Fewer than Two-Thirds of Veterans Receive Timely Lung Cancer Screening Follow-Up
Lung cancer remains the leading cause of cancer mortality, but research shows that yearly lung cancer screening (LCS) achieves a 20% relative reduction in mortality. Although the U.S. Preventive Services Task Force has recommended LCS for high-risk individuals since 2013, there has been limited evidence on follow-up after initial LCS in real-world settings. This retrospective cohort study sought to determine adherence to recommended next steps (i.e., annual screening or evaluation of screen-detected findings) in a national cohort of Veterans screened for lung cancer – and to identify factors associated with delayed or absent follow-up. Using VA data, investigators identified 28,294 Veterans ages 55-80 with >30 pack per year smoking history and who either currently smoked or quit <15 years ago – and who underwent initial LCS in any VA facility from 1/1/2015 through 11/30/2019. The primary outcome was receipt of the recommended next step following index LCS according to Lung-RADS assessment categories for LCS (i.e., incomplete, negative, benign, suspicious, very suspicious). The covariates examined included patient demographics, priority status, healthcare use, comorbidities, and distance to a VA healthcare facility. Random chart reviews also were conducted.
- Less than two-thirds of Veterans received timely recommended follow-up after an initial lung cancer screening, with higher risk of delayed or absent follow-up among marginalized populations that have long experienced disparities in lung cancer outcomes. Of the 28,294 Veterans in this study, 63% underwent recommended follow-up, while 29% received delayed (13%) or no (16%) follow-up.
- Veterans with higher-risk findings (higher Lung-RADS category) and those in high-volume or academic centers were more likely to receive timely follow-up. Black Veterans, Veterans with mental health disorders or lower income were more likely to have delayed or absent follow-up.
- Most Veterans (21,557, 76%) had low-risk findings on index LCS (Lung-RADS 1 or 2; negative or benign appearance), while 4,001 (14%) had indeterminate results (Lung-RADS 3; probably benign), and 2,736 (10%) had suspicious findings (Lung-RADS 4; suspicious or very suspicious).
- To optimize the mortality benefit of lung cancer screening, further work must be done to improve adherence, overall, and especially among marginalized populations.
- Investigators were unable to capture care received outside of VA or Medicare.
- Investigators could not measure patient-centered outcomes (i.e., lung cancer diagnoses and mortality), so focused on adherence to screening which is a key factor in lung cancer mortality.
This study was partly funded by HSR&D (IIR 18-075). Drs. Nunez, Zhang, Glickman, Miller, and Wiener, and Mss. Qian and Boudreau are part of HSR&D’s Center for Healthcare Organization and Implementation Research (CHOIR) in Bedford and Boston, MA.
Nunez E, Caverly T, Zhang S, Glickman M, Qian S, Boudreau J, Slatore C, Miller D, and Wiener R. Adherence to Follow-Up Testing Recommendations in US Veterans Screened for Lung Cancer, 2015-2019. JAMA Network Open. July 8, 2021;4(7):e2116233.