Barriers to accessing lung cancer screening and thoracic surgery in US rural communities

Lung cancer remains the leading cause of cancer-related deaths in the United States (US) despite decreased smoking rates (1). The clinical stage at the time of initial diagnosis has profound implications for a patient’s clinical prognosis. Individuals with localized (i.e., stage I) lung cancer have an observed 5-year relative survival rate of 63.7%, while those with regional and distant cancer have rates of 35.9% and 8.9%, respectively (1). Moreover, individuals with a stage IA lung cancer diagnosis have a greater than 90% survival rate at 5-year. Early detection is thus critical for improving outcomes and long-term survival.

Lung cancer screening (LCS) with yearly low-dose computed tomography (CT) can reduce lung cancer-related mortality by 20% (2). The US Preventive Services Task Force currently recommends screening for high-risk individuals aged 50–80 years with at least a 20-pack-year smoking history who either currently smoke or quit smoking within 15 years (3). Yet, more than a decade since LCS was first recommended, only 5–10% of the eligible US population has been screened (1). Alarmingly, rural communities are disproportionately impacted by both lung cancer and poor uptake of LCS, and if these trajectories continue, disparities in lung cancer outcomes in these communities will only worsen (4).

Adults living in rural communities smoke at nearly twice the rate as those living in urban areas. Moreover, they are more likely to be heavy smokers, smoking at least 15 cigarettes daily compared to urban smokers, and have higher lung cancer incidence rates compared to urban areas (5). From 1999 to 2020, rural communities experienced the highest rates of age-adjusted lung cancer-related mortality and the slowest rate of decrease compared with urban populations (6). Not only are individuals living in rural communities less likely to receive an initial LCS, they are also approximately 14–44% likely to have guideline-recommended annual screening completed after their initial screening (7). This is an important consideration, as clinical trials have shown that lung cancers were detected at similar rates in each of the three rounds of annual screening (2). It is important to note that the term “rural” can have varying definitions based on population density, geography (e.g., census tract, zip codes), and commuting patterns (8). In this editorial, we use the U.S. Census Bureau definition, which broadly classifies an area as rural if it does not meet any criteria for an urban designation.

We seek to discuss the various barriers to LCS in US rural communities and provide some insight into possible solutions for improving utilization of LCS. The socioecological model helps understand multi-level barriers to LCS at the individual, provider, healthcare system, and policy levels, with interrelated levels that create a complex network impeding implementation of high-quality LCS (Figure 1).

Figure 1 The socioecological model of lung cancer screening barriers in rural communities: individual, provider, system, and policy-level barriers.

Individual-level barriers

One of the most significant individual-level barriers in rural populations is the lack of media coverage and educational resources, resulting in limited awareness of screening availability and eligibility criteria (9). The absence of media coverage and national awareness campaigns, especially in rural communities, contributes to a knowledge deficit, preventing high-risk smokers in these areas from being aware of the availability of LCS. Additionally, smoking-associated stigma, fear of cancer, and distrust of healthcare systems may deter rural-living individuals from seeking screening (10). Ineffective media campaigns which use scare tactics, and limited access to tobacco treatment resources, often lead to a lack of patient engagement and a sense of marginalization, fostering further distrust (11). This can prevent patients from informing their providers about their smoking history, hinder LCS eligibility determination, and reduce engagement in LCS due to the stigma surrounding smoking.

Additionally, another significant barrier to LCS in rural communities is lack of health insurance. Despite national trends show an overall increase in insurance coverage, rural communities continue to have a higher percentage of uninsured individuals compared to urban communities (12.3% vs. 10.1%, respectively) (12). Lastly, a key obstacle is the lack of transportation and the need to travel long distances to screening facilities (13). Radiology-certified screening facilities are often concentrated in metropolitan areas, creating significant hurdles for rural populations (14). Even when LCS is obtained, it is often outside of their healthcare system, which can lead to a lack of coordination and delays in managing screen-detected findings. In addition to lack of transportation, there is an individual’s inability to take time off from work to attend appointments. If an individual takes time off from work this could lead to loss of income, especially for individuals who are paid hourly. Also, there is the added stress of childcare when taking time from work. Another important individual barrier is financial burden and cost of LCS, with out-of-pockets costs having been previously demonstrating to influence screening access.

