Experts say cost barriers and stigma keep eligible adults from lung cancer screening

Health plans could raise low lung cancer screening rates by reaching out to eligible members and, most importantly, by first removing cost, coverage and approval barriers, according to the lead author of a recent American Cancer Society (ACS) study.

Fewer than 1 in 5 eligible U.S. adults are up to date on lung cancer screening, according to the ACS study published in JAMA. The issue drew new attention this week after the Vatican said Pope Leo XIV has lung adenocarcinoma. The nodule was found during what the Vatican described as routine medical checks, and surgeons removed the lower lobe of his right lung.

It isn't known whether the pope would have qualified for screening. Timothy Mullett, M.D., MBA, medical director of the University of Kentucky Markey Cancer Center, said the “routine checkup” the Vatican described could have included screening if the pope had a past history of tobacco use. Otherwise, it would have been an incidental finding caught at an early stage.

Related: Pope Leo XIV's lung cancer diagnosis puts a spotlight on low U.S. screening rates

Why lung cancer screening lags behind other cancer screenings

Part of the gap may be that lung cancer screening was recommended more recently than breast and colorectal cancer screening, said Priti Bandi, Ph.D., scientific director of risk factors and screening research at ACS. The U.S. Preventive Services Task Force (USPSTF) first recommended annual lung cancer screening in 2013, but Bandi said timing is not the full story.

The biggest barriers are structural, she said. They include costs, coverage and approval requirements set at the payer and policy levels. Many systems also lack organized, centralized screening programs that reach out to eligible patients and help guide them through the process. Bandi added that these gaps can also feed patient and provider barriers, such as low awareness and the stigma tied to smoking.

Mullett said many barriers start before a patient ever reaches a primary care office. He described to MHE a widespread sense of “fatalism” among eligible patients, many who have watched family members die of lung cancer or go through aggressive treatment. Some patients also feel “I did this to myself,” which Mullett described as nihilism.

“This interferes with interest or worthiness of participation in screening,” he said.

How health plans can raise lung cancer screening rates

“Health plans will be central to addressing low uptake by actively reaching out to members regarding their eligibility to be screened, but most importantly by first addressing cost, coverage, and approval barriers,” Bandi said.

Adults who now qualify for screening are at high risk because of their smoking history, and they are disproportionately of lower socioeconomic status, Bandi said. Cost, coverage and approval barriers are major reasons for low uptake in this group.

Under the Affordable Care Act, most private plans must cover the screening scan itself without cost-sharing. But follow-up tests after an abnormal result can still come with out-of-pocket costs. New York will bar cost-sharing for those follow-up tests in state-regulated plans starting Jan. 1, 2027.

ACS also supports expanding who qualifies for screening beyond the current USPSTF criteria. Robert Smith, Ph.D., senior vice president of early cancer detection science at ACS, pointed to the JAMA study's findings on that question.

Researchers estimated that expanding eligibility to two groups could prevent about 19,000 more lung cancer deaths over the next five years. The first is former smokers with at least 20 pack-years who quit 15 or more years ago, as the updated 2023 ACS guideline allows. The second is current smokers with at least 20 years of smoking, as the National Comprehensive Cancer Network guideline allows. That estimate assumes everyone newly eligible would be screened.

Why stigma and provider attitudes affect lung cancer screening

The solution to these barriers is education at both the community and provider levels, Mullett said. Patients need to understand the value of early detection and how it improves survival. Clinicians need to be ready to encourage patients and validate screening as a lifesaving test.

“Helping patients feel better about screening can be counteracted by a provider who holds the same sense of futility or perception of nihilism,” Mullett said, adding that lung cancer screening should be a routine part of care for eligible patients, similar to mammograms or colorectal cancer screenings.

“Treating screening differently highlights the stigma of cancer,” Mullett said.