
==== Front
JTO Clin Res Rep
JTO Clin Res Rep
JTO Clinical and Research Reports
2666-3643
Elsevier

S2666-3643(24)00075-4
10.1016/j.jtocrr.2024.100705
100705
Brief Report
A Brief Report of Lung Cancer Screening Utilization Before, During, and in the Later Stages of the COVID-19 Pandemic in the United States
Poghosyan Hermine PhD, MPH, FAAN hermine.poghosyan@yale.edu
ab∗
Sarkar Sayantani PhD a
Richman Ilana MD, MHS bc
Pietrzak Robert H. PhD, MPH def
Carter-Bawa Lisa PhD, MPH, APRN, ANP-C, FAAN gh
Cooley Mary E. PhD, RN, FAAN i
a Yale School of Nursing, Yale University, New Haven, Connecticut
b Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
c Department of Medicine, Yale School of Medicine, New Haven, Connecticut
d U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, Connecticut
e Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
f Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut
g Cancer Prevention Precision Control Institute, Center for Discovery & Innovation at Hackensack Meridian Health, Nutley, New Jersey
h Department of Oncology, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University School of Medicine, Cancer Prevention & Control Program, Washington, District of Columbia
i Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, Massachusetts
∗ Corresponding author. Address for correspondence: Hermine Poghosyan, PhD, MPH, FAAN, Yale School of Nursing, 400 West Campus Drive, Orange, CT 06477. hermine.poghosyan@yale.edu
06 7 2024
9 2024
06 7 2024
5 9 1007053 4 2024
8 5 2024
3 7 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

Although COVID-19 has affected health care and screening utilization, its impact on lung cancer screening (LCS) uptake remains unclear. Our study investigated LCS utilization and associated predictors among adults eligible for LCS before (2019), during (2020–2021), and at a later stage (2022) of COVID-19.

Methods

We used cross-sectional, nationally representative, population-based data from the Behavioral Risk Factor Surveillance System over 4 consecutive years: 2019 (n = 4484; weighted n = 1,559,37), 2020 (n = 1239; weighted n = 200,301), 2021 (n = 1673; weighted n = 668,359), and 2022 (n = 20,804; weighted n = 9,458,907). The outcome was self-reported LCS uptake (0 = did not have LCS in the past 12 mo and 1 = underwent LCS in the past 12 mo). We conducted weighted statistics and multivariable logistic regression.

Results

Overall, of 11,886,704 million individuals eligible for LCS, 2,129,900 received LCS in 4 years (2019–2022). National rates of LCS among individuals eligible for screening were 16.3% (95% confidence interval [CI]:14.4–18.5), 19.4% (95% CI:15.3–24.3), 18.3% (95% CI:15.6–21.3), and 18.1% (95% CI:17.1–19.2) in 2019, 2020, 2021, and 2022, respectively. Respondents reporting lung disease and cancer (other than lung cancer) history were more likely to receive LCS across all 4 years. During the pandemic (2020), Hispanic (versus White), and rural (versus urban) residents had lower odds of LCS utilization. In 2022, men had increased odds of reporting LCS use relative to women. No sex differences in LCS use were observed in previous years.

Conclusions

Our findings indicate consistently low LCS utilization (<20%) over 4 years. Nationwide efforts to boost LCS awareness and utilization are essential for mitigating the lung cancer burden in the United States.

Keywords

Lung cancer screening
Lung cancer
LDCT screening
COVID-19
==== Body
pmcIntroduction

Lung cancer remains the leading cause of cancer-related death in the United States, with an estimated 125,070 deaths expected in 2024.1 Although lung cancer screening (LCS) with low-dose computed tomography scans reduces lung cancer mortality by at least 20%, it remains underused in the United States.2 The COVID-19 pandemic caused substantial disruption in cancer screening. For example, some studies revealed up to a 62% decrease in breast, cervical, prostate, and colorectal cancer screening during the COVID-19 pandemic, rebounding in the fall of 2021.3, 4, 5 Nevertheless, little is known about how COVID-19 affected the already low rates of LCS utilization in the United States. To address this gap, this study estimated the prevalence of LCS utilization and identified individual-level predictors associated with LCS use before (2019), during (2020 and 2021), and in the later stages (2022) of the COVID-19 pandemic among adults eligible for LCS in the United States.

