Assessment of Uptake Appropriateness of Computed Tomography for Lung Cancer Screening According to Patients Meeting Eligibility Criteria of the US Preventive Services Task Force

Abstract

ImportanceCurrently, computed tomography (CT) is used for lung cancer screening (LCS) among populations with various levels of compliance to the eligibility criteria from the US Preventive Services Task Force (USPSTF) recommendations and may represent suboptimal allocation of health care resources.ObjectiveTo evaluate the appropriateness of CT LCS according to the USPSTF eligibility criteria.Design, Setting, and ParticipantsThis cross-sectional study used the 2019 Behavioral Risk Factor Surveillance System (BRFSS) survey. Participants included individuals who responded to the LCS module administered in 20 states and had valid answers to questions regarding screening and smoking history. Data were analyzed between October 2021 and August 2022.ExposuresScreening eligibility groups were categorized according to the USPSTF 2013 recommendations, and subgroups of individuals who underwent LCS were analyzed.Main Outcomes and MeasuresMain outcomes included LCS among the screening-eligible population and the proportions of the screened populations according to compliance categories established from the USPSTF 2013 and 2021 recommendations. In addition, the association between respondents’ characteristics and LCS was evaluated for the subgroup who were screened despite not meeting any of the 3 USPSTF screening criteria: age, pack-year, and years since quitting smoking.ResultsA total of 96 097 respondents were identified for the full study cohort, and 2 subgroups were constructed: (1) 3374 respondents who reported having a CT or computerized axial tomography to check for lung cancer and (2) 33 809 respondents who did not meet any screening eligibility criteria. The proportion of participants who were under 50 years old was 53.1%; between 50 and 54, 9.1%; between 55 and 79, 33.8%; and over 80, 4.0%. A total of 51 536 (50.9%) of the participants were female. According to the USPSTF 2013 recommendation, 807 (12.8%) of the screening-eligible population underwent LCS. Among those who were screened, only 807 (20.9%) met all 3 screening eligibility criteria, whereas 538 (20.1%) failed to meet any criteria. Among respondents in subgroup 2, being of older age and having a history of stroke, chronic obstructive pulmonary disease, kidney disease, or diabetes were associated with higher likelihood of LCS.Conclusions and RelevanceIn this cross-sectional study of the BRFSS 2019 survey, the low uptake rate among screening-eligible patients undermined the goal of LCS of early detection. Suboptimal screening patterns could increase health system costs and add financial stress, psychological burden, and physical harms to low-risk patients, while failing to provide high-quality preventive services to individuals at high risk of lung cancer.

Is Lung Cancer Screening Reaching the People Who Are Most Likely to Benefit?

“…According to limited information about comorbid conditions presented in the present study by Liu et al, 5 individuals who did not undergo screening despite meeting USPSTF criteria appeared to have fewer comorbid conditions than those who were screened by self-report, although substantial numbers in both groups reported a history of chronic obstructive pulmonary disease (>30%), depression (>25%), diabetes (>20%), and myocardial infarction (>15%). Prior analyses of the 2017 to 2019 BRFSS data observed that, among participants who reported undergoing lung cancer screening, 28% had 3 or more chronic comorbid conditions.…”

“…Indeed, a modeling study from the Cancer Intervention and Simulation Network conducted by Meza and colleagues 8 showed that the 2021 USPSTF criteria would lead to greater increases in eligibility for Black, Hispanic, American Indian, and Alaska Native populations relative to White and Asian populations. 8 Comparing the 2021 and 2013 USPSTF criteria in their sample of BRFSS survey respondents, Liu et al 5 found that the proportion of those who met all criteria increased from 20.9% to 31.1%.…”

“…The real problem with screening individuals who do not meet criteria manifests at the population level. If we accept the results of the analysis of Liu et al 5 of BRFSS data at face value, then more than three-quarters of screening LDCT scans are being performed in individuals who are unlikely to derive benefit, which is a wasteful and inefficient use of resources in a health care system that is struggling to improve quality and affordability.…”

“…Approximately 8.3 to 13.3 million US residents met the 2013 criteria, representing 8.3% to 13.4% of 50 to 80 year-old individuals in the US population, and approximately 17.5 million US residents are expected to meet the expanded criteria. 4 It is in this context that a population-based study by Liu et al 5 in the current issue of JAMA Network Open makes an important contribution to the literature by estimating the uptake and appropriateness of lung cancer screening with LDCT according to adherence to the 2013 USPSTF criteria. Using cross-sectional data from the 2019 Behavioral Risk Factor Surveillance System (BRFSS) survey, the study reported 2 important findings.…”

“…The BRFSS data have some important limitations, as acknowledged by the authors. 5 For example, there is concern regarding the generalizability of the findings due to limited participation from the southeastern states that have a disproportionately high burden of lung cancer and associated risk factors. More importantly, the BRFSS definition of screening is derived from selfreport, making it difficult to distinguish between a screening LDCT scan and a diagnostic CT scan that was ordered to evaluate symptom(s).…”