Estimated Lung Cancer Screening Rates "Extremely Low" Across Insurance Types

Rates of lung cancer screening with low-dose CT (LDCT) were extremely low among eligible patients across insurance types in 2017, with rates varying between patient demographics, according to a study published in Journal of the American College of Radiology.¹

LDCT screening is covered and has no out-of-pocket costs for eligible insured patients regardless of coverage type. Still, the study found that among individuals with commercial insurance, Medicare, or Medicare Advantage who were estimated to be eligible for screening in 2017, just 1.75%, 3.37%, and 4.56% got screened, respectively.

“Lung cancer is deadly if not caught early, so it is concerning that at-risk Americans are not getting the screening needed for early detection. Cost has been eliminated as a barrier, so it is important to understand more about who is and isn’t getting the recommended LDCT,” said study author Bob Smith, PhD, senior vice president of early cancer detection science at the American Cancer Society, in a statement.²

The eligibility criteria in 2017 included individuals aged 55 to 77 years who had a 30-pack-year smoking history and currently smoked or had quit within the past 15 years. In light of new evidence, those guidelines were adjusted in 2021 to include individuals aged 50 to 80 years with a 20-pack-year smoking history who currently smoke or have quit within the past 15 years.

Despite the removal of financial barriers for most insured individuals, the authors highlight several potential barriers to screening that may persist: the clinical challenge of identifying individuals who are eligible for screening based on history of tobacco use, low referral rates from primary care physicians, a lack of health insurance in patients younger than 65 years who would be eligible for screening, a lack of LDCT facility access, and concerns about cost sharing that may arise from recalls after a positive LDCT test.

The current study used data from Optum’s de-identified Clinformatics Data Mart that included 2,204,652 commercial and 3,230,763 Medicare Advantage enrollees aged 55-77 in 2017; and data from CMS' 5% Research Identifiable Files (RIF) that included 1,441,328 Medicare fee-for-service (FFS) enrollees in 2017.

Researchers estimated and compared LDCT screening rates between insurance types, enrollee demographics, and geographic characteristics based on 2017 United States Preventive Services Taskforce (USPSTF) eligibility criteria. Of the 6,876,743 total enrollees, the researchers estimated that 1,077,142 (15.7%) were eligible for lung cancer screening based on the 2017 USPSTF criteria.

Overall, the estimated screening rate was 1.75% among individuals with commercial insurance plans, 3.37% in patients covered by Medicare FFS, and 4.56% for Medicare Advantage enrollees. The lowest screening rates were seen in females, individuals aged 75 to 77 years, people living in rural locales, and those living in the West.

In Medicare FFS enrollees with race/ethnicity data available, non-Hispanic Whites had the highest screening rate (3.71%), followed by non-Hispanic Black enrollees (2.17%) and enrollees categorized as “Other” in the 5% RIF data (1.68%).

“These results indicate that efforts aimed at historically vulnerable populations could present opportunities for outsized gains to public health,” said Danny R. Hughes, PhD, professor at Arizona State University and lead study author. “Together, these data can inform practitioners and policy makers on how to best target efforts to increase lung cancer screening in vulnerable populations.”

The findings are largely in line with previous estimates of LDCT screening utilization, with some variations between subgroups. The authors noted several limitations, including the lack of generalizability to Medicaid or uninsured populations, as well as to commercial insurance providers not included in the study sample. The reliance on self-reported smoking data is another limitation.

Overall, the findings emphasize a need for future research to explore potential barriers leading to extremely low LDCT screening rates for those at risk of lung cancer.

“We hope this publication will serve as a call to action to explore strategies to increase screening and save lives,” said study author Elizabeth Y. Rula, PhD, executive director of the Harvey L. Neiman Health Policy Institute.

References

1. Hughes DR, Chen J, Wallace AE, et al. Comparison of lung cancer screening eligibility and use between commercial, Medicare, and Medicare Advantage Enrollees. J Am Coll Radiol. 2023;20(4):402-410. doi:10.1016/j.jacr.2022.12.022

2. Lung cancer screening rates extremely low, worst among the commercially insured. News release. Harvey L. Neiman Health Policy Institute. March 29, 2023. Accessed April 14, 2023. https://www.neimanhpi.org/press-releases/lung-cancer-screening-rates-extremely-low-worst-among-the-commercially-insured/