Reflections on Lung Cancer Awareness Day 2024

Author: Dr. Eric Perakslis, PhD

August 1st marks World Lung Cancer Day and this year, we’re taking a moment for some reflection and introspection. According to Google AI, Lung Cancer Awareness Day intends to raise awareness of lung cancer, reduce stigma, and highlight the importance of early detection and research. The day also encourages people to unite in the fight against the disease and work together to improve outcomes. Having had the privilege of working in healthcare overseas in Europe, West Africa, the Middle East and Asia, I know first-hand that lung cancer, really all cancers, are perceived and experienced very differently around the world. We should take this opportunity to learn from cultures on certain facets and share learning experiences.

Stigma

Let’s start with stigma as it stubbornly persists nationally and internationally. According to the CDC, 209,500 new cases of lung cancer were reported in 2021, an incidence of roughly 49 out of 100,000 people. This makes lung cancer the 3rd highest incidence of newly reported cancers, with tobacco use cited as causing 80-90% of the new cases. The good work done by smoking cessation programs has benefited many but, like all health interventions, there are unintended outcomes. In the United States, for lung cancer, the stigma is that many believe the cancer is always due to smoking even though 10-20% of new lung cancer cases are non-and-never smokers. This can make victims feel judged that they ‘did this to themselves’ in some manner and shame can inhibit care and treatment compliance. The differences outside the US are striking in that many nations have not had large scale smoking cessation efforts or tobacco regulation and the marketing of nicotine addiction is historically ubiquitous in parts of Asia and Africa. In these areas, open talk of any cancers can lead to shunning and even abandonment. We have a long way to go on this one.

Early Detection and Research

Almost annually, one area of visible progress is in early detection methods. From low-dose CT scans (LDCT) to blood, urine and inhalation-based detection systems the forward march of technology is impressive, but only if people are willing to use them. A large-scale lung cancer screening study run by the Veteran’s Health Administration (VA) found that only 58% of patients that met the criteria for Lung Cancer Screening agreed to undergo the screening. Out of the patients that underwent screening, approximately half had nodules and/or required active surveillance. Most importantly (possibly) the study found that lung cancer screening, despite screening capacity and availability, to be challenging and complex citing the need for dedicated patient coordination. Why is this? This appears to be where our system in the US breaks down.

Despite the clear evidence that early detection via LDCT leads to 20-year survival rates for 80% of those diagnosed through early screening, incidence rates and poor outcomes for those diagnosed with later progression are still far too common. Over half of patients diagnoses only survive 1 year or less after diagnosis. How to fix this? If we are to learn from the VA study, and we should, the complicating element is patient coordination.

Lack of access to screenings is not surprising given that it is reported that between ¼ of and 1/3rd of Americans have no primary care physician or access to a ‘usual source of care’. In our work, we are finding that sometimes over half of the populations we serve may not have a primary care doctor. We know that primary care saves lives just as we know the comorbidities and poor health outcomes expected from its absence but the vacuum continues to grow as fewer physicians select primary care careers. For those of us in healthcare and health technology, there are few examples of such technologically low-hanging fruit yet successful models elude. We surely need some new ones.

We all need a Quarterback: Deprioritizing the single-use patient use cases

In the spirit of uniting in the fight against lung cancer and committing to improved outcomes there are obvious potential points of intervention. Having had the pleasure of working closely with our current FDA Commissioner, Dr Rob Califf, I have frequently heard him opine on the limitations of our pay-for-procedure health system. Our hospitals, clinics, labs and myriad specialty treatment centers are highly optimized to do specific things in as profitable way as possible and this greatly exacerbates the need for and obstacles to, better patient care coordination.

One view would be that patients must ‘become their own quarterback’ and take control of their own care. For most, this is likely wishful thinking in bad taste given the social drivers and pressures of many who lack primary care. This is further compounded by inherently complicated and often siloed care models that after often segmented further by specialties and even subspecialists. Can we expect an aggregate decentralized approach? Probably not. Most clinicians are too busy, too harried and too limited by liability to regularly have the bandwidth to go beyond their current problem list and specialty. It likely is nearly impossible to identify and address the totality of health problems ---sifting through long health histories, all the care gaps sitting in front of them during each patient encounter, and multi-factorial drivers that influence in access to addressing such problems encapsulated in one visit --although many try anyway. This inevitably places the burden on patients themselves.

Enabling comprehensive point of contact care

Can we enable people to be their own quarterback for their own well-being? I would like to think so, at least for a fair percentage. Doing so would only require three main things. First, a patient’s comprehensive medical history would need to be centrally available directly to them and their care team, ready for each clinical encounter. Second, the information available at clinical encounters should be served to clinicians in a manner that directly enables more comprehensive healthcare at each interaction. For example, a global and centrally available problem list organized for clinical teams enables each clinician to quickly and efficiently contribute to treatment interventions more comprehensively at each encounter. Third, patients should have overarching treatment options that quickly address their care needs that are convenient and accessible. To unify all this though--taking lessons learned from covid--special attention to appropriate trusted clinical guidance is key to making this reliably happen since public health awareness has become politically polarized, like so many other facets of our society. We should redouble our efforts and communications to minimize misinformation. In order to foster trust and engagement in screening campaigns that accelerate access to life-saving treatments, this requires special attention to not only coordinating well for patients, but also with patients.

Every one of us has something to gain from greater access to lung cancer screening. We may need more than one day per year dedicated to make it happen.