As people with HIV live longer lives with anti-retroviral therapy, lung cancer has emerged as a leading cause of death. This is primarily because people with HIV are twice as likely to smoke, and they face higher cancer risks at younger ages. Immunosuppression and inflammatory processes also play a role. Subhashini Sellers, MD, MSCR, an assistant professor in pulmonary critical care, led a study supported by a CFAR Developmental Award that examined lung cancer screening eligibility and uptake at UNC Health. She presented the study at a recent Friday Conference.
“While lung cancer is a leading cause of cancer death among people with HIV in the U.S., screening uptake and adherence remain extremely low. We know screening improves mortality, but the process is complex, with multiple barriers at the individual, provider, and community levels. We need to identify the specific factors that impede screening so that we can design tailored interventions to improve screening.”
Guidelines for Lung Cancer Screening
In 2011, the National Lung Screening Trial (NLST) demonstrated a 20% relative reduction in lung cancer mortality with annual CT screening, with a low dose CT scan. This became the basis of the 2013 U.S. Preventive Services Task Force (USPSTF) recommendation to screen adults who are ages 50 to 80, with at least a 30-pack per year smoking history, who are currently smoking or quit within the last 15 years. In 2021, the USPSTF expanded screening criteria to include younger adults, with at least a 20-pack per year smoking history. However, people living with HIV were not included or accounted for in any of the modeling studies.
Currently, only 3-5% of the 9 million people in the general population who are eligible for lung cancer screening are being screened. Sellers describes the current state as abysmal and complicated.
“Once individuals are eligible and start screening, adherence to annual screening is poor compared to those without HIV, likely because people with HIV already experience barriers to healthcare access.”
“A patient first has to be identified as high risk, either through a provider or by self-identification, and shared decision making needs to occur. Then, the provider places the order, and the CT is scheduled. And the CT has to be completed. After that, we have to do this again, every year.”
Sellers says different factors play a role from the beginning to end, including clinical co-morbidities and insurance status; provider health system factors like clinical prioritization and ease of scheduling; and community level factors, such as distance from the clinic and medical mistrust.
Designing a Study
Dr. Sellers led a team that looked at 7,000 people with HIV who have received care at UNC Health, reviewing electronic health records for demographic and clinical data, HIV disease characteristics, substance use history and codes for lung cancer screening. The team also used patient reported outcomes from screeners, as well as external data sources such as the USDA Rural and Urban Community Program. For 2014 to 2021, the team applied 2013 criteria for lung cancer screening. For 2022 and 2023, they applied 2021 criteria.
Findings
They first looked at who was eligible for screening according to USPSTF criteria, and then who got screened once they were eligible. In 2014, 9% of patients who were eligible were screened. In 2023, 29% of patients who were eligible were screened
“Screening uptake has improved over time, which is good news, but unfortunately the screening gap persists. We are also looking at an aging cohort, so the screening gap also persists over time.”
Researchers also found Black and Hispanic people with HIV were less likely to be eligible than white people with HIV. Uninsured patients were also less likely to meet eligibility criteria, compared to insured patients and people with the most recent CD4 count of less than 250, or those with a viral load of 200 count or more.
Future Studies
Next, Dr. Sellers will analyze the time from eligibility to initial screening, and the time to the second screening CT, to address adherence questions.
“We need to be able to implement multiple evidence-based solutions to support lung cancer screening in this group of patients. Some potential solutions that have been explored in the general population may be applicable here, focusing on patient outreach, aiding patient navigation, and certainly optimizing provider and health systems. But I think given the fact that barriers are unique to this population, we really need to tailor interventions to make sure that they work.”
“I’m really appreciative to the CFAR for this developmental award, and the support from my mentor, Dr. Sonia Napravnik, and graduate research assistant Lindsay Brown, who helped identify creative solutions to working with this data.
Detected – One Patient
As Dr. Sellers’s lecture ended, the audience was invited to ask questions. During this time, Dr. David Margolis shared a success story. One of his patients was identified as being eligible for screening, and was willing to get a CT scan. The results showed this patient had early lung cancer. In the end, the patient was able to receive life-saving surgery to remove a tumor.