So, the fourth speaker I'd like to introduce and our final speaker for the session is Dr. Ella Casaruni. She is the professor of radiology at University of Michigan and also chair of the Lung Cancer Screening Registry at the American College of Radiology. She's also the current and founding chair of the National Lung Cancer Roundtable at the American Cancer Society. And today, Dr. Casaruni will share the U.S.'s experience implementing CT lung cancer screening. Any moment now, there we go. Thank you so much, Jeff and colleagues, for the opportunity to present where we are in the United States with the implementation of lung cancer screening. I think, as you'll see, the heterogeneity of the way lung cancer screening is implemented is often related to the way healthcare is funded in an individual country. And that certainly is the case in the U.S. and probably different than the way it is in many other countries. I like to say we have a quilt of healthcare coverage in the United States. And you'll see this play out in some of the data that I'll share with you. For individuals who are 65 years of age and older, there is national healthcare coverage through the Medicare program. For individuals who are below the poverty line, there is healthcare coverage at the state level and that is heterogeneous in the way it's implemented. At a state level, providing healthcare insurance for those in poverty. And then in between, there is largely employer-based healthcare coverage as a benefit provided by your employer. Or for others, there is pay out of pocket for a healthcare plan to an insurance company to cover their healthcare costs. So that heterogeneity really impacts how lung cancer screening is implemented. And then we have systems like the Veterans Healthcare Administration, which covers our veterans across all states. So I'll talk about our current screening uptake and adherence. Some strategies and programs that are underway across the United States to accelerate the quality and uptake of lung cancer screening. And the updated American Cancer Society guideline from November 2023, which is both an opportunity for us, but is a challenge given that quilt of healthcare reimbursement decision-making. I'll start with the current data that we have, which is from 2022. These are two papers that were published this year that are cross-sectional studies using the Behavioral Risk Factor Surveillance System, or BRFSS surveys, that are population-based, nationwide and have representation across all the states. This was done for individuals who are 50-79 years of age in the lung cancer screening population where the questions were asked, who are eligible for screening according to either the 2013 or 2021 eligibility criteria. These responses are self-reported by patients. I happened to get a call myself by a BRFSS survey interviewer. And as they were asking my questions, I wondered, is this the BRFSS survey? And I asked them, and sure enough, it was. I'm a first-hand respondent, and when I got to the questions that had to do with smoking history or not, I stopped the interviewer and asked, if I were to say yes, what would you have asked me next? So that I could learn first-hand. And this is done for all 50 states and the District of Columbia. The first data that came out of BRFSS surveys came from 2019, a survey of 20 states. It was voluntary, not a required part of the survey. And the screening rate based on that information in 2019 was 12.8%. There was another survey conducted only in four states which showed a 21.2% uptake of lung cancer screening in 2021. However, it's only four states. The positive news is it showed an increase in screening between 2019 and 2021 in those states. But those four states happen to be some of the highest rates of uptake across the country. So it's a skewed population of only four states. There are some things that we can learn. Women were more likely than men to undergo screening by a large proportion, at least in these four states, 22.6% versus 4.4%. In Rhode Island, we had the highest rates of screening at that time, 30.3%. New Jersey, the lowest. Again, just of these four states, 17.5%. White individuals were more likely to be screened than their black counterparts, 21 versus 16%. And importantly, patients with a primary care provider had a higher rate of screening than those who did not, 22.2 versus 7.6%. Individuals who used to smoke were more likely to undergo screening than those who currently smoke, 25.3 versus 17.7%, suggesting that the stigma that clouds individuals who currently smoke and prevents them from coming fully forward and staying with healthcare may be impacting their willingness to undergo screening. In 2022, the Survey for Lung Cancer Screening Questions became a mandatory part of the BRFSS survey. So it was no longer optional. And so we had this opportunity for the first time to have nationwide data. And there were two publications that looked at this. The first, their goal was to report an update on the prevalence of screening nationwide using the 2021 USPSTF criteria of 20 PAC years and 50-80 years of age. Before