Materials and Methods

We analyzed cross-sectional, nationally representative, population-based data from the Behavioral Risk Factor Surveillance System (BRFSS) for 2019 (n = 4484: 1.5 million U.S. adults), 2020 (n = 1239: 200,301), 2021 (n = 1673: 668,359), and 2022 (n = 20,804: 9.4 million).6 Participants eligible for LCS considered for this study were based on the U.S. Preventive Services Task Force (USPSTF) criteria.7 For 2019 and 2020, the eligibility criteria were defined based on the USPSTF initial (2013) criteria—adults aged 55 to 80 years old who currently smoke or quit within the past 15 years with at least 30 pack-years of smoking history. For 2021 and 2022, we used the USPSTF updated criteria (2021)—adults aged 50 to 80 years who currently smoke or quit within the past 15 years with at least 20 pack-years of smoking history. Using the National Cancer Institute’s definition of pack-year tobacco exposure history, we calculated smoking pack-year using the following formula: (age at which participants reported last smoking cigarettes regularly − the age at which participants started smoking cigarettes regularly) × (number of cigarettes participants smoked each day on average/20). Adults who had a smoking pack-year history of up to 30 years and up to 20 years were excluded from the 2019-to-2020 and 2021-to-2022 data, respectively. We also excluded participants with a history of lung cancer (Fig. 1 presents details about the sample sizes). The BRFSS data set collapsed participants aged 80 years and older; therefore, our study included participants aged 50 to 79 years.Figure 1 Flow chart displaying sample selection. BRFSS, Behavioral Risk Factor Surveillance System.

The primary outcome was the self-reported utilization of LCS in the past 12 months and was categorized into a binary variable with 1 = had a computed tomography or computerized axial tomography scan to check for lung cancer in the past 12 months and 0 = did not have computed tomography or computerized axial tomography scan to check for lung cancer in the past 12 months. Individual-level, self-reported covariates included age, sex, race and ethnicity, marital status, education, annual household income, employment, residency, health insurance, delayed medical care, tobacco use, general health status, and chronic health conditions (Table 1).Table 1 Sociodemographic, Behavioral, and Health Characteristics of Adults Eligible for LCS and LCS Utilization Rates, BRFSS 2019 to 2022

