The third and final part of Let's Get Screened, a three-part series on the Abramson Cancer Center (at the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center and Pennsylvania Hospital)'s efforts to bring breast, colon and lung cancer screenings to residents of our community who most need them.
Lung Cancer Screenings
You just turned 50. It’s time for a colonoscopy. Family history, personal history of cancer or other factors may come into play but, for the most part, the guideline is straightforward.
You hit 50 and your doctor refers you for a colonoscopy. The risk is minimal and the potential benefit great. Other screenings – like that for lung cancer – require more complex decision-making.
Lung cancer is the 2nd most common cancer in the U.S. It is often diagnosed at later stages, when symptoms finally appear. In a given year, lung cancer accounts for more deaths from cancer than breast, colon and prostate combined. Anyone can develop lung cancer but there are factors that increase our risk. The most significant and best known is tobacco use.
People who smoke now or in the past may be aware of the risk. What they many not know is that they may be eligible for lung cancer screening.
Are You Eligible for a Lung Cancer Screening?
Lung cancer screening uses a low-dose CT scan. The scan detects lung cancer before symptoms appear. Early diagnosis lowers the risk of dying from lung cancer by 20 percent.
Yet, screening comes with risk. The results can be unreliable. The scan may find cancer where it does not exist. In rare cases, testing may lead to unnecessary treatment.
For these reasons, lung cancer screening is not for everyone. Some people at high risk may benefit from peace of mind when tests are negative. If cancer is found early, patients have the potential for more and better treatment options.
The U.S. Preventive Services Task Force (USPSTF) recommends screening for patients between ages 55-80 with at least a 30-pack year smoking history who smoke or who have quit within the past 15 years. A pack year describes the amount smoked multiplied by the number of years. It could be more smoking for fewer years, or less smoking for many years.
The USPSTF suggests that doctors and patients use “shared decision making” to figure out if screening is the right step. This often takes the form of a conversation. Yet, research shows that conversations about lung cancer screening seldom meet the standard of shared decision-making.
An effective conversation requires that patients have both knowledge of the screening and an understanding of its strengths and drawbacks. Both of which relate to health literacy.
Helping People Understand the Benefits and Risks of Lung Cancer Screening
A Penn pilot study looked at interest in lung cancer screening and health literacy. The research team was led by Carmen Guerra, MD, MSCE, FACP, Ruth C. and Raymond G. Perelman Professor in Internal Medicine, and included Lauren De La Ossa, a senior at Haverford College. Ms. De La Ossa participated in the highly selective Penn Access Summer Scholars Program at the Perelman School of Medicine during the summers of 2017 and 2018. The pair recruited volunteers from Penn's Comprehensive Smoking Treatment Program. Frank Leone, MD, MS, Associate Professor of Medicine, directs the clinic.
A total of 41 patients enrolled in the pilot study. 64 percent were African American. All had a history of heavy smoking but did not necessarily meet the guidelines for screening.
Patients were surveyed before and after meeting with doctors. Brief quizzes assessed participants’ literacy level, knowledge of the screening and trust in the health system. The results were unexpected.
People in the study overwhelmingly opted to get screened. Even those who did not meet USPTF’s guideline chose screening. The result was even stronger for people with low health literacy. All opted to get screened (100 percent of those with inadequate health literacy compared to 88 percent of those with adequate health literacy). Of the 100 percent with inadequate health literacy who elected to be screened for lung cancer, only 56 percent were eligible.
This work builds on an earlier study testing a lung cancer screening decision aid. The website, shouldiscreen.com, is an online tool to promote shared decision-making. Users answer basic questions about age, height, weight and smoking history. The site is easy to use and takes a few minutes or less. It concludes with a recommendation on screening and data on the patient’s risk of lung cancer.
Dr. Guerra notes that tools like this may help patients, especially those with low literacy, make better informed decisions. She says, “Lung cancer screening is complicated and partly dependent on individuals’ preferences and comfort with risk. Shouldiscreen could help patients understand the risks and benefits, and facilitate more productive conversations with health care providers.”
Read part 1 on colon cancer screening