when they go see their primary care doctor and say, “Hey, I have smoked in the past. Am I eligible for lung cancer screening?”

One thing that's worth mentioning is that oftentimes patients are a little bit apprehensive about the cost, but because the USPSTF recommended this, it is mandatory for major insurance providers to cover this with no cost-sharing. In other words, there's no copay, no bill shows up, and the scan is covered, so I think that's important for people to know.

There are also movements to try to increase early detection through other means than screening. At GW, we have an internal lung nodule program, and these are starting to crop up all over, not just at GW. These are really important because, as I mentioned, there's pretty stringent criteria on who qualifies for lung cancer screening under the current guidelines, and we do know that there is a segment of patients with lung cancer who have smoked but don't meet those criteria and may still develop lung cancer.

Early detection programs outside of screening, like these lung nodule programs, can sometimes capture those patients and offer a second avenue for patients, or even never smokers, who are not currently eligible for lung cancer screening under the traditional pathway. They may still get detected, treated, and managed appropriately in a lung nodule program and have the opportunity for early detection and early treatment.