Provider-level barriers

Providers (mostly primary care physicians) are crucial for initiating LCS, annual monitoring, and downstream evaluation of screen-detected findings. However, providers are often unsure of LCS eligibility criteria, have insufficient time to conduct shared decision-making with their patients, and when they do discuss screening, they tend to overemphasize the benefits of LCS with little mention of harms (15-17). Proposed provider-level barriers have previously included lack of buy-in, knowledge gaps about LCS guidelines and patient eligibility among rural providers, as well as awareness of the availability of LCS programs and specialist support within their community (18). However, a recent study suggests that rural providers understand the benefits of LCS and support its implementation (19). Moreover, a recent observational study supports this conclusion, showing no difference whether providers deemed patients to be appropriate for LCS between rural patients and those living in urban areas (20). Thus, the main challenges for providers are related to workflow processes, time constraints, and addressing patients’ social determinants of health.

System-level barriers

System-level barriers include the lack of resources to support LCS and effective electronic health record (EHR) tools. Recent studies have demonstrated that patients who undergo their initial screening through centralized LCS programs are more likely to receive guideline-recommended follow-up compared to those in decentralized programs (21,22). In general, in centralized LCS programs, patients are referred to a dedicated LCS program and the program personnel (e.g., LCS coordinators) handle several of the key functions of LCS (e.g., verifying eligibility, conducting shared decision making, ordering the LCS, notifying the patient of their results and managing follow-up care). In decentralized programs, the ordering primary care provider (PCP) is responsible for all the key functions and refers the patient to specialists as appropriate. Current guidelines do not recommend one program type over the other, but recommended selecting the program model that best matches the available resources available and local community needs (23). In practice, many programs may operate as a hybrid model, incorporating elements of both centralized and decentralized models. Importantly, primary care clinics and healthcare systems that serve rural patients often lack access to LCS-accredited radiology facilities, as well as possibly the necessary resources to implement high-quality centralized screening programs, increasing the risk of patients falling through the cracks without adequate support for PCPs and effective care coordination (24,25).

Additionally, one of the key barriers to LCS is the incomplete or inaccurate smoking histories in the EHR in up to 80% of LCS-eligible individuals (26). Leveraging the EHR is critical to identifying LCS-eligible patients and developing interventions targeted at high-risk individuals. For example, a recent study demonstrated that EHR-based algorithms can be used to reliably identify LCS eligible individuals (27). Additionally, clinical reminder tools can improve smoking documentation while prompting providers to consider screening their patients (28). Lastly, EHR-based risk prediction tools integrated at point of care, could be vital for identifying patients who would benefit most from early lung cancer detection and increasing LCS uptake (29). Rural-serving healthcare systems may lack the necessary infrastructure and information technology (IT) support to implement several promising avenues to improving LCS.

Policy-level barriers

LCS is recommended by US Preventive Service Task Force and covered by Centers of Medicare and Medicaid mandate in 2015. The Affordable Care Act extends this insurance coverage mandate to private insurers. However, insurers, including state Medicare and Medicaid, may still require co-payments or prior authorization, creating significant obstacles to accessing screening that can impact US states with large rural populations (30). For example, there are currently 10 states, mostly in the southeastern US, that have not expanded Medicaid under the Affordable Care Act. Medicaid expansion has been linked to increased LCS use, and approximately 5 million low-income individuals, many in rural areas, could gain insurance coverage through expansion (31). Lastly, funding for lung cancer lags other types of cancers despite large settlements from the tobacco industry.

Lack of access to thoracic surgeons

Beyond the barriers that rural patients face with LCS, they also face a lack of access to thoracic surgeons once they have an early-stage diagnosis of lung cancer (32). In a recent study by Potter et al., from 2010 to 2018, the number of cardiothoracic surgeons in the US per 100,000 people decreased by 12%, while stage I non-small cell lung cancer cases increased by 40%. Additionally, there was a greater decrease in the percentage of patients who underwent surgery in nonmetropolitan and underserved regions which corresponded with worse outcomes (33). It is not surprising that there are clusters of thoracic surgeons in more metropolitan regions of the country, specifically in the northeast, in comparison to more rural regions of US (34). Importantly, rural patients are more likely to be recommended non-surgical management, have surgery deemed too risky, or to be recommended for surgery but not have it performed, ultimately leading to worsened outcomes (35). Thus, the importance of thoracic surgeons for lung cancer resections cannot be understated. They specialize not only in oncologic resections but also in performing thorough lymph node dissections vital for accurate staging and effective management plans. Additionally, rural communities not only lack access to thoracic surgeons but also multiple specialists with advanced diagnostic capabilities (e.g., navigational bronchoscopy, interventional radiology) and multidisciplinary tumor boards.

