Lung cancer is treatable and potentially curable but we have to catch it early.Rian M. Hasson, MD
Rural populations, which make up almost half of the patients cared for by Dartmouth's and Dartmouth-Hitchcock’s Norris Cotton Cancer Center (NCCC) here in northern New England, face many health disadvantages compared to urban areas. Among those is easy access to life-saving cancer screening programs.
As a first step to improving access options, a team of clinical researchers from NCCC’s Comprehensive Thoracic Oncology Program recently published a study on rural barriers to screening, particularly for early lung cancer.
“Urban dwellers have academic medical centers in the heart of town that they can get to fairly easily, whereas rural populations often have a distance barrier,” says Rian M. Hasson, MD, a thoracic surgeon at NCCC and lead author of the paper.
Healthcare maintenance is also not as up-to-date in rural areas as it should be. Rural populations generally fall behind in multiple screening efforts. Like the domino effect, delayed screening can lead to a later diagnosis that then requires more complex care, the frequency of which poses the same access challenges. “If you're traveling 50 miles for every doctor's appointment, and you have radiation therapy five days a week for five weeks straight, commuting can be overwhelming,” says Hasson. “Especially if you don't have the social support or resources to help get you to those appointments.”
In rural areas, general education and medical literacy levels tend to be a bit lower. “We did an interesting study published in the Journal of Rural Health where we asked focus groups in New Hampshire and Vermont their thoughts on lung cancer and other screenings,” says Hasson. “They understood that breast and colorectal cancer screening needed to be done yearly. But they thought lung and other screenings should be done after symptoms present, which actually defeats the purpose of the screening.” The study also surfaced some participants’ assumptions that a clean lung cancer screening meant tobacco users did not have to quit smoking.
New Hampshire’s much higher incidence of lung cancer incidence and mortality is thought to be connected to a larger population that uses tobacco. Eighty percent of lung cancers are thought to be directly caused by tobacco use. Research shows marijuana use can lead to tobacco use or to vaping, that can also cause lung injury.
“So there definitely needs to be education efforts around recently updated criteria for lung cancer screening specifically, and the many, many benefits of quitting tobacco and other substances. That said, patients and providers both need the tools to act,” says Hasson.
Bridging the divide
Two areas Hasson’s study notes would improve screening rates include placing accredited screening centers in areas of lower education levels and higher cancer incidence rates, for example, in towns known to have high rates of smoking and tobacco use, and focusing on provider buy-in. “This is where the providers come into play,” says Hasson. “It's known in the literature that most patients will be more likely to get screened if their provider encourages it. But if you already have a baseline lower education level, and your provider is not talking about screening, and you're far away from an accredited center, which we saw in New Hampshire and Vermont as a problem, then you're going to be less likely to get screened.”
Other focus areas include working to improve insurance reimbursement rates—after all, as Hasson notes, the cost of screening is much lower than the cost of cancer treatment—and standardizing screening scoring mechanisms to help providers understand the meaning and determine next steps.
The tools to act
One of Hasson’s current projects is getting mobile CT lung cancer screening units into areas that don't have screening programs. “Mobile units have been shown to be helpful with breast and cervical cancer screening. A town in North Carolina actually piloted a program through private funding to have low-dose lung cancer screening for patients who don't have insurance, and it worked out very well. They had excellent participation. I think we could use that model to help reach patients in New Hampshire and Vermont too,” says Hasson.
Working directly with community members to understand their needs is key to the mobile unit’s success. “I can't just pop a van in the middle of town on a Wednesday morning and expect people to come. I need to ask, ‘Is this the best day for you to go? Would you prefer a van on Saturday? Would you prefer the van near the local Dollar General?’” Dollar General is not only a trusted facility by rural populations but is actually such a champion of screening efforts that they have added a chief medical officer and have served as a key place for holding medical information sessions.
Hasson’s team also has survey efforts underway for patients and providers to gather specifics to the barriers in play for lung cancer screening, including why patients do and don’t get screened, and why providers do and don’t recommend screening.
A pulmonary nodule clinic also opened recently at NCCC to help primary care providers with the next steps if screening scans show findings that they aren’t sure what to do with. “Taking the burden off the provider's shoulders and simply having them refer patients to the pulmonary nodule clinic is a huge step,” says Hasson.
Call to action
Lung cancer screening saves lives. Multiple large studies show that. “I encourage my medical colleagues to educate themselves about screening,” says Hasson. “There's already so much that you do to help keep our patients alive and healthy. This is an opportunity to participate in something that has been shown over and over again to save lives. Lung cancer is treatable and potentially curable, but we have to catch it early.”
Hasson encourages patients to ask their providers about screening and not to be afraid of what comes along with that. “We will help you along the way. But this is something that could save your life.”
To learn more, please talk with your provider or visit Lung Cancer Screening.