Characteristics	2019a	2020b	2021c	2022d	
Unweighted Sample	Weighted % (95% CI)	Unweighted Sample	Weighted %
(95% CI)	Unweighted Sample	Weighted %
(95% CI)	Unweighted Sample	Weighted %
(95% CI)	
n = 4484	n = 1,559,137	n = 1239	n = 200,301	n = 1673	n = 668,359	n = 20,804	n = 9,458,907	
Age (y)									
 55–64	2181	58.2 (55.4–60.9)	590	58.8 (53.5–64)	941	64 (60.3–67.5)	11,378	61.1 (59.8–62.4)	
 65–74	1887	35.5 (32.9–38.3)	539	34.3 (29.5–39.5)	611	28.5 (25.4–31.9)	7617	31.4 (30.2–32.6)	
 75–79	416	6.3 (5.2–7.6)	110	6.9 (5–9.4)	121	7.5 (5.6–10)	1809	7.5 (6.8–8.3)	
Sex									
 Female	1940	42.2 (39.5–45)	568	40.4 (35.1–46)	825	48.5 (44.7–52.4)	9926	44.5 (43.2–45.9)	
 Male	2544	57.8 (55–60.5)	671	59.6 (54.1–64.9)	848	51.5 (47.7–55.3)	10,878	55.5 (54.1–56.8)	
Race and ethnicity									
 American Indian/Alaskan Native, non-Hispanic	88	1.7 (1.1–2.6)	48	1.6 (0.9–2.9)	27	2.0 (1.4–3.0)	465	1.6 (1.4–2.0)	
 Black, non-Hispanic	116	5.7 (4.3–7. 5)	17	5.7 (3.2–9.8)	45	5.7 (3.9–8.2)	1047	8.1 (7.3–9.0)	
 Hispanic	47	0.7 (0.5–1.1)	17	3.0 (1.5–6.3)	40	4.1 (2.8–6.0)	614	5.8 (5.1–6.7))	
 White, non-Hispanic	4112	90.1 (88.2–91.8)	1120	86.7 (81.9–90.3)	1505	86.5 (83.5–88.9)	17,972	79.4 (78.1–80.6)	
 Othere	121	1.7 (1.1–2/6)	37	3.0 (1.5–6.0)	56	1.7 (1.2–2.5)	706	5.1 (4.4–6.0)	
Marital status									
 Never married	339	6.7 (5.6–8.3)	133	12.5 (9.2–16.8)	168	8.0 (6.2–10.0)	2028	9.8 (9–10.6)	
 Married	2076	52.7 (49.9–55.4)	585	54.7 (49.0–60.2)	816	54.1 (50.3–57.8)	9627	51.1 (49.8–52.4)	
 Divorced/separated	1378	27.7 (25.2–30.3)	355	24.0 (19.3–29.3)	467	24.9 (21.8–28.2)	6012	26.3 (25.2–27.4)	
 Widowed	691	12.9 (11.2–14.7)	166	8.8 (6.7–11.3)	222	13.0 (10.5–15.8)	3137	12.8 (12.1–13.7)	
Education									
 High school or less	2146	56.3 (53.6–59)	579	57.1 (51.7–62.3)	728	51.9 (48.1–55.7)	9189	51.3 (50–52.6)	
 Attended college	1484	32 (29.5–34.6)	396	29.5 (24.9–35.5)	538	34.8 (31.2–38.6)	7189	35 (33.8–36.3)	
 Graduated college	854	11.7 (10.4–13.1)	264	13.4 (10.5–17)	407	13.3 (11.3–15.5)	4426	13.7 (12.9–14.5)	
Income									
 ≤$35,000	2353	48.3 (45.6–51.1)	604	39.4 (34.5–44.6)	734	38.5 (34.9–42.3)	9316	43.5 (42.2–44.8)	
 $35,000 to <$75,000	1398	32.8 (30.1–35.5)	390	32 (26.8–37.7)	530	31.3 (27.9–35)	6523	29.7 (28.6–30.9)	
 $75,000+	733	18.9 (16. 8–21.2)	245	28.6 (23.5–34.3)	409	30.2 (26.6–33.9)	4965	26.8 (25.6–28)	
Employment									
 Not in a workforce	1063	27 (24.6–29.4)	260	22.6 (18.8–26.9)	424	28 (24.5–31.9)	4839	26 (24.9–27.2)	
 Employed	1398	34.5 (31.9–37.2)	393	37.3 (31.8–43.3)	618	38.5 (34.9–42.2)	7510	38.4 (37.1–39.7)	
