Yale Pulmonologist Dr. Hilary Cain Outlines How to Improve Lung Cancer Screening Numbers in the U.S.

Lung cancer is a leading cause of death in the United States, accounting for 25 percent of cancer deaths, yet it is estimated that only 6 to 8 percent of eligible people in the U.S. are screened for the disease.

Hilary Cain, MD, says we need to do better. Cain is an associate professor of medicine (pulmonary, critical care and sleep medicine) at Yale School of Medicine, and is also the section chief of pulmonary, critical care and sleep medicine at VA CT Healthcare System, West Haven.

“Screening for lung cancer has been incredibly neglected in the United States,” says Cain. “We are way under screening for the most lethal cancer. It's pretty shocking that we haven't made more of a public health effort in that regard.”

In 2010, the National Lung Screening Trial (NLST) reported that screening with low dose computed tomography reduced lung cancer mortality by 20 percent in trial participants who were at an increased risk for lung cancer.

Partially in response to these findings, the U.S. Preventive Services Task Force (USPSTF) released the first set of guidelines for lung cancer screening in 2013, making people 55 and older who had a minimum smoking history of 30 pack-years eligible and who were current cigarette smokers or who had recently quit smoking; in 2021, the Task Force lowered the screening starting age from 55 to 50 years and minimum smoking history from 30 to 20 pack-years. Lowering the age and number of pack-years allows more women and people from minority groups to be eligible, as these groups tend to develop lung cancer younger and with a shorter smoking history than whites.

However, while this represents progress, Cain says it’s not simply about expanding the criteria for who is eligible at this point. “It's about educating the medical community and to have them explain to patients why they may benefit from screening. “We have our primary providers on the front line who should know comorbidities best and who should hopefully have some idea about whether or not the patient has specific goals of care and priorities in their life that might actually be important as far as undergoing screening.”

Public health efforts also need ramping up. “As we go forward, we need to think about targeting the most at-risk populations, making resources available to people in underserved and rural communities and places where it's hard to get access to medical care. “We need to exploit what we can do in public health strategies, using community health workers to help us understand why some communities are more or less likely to get screened, and try to overcome some of those barriers.”

Cain also stresses that screening only has mortality benefits when it's done by a facility that has a comprehensive lung cancer screening program. These facilities (of which there are too few) have physicians and other healthcare providers who know how to analyze the CT scan, how to triage the patient, and how to recommend next steps. The VA CT Healthcare System and Yale New Haven Health offer these services.

One way around this for those who don’t have access to these facilities is to take advantage of telemedicine.

“There is no way you can do real screening without really robust electronic resources like we have at the VA, and that's something that we all need to think about going forward. Leveraging some of these telemedicine options to try to reach people in rural areas can be tremendously helpful because [a patient’s primary care provider] can transmit the scans and the patient data to a central program where the CT scan and the data can be analyzed and then they can get back to the private provider and guide them on what to do.”

Ultimately, Cain says she’d like to see 75 to 80 percent of eligible patients in the U.S. undergo screening. “That would be a success.”