Potential solutions and interventions

To improve LCS uptake in rural communities, multi-level interventions are needed to meaningfully address current barriers. At the patient level, there needs to be a focus on improved dissemination of information through outreach and education. Efforts may include media campaigns, direct patient outreach, and education platforms aimed at both patients and providers. For example, Cardarelli et al. demonstrated that multimodal outreach including mailed postcards, advertisements in community newspapers, and local public radio announcements could improve LCS uptake in rural counties in Kentucky (36). Additionally, the increasing access to technology expands the ability to promote LCS in rural communities through texts-based interventions and social media outreach. However, it must be considered that several rural communities remain without reliable access to internet or phone service.

At the provider level, supporting PCPs and auxiliary personnel to conduct shared decision making that is values-based and engages patients in LCS is critical to improving LCS. Promisingly, telemedicine represents an ideal opportunity to provide high-quality care throughout the lung cancer continuum to rural patients who lack access to specialists and advanced procedure techniques. Indeed, implementation of telehealth visits for the discussion of LCS is actively being explored (37). Importantly, it is crucial that telehealth medicine is integrated with patient navigation to alleviate the burden of travel and access to care. Interventions that promote a strong patient-provider relationship are necessary for the uptake of LCS as well as the continued maintenance of annual screening.

Potential healthcare system LCS interventions include EHR-based strategies and allocation of resources to support LCS. One potential strategy is to leverage the EHR to help identify high-risk patients and integrate into the providers’ clinical workflow (38). Additionally, mobile CT scanners present a promising strategy for engaging individuals with limited geographic access to radiology services or who have transportation difficulties. An initial pilot trial in the US has shown that mobile scanners may effectively engage populations from diverse racial and ethnic backgrounds, as well as those living in rural areas (39). Indeed, several exciting mobile screening programs have been providing LCS for rural populations now for several years including throughout the Appalachian Valley and in other parts of the US (40). An example of such a successful mobile screening initiative is the CHI Memorial Chattanooga’s Mobile Lung Screening program. Utilizing a state-of-the-art mobile screening bus, in 2018 for a 10-month period, they were able to travel to 104 different sites and screened about 548 eligible patients (41).

Importantly, advocacy to reduce insurance barriers to accessing screening and expand access to rural populations are key components to improving screening in rural communities. Additionally, increased funding for LCS initiatives through local, state, federal, and non-profit support can help deliver cost-effective interventions targeted at rural communities. Critically, navigating access to thoracic surgery and other specialists involved in the care of downstream findings will be needed to achieve the full mortality benefit from LCS.

Engaging community partners throughout the entire process, from intervention design to maintenance, will be critical for developing and implementing impactful strategies that address these multi-level barriers in a tailored, acceptable, and culturally relevant way.

Summary

In conclusion, clear barriers exist for rural populations in the US concerning both LCS and access to thoracic surgeons. These barriers exist at multiple levels which are complex, inter-related, and difficult to overcome with current approaches. To meaningfully address barriers to LCS in rural communities, multicomponent interventions incorporating several of the discussed strategies are likely necessary. Further studies are still needed to elucidate which high-value interventions are effective in rural populations and feasible in healthcare systems with limited resources.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Current Challenges in Thoracic Surgery. The article has undergone external peer review.

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-24-31/prf

Funding: This work was supported by the LUNGevity Foundation and by the UMass-Baystate Department of Healthcare Delivery and Population Sciences (to E.R.N.; GRANT ID # 2021-03). The content is solely the responsibility of the authors and does not necessarily represent the official views of the LUNGevity Foundation, or the University of Massachusetts Chan Medical School-Baystate Administration.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-24-31/coif). E.R.N. received grant funding of 2021 Health Equity and Inclusiveness Research Fellow in a part time and also was supported from the UMass-Baystate Department of Healthcare Delivery and Population Sciences (Award #2021-03). The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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