Lung Cancer Screening With Low-Dose Computed Tomography in the United States—2010 to 2015

Lung cancer is the most preventable and leading cause of cancer deaths in the United States, with about 155 870 deaths each year.¹ In December 2013, the United States Preventive Services Task Force (USPSTF) recommended annual screening for lung cancer with low-dose computed tomography (LDCT) for asymptomatic persons aged 55 to 80 years who have a 30 pack or more per year smoking history and currently smoke or have quit within the past 15 years.² According to the 2010 National Health Interview Survey (NHIS), only 2% to 4% of high-risk smokers received LDCT for lung cancer screening in the previous year.³ In this study, we examined whether LDCT screening has increased following the USPSTF recommendation.

We used the 2010 and 2015 NHIS, which included 2347 respondents who met the USPSTF criteria for LDCT.² Self-reported LDCT in the past year for lung cancer screening was the primary outcome of the study. Analyses excluded respondents with unknown (n = 6) or self-reported history of lung cancer (n = 41) or were missing LDCT testing information (n = 133), leaving 2167 adults available for analyses. Weighted prevalence of LDCT for lung cancer screening in the past year was calculated by factors of interest. Multivariable prevalence ratios of LDCT in the past year were estimated using predicted margins. All statistical analyses accounted for complex sampling design and were conducted with SAS callable SUDAAN statistical software (version 9.0.3, SAS Institute). The study was based on deidentified publicly available database and exempt from institutional review board and informed consent.

From 2010 to 2015, the percentage of eligible smokers who reported LCDT screening in the past 12 months remained low and constant, from 3.3% in 2010 to 3.9% in 2015 (P = .60); an even lower proportion of noneligible smokers received LDCT (Table 1). Of the 6.8 million smokers eligible for LDCT screening in 2015, only 262 700 received it. Furthermore, there was no significant increase in screening from 2010 to 2015 for any of the sociodemographic groups, nor were there significant subgroup differences in screening, except between participants with or without a history of bronchitis (Table 2). Of note, over 50% (1230/2167) of smokers meeting USPSTF recommendations for LDCT screening were uninsured or Medicaid insured (Table 1).

Screening for lung cancer using LDCT among eligible current and former smokers remained low and unchanged in 2015 following the 2013 USPSTF recommendation for annual screening. Reasons for exceptionally low uptake of screening may include gaps in smokers’ knowledge regarding LDCT, lack of access to care as well as physicians’ knowledge about screening recommendations⁴ and reimbursement. For example, according to a 2015 survey of physicians in South Carolina, 36% of physicians correctly stated that LCDT screening should be conducted annually in high-risk individuals, and 63% of physicians did not know that Medicare covers LDCT for lung cancer screening.⁴ It is also possible that physicians may be aware of LDCT screening, but have limited access to the high-volume, and high-quality radiology centers, a recommendation set forth by public health organizations⁵ and a stipulation on Medicare reimbursement.⁶ The decrease in the number of screening-eligible smokers from 8.4 million in 2010 to 6.8 million in 2015 reflects progress in tobacco control, and this has implications for the future provision of LDCT screening. Receipt of LDCT and smoking history were self-reported and subject to recall bias and the limited time following the USPSTF recommendation and Medicare-reimbursement are limitations of our study. Despite this, our study provides the first national estimate of LDCT following the USPSTF recommendation.

In conclusion, annual LCDT screening among heavy current and former smokers remains low and unchanged following the USPSTF recommendation despite the potential to avert thousands of lung cancer deaths each year. This underscores the need to educate clinicians and smokers about the benefit and risks of lung cancer screening for informed decision making.

Corresponding Author: Ahmedin Jemal, DVM, PhD, Surveillance & Health Services Research, American Cancer Society, 250 Williams St NW, Atlanta, GA 30303-1002 (ajemal@cancer.org).

Published Online: February 2, 2017. doi:10.1001/jamaoncol.2016.6416

Author Contributions: Dr Fedewa had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Fedewa.

Conflict of Interest Disclosures: None reported.

Funding/Support: The American Cancer Society funded the analysis, interpretation, and presentation of the manuscript.

Role of the Funder/Sponsor: Staff in the Surveillance and Health Services Research of the American Cancer Society designed and conducted the study, including analysis, interpretation, and presentation of the manuscript. No staff at the American Cancer Society, other than the study investigators, reviewed or approved the manuscript.