Leveraging Mammography to Increase Awareness of Lung Cancer Screening: A Feasibility Survey

Following publication of the landmark National Lung Screening Trial (NLST), which demonstrated a statistically and clinically significant reduction in lung cancer and all-cause mortality associated with low-dose computed tomography, the USPSTF offered its first ever recommendation favoring implementation of lung cancer screening among individuals at high risk for lung cancer (B Grade). Many other professional organizations and authoritative agencies have similarly recommended implementation of LDCT with slightly varying guidelines. Language embedded within the Patient Protection and Affordable Care Act dictated first dollar coverage of lung cancer screening among individuals with health insurance. Subsequently, CMS’s National Coverage Determination extended coverage to the population of individuals at high risk who have health insurance coverage through Medicaid and Medicare, ensuring that the vast majority of Americans have reasonable health insurance coverage for lung cancer screening. Despite coverage and the rapid proliferation of lung cancer screening programs, uptake of LDCT services has grown very slowly and sub-optimally due to a host of factors. First, many primary care providers remain unaware of recent data and policy changes regarding implementation of lung cancer screening. This is exacerbated by almost zero awareness of the option to pursue lung cancer screening among the general public and the target population of individuals who might benefit. Second, even among clinicians and the population of individuals at risk who are aware of lung cancer screening, provider and patient preferences remain inconsistent with screening participation and are likely influenced by misinformation, biases associated with current and previous tobacco use, stigma associated with lung cancer, and fatalistic or at best pessimistic beliefs about lung cancer treatment options. Third, while health care systems have begun to adopt and implement lung cancer screening programs, these programs are just beginning the process of developing the necessary operational systems to support high quality screening and need to develop referral patterns and care pathways that can translate into optimal screening processes and outcomes that reduce mortality. To some extent the sluggish uptake of lung cancer screening can be understood from the traditional challenges of diffusing health innovations; however, the substantial potential benefit of this life-saving intervention warrants early efforts to facilitate implementation and innovative approaches to reach this underserved and commonly difficult to engage population of individuals at high risk for lung cancer. One approach to reach women at risk for lung cancer involves creating a teachable moment by leveraging women’s engagement with mammography, the most widely adopted cancer screening modality among women over 50. The mammography setting provides a unique opportunity to raise awareness and expand opportunities for lung cancer screening uptake. By identifying women who meet basic lung cancer screening eligibility criteria, it would be possible to implement an awareness campaign or referral pathways to facilitate informed choices about lung cancer screening. While using the teachable moment framework is not novel within cancer screening, it has yet to be considered in the context of lung cancer screening. Further, it may be a particularly potent strategy given the need to expand awareness rapidly and in a targeted fashion. While there is a rational appeal to this approach, feasibility must be an initial consideration, and this study proposed to utilize the resources of the Neiman Health Policy Institute and the American College of Radiology to explore program-level perspectives on receptivity among mammography programs to integrate consideration of lung cancer screening into clinical practice routines. We propose to field a survey among mammography programs identified by the ACR to examine attitudes, practice characteristics, and concept feasibility regarding integrating a lung cancer screening teachable moment within the mammography screening platform. We also seek to explore feedback and guidance from mammography programs on how to design and target an intervention that could be readily tested in advance of adoption, dissemination, and implementation. This investigative team combines a range of expertise pertaining to lung cancer screening implementation (Eberth & Studts), radiology and health services research (Hughes and Carlos), as well as behavioral interventions based on the teachable moment framework (Carlos and Studts) to enhance risk reducing and health protective behavior. Together, this team has the knowledge and skills to conduct translational research to expand awareness, access, and appropriate uptake of LDCT among women at high risk for lung cancer.