 Retired	2023	38.5 (36–41.2)	586	40.1 (35–45.5)	631	33.5 (30–37.2)	8455	35.6 (34.4–36.9)	
Residency									
 Rural	1255	14.4 (12.7–16.2)	469	12.4 (10.9–13.9)	471	11.7 (9.9–13.8)	3636	10.5 (10–11.1)	
 Urban	3229	85.6 (83.8–87.3)	770	87.6 (86.1–89.1)	1202	88.3 (86.2–90.1)	17,168	89.5 (88.9–90.1)	
Health insurance									
 Yes	4217	93 (91.4–94.4)	1161	91.4 (87.8–94)	1615	96.5 (94.5–97.8)	19,817	94.5 (93.9–95.1)	
 No	267	7 (5.3–8.6)	78	8.6 (6–12.2)	58	3.5 (2.2–5.5)	987	5.5 (5–6.1)	
Delayed medical caref									
 Yes	504	13 (11.3–15)	109	10 (6.8–14.5)	118	7.7 (5.9–9.8)	2033	11.3 (10.4–12.2)	
 No	3980	87 (85–88.7)	1130	90 (85.5 –93.2)	1555	92.3 (90.2–94.1)	18,771	88.7 (87.8–89.7)	
General health status									
 Fair/poor	1776	41.7 (38.9–44.5)	370	30.5 (25.5–36)	499	28 (24.7–31.5)	7058	35.2 (33.9–36.5)	
 Good	1509	34.1 (31.4–4)	415	35 (30.2–40.3)	628	37.4 (33.8–41.1)	6241	29.1 (27.9–30.2)	
 Excellent/very good	1199	24.2 (22.1–26.6)	454	34.5 (29.2–40.3)	546	34.6 (31–38.4)	7505	35.7 (34.5–37)	
Lung diseaseg									
 Yes	1640	35.4 (32.8–38.1)	425	34.1 (29.2–39.4)	582	32.6 (29.1–36.4)	6844	31.9 (30.7–33.2)	
 No	2844	64.6 (61.9–67.2)	814	65.9 (60.6–70.9)	1091	67.4 (63.7–70.9)	13,960	68.1 (66.8–69.3)	
Asthma									
 Yes	690	14.5 (12.7–16.5)	169	13.3 (10–17.5)	277	12.1 (10.2–14.3)	3373	16.5 (15.5–17.6)	
 No	3794	85.5 (83.6–87.3)	1070	86.7 (82.6–90)	1396	87.9 (85.7–89.8)	17,431	83.5 (82.4–84.5)	
Cancer history									
 Yes	722	16.3 (14.4–18.4)	164	10 (7.6–14.3)	233	12.9 (10.6–15.8)	3345	15.7 (14.7–16.7)	
 No	3762	83.7 (81.6–85.6)	1075	90 (85.7–92.3)	1440	87.1 (84.2–89.5)	17,459	84.3 (83.2–85.3)	
Skin cancer history									
 Yes	580	12.8 (11.1–14. 8)	135	10.1 (7.1–14.2)	190	10.8 (8.8–13.2)	1898	9.1 (8.3–9.9)	
 No	3904	87.2 (85.2–88.9)	1104	89.9 (85.8–92.9)	1483	89.2 (86.8–91.2)	18,906	90.9 (90.1–91.7)	
Smoking status									
 Current	2186	51.7 (49–54.5)	614	49.8 (44.3–55.4)	881	57.3 (53.4–61.1)	12,717	60.8 (59.5–62.1)	
 Former	2298	48.3 (45.5–51)	625	50.2 (44.6–55.7)	792	42.7 (38.9–46.6)	8087	39.2 (37.9–40.5)	
LCS									
 Yes	794	16.3 (14.4–18.5)	212	19.4 (15.3–24.3)	323	18.3 (15.6–21.3)	3870	18.1 (17.1–19.2)	
 No	3690	83.7 (81.5– 85.6)	1027	80.6 (75.7–84.7)	1350	81.7 (78.7–84.4)	16,934	81.9 (80.8–82.9)	
Notes: 2019, 2020, and 2021 BRFSS data include LCS questions in their BRFSS optional module. All the states that we included in this study have completed the optional LCS module (Combined Land Line and Cell Phone data) in the years 2019, 2020, and 2021.

