Approximately 60% of Medicare beneficiaries with a positive lung cancer screening result received guideline-concordant diagnostic follow-up within 1 year, though nearly one-fifth of surgical resections were ultimately benign, according to a recent study.
Overall, 60% of Medicare beneficiaries with a positive low-dose computed tomography lung cancer screening result received guideline-concordant diagnostic follow-up within 1 year, while approximately one third received less intensive care than recommended and 8% received more intensive care. More intensive care was applicable only to Lung Imaging Reporting and Data System categories 3 and 4A, where rates were 12% and 7%, respectively. Concordance increased with higher radiographic suspicion, ranging from 49% for category 3 to 80% for category 4X.
Researchers used linked data from the American College of Radiology Lung Cancer Screening Registry and Medicare enrollment and claims files to evaluate real-world diagnostic follow-up after positive screening results between 2015 to 2022. The cohort included 64,555 adults aged 65 years or older with a first positive screening examination, defined as a Lung Imaging Reporting and Data System (Lung-RADS) category of 3, 4A, 4B, or 4X, who had continuous fee-for-service Medicare coverage for up to 12 months after the index examination.
Published in Annals of Internal Medicine, researchers assessed the timing and type of diagnostic procedures, including chest computed tomography, positron emission tomography, bronchoscopy, needle biopsy, and lung resection. Follow-up was classified as guideline-concordant, less intensive, or more intensive based on Lung-RADS recommendations. Guideline-concordant follow-up was defined as chest CT within 120 to 240 days for category 3; chest CT within 45 to 135 days or PET within 135 days for category 4A; and imaging or invasive procedure within 60 days for categories 4B and 4X. Multivariable logistic regression models identified demographic and clinical factors associated with nonconcordant follow-up.
Overall, 60% of adults received guideline-concordant care, 32% received less intensive care, and 8% received more intensive care than recommended. Less intensive follow-up was most common among adults with Lung-RADS category 3 findings and declined with increasing radiographic suspicion. Among adults with category 3 or 4A findings, non-Hispanic Black patients, Asian patients, Hispanic patients, patients who currently smoked, and those undergoing baseline screening were significantly more likely to receive less intensive follow-up than guideline-concordant care. Screening during the COVID-19 pandemic period was also associated with less intensive follow-up, although excluding this period changed concordance rates by only approximately 1 percentage point. Because all adults had Medicare coverage, these disparities likely reflect other factors, such as implicit bias, geographic access to care, or unmeasured institutional characteristics; researchers noted that further research is needed to identify and address the drivers of these differences.
Within 1 year of the positive screening result, 12% of adults received a lung cancer diagnosis, with incidence increasing from 2% in category 3 to 59% in category 4X. However, researchers cautioned that cancer diagnosis depends on diagnostic procedures, and adults with less intensive follow-up—many of whom had no follow-up within the year—were more likely to have undiagnosed cancer during that period. The pattern of lower cancer risk among those with less intensive follow-up persisted through 2 years, though further studies are needed to confirm whether this reflects true lower risk or delayed diagnosis.
Imaging procedures were most often the initial diagnostic step, whereas invasive procedures generally occurred later in the diagnostic pathway. Invasive procedures were performed in 16% of all adults and in 7% of those without lung cancer. Bronchoscopy was the most common invasive procedure, and 40% of bronchoscopies were performed in adults without cancer; lung resection occurred in less than 1% of adults without subsequent cancer diagnosis, representing 21% of all resections.
The study had several limitations. The cohort was restricted to fee-for-service Medicare beneficiaries, excluding those in Medicare Advantage plans, and researchers could not determine whether procedures were performed specifically for lung cancer follow-up or for other acute or chronic conditions. Data on institutional characteristics and patient socioeconomic factors were limited, and the study did not assess the impact of follow-up intensity on cancer stage at diagnosis or mortality.
Researchers noted that invasive procedure rates in adults without cancer were reassuringly low but emphasized that 21% of surgical resections were ultimately benign, and opportunities for improvement remain to reduce unnecessary high-risk procedures. "This finding clarifies that the main opportunity for improvement among US lung cancer screening participants is ensuring timely and appropriate follow-up—therefore interventions to address the underuse problem, not addressing harms from overuse," wrote lead study author Paul F. Pinsky, PhD, of the National Cancer Institute, Bethesda, Maryland, and colleagues, though they acknowledged the need to balance avoiding overtreatment with preventing delays that could lead to cancer upstaging.
Full disclosures can be found in the published study.
Source: Annals of Internal Medicine