Positive lung cancer screens frequently receive suboptimal follow-up

1. In this retrospective cohort study, most patients with a positive lung cancer screening result received guideline-concordant follow-up, though nearly one-third received less-than-recommended care.

2. Invasive procedures were performed in a small proportion of patients who did not ultimately receive a lung cancer diagnosis.

Evidence Rating Level: 2 (Good)

Study Rundown: Low-dose computed tomography (LDCT) screening reduces lung cancer mortality, yet uptake remains low due to concerns about effectiveness, resource requirements, and benefit-harm tradeoffs. Follow-up of positive screening results in clinical practice is not well characterized. This study examined diagnostic testing and adherence to guideline-recommended care in a Medicare cohort after positive LDCT results. Most participants received guideline-concordant follow-up, but a substantial proportion received less-intensive care, particularly those with lower-risk Lung-RADS scores, while a smaller subset received more-intensive follow-up than recommended. Racial and ethnic disparities were evident: non-Hispanic Black, Asian, and Hispanic participants were more likely than non-Hispanic White participants to receive less-intensive care, and Hispanic participants were also more likely to receive more-intensive follow-up. The most common invasive procedures were bronchoscopy, needle biopsy, and lung resection, which were performed in a small subset of participants. The rates of invasive procedures among those without an eventual lung cancer diagnosis were overall low. Limitations include restriction to fee-for-service Medicare participants and lack of data on institutional or socioeconomic factors. Despite these limitations, the findings suggest that while most patients receive guideline-concordant follow-up after positive LDCT screening, a notable proportion continue to receive less-than-intensive care, highlighting opportunities to improve both the consistency and equity of lung cancer diagnostic management.

Click to read this study in AIM

Relevant Reading: Use of Imaging and Diagnostic Procedures After Low-Dose CT Screening for Lung Cancer

In-Depth [retrospective cohort]: This retrospective cohort study examined guideline-concordant follow-up and diagnostic procedures among Medicare beneficiaries with positive low-dose computed tomography (LDCT) results from the Lung Cancer Screening Registry of the American College of Radiology. Eligible patients were aged ≥65, had a positive screening result (Lung-RADS 3, 4A, 4B, or 4X), no prior positive result before 65, and fee-for-service Medicare coverage for 12 months after the result. Outcomes included rates of guideline-concordant, less-intensive, and more-intensive follow-up by Lung-RADS category, and cumulative procedure rates within 12 months, excluding procedures after lung cancer diagnosis. Among 64,555 participants, 52% were men, 90.8% non-Hispanic White, and 53% current smokers. Lung-RADS distribution was 52.6% category 3, 28.4% 4A, 14.2% 4B, and 4.8% 4X; the 1-year lung cancer rate was 12.4%. Chest CT was the main initial procedure for category 3, while PET scans were most common for 4A–4X. Overall, 59.7% received guideline-concordant follow-up, 32.3% less-intensive care, and 7.9% more-intensive care, with adherence increasing with higher Lung-RADS category (49.2% for 3, 68.6% for 4A, 74.1% for 4B, 79.5% for 4X). For Lung-RADS 3, participants aged ≥75 were more likely than those 65–69 to receive less-intensive (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.01–1.16) or more-intensive follow-up (OR, 1.29; 95% CI, 1.17–1.43). Non-Hispanic Black (OR, 1.26; 95% CI, 1.12–1.41), Asian (OR, 1.66; 95% CI, 1.28–2.14), and Hispanic (OR, 1.56; 95% CI, 1.30–1.88) participants were more likely to receive less-intensive follow-up; Hispanic participants were also more likely to receive more-intensive follow-up (OR, 1.45; 95% CI, 1.10–1.91). Invasive procedures occurred in 16.2% of participants and 7.3% of those without an eventual cancer diagnosis. Most patients received guideline-concordant care, but nearly one-third received less-than-intensive follow-up, highlighting opportunities to improve both consistency and equity in lung cancer diagnostic management.

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