BRFSS, Behavioral Risk Factor Surveillance System; CI, confidence interval; LCS, lung cancer screening.

a 2019 data come from 16 U.S. states (Arizona, Idaho, Kentucky, Maine, Minnesota, Missouri, Montana, North Carolina, North Dakota, Pennsylvania, Rhode Island, South Carolina, Utah, Vermont, West Virginia, Wisconsin).

b 2020 data come from five U.S. states (Delaware, Maine, New Jersey, North Dakota, South Dakota).

c 2021 data come from four U.S. states (Maine, Michigan, New Jersey, Rhode Island).

d 2022 data come from all U.S. states. In 2022, LCS questions were included in the core questionnaire.

e Other race and ethnicity category includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic Multiracial, and non-Hispanic other race.

f Delayed medical care. Participants self-reported whether they delayed needed medical care in the past 12 months owing to cost.

g Lung disease included chronic obstructive pulmonary disease, emphysema, and chronic bronchitis.

Statistical Analysis

To generate population estimates, we used the recommended sampling weights procedures to account for the complex survey design used in BRFSS.6 We computed descriptive statistics, including unweighted frequencies and weighted percentages with their corresponding 95% confidence intervals (CI). To identify individual-level factors associated with LCS utilization, we conducted multivariable logistic regression models and reported adjusted OR with their corresponding 95% CI. Data were analyzed in STATA version 17 with a two-sided p value of <0.05 considered statistically significant. BRFSS data are publicly available and deidentified; thus, no institutional review board approval was needed.

Results

Of the 11,886,704 individuals eligible for LCS, 2,129,900 received LCS in 2019 to 2022. National rates of LCS among individuals eligible for screening were 16.3% (95% CI: 14.4–18.5), 19.4% (95% CI: 15.3–24.3), 18.3% (95% CI: 15.6–21.3), and 18.1% (95% CI: 17.1–19.2) during the 2019-to-2022 period, respectively (Table 1). Logistic regression analysis suggested that adults with a cancer history "and" or "or" lung diseases had higher odds of receiving LCS than did adults without these conditions in all years. In 2022, men had 21% increased odds (95% CI:1.04–1.41) of reporting LCS in the past year relative to women. No sex differences in LCS use were observed in previous years. Before (2019) and during the late phase (2022) of the pandemic, individuals with health insurance had higher odds of reporting past-year LCS use (OR2019 = 3.91, 95% CI: 1.58–9.70; OR2022 = 2.80, 95% CI: 1.75–4.47) but not during the pandemic (2020 and 2021). During the pandemic (2020), Hispanic individuals had lower odds of receiving LCS than did White individuals (OR2020 = 0.06, 95% CI: 0.01–0.64).

Participants reporting delayed medical care due to cost in the past year were less likely to undergo LCS in 2019 and 2022, but no statistically significant differences were observed in 2020 and 2021. During the pandemic (2020), adults eligible for screening who lived in urban areas were more likely to report LCS use than were those living in rural areas (Table 2).Table 2 Regression Models Showing Sociodemographic, Behavioral, and Health Correlates of LCS Utilization, BRFSS 2019 to 2022

