• The policy calls for improved physician education and support for interventions to improve screening access.
• An expert discussed the new policy and what PCPs need to know.

The AMA adopted policy to improve physician education on the effectiveness of low-dose computed tomography, or LDCT, at its annual House of Delegates meeting.

In the U.S., lung cancer is the top cause of cancer deaths and is the second most common overall cancer, but screening rates are still low, according to a press release from the AMA.

In the new policy, the organization “will also encourage education, technological innovation and continued research around the detection of coronary artery calcification on low-dose CT performed as a part of a lung cancer screening program,” according to an AMA spokesperson. The AMA additionally intends to support any efforts from key stakeholders in various specialties like cardiology, oncology and pulmonology “to research interventions to improve access to and use of lung cancer screening with low-dose CT scans in high-risk patients.”

“We know that lung cancer has significant health and economic impacts in the U.S. It is also typically diagnosed at late stages, and as a result often comes with a poor prognosis,” AMA President-elect Sandra Adamson Fryhofer, MD, said in the release. “Fortunately, evidence shows that targeted screening with low-dose CT can result in earlier diagnosis and better health outcomes like reduced lung cancer-specific mortality.”

Martin J. Edelman, MD, FACP, FASCO, G. Morris Dorrance Jr. Chair in Medical Oncology, deputy cancer center director for clinical research and department chair of hematology/oncology at Fox Chase Cancer Center, told Healio that primary care providers are the primary contact point for screening — “not only for lung cancer but for breast cancer, hypertension, hyperlipidemias, etc.”

“Obviously, the other specialties should also be involved as well, but this really should fall on the general internist, family practitioner, etc.,” he said.

In 2021, the U.S. Preventive Services Task Force updated its guideline for lung cancer screening, marking the first change to the recommendation since 2013. As Healio previously reported, the task force recommends screening adults aged 50 years to 80 years who also have a smoking history of 20 pack-years and either are current smokers or who have quit in the last 15 years.

In 2023, the American Cancer Society updated its lung cancer screening guidance to adopt similar recommendations: annual LDCT screening for patients aged 50 years to 80 years who currently smoke or have at least a 20 pack-year history. However, it eliminated the 15-year quit-time limit.

But one recent study revealed that these screening guidelines could exclude more than 60% of patients who develop lung cancer, and other medical specialties have different eligibility criteria for LDCT, especially when it comes to stopping routine screening.

Edelman said that, in his opinion, duration of smoking can be more important than pack-years of smoking, but it all comes down to individualized care. For example, when comparing two patients, both aged 75 years, but one is “quite ill” and the other is “very healthy looking” and exercises regularly, “you have to adjust to life expectancy.”

However, this advice is only good if patients are actually being screened.

Edelman said there are multiple barriers to LDCT screening at the patient, provider and systemic levels — “the usual folie a trois of the U.S. health care system” — but a key point is underestimating LDCT’s effectiveness.

“People in primary care need to understand that lung cancer screening should be up there with mammography,” Edelman said. “Nobody debates or questions mammography, and yet the data unequivocally show that lung cancer screening will save more lives per patient screened than mammography.”

But it is more difficult to order LDCT screening than mammograms, partly due to availability and scheduling issues, Edelman said.

“Within the system, there are issues of how insurance picks stuff up, availability of CT scans, qualified readers. It is a somewhat more complicated issue to address than other screening aspects at this time,” he said.

But there is also “a lack of understanding of the enormous progress that’s been made for the treatment of lung cancer at every stage” among patients. “Every woman knows about mammography, and yet what really kills women? Lung cancer, not breast cancer. Lung cancer kills more women each year than breast and colon cancer combined,” Edelman said. “Breast cancer is more common; lung cancer is more lethal. So, it’s a women’s issue that’s just simply not recognized.”

Despite the fact that many conditions can be attributed to lifestyle choices, Edelman said stigma can also be an issue since lung cancer is a smoking-related disease.

“Much of cardiovascular and pulmonary disease is related to issues of diet, tobacco use, exercise and other lifestyle issues, but lung cancer seems to almost uniquely be associated with this stigma,” he said.

Edelman said LDCT screening for lung cancer “has been clearly established as an evidence-based way of preventing death from lung cancer and actually increasing life expectancy in the screen population; this is not subject to debate.” So, “if you’re ordering mammograms, you should be ordering low dose CT scans on the appropriate population.”

“Our ability to cure patients at literally all stages is something I couldn’t dream of seeing 10 years ago. The ability to intervene with effective therapies is dramatically better than where it was,” he said. “It’s [the PCPs’] responsibility to screen and get these patients to us as quickly as possible, because the sooner the lung cancer therapeutic team sees somebody, the better the outcome will be.”

He also said PCPs can also use these screenings as teachable moments for patients. For example, when going over the findings, they can “address other risk factors for cardiopulmonary mortality and morbidity, including hypertension, hyperlipidemia,” as well as other lifestyle issues like smoking cessation and exercise.

Another “great teachable moment” is when a coronary artery calcification is identified incidentally, because “if you’re on the fence about whether or not to treat somebody’s cholesterol, that sort of pushes you to be aggressive with that.”

“I think certainly these are the moments to make sure that blood pressure is well controlled using the modern standard; dietary, exercise interventions are important,” Edelman said. “I think these are things again that would need to be addressed. I don’t know what the cardiology recommendations are to deal with incidentally discovered calcification, but certainly no one would argue with aggressive control of risk factors.”

Martin J. Edelman, MD, FACP, can be reached at primarycare@healio.com.