Editor’s Note: November is Lung Cancer Awareness Month, so we asked Neel Chudgar, M.D., assistant professor of cardiothoracic & vascular surgery at Albert Einstein College of Medicine, a cancer surgeon at Montefiore, and a member of the Montefiore Einstein Cancer Center, about recent advances in lung cancer prevention and his new grant to conduct research that addresses cancer health disparities.
Q: There have been significant changes in the prevention of lung cancer in recent years—most notably, CT [computed tomography] lung cancer screening. What do people need to know?
A: Yes, the major change in screening is the use of low-dose CT scans for people at high risk for lung cancer. It was first recommended by the United States Preventive Services Task Force in 2013, following publication of the landmark National Lung Screening Trial. CT scans can help find abnormal areas in the lungs that may be cancerous, and they were shown to lower the risk of dying from lung cancer by about 20%. If everyone in the United States who is eligible were screened, close to 48,000 lives could be saved a year.
Those eligible include people ages 50 to 80 who have a smoking history of at least 20 pack-years (number of packs smoked per day multiplied by number of years smoked), and who are either current smokers or who quit within the past 15 years. The guidelines were recently updated to expand the age range and reduce the pack-year smoking requirement in order to increase eligibility; this primarily affects women and minorities.
Q: Why is early detection so important?
A: Lung cancer screening is critical because it can find disease at an earlier stage, when it is more treatable. Currently, 57% of patients are diagnosed with cancer that has already spread, and the five-year survival rate is extraordinarily low—just 6%. In contrast, the five-year survival rate is 59% for early-stage lung cancer, but only 17% of patients are diagnosed at that stage. A key goal of lung cancer screening programs is to identify people earlier, in order to improve survival.
Q: If not through CT scan screening, how is lung cancer found early?
A: Each year, more than 1.5 million incidental pulmonary nodules are found when CT scans are performed for other reasons—such as when a patient has a chest injury or cardiac symptoms. Cancer rates for these lesions can approach 10%, which is higher than rates found through lung cancer screening programs. Many times, these scans are done in an emergency room when an individual comes in for an unrelated problem. As a result, patients may not be aware that they have a nodule, or they may receive inadequate instructions for follow-up; nationally only 38% of patients with incidental lung nodules receive appropriate care. The consequences are unfortunately clear, as these missed nodules may develop into cancer that is identified only at a later stage of the disease.
Q: Are Black and Hispanic patients affected by lung cancer the same way white patients are?
A: Racial disparities in lung cancer diagnosis, management, and outcomes are stark. Black and Hispanic patients are 16% and 13%, respectively, less likely to be diagnosed at an early stage than white Americans. Black men have the highest incidence of lung cancer compared with other racial groups, and Black patients suffer from the highest mortality rates. As a result, the Montefiore Einstein Cancer Center, which cares for a large population of diverse and socioeconomically disadvantaged patients, has a relatively low proportion of patients diagnosed with early-stage disease.
Data also suggest that racial and ethnic disparities exist in the follow-up of incidental lung nodules. In a study conducted at a different institution, of 1,562 patients with a nodule requiring follow-up, only 49.1% of Hispanic patients and 55.1% of Black patients were notified of the nodule, compared with 79.5% of white patients. Similarly, nonwhite patients had significantly lower rates of orders for and adherence to follow-up imaging, and were more likely to delay follow-up.
Q: What accounts for these differences?
A: A long history of structural racism is at the crux of the poorer outcomes experienced by patients of color, leading to disproportionate access to medical care and lower rates of screening. Studies have also shown that Black and Hispanic patients are less likely to receive surgical—or any other—treatment for lung cancer after they are diagnosed. Unfortunately, Black patients also appear to be differently affected by tobacco use; they develop cancers with a lesser smoking history, which prompted the recent changes in screening eligibility. And involvement of minorities in research is problematic. Of over 50,000 patients enrolled in the National Lung Screening Trial, for example, only 4.5% of the participants identified as Black and 1.7% identified as Hispanic.
Q: What is the Montefiore Einstein Cancer Center doing to address these disparities?
A: Our cancer center has created lung cancer screening initiatives to help address existing gaps in care. To kick off Lung Cancer Awareness Month, we are launching a lung nodule clinic staffed by thoracic surgeons and interventional pulmonologists. Working closely with support staff, we will improve care by reducing the time between imaging results and follow-up to keep patients from “falling through the cracks.” We understand that signing up for and completing screenings can be challenging for our patients, so we will have volunteer cancer survivors help patients through this process.
There is great momentum for and excitement about advances in lung cancer treatment, and our cancer center is at the forefront. Several ongoing clinical trials are available to patients; chemotherapy, immunotherapy, targeted treatment agents, and radiation are all offered and intensely studied. We also are leaders in surgical care, offering robotic-assisted surgery and high-quality postoperative care.
Q: You recently received a LUNGevity/Janssen R&D Health Equity and Inclusiveness Junior Investigator Award, which focuses on bridging health disparities in underrepresented communities and medically underserved populations. What will you be doing with this grant?
A: The LUNGevity Foundation has graciously funded a study at the Montefiore Einstein Cancer Center to capture and study incidental pulmonary nodules within the diverse population our institution serves and to address the disparities I mentioned. We will establish an incidental pulmonary nodule management program using a multipronged approach. First, we will incorporate software into our electronic medical records to automatically detect the notation of a lung nodule in radiology reports. The patients will be identified and integrated into the nodule follow-up clinic. Second, we will use artificial intelligence to develop a calculator to predict the risk of cancer of a nodule. Finally, we will evaluate a blood-based cancer biomarker to facilitate the detection of early-stage lung cancers. Our overall objective is to ensure that people with incidental nodules are identified and followed so we can reduce the chance of missing a case of lung cancer.
Q: Why did you choose to focus your research on underserved communities?
A: Patients in underrepresented communities have consistently had poorer outcomes in several areas of healthcare. During my surgical training, I cared for patients at a community hospital in Queens that predominantly served minority patients. Unfortunately, it was not uncommon to diagnose advanced cancer in patients who came to the emergency room with symptoms they could no longer ignore. While I have long had an interest in the surgical management of cancers, these more-visceral experiences shifted my clinical and research interests toward addressing disparities in cancer care. The LUNGevity/Janssen R&D Health Equity and Inclusiveness Junior Investigator Award provides the perfect opportunity to advocate for Montefiore-Einstein patients in need. I hope to institute lasting changes in the way we manage patients at risk for lung cancer so we can improve outcomes and survival in our community.