Characteristics	2019a	2020b	2021c	2022d	
OR (95% CI)	p Value	OR (95% CI)	p Value	OR (95% CI)	p Value	OR (95% CI)	p Value	
Age (y)									
 55–64	Reference		Reference		Reference		Reference		
 65–74	1.18 (0.81–1.70)	0.392	1.08 (0.52–2.27)	0.832	2.42 (1.51–3.89)	<0.001	1.50 (1.24–1.83)	<0.001	
 75–79	0.64 (0.31–1.32)	0.230	0.98 (0.33–2.89)	0.966	0.82 (0.38–1.78)	0.621	1.51 (1.13–2.02)	0.006	
Sex									
 Female	Reference		Reference		Reference		Reference		
 Male	1.07 (0.79–1.47)	0.650	1.23 (0.74–2.07)	0.425	1.16 (0.76–1.76)	0.488	1.21 (1.04–1.40)	0.013	
Race and ethnicity									
 Non-Hispanic White	Reference		Reference		Reference		Reference		
 American Indian/Alaskan Native, non-Hispanic	0.92 (0.39–2.15)	0.843	0.63 (0.20–1.97)	0.424	12.37 (4.39–34.88)	<0.001	0.60 (0.34–1.04)	0.069	
 Black, non-Hispanic	1.31 (0.59–2.91)	0.514	1.01 (0.22–4.55)	0.991	0.46 (0.16–1.37)	0.162	1.11 (0.84–1.45)	0.463	
 Hispanic	1.22 (0.40–3.71)	0.727	0.06 (0.01–0.64)	0.020	0.92 (0.27–3.15)	0.896	1.28 (0.83–1.98)	0.264	
 Other	0.44 (0.12–1.54)	0.199	0.19 (0.04–0.98)	0.048	1.88 (0.72–4.89)	0.195	0.85 (0.44–1.65)	0.635	
Marital status									
 Never married	Reference		Reference		Reference		Reference		
 Married	1.57 (0.81–3.06)	0.185	1.67 (0.67–4.15)	0.272	0.74 (0.37–1.49)	0.397	1.01 (0.77–1.34)	0.932	
 Divorced/separated	1.42 (0.73–2.75)	0.299	1.19 (0.46–3.05)	0.722	0.56 (0.26–1.20)	0.133	0.92 (0.69–1.21)	0.540	
 Widowed	1.41 (0.68–2.92)	0.350	0.50 (0.17–1.50)	0.214	1.02 (0.46–2.24)	0.969	0.76 (0.56–1.03)	0.080	
Education									
 High school or less	Reference		Reference		Reference		Reference		
 Attended college	1.17 (0.84–1.64)	0.361	0.51 (0.29–0.89)	0.019	1.42 (0.89–2.25)	0.140	1.02 (0.87–1.20)	0.781	
 Graduated college	1.08 (0.73–1.59)	0.700	0.50 (0.22–1.13)	0.096	1.31 (0.75–2.27)	0.345	1.07 (0.86–1.33)	0.562	
Income									
 ≤$35,000	Reference		Reference		Reference		Reference		
 $35,000–<$75,000	1.04 (0.71–1.54)	0.834	1.55 (0.83–2.88)	0.169	0.90 (0.53–1.53)	0.690	1.07 (0.91–1.26)	0.411	
 $75,000+	0.81 (0.49–1.32)	0.395	1.19 (0.53–2.65)	0.674	0.89 (0.47–1.67)	0.715	1.08 (0.85–1.38)	0.515	
Employment									
 Not in a workforce	Reference		Reference		Reference		Reference		
 Employed	0.75 (0.47–1.22)	0.250	0.21 (0.10–0.47)	<0.001	0.87 (0.49–1.52)	0.614	0.75 (0.59–0.95)	0.017	
 Retired	1.04 (0.67–1.61)	0.857	0.63 (0.27–1.48)	0.289	0.62 (0.34–1.12)	0.112	1.06 (0.85–1.31)	0.602	
Residency									
 Rural	Reference		Reference		Reference		Reference		
 Urban	0.94 (0.64–1.36)	0.720	2.17 (1.27–3.73)	0.005	1.17 (0.70–1.97)	0.548	1.11 (0.91–1.34)	0.304	
Health insurance									
 No	Reference		Reference		Reference		Reference		
 Yes	3.91 (1.58–9.70)	0.003	2.60 (0.80–8.45)	0.111	2.92 (0.55–15.68)	0.210	2.80 (1.75–4.47)	<0.001	
Delayed medical care									
 No	Reference		Reference		Reference		Reference		
 Yes	0.55 (0.34–0.90)	0.017	0.50 (0.16–1.57)	0.235	1.09 (0.44–2.71)	0.856	0.47 (0.37–0.62)	<0.001	
General health status									
 Fair/poor	Reference		Reference		Reference		Reference		
 Very good/excellent	0.95 (0.62–1.45)	0.818	0.69 (0.33–1.44)	0.321	0.91 (0.50–1.66)	0.751	1.04 (0.88–1.23)	0.646	
 Good	1.00 (0.69–1.45)	0.995	0.90 (0.47–1.72)	0.751	0.69 (0.41–1.17)	0.173	0.86 (0.70–1.05)	0.127	
Lung disease									
 No	Reference		Reference		Reference		Reference		
 Yes	2.50 (1.79–3.52)	<0.001	2.59 (1.43–4.71)	0.002	2.11 (1.34–3.32)	0.001	3.16 (2.70–3.69)	<0.001	
Asthma									
 No	Reference		Reference		Reference		Reference		
 Yes	0.86 (0.56–1.33)	0.498	0.77 (0.39–1.52)	0.445	1.02 (0.59–1.78)	0.945	0.83 (0.68–1.02)	0.074	
Cancer history									
 No	Reference		Reference		Reference		Reference		
 Yes	2.40 (1.68–3.42)	<0.001	2.20 (1.16–4.20)	0.016	1.81 (1.07–3.08)	0.028	1.75 (1.47–2.08)	<0.001	
Skin cancer history									
 No	Reference		Reference		Reference		Reference		
 Yes	1.01 (0.66–1.54)	0.961	1.35 (0.66–2.78)	0.416	1.45 (0.83–2.55)	0.193	1.31 (1.04–1.66)	0.024	
Smoking status									
 Former	Reference		Reference		Reference		Reference		
 Current	0.94 (0.70–1.27)	0.703	0.84 (0.49–1.44)	0.525	0.67 (0.45–1.01)	0.058	0.97 (0.83–1.13)	0.668	
Notes: 2019, 2020, and 2021 BRFSS data include LCS questions in their BRFSS optional module. In 2022, LCS questions were included in the core questionnaire. All the states that we included in this study completed the optional LCS module (Combined Land Line and Cell Phone data) in the years 2019, 2020, and 2021.

