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Fewer than one in five people eligible for lung cancer screening reported being up to date with screening in 2022, though patient navigation added to usual care could be a way of increasing these rates, according to two studies published in JAMA Internal Medicine.

Among nearly 26,000 respondents in a , the overall prevalence of up-to-date lung cancer screening was 18.1%, but varied across states (range 9.7% to 31%), with relatively lower rates in Southern states that have a high lung cancer mortality burden, noted Priti Bandi, PhD, of the American Cancer Society, and colleagues.

"The largest disparities in [up-to-date lung cancer screening] were according to healthcare access factors and across U.S. states," they wrote. "Therefore, improving healthcare access for persons with low income through Medicaid expansion and increasing screening capacity may be associated with increased uptake and reduced disparities."

In a conducted within the Boston Health Care for the Homeless Program, 43.4% of participants who had assistance from a patient navigator compared with 9.2% of those who received usual care only had completed lung cancer screening with low-dose CT at 6 months after randomization (P<0.001), representing a 4.7-fold difference, reported Travis P. Baggett, MD, MPH, of Massachusetts General Hospital in Boston, and colleagues.

"These findings complement the results of nonexperimental studies in other homeless healthcare settings and add to a growing body of work demonstrating the impact of patient navigation for cancer screening in vulnerable populations," Baggett and team noted.

In an , Ilana B. Richman, MD, MHS, and Cary P. Gross, MD, both of the Yale School of Medicine in New Haven, Connecticut, wrote that the two studies "prompt us to consider what successful implementation of lung cancer screening in the U.S. looks like."

"One definition of success in implementing lung cancer screening might be that all eligible patients are identified, are offered screening, have the opportunity to weigh risks and benefits while considering their own values carefully, and do not face structural barriers to screening and follow-up," they wrote. "A multipronged approach that addresses structural and patient-level barriers to screening, while facilitating and supporting high-quality shared decision-making needs, may help get us closer to this ideal."

The cross-sectional study included 25,958 screening-eligible individuals who responded to the 2022 Behavioral Risk Factor Surveillance System (BRFSS) population-based, nationwide, state-representative survey. Median age was 62 (64.4% were 60 and older), and 54.4% were men. The majority were white (78.4%), 8.1% were Black, and 6.7% were Hispanic.

Of the respondents, 61.5% were current smokers, 53% had a high school education or less, 89.5% lived in urban counties, 36.3% had private insurance, 32.4% had Medicare, and 14.5% had Medicaid. About 81% reported one or more comorbidities, of whom 35.6% reported three or more comorbidities.

Prevalence of up-to-date lung cancer screening increased with age, with a rate of 6.7% for those ages 50-54 and 27.1% for those ages 70-79, as well as number of comorbidities (no comorbidities: 8.7%; three comorbidities: 24.6%). Nearly 4% of those without insurance and 5.1% of those without a usual source of care were up-to-date with lung cancer screening, but state-level Medicaid expansions (adjusted prevalence ratio [APR] 2.68, 95% CI 1.30-5.53) and higher screening capacity levels (high vs low: APR 1.93, 95% CI 1.36-2.75) were associated with higher prevalence of up-to-date lung cancer screening.

Bandi and colleagues also found that there was a wide variation in prevalence of up-to-date lung cancer screening across the U.S., with the highest prevalence in Rhode Island (31%) and the lowest in Wyoming (9.7%).

Fifteen of 17 states in the South were classified as having a high or medium lung cancer burden, but just two states had a prevalence of up-to-date lung cancer screening that was significantly above the national mean. On the other hand, all nine Northeastern states had low or medium lung cancer burden, with prevalence of up-to-date lung cancer screening that was significantly above the national mean in seven of those states.

In the parallel-group, pragmatic, mixed-methods randomized trial conducted from November 2020 through March 2023, Baggett and colleagues included 260 participants from the Boston Health Care for the Homeless Program, a federally qualified program that provides tailored, multidisciplinary care to nearly 10,000 homeless-experienced patients annually. Mean age was 60.5, 70.8% were men, 36.9% were Black, and 36.9% were white.

To be eligible, participants had to have a lifetime history of homelessness and a primary care practitioner within the program, be proficient in English, and meet the pre-2022 Medicare coverage criteria for lung cancer screening (ages 55-77, a 30 pack-year history of smoking, and smoking within the past 15 years).

Of the participants, 50.8% reported fair or poor health, 29.1% screened positive for a mental health disorder, 24% for alcohol use disorder, and 27.8% for drug use disorder. Most (85%) were current smokers, and the entire cohort had a mean of 48.1 pack-years of smoking.

The participants were randomized 2:1 to usual care either with or without patient navigation. Following a "theory-based, patient-centered protocol," the navigator provided lung cancer education, facilitated shared decision-making visits with primary care physicians, assisted participants in making and attending appointments, arranged follow-up when needed, and offered tobacco cessation support for current smokers.

In a time-to-event analysis, participants in the patient navigation arm underwent lung cancer screening sooner than participants in the usual care-only arm.