How a Federally Qualified Health Center quashed common barriers to lung cancer screening

A Texas Federally Qualified Health Center is offering insight into how it was able to bolster lung cancer screening uptake among challenging patient populations. 

Such lung disease is the leading cancer killer, with over 125,000 deaths in the U.S. anticipated in 2024. Patients who are black, poor or with lower levels of educational attainment are more likely to die from the disease, researchers detailed in the American Journal of Preventive Medicine [1].

One “promising” setting to improve low-dose CT screening uptake is at Federally Qualified Health Centers, which care for large populations at increased risk of lung cancer. Tobacco use also is higher among FQHC patients at 26% compared to 21% in the general population. 

“While [Federally Qualified Health Centers] serve a higher-risk population and hence present a compelling opportunity for lung cancer risk reduction, there are barriers to implementing lung cancer screening and intensive smoking cessation,” Nicole Kluz, assistant director for cancer prevention research with the University of Texas at Austin Dell Medical School, and co-authors noted. “Key barriers include costs; lack of access to specialty care (including treatment resources); competing clinical demands, exacerbated by social stressors and poverty; and provider/staff turnover and/or lack of training opportunities."

To address this, new lung cancer screening pathways were developed within CommUnityCare Health Centers—a large, diverse FQHC system in Central Texas. Kluz and colleagues conducted a prospective study using a multi-component intervention “designed to promote equitable implementation across the spectrum of care.” 

From 2020 to 2023, researchers identified patients ages 55 to 77 who smoked or had quit within 15 years and had greater than 20 pack-years of exposure. They pinpointed potential subjects through querying the electronic health record, reaching out via snail mail and direct provider referrals. A bilingual social worker also confirmed eligibility, provided telehealth-based shared decision-making, coordinated CT screening and offered smoking cessation help. The institution provided financial support for screening to help overcome costs (especially for the uninsured) and fear of financial barriers to care. 

A total of 479 patients responded to mailed materials, of whom 108 (or 23%) were eligible and 71 (about 66%) participated in shared decision-making. Another 629 were referred internally and 579 (92%) completed SDM. Of the 650 total who took part in shared decision-making, 636 (or 98%) agreed to screening.  

The study population was diverse, the authors noted, including about 36% Latino, 18% African American, and 27% users of Medicare or Medicaid. Another 48% used the county medical assistance program, 14% were uninsured and 77% currently smoked, with an overall average age of 62 across the study population. About 83% (or 528) patients completed CT screening, and there were no statistically significant differences based on age, gender, race/ethnicity or insurance status. Spanish-speaking subjects and those who formerly smoked were more likely to complete screening than patients who currently smoked. 

Kluz and co-authors noted that the program was able to achieve equitable implementation, as measured by completion rate (80% or higher in all groups) and time to completion (a median of 27 days). The latter was longer for black patients (by 1 week), patients on Medicaid (2 weeks) and current smokers (5 days). However, these differences were not statistically significant. For those who completed screening, 88% (or 465) had normal results of Lung-RADS 1 or 2, about 9% had Lung-RADS 3, and 3% had Lung-RADS 4. Seven patients (or 1.3%) were diagnosed with cancer. 

“Beyond equitable screening implementation, the multidisciplinary team was also developed and empowered to ensure high-quality care,” the authors noted. “The proportion of abnormal findings was consistent with other programs who reported their results and were manageable in terms of volumes. Engaging a board-certified chest radiologist helped refine initial assessments and minimize ‘false positive’ findings. Team navigators ensured that patients with Lung-RADS 3 and 4 findings received additional workups and surveillance scans as well.”

Read more about the study results, including potential limitations, at the link below.