BRFSS, Behavioral Risk Factor Surveillance System; CI, confidence interval; LCS, lung cancer screening.

a 2019 data come from 16 U.S. states (Arizona, Idaho, Kentucky, Maine, Minnesota, Missouri, Montana, North Carolina, North Dakota, Pennsylvania, Rhode Island, South Carolina, Utah, Vermont, West Virginia, Wisconsin).

b 2020 data come from five U.S. states (Delaware, Maine, New Jersey, North Dakota, South Dakota).

c 2021 data come from four U.S. states (Maine, Michigan, New Jersey, Rhode Island).

d 2022 data come from all U.S. states.

Discussion

Our study findings suggest that LCS utilization among U.S. adults remained surprisingly stable before, during, and in the later phases of the COVID-19 pandemic. Prior work has found that LCS rates decreased during the first few months of the pandemic, starting in March 2020, and rebounded in the fall of 2020.4,5 Nevertheless, it is difficult to compare our study findings with those findings because we evaluated LCS utilization yearly, not monthly. We found that the LCS rate ranged from 16.3% to 19.4% among adults eligible for screening, which is much higher than the LCS rate published recently by the American Lung Association, stating that only 4.5% of adults eligible for LCS underwent LCS in 2022.8 Earlier studies also revealed that only approximately 4% of eligible adults received LCS in 2015,9 but more recent data suggest that approximately 17% of adults eligible for screening received LCS.10 Still, LCS uptake is low, and many individuals eligible for screening did not receive this life-saving screening during the 2019-to-2022 period. In fact, our study findings estimated that 10,172,809 adults eligible for LCS at high risk for developing lung cancer did not receive LCS during the 2019-to-2022 period. Effective strategies and efforts should be focused on increasing LCS awareness and uptake across the U.S. to help mitigate the burden of lung cancer. Although previous research has indicated lower LCS utilization among current smokers, our study did not observe a statistically significant association between smoking status and LCS utilization.11 Hence, further investigation is warranted to explore the impact of smoking status on LCS uptake.

