ABSTRACT
RATIONALE: Although lung cancer screening (LCS) uptake has increased to 5-16% nationally, screening initiation and adherence rates are threatened by the ongoing COVID-19 pandemic. Consistent with guidelines from a CHEST expert panel, our LCS program deferred new and annual low-dose CT (LDCT) screens during the pandemic's spring surge. Upon resuming screening, we pivoted to shared decision-making (SDM) via telemedicine. We characterized how these changes in screening implementation impacted our LCS volume and adherence. METHODS: We measured LCS patient- and LDCT scan-related volumes through our centralized program during pre-COVID (2019), deferral (March 18-May 18, 2020), and follow-up (May 18-November 18, 2020) to measure 3 outcomes: 1). Monthly volume of LDCTs in 2020 compared to 2019, 2). LDCT completion rate for SDM via telemedicine during the follow-up period, and 3). Adherence rates among patients due for LDCT during the deferral period and returned in the subsequent 6 months, compared to adherence among pre-COVID LCS patients. Adherence was defined as a subsequent CT within 11-18 months of a Lung-RADS 1 or 2 result, 4-8 months for Lung-RADS 3, and 2.5-4.5 months for Lung-RADS 4 patients recommended for 3-month follow-up. RESULTS: Monthly scan volume in our LCS program decreased during the COVID-19 first wave but increased following resumption of screening, and by August, the number of LDCTs exceeded 2019 (Figure). The number of patients screened between May-November 2020 and May-November 2019 was comparable (491 and 505 patients, respectively). However, the frequency of patients returning for follow-up was higher in 2020 compared with 2019 (62.1% vs. 46.3%). Following implementation of telemedicine, the screening completion rate decreased during May-November 2020, with 88.6% of patients (435/491) completing SDM but not LDCT, compared with 100% between May-November 2019. During the deferral period March-May 2020, 124 patients were due for a follow-up scan, and 54 (43.5%) received their scan within the study period. In comparison, 60.3% due for follow-up during the same period in 2019 completed their scan. CONCLUSIONS: Maintaining screening adherence has become a focus for many LCS programs. We observed that following the spring surge of the COVID-19 pandemic, the frequency of returning patients was greater than that of new patients initiating screening. Conducting SDM via telemedicine may introduce a barrier to LCS completion. Adherence rates decreased from 2019, with the lowest rates among Lung-RADS 3 patients due for a 6-month follow-up. Additional research should test LCS implementation strategies to improve adherence during the COVID-19 pandemic.
ABSTRACT
RATIONALE: During the COVID-19 pandemic's spring surge, many lung cancer screening (LCS) programs delayed scans. Upon resuming screening, programs pivoted to telemedicine for shared decision-making (SDM) to minimize COVID transmission risks. This can lead to a cascade of alterations in LCS implementation, exacerbating disparities in screening. We hypothesize these changes have altered the sociodemographic characteristics of our LCS population. METHODS: At our institution in Philadelphia, LCS was deferred beginning March 18, 2020. We analyzed data from patients living in Philadelphia undergoing LCS through our centralized program upon resumption of screening on May 18 and the subsequent 6 months. Patient-level sociodemographic characteristics were compared with a “Pre-COVID” cohort screened May-November 2019. Geospatial analysis was performed for neighborhood-level internet access among patients receiving SDM inperson vs. telemedicine. RESULTS: The 408 patients screened after program reopening had a mean age of 64.2±5.8 years, 246 patients (60.3%) were female, 204 (50.1%) were White and 196 (48.2%) were Black/African-American. Over half were current smokers (n=224, 54.9%), and 172 patients (42.2%) had COPD. Compared with the Pre-COVID cohort, the Post-reopening cohort had no statistically significant differences in age, sex, race, smoking status or intensity, BMI, COPD, personal or family history of lung cancer, or insurance status. Education was significantly different between the two groups, with the Post-reopening cohort comprised of a lower percentage of patients with <HS education (16.9% vs. 11.3%), a greater frequency of patients with a HS diploma (42.6% vs. 46.1%), and fewer patients with education beyond HS (39.2% vs. 35.2%) (p<0.001). There was no significant difference in mean PLCOm2012 lung cancer risk (6.5±5.6% vs. 6.4±5.7%) or frequency of positive screens (≥Lung-RADS 3;8.9% vs. 8.4%). After excluding follow-up patients, education remained the only significant difference between groups. Analysis of neighborhood-level household internet access revealed no difference in the number of patients from census tracts with the lowest availability of household internet. Among the 15 census tracts with the greatest loss of patients from Pre-COVID to Postreopening, only 26.7% were in the highest quartile of internet deficit. CONCLUSIONS: LCS disparities can include disproportionate underscreening of individuals who are Black/African-American, live in rural areas, or have low socioeconomic status. Despite significant changes to our LCS program's workflow, the only significant difference between our Pre-COVID and Post-reopening cohorts was education level. Future research should be directed toward developing strategies to support LCS-eligible patients with low levels of education in the era of telemedicine.