Ashley Gallagher

Adherence to follow-up screening in patients with lung cancer was found to be low, showing that many do not follow the American College of Radiology (ACR) Lung CT Screening Reporting and Data System (Lung-RADS) recommendations.

, also showed that the association of extending the follow-up time of screen-detected nodules with outcomes for individuals who are Black, male, or smokers remains unknown.

The study included individuals who had lung cancer screening examinations between January 1, 2015, and July 31, 2020, with a follow-up through July 31, 2021, from 5 academic and community lung cancer screening sites in North Carolina. Investigators led by M. Patricia Rivera, MD of Rochester University Medical Center in Rochester, New York collected data from the North Carolina Lung Screening Registry, which is a National Cancer Institute-funded registry that prospectively collects data on individuals who undergo lung cancer screening at participating locations in the state.

The registry has data on individual risk factor and sociodemographic information, screening exam and follow-up information, and outcome data from data exports, electronic health records, radiology reports, and state cancer registry data.

There were 685 adults with a positive screening exam, Lung-RADS, in categories 3, 4A, 4B, and 4X. Study participants were required to have at least 1 year of follow-up after their low-dose computed tomography examination.

Rivera et al performed the statistical analysis between December 2020 and March 2022.

Among the 685 individuals, 60.7% were aged at least 65 years or older, 18% were Black, 51.5% were male, and 82% were White.

Overall adherence to the recommend follow-up was 42.5% but varied by Lung-RADS category. The follow-up was 30% for Lung-RADS 3, 49.5% for Lung-RADS 4A, 68% for Lung-RADS 4B or 4X. When the follow-up time was extended, the adherence increased to 68.6% within 9 months, 77.3% within 5 months, and 80.5% within 62 days, respectively.

For Lung-RADS 3, the recommended follow-up was less likely for those who are smokers compared with those who had quit. Additionally, in Lung-RADS 4A, individuals who were Black were less likely to adhere to the recommended follow-up compared with white individuals.

For Lung-RADS 4B or 4X, individuals who were female were more likely to adhere to the follow-up compared with individuals who were male. Furthermore, individuals who are smokers were less likely to follow up for these categories than those who quit smoking.

Some limitations of the study included it being conducted in just 1 geographic area.

Additionally, individuals may have received follow-up care outside the locations where they were screened, which would not be evident in these data, according to Rivera et al.

The investigators also added that the impact of delays in follow-up care is not well-known, so it is unclear what the impact of increased follow-up would cause for individuals.

“Strategies to improve follow-up after a positive screening examination should focus on improving adherence to ACR-recommended follow-up for Lung-RADS 3 and 4A nodules with special attention on Black individuals, men, and those currently smoking to obtain timely follow-up. In addition, because there is no clear recommendation for the appropriate time to follow-up of Lung-RADS 4B and 4X nodules, consensus is needed on the appropriate follow-up timeline for these high-risk nodules. This is crucial given data from other studies suggesting delays in early-stage lung cancer care are associated with worse survival,” wrote Rivera et al.

Rivera MP, Durham DD, Long JM, et al. Receipt of recommended follow-up care after a positive lung cancer screening examination. 

. 2022;5(11):e2240403. doi:10.1001/jamanetworkopen.2022.40403

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According to a prospective study of lung cancer screening examinations conducted over a 5-year period, there is low adherence to guidelines recommending follow-up radiologic imaging or diagnostic procedures in patient with lung cancer.

Low Receipt of ACR-Recommended Follow-Care Discovered Among Patients With Lung Cancer

Patient overall survival (OS) estimates for advanced non–small cell lung cancer (NSCLC) from US-based clinical practices could validate decision making for physicians in Canada, according to the results of a study published in 

The results showed that, under specific circumstances and criteria, OS estimated from clinical practices in the United States can be adjusted, using baseline clinical characteristics, to approximate OS in selected populations of patients in Canada who have advanced NSCLC.

Investigators used transportability analysis to assess if the adjustment for pretreatment characteristics of eligible patient cohorts could approximate OS from patients in the United States to those in Canada. They found data on 17,432 individuals who were diagnosed with advanced NSCLC on or after January 1, 2011, who were followed up with until September 30, 2020.

Ethnicity and race were available in the United States database but not in the Canadian database, so these characteristics were not analyzed.

Among the 17,432 individuals, 15,669 were from the United States and 1763 were from Canada. Of those, 11,863 were included in the subset of individuals with complete data for baseline covariates.

Investigators reported that 13,532 individuals from the United States received first-line chemotherapy and 2137 received first-line pembrolizumab monotherapy. Approximately 62.4% of individuals in the chemotherapy group and 77.3% in the pembrolizumab group had complete data on baseline covariates for the outcome estimations.

Additionally, 1476 individuals from Canada received first-line chemotherapy, and 287 received first-line pembrolizumab monotherapy and were identified from the target population.

Investigators used standardization to baseline patient covariates in the Canadian cohorts. They found that with the OS estimates there was less than a 5% mean absolutely difference from the observed OS in the target population, with 0.56% over 60 months of follow-up for the first-line chemotherapy group and 4.54% over 30 months of follow up in the first-line pembrolizumab group.

The negative control analysis, which used a mismatched outcome model, showed a 6.64% discrepancy and an incompatible survival curve shape, according to investigators.

The results showed robust assumptions of random missingness for baseline covariates, as well as unadjusted differences in baseline comorbidities and metastases. Additionally, the results showed differences in the standard of care between individuals in Canada and the United States, which were related to administration of second-line anti-programmed cell death 1 ligand 1 immunotherapy for individuals who had first-line chemotherapy.

Investigators reported that the study had limitations, which included that model misspecification could be a bias for parametric outcome models. Additionally, the analyses were conducted among a selected group of individuals, so the results might not be generalizable to individuals with recurrent disease or other disease sites, drug indications, or geographic regions.

Other unmeasured factors, such as PF-L1 expression for the first-line pembrolizumab cohort, could not be ruled out, investigators said.

Ramagopalan SV, Popat S, Gupta A, et al. Transportability of overall survival estimates from US to Canadian patients with advanced non–small cell lung cancer with implications for regulatory and health technology assessment. 

. 2022;5(11):e2239874. doi:10.1001/jamanetworkopen.2022.39874

Data from patients with non–small cell lung cancer in the United States are adjustable to approximate overall survival in selected populations of Canadian patients

Ashley Gallagher | Authors

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Low Receipt of ACR-Recommended Follow-Care Discovered Among Patients With Lung Cancer

NSCLC Patients Survival Estimate Appear Transferable from US and Canada