Consistent with prior research, our study findings revealed that adults with lung disease and cancer history were more likely to undergo LCS than were those without.10,12 Advani et al.12 analyzed 2017-to-2019 BRFSS data and found that adults eligible for LCS who self-reported having five or more comorbid conditions were more likely to be screened for lung cancer than were those without comorbid conditions. One explanation may be frequent health care visits by people with comorbid conditions may facilitate LCS discussion and utilization.

There were some variations in LCS utilization by sociodemographic factors. During the pandemic, our findings revealed that Hispanic individuals were less likely to undergo LCS than were non-Hispanic White individuals. Nevertheless, these findings must be interpreted with caution because the data set included a relatively small number of Hispanic individuals. Besides, racial and ethnic differences in LCS have been reported previously, showing that individuals from ethnoracial minorities are less likely to undergo LCS than are White individuals.10,13 Nevertheless, most prior work evaluating differences in LCS utilization has focused on Black and White individuals. Further research is needed with a large and diverse sample to better understand ethnoracial differences in LCS utilization. We also found sex differences in LCS utilization, with men being more likely than women to receive screening in 2022. Studies focused on sex differences in LCS have yielded mixed results, with some reporting similar findings and others reporting no sex differences.14,15 More research is needed to evaluate sex differences in LCS utilization. In line with previous research,10,13 our finding that individuals eligible for LCS without health insurance and those delaying medical care owing to cost were less likely to use LCS underlines the need to improve access to LCS programs.

Our findings have limitations that need to be acknowledged. Findings from the years 2019 to 2021 may not generalize to all adults eligible for LCS living in the U.S. because items for measuring LCS were included in the optional Lung Cancer Screening Module and not in the core questionnaire, and not every state completed the optional module. Given the data were cross-sectional, we could only report associations and not causal relationships. LCS use information was self-reported, which is subject to reporting bias. Moreover, BRFSS data were less racially and ethnically diverse than the overall U.S. population during these years, cautioning the interpretation of findings. Furthermore, a complete case analysis was conducted by eliminating missing values that may have affected results. Nevertheless, our adherence to the BRFSS weighting recommendation may reduce such risks.

Despite these limitations, the present study is strengthened by using large population-based nationally representative data of adults eligible for LCS to provide evidence on LCS over 4 years. Overall, LCS uptake remained low but stable during the 2019-to-2022 period. Effective strategies are needed to improve LCS uptake, particularly in vulnerable segments of the U.S. adult population. Moreover, initiatives focused on LCS awareness and more personalized aids for facilitating informed LCS decision-making are necessary to enhance LCS utilization, a critical step for reducing the lung cancer burden.

CRediT Authorship Contribution Statement

Hermine Poghosyan: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing—original draft preparation, Writing—reviewing and editing.

Sayantani Sarkar: Formal analysis, Writing—original draft preparation, Writing—reviewing and editing.

Ilana Richman: Writing—original draft preparation, Writing—reviewing and editing.

Robert H. Pietrzak: Writing—original draft preparation, Writing—reviewing and editing.

Lisa Carter-Bawa: Writing—original draft preparation, Writing—reviewing and editing.

Mary E. Cooley: Writing—original draft preparation, Writing—reviewing and editing.

Disclosure

The authors declare no conflict of interest.

Acknowledgments

This research received no specific grant from funding agencies in the public commercial or not-for-profit sectors. The authors thank Yosra Raziani, PhD student at Yale School of Nursing, for helping them with Table 1.

Cite this article as: Poghosyan H, Sarkar S, Richman I, et al. A brief report of lung cancer screening utilization before, during, and in the later stages of the COVID-19 pandemic in the United States. JTO Clin Res Rep. 2024;5:100705.
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