Lung cancer is one of the fastest-growing and most aggressive forms of cancer. Smoking cigarettes is the number one risk factor, but exposure to secondhand smoke as well as other tobacco use and the environment are among other risk factors. We asked Dr. Naomi Tan, who has a Ph.D. in health communication and focuses her research on shared decision-making for lung cancer screening, about screenings and how the support of family and clinicians can improve survival rates.
New Jersey Family: What is the general risk for developing lung cancer, and who is most at risk?
Dr. Naomi Tan: The number one risk factor for lung cancer is smoking cigarettes. About 80% of lung cancer deaths are thought to result from smoking cigarettes. Other types of smoking, like tobacco use, cigar smoking, pipe smoking and smoking menthol cigarettes can also increase the risk of lung cancer.
There are also environmental exposures that pose a risk, such as exposure to secondhand smoke, getting radiation therapy, exposure to radon gas from the breakdown of uranium in the environment, and exposure to asbestos or other kinds of carcinogens. Those are believed to be secondary risk factors compared to cigarette smoking.
People who have a family history of lung cancer might have a greater genetic predisposition for lung cancer.
NJF: We’ve heard of secondhand smoke, but what is tertiary smoke exposure?
Dr. Tan: It’s also called thirdhand smoke. It happens when you smoke indoors and the pollutants settle on surfaces in the home. For example, it might get embedded in fabrics around the house and if you have carpet or wallpaper, anything porous like your drapes or curtains, or even bedding. It can also settle on harder surfaces in the form of dust-like particles. This is difficult to clean up. Airing out the room, ventilating the room, or using household cleaning products are not going to entirely remove the thirdhand smoke.
Research has shown that tertiary smoke exposure can be a health hazard because it’s a pollutant. The long-term effects are not very well studied. Infants and young children might be at increased risk because they tend to crawl around the house or put objects in their mouths that may contain thirdhand smoke residue.
ScreenNJ is a statewide service that provides education about cancer prevention and detection to the community and professionals. ScreenNJ supports NJ residents to obtain cancer screening through navigation and mobile health services regardless of their ability to pay. For more information about ScreenNJ visit screennj.org.
NJF: Who is eligible for lung cancer screening and what types of screenings are available?
Dr. Tan: The most important benefit of lung cancer screening is that you find lung cancer early when it can be more easily treated, especially because lung cancer can develop and progress very quickly. For those who are eligible for lung cancer screening and want to be screened, it’s really important that you are screened every year to catch lung cancer early.
The U.S. Preventive Services Task Force recommends lung cancer screening for those who are ages 50 to 80, who either currently smoke cigarettes or quit within the past 15 years, and who have a pack-year smoking history of at least 20 pack years. How does that work? Pack years are calculated by multiplying the average packs of cigarettes smoked per day by the number of years that you have smoked. For example, if someone has smoked a pack a day for 20 years, then they have 20 pack years.
They recommend that lung cancer screening be performed with a low-dose computed tomography (CT) scan. This is the only screening modality they have found in clinical trials to be effective in detecting lung cancer and reducing mortality. The low-dose CT is a donut-shaped machine with a special X-ray that takes images of the lungs from different angles as you’re lying down on the table. A computer will combine these images to form a detailed image of your lungs. That’s what the radiologist will examine to identify if there are any abnormal findings. This procedure is painless and takes less than a minute. There are no injections or IVs or dyes involved in this scan. Many people might think of an MRI machine, which is really loud and takes a long time, but is much quieter and quicker.
The National Lung Screening Trial compared a low-dose CT scan vs. using chest radiography, and people in the trial who had received three annual CT scans had a 15% to 20% lower risk of dying from lung cancer. It is the most effective screening modality that we currently have.
NJF: Does the data show if certain subgroups are more susceptible to lung cancer than others?
