How the Latest Lung Cancer Screening Guidelines Impact Women, Race, Addiction and Covid-19

The second most common cancer and the leading cause of cancer death in the United States may see its numbers drop.

Yesterday, the US Preventive Services Task Force (USPSTF) updated its 2013 recommendations by commissioning a systematic review on the accuracy of lung cancer screening using low-dose computed tomography (CT) scans. They also weighed the pros and cons of screening and determined the optimal age and interval for screening. The 2013 statement recommended screening adults aged 55 to 80 with a 30-year history of smoking and who currently smoke or have quit within the past 15 years.

Last year, more than 228,000 people in the United States were diagnosed with lung cancer and approximately 135,000 Americans died from the disease. In general, lung cancer has a rather poor prognosis: the National Cancer Institute (NCI) reports the overall rate at 5 years at 20.5% (compared with 90% and 97.8% for breast and breast cancer. prostate, respectively). But if it’s caught earlier, the prognosis improves because early-stage lung cancer lends itself better to treatment.

Updated recommendations

Eligibility for lung cancer screening, according to the USPSTF, includes people between the ages of 50 and 80 who have a 20-pack smoking history and who currently smoke or have quit within the past 15 years. Screening should be annual, but stopped once a person has not smoked for 15 years or develops a health problem that significantly reduces life expectancy or the ability to undergo curative lung surgery.

Lung cancer is not a disease

There are two main types of lung cancer: non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC), each with different prognoses and treatment regimens. NSCLC accounts for 80-85% of all lung cancers and includes the subtypes of adenocarcinoma, squamous cell carcinoma and large cell carcinoma. Treatment options include surgery (curative, if caught early), chemotherapy, and radiation therapy. SCLC, which accounts for 10-15% of all lung cancers, tends to spread faster than NSCLC and generally responds well to chemotherapy and radiation therapy. Without treatment, SCLC progresses aggressively, with a median survival from the date of diagnosis of two to four months. For more information, see the NCI and the American Cancer Society (ACS).

The good news

The updated screening guidelines take another step forward in addressing disparities in the diagnosis of lung cancer among black Americans and women. Both groups, according to the USPSTF, tend not to be heavy smokers and therefore may not have followed previous guidelines for testing. One in five women diagnosed with lung cancer has never smoked, according to the Office on Women’s Health.

The bad news

Updates to lung cancer screening guidelines do not necessarily translate into improved patient care. Research shows that half of the population eligible for screening is uninsured.

“The problem is, most of the eligible people are not screened due to lack of insurance,” says Divya Bappanad, MD, a pulmonologist and intensive care physician at PeaceHealth who frequently orders screening CT scans. “There are several states where Medicaid does not cover low dose screening, and the difference in mortality between early and advanced lung cancer is huge.”

According to the ACS, black Americans still have the highest death and survival rates for most cancers, including lung cancer, among any racial or ethnic group. Changes in screening guidelines will only have an impact if we overcome structural and systemic barriers, including lower socioeconomic status and reduced access to health care. Also, some doctors and clinics may not promote lung cancer screening as much as other preventative measures such as mammograms and colonoscopies.

Possibility of treating tobacco addiction

Smoking is not only the main risk factor for lung cancer, but according to the Centers for Diesease Control and Prevention (CDC), it is the leading cause of preventable death in the United States.

“Quitting smoking reduces the risk of death, disability and many diseases, from drug addiction and cancer (bladder, colon, leukemia) to stroke and COPD,” says Richard Saitz, MD, MPH , FACP, chair of the Department of Community Health Sciences at Boston University School of Public Health.

However, tobacco addiction (nicotine) remains largely under-treated. “Clinicians should use this learning moment to help patients quit smoking, regardless of the screening result,” says Peter D. Friedmann, MD, MPH, DFASAM, Clinical Research Chair at Baystate Health.

The National Institutes of Drug Abuse (NIDA) approves several effective and evidence-based treatments, including behavioral therapies and FDA-approved drugs such as nicotine replacement (patch, lozenges, gum, inhalers, sprays), bupropion (“Wellbutrin”) and varenicline (“Chantix.”)

Harm reduction strategies should be used for people who are unwilling or unable to quit despite multiple attempts. Motivational interviewing can also be effective in holding people accountable for their behaviors by asking, “What do you like to smoke?” and “Can you describe how life could be different if tobacco was no longer a part of it?

The COVID connection

As with most aspects of life today, SARS-CoV-2 is involved. Studies show that people who smoke or have ever smoked are more likely to be hospitalized or die from Covid-19 than people who do not smoke. As a result, the CDC has prioritized vaccinations for people who smoke, angering many who think tobacco addiction is a choice. An important reminder: drug addiction is a chronic brain disease that interferes with a person’s ability to control their substance use, despite the harm caused to the user or to those around him. It is NOT a sign of moral weakness or failure. Countless patients have told me that quitting smoking is MUCH more difficult than quitting heroin or cocaine.

The Covid-19 pandemic has also exposed and amplified pre-existing disparities among marginalized groups. Joshua Barocas, MD, infectious disease physician at Boston Medical Center: “With a disproportionate burden of smoking-related illnesses on veterans, homeless people, and those with comorbid medical and psychiatric conditions, we must implement these preventive health screening guidelines in all underserved populations and improve access to care. “