that, our first criteria from USPSTF in 2013 were 30 PAC years and a starting age of 55. This expanded the eligible population for lung cancer screening with a goal of increasing screening rates among individuals who are increasing the opportunity for screening among black Americans and women who have a higher rate of lung cancer risk at a different PAC year history. The up-to-date screening prevalence reported for 2022 was 18.1%. But you'll see the heterogeneity across states from about 9.5% to 31%. It's lower in individuals with no health insurance, not surprisingly, or have no usual source of care, are not seeing a primary care physician, for example. Screening rates were higher in individuals with increasing age, not surprising. Medicare coverage kicks in at age 65. Individuals who had more comorbidities, again not surprising because older individuals have more comorbidities. Medicare and states with a Medicaid expansion, which expanded coverage in Medicaid states that was adopted by the state government. And that was heterogeneously adopted across the United States. Some states did, some states didn't. It was also associated with an increased number of lung cancer screening facilities had a higher rate of screening. Of individual screened as a snapshot, 61.5% reported currently smoking, gender 54.5% male, age 64.4% were age 60 and older, Medicare coverage kicks in at 65, and education, 53% at a high school education or less. And that may speak to the population of cigarette smoking intensity. Graphics, I think, can convey a lot. The figure at left shows you a color scale of the heterogeneity by state. But it's not only important to look at the heterogeneity by state uptake of lung cancer screening, but is lung cancer screening being performed in the states that have the highest risk of lung cancer. And if you look at this with the population, the rate of screening and the mortality rate of lung cancers on the bottom, you'll see in this blue circle a number of states in the southern part of the U.S., southeast part of the U.S. will have some of the highest lung cancer mortality, but also the lowest lung cancer screening rates. Many of these states did not take the Medicaid expansion. Kentucky is an outlier where lung cancer screening investment and outreach across the state of Kentucky has been underway for many years in a state that is dedicated to reducing lung cancer mortality among its high-risk population and should be applauded. The second study, which looked at the same data set, did a slightly different lens. They compared the USPSTF 2021 and 2013 criteria, respectively, the lung cancer screening prevalence being 16.4% once the expanded criteria were adopted, increasing the population significantly eligible versus nearly 20% in the 2013 criteria. Thirteen-and-a-half individuals eligible using USPSTF 2021 were screened versus 8.1 million using USPS 2013. Among individuals newly eligible under the 2021 criteria, the majority were younger and had a lower package of smoking as expected. Aligned with state intentions of the US 2021 recommendations, the expanded criteria had the greatest relative increase among Asians, black individuals, and Hispanics, and the number of eligible female individuals increased in screening. It was higher in individuals who reported fair or poor health and trended by education level, lowest with those with less than a high school education. It's not only important to get screened, but it's important to adhere to screening. And rates reported from the first 1.2 million screens in the US were only 22%. Newer data from an analysis in more recent years show that it's up to 40%. And the American College of Radiology has made this a key performance indicator for facilities participating in the registry, as well as provided tools to help facilities understand how to increase their adherence. I want to give a shout out to the Veterans Health Administration who's making a concerted effort to require facilities to start lung cancer screening and get the resources to do so with nearly a million individuals eligible for lung cancer screening in this patient population. And then lastly, a HEDIS measure for lung cancer screening in the US drives policy. The National Committee for Quality Insurance develops these and works with health plans to improve quality and lower costs by these measures. The HEDIS measure domains cover things such as access and availability of care and utilization of screening. They are executed through exports of health systems electronic health record data. And the two that are under consideration for development currently with an expected rollout in 2026 are the percent of eligible individuals getting screened and pack your documentation in the medical record beginning as young as age 12. These are under testing and when rolled out will be a way for health care plans to work with the systems in which their patients are having care to increase screening rates at a policy level. Thank you very much.

CT lung cancer screening

healthcare funding systems

Medicare coverage

screening rates

HEDIS measures