Dr. Tan: In 2021, the U.S. Preventative Services Task Force, a panel of experts who make testing recommendations based on the latest research available, expanded the screening criteria. Recommendations from the U.S. Preventative Services Task Force are widely adopted by clinicians and used in determining coverage by the Centers for Medicare and Medicaid. It was previously recommended for those aged 55 to 80 but is now recommended for people aged 50 to 80. They also reduced the pack year requirements from 30 to 20 pack-year. This was intended to make sure that more people who are at risk would be able to access screening. With the previous guidelines, research found that there were some disparities in screening, such that women, Black individuals, and other ethnic minorities were not able to get screening even though they were at high risk of lung cancer.
NJF: Are there any risk factors for getting screened?
Dr. Tan: As with all medical procedures, there are some potential risks involved with getting screened.
Like other scans, a low-dose CT will expose you to a small amount of radiation, but this is about 5 times less than a diagnostic CT scan.
Your screening result may also show false positives, meaning that the scan might suggest that you have cancer when you do not. About 1 in 12 scans will be a false positive, but these do become less common with yearly screening because you can compare the scans over the years.
Another thing is that lung cancer screening is just the first step in the screening process. If there is an abnormal finding, then you may need to undergo additional testing to find out if it is cancer or not. You might need to go for more scans or undergo a biopsy which may have complications, such as pain, bleeding, or a collapsed lung. It is important to ask your provider what types of additional tests you may need, risks, and possible side effects. About 13 in 1,000 people will need additional testing, but fewer than 1 in 1,000 will have a major complication.
The scan will show not only the lungs but other surrounding organs, so it might find other abnormalities in the heart or different parts of the body. This is called an incidental finding. If something abnormal is found, your doctor might want to do additional tests to check if anything needs to be done. About 1 in 13 patients will have an incidental finding. Some patients might see this as a benefit for them as they’re finding out about other potential health issues. However, it’s important to bear in mind that this might mean that you are undergoing testing or treatment that is not necessary. The last thing I wanted to address is over-diagnosis. This happens when lung cancer screening finds a cancer that wouldn’t have caused you any harm in your lifetime or caused any symptoms. This might be a very slow-growing cancer. Over-diagnosis might result in you receiving treatment that you didn’t need. As doctors don’t really have a way of knowing if a cancer is going to be slow growing or not, they usually will treat it to ensure that it doesn’t harm you.
ScreenNJ is a statewide service that provides education about cancer prevention and detection to the community and professionals. ScreenNJ supports NJ residents to obtain cancer screening through navigation and mobile health services regardless of their ability to pay. For more information about ScreenNJ visit screennj.org.
NJF: Does insurance cover lung cancer screenings?
Dr. Tan: Most insurance plans should cover lung cancer screening at no cost to the patient. It’s important to reach out to your insurance provider to check because the screening facility or the provider may be out of network and that might incur additional costs. It’s also important to note that the coverage for lung cancer screening is for the low-dose CT scan. If there are any other procedures or additional testing that needs to be done, that might be an additional cost for the patient as well.
Lung cancer screening is covered by the Centers for Medicare and Medicaid (CMS), but an important difference is that while the U.S. Preventive Services Task Force recommends lung cancer screening for those aged 50 to 80, CMS covers lung cancer screening from age 50 to 77. Hence, if you have Medicare and Medicaid, the window for lung cancer screening is a little bit smaller.
ScreenNJ Patient Navigators are standing by to support New Jersey residents in finding, accessing, and receiving cancer screening at no cost to the individuals. To speak to a navigator, call (833)727-3665.
NJF: Your research, in particular, focuses on shared decision-making for lung cancer screenings. Can you explain what this is and how it works between individuals and their doctors?
Dr. Tan: Shared decision-making is a collaborative process where a patient and their family member and a clinician share information, and then come to an agreement on the optimal decision for the patient. This is an important part of patient-centered care and part of respecting patient autonomy. The goal is for the patient to make an informed decision that’s also in line with their values because they might weigh the benefits and potential benefits and harms of a medical procedure differently.
