Breaking down barriers to improve lung cancer health equity

Lung cancer is the country’s most lethal cancer, causing almost 20% of all cancer deaths – and most cases (53%) are not caught until a late stage, when the survival rate is only 8%. Its effects aren’t equal, either: Black Americans with lung cancer are 16% less likely to survive five years compared to white Americans.

Why is that? One major issue is a lack of early detection through screening. Despite evidence that screening in high-risk populations reduces mortality by up to 20%, uptake has been low, with only about 6% of eligible patients having been screened for lung cancer. Black Americans with lung cancer are 15% less likely to be diagnosed early compared to white individuals in America, demonstrating a harmful disparity in early screening.

Over 60% of the 27.5 million non-elderly uninsured Americans are people of color, illustrating an issue in access to preventive care and early detection. But beyond access, many cultural, social and economic roadblocks prevent people of color from being screened for lung cancer as frequently as their white counterparts. This includes everything from historical distrust of the medical system to multigenerational living and caregiving responsibilities that make it challenging to attend in-person appointments.

“It’s not just an insurance issue, we realized. A lot of it has to do with trust,” said Susan Garwood, MD, National Physician Director of Pulmonary Disease at HCA Healthcare.

Dr. Garwood is helping lead HCA Healthcare’s new pilot program to increase lung cancer screenings among non-white populations. The program, which had an alpha pilot phase at TriStar Centennial Medical Center in Nashville, Tennessee, and has recently expanded to a beta pilot phase in Richmond, Virginia, is designed to help overcome some of the trust barriers that keep people from getting screened.

Identifying eligible patients

One of the first roadblocks is a need for more understanding about eligibility. Many patients aren’t aware of the screening guidelines, which the American Cancer Society updated earlier this month. These updated guidelines mean that more people than ever are eligible for screening and may not know it.

“The people who are at most at-risk for lung cancer are smokers or former smokers, and that education is key,” said Regina Bowe, MD, a physician at The Frist Clinic in HCA Healthcare’s TriStar Division. “If you don’t know that screening is available, it’s not something you will bring up with your providers. It’s not like mammograms and colonoscopies and Pap smears, which get talked about regularly as part of your preventative health care.”

The pilot program is designed to reach eligible patients and expand early testing by leveraging technology to identify potential candidates. Care navigators then flag appropriate patients for follow-up calls to determine if they meet the screening requirements, which helps proactively identify people who should consider being screened.

“When we think about lung cancer screening, we’re usually waiting for physicians to push those patients to a screening,” explained Dr. Garwood. “Instead of that, this program is trying to pull the patients, to meet the patient where they are and to take some of the burden off the primary care physician.”

This is critical since physicians often focus on treating patients for what they came in for. They need more time to look through records for other issues proactively in order to follow up with all potentially eligible patients. That’s why Dr. Bowe chose to be part of the program.

“I felt that I would reach more people if it were not just me making that phone call,” she explained. “There is a group of people directly charged with finding my patients who are at risk,  who I may miss because of the many other ways I’m working to treat them.”

Increasing the number of eligible people who should be screened could have a significant impact. Currently, 14.2 million Americans are eligible for lung cancer screening. Based on HCA Healthcare’s market size, roughly 750,000 patients who pass through its facilities are eligible. Identifying and increasing the number of screenings for those patients can make a huge difference, especially among underserved communities.

Reaching out and building trust

Once potentially eligible patients are identified, the next step is outreach. For many people who are distrustful of the healthcare system, it can be off-putting to have someone other than their physician contact them about their health. The program’s care navigators are trained to handle those conversations and overcome those roadblocks.

“The key to success is a medical record trigger, which identifies potentially eligible patients who are then brought to the attention of care navigators,” said Dr. Garwood. “The care navigators work to overcome barriers to screening, including the trust issue.”

Navigators and providers in the pilot program are trained to more easily overcome barriers using a “HealthCaring Conversations” toolkit, a behavioral-health informed communication framework developed in conjunction with behavior scientists at Johnson & Johnson Health and Wellness Solutions.

“When they were coming up with the questionnaires and which patients to reach out to, it was important that our questions would be appropriate from a cultural and social standpoint,” explained Dr. Bowe. “We wanted to remove some of the fear that comes along with testing, as it pertains to people being targeted because of their race, socioeconomic status or ethnicity.”

The human aspect is critical, as the care navigator can inform patients that they are eligible and alert their physicians, helping ensure eligible patients are flagged for screening at their next appointments.

“The key is our care coordinators being able to have that conversation with patients and then promptly connecting them with an advanced practice provider,” says Dr. Garwood.

Dedicated focus and follow-up

The other major role of care navigators, beyond building initial trust, is their ongoing support in helping each patient navigate roadblocks to care. By asking the right questions, the care navigator can help identify potential problems, such as payment, transportation or language barriers, and connect patients and their families to resources that can help.

“Much of it has to do with who you’re engaging within the family,” said Dr. Garwood. “For example, women tend to direct healthcare decision-making, so engaging with the wife or having a grandmother present can be key. We’re learning more about where our barriers and opportunities may be, and that’s the beauty of this pilot project.”

The care navigator also ensures that patients attend follow-up appointments, which is critical to improving survival rates. Data indicates that around 70% of people with incidental findings or abnormal screens don’t get the necessary follow-up at two years, and care navigators dedicate time for follow-up conversations to ensure adherence.

“If we think about what we would share that we’re doing that’s going well and what other health systems could learn from, I think that the care coordinators are essential,” says Dr. Garwood. “This is not a problem that a piece of equipment or technology will change. You still need a human element for success and connectivity. It’s important to have that critical piece, that investment in care coordinators and navigators.”

Next steps

Over the past 18 months, the lung health program has helped increase the percentage of all populations, including people of color, who are screened for lung cancer at HCA Healthcare facilities in the Nashville and Richmond areas.

HCA Healthcare is looking to scale the program to reach even more communities. “I am excited about the ways we can expand the program beyond HCA Healthcare’s walls in partnership with nonprofit and other organizations, and to share what other healthcare systems can do to help improve health equity and reduce lung cancer deaths across the country,” said Dr. Garwood.