CMS requires that the patient has a shared decision-making and counseling visit for lung cancer screening before the initial low-dose CT scan in order for the scan to be reimbursed. Requiring a shared decision-making visit for reimbursement is an unprecedented mandate and I think that it really highlights the importance of the patient making an informed decision. It’s essential that patients are informed and that they weigh the benefits and harms before making a decision.
NJF: What is the survival rate if lung cancer is caught early and how can shared decision-making improve those survival rates?
Dr. Tan: Lung cancer is the leading cause of cancer death for non-small cell lung cancer, which is the most common type of lung cancer. At the localized stage, meaning that cancer hasn’t spread yet, the survival rate is 65%. At the regional stage, meaning cancer has spread to nearby tissues or organs, the survival rate is 37%. At a distant stage, meaning cancer has spread to distant parts of the body, the survival rate is 9%. These are all five-year survival rates. You can see that, if you find lung cancer late, the survival rate is really low. That’s why it’s so important to get screening yearly, starting from age 50.
In shared decision-making, the focus is on helping patients to make an informed decision and to minimize any potential harms from screening, rather than encouraging patients to undergo lung cancer screening. Research has shown that many people are not aware of lung cancer screening, which can be addressed during the shared decision-making visit. The shared decision-making process should also address any concerns or lingering questions patients have that a barrier to getting screened.
Finally, the shared decision-making process prioritizes patient autonomy and ensures that patients are able to make a decision they’re comfortable with. Research has shown that patients who participate in a high-quality shared decision-making process feel less conflicted about their decision and are more likely to continue being screened each year.
ScreenNJ is a statewide service that provides education about cancer prevention and detection to the community and professionals. ScreenNJ supports NJ residents to obtain cancer screening through navigation and mobile health services regardless of their ability to pay. For more information about ScreenNJ visit screennj.org.
NJF: How is information about lung cancer screenings disseminated to the general public?
Dr. Tan: I’ve seen mass media campaigns about lung cancer screening. There was, I think a couple of years back, an ad called Saved by the Skin. It was run by the American Lung Association and the Ad Council. From time to time, I do see bus ads or train ads about lung cancer screening programs at different hospitals and health organizations.
I also see a lot of public educational seminars, like on Zoom, where someone delivers a lecture about lung cancer or screening and the public can attend and ask questions. Community-based organizations often have their own educational seminars.
Did you know that ScreenNJ has Community Cancer Control Specialists, health educators, that provide free education directly to the community. ScreenNJ serves all 21 counties in New Jersey. Visit our website, screennj.org to learn more and to contact the team.
NJF: Is anything being done to target historically medically underserved communities and expand awareness and screenings?
Dr. Tan: I’m currently working on a study led by Dr. Anita Kinney, Dr. Richard Hoffman, and Dr. Robert Volk called “Telehealth shared decision-making coaching and navigation for lung cancer screening in primary care” or TELESCOPE. In the TELESCOPE study, patient navigators conduct a telehealth decision coaching session with patients where they inform patients about the potential benefits and harms of lung cancer screening, address barriers to screening, provide access to smoking cessation services if the patient is interested, and if the patient wants to be screened, put in a lung cancer screening order with their provider. Currently, we’re identifying people within the health system who are eligible for screening, so it’s not open to the public yet.
We are ensuring that Black and Hispanic individuals are well-represented in the study. As part of the TELESCOPE trial, we work with a very diverse community advisory board to make sure that all of our recruitment materials and any patient-facing materials or study materials are culturally sensitive and appropriate to patients and to make sure they’re willing to participate and feel safe to do so.
ScreenNJ promotes research around cancer prevention and screening. The TELESCOPE Trial is an example of these efforts.
Dr. Naomi Q. P. Tan is an Instructor at the Department of Medicine, Robert Wood Johnson Medical School, and at Rutgers Cancer Institute of New Jersey, and a researcher in the Cancer Prevention and Control Program at Rutgers Cancer Institute. She has a Ph.D. in Communication from The Ohio State University and completed her postdoctoral training at the Decision Support Lab at MD Anderson Cancer Center. Her research focuses on shared decision-making for lung cancer screening among minority and underserved populations.
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