Dr. Hina Khan on Closing the Gap: Lung Cancer Screening Disparities and the Fight for Equitable Low-Dose CT Access

Dr. Hina Khan on Closing the Gap: Lung Cancer Screening Disparities and the Fight for Equitable Low-Dose CT Access

Lung cancer remains the leading cause of cancer death, yet screening rates are alarmingly low. This expert perspective explores disparities in low-dose CT (LDCT) access and practical solutions to improve early detection and equity in care.

Introduction: A Crisis Hidden in Lung Cancer Screening

Lung cancer remains the leading cause of cancer-related mortality in the United States — and yet, despite more than a decade of evidence supporting low-dose CT (LDCT) screening, screening rates remain strikingly, even shockingly, low. While approximately 67% of eligible patients receive colorectal cancer screening, nearly 80% receive breast cancer screening, and 75% receive cervical cancer screening, lung cancer screening rates have historically lingered in the low single digits — around 3–4% — and have only recently edged up to an estimated 15–18% nationally. In some states, the numbers are even lower.

This gap is not simply a matter of awareness or logistics. It reflects deep, layered, and intersecting disparities — racial, socioeconomic, geographic, and systemic — that have persisted even as the science has advanced. Understanding why this gap exists, and what we can do about it, is one of the most pressing challenges in thoracic oncology today.

The Human Cost of Missed Screening Opportunities: A Case That Asks "What If?"

To understand the stakes, consider a patient I saw in clinic: a 62-year-old African American man with a 40 pack-year smoking history who had quit five years prior. He lived in a semi-rural area, carried Medicaid insurance, and did not have a primary care physician. He presented to the emergency room with six months of cough and weight loss. The workup confirmed Stage 4 non-small cell lung cancer.

It is a story many of us recognize. But this patient would have been eligible for lung cancer screening approximately 12 years earlier, under current U.S. Preventive Services Task Force (USPSTF) guidelines — which recommend annual LDCT for adults aged 50 to 80 with a 20 pack-year smoking history who currently smoke or have quit within the past 15 years. Annual screening could, hypothetically, have detected this cancer at an early, treatable stage.

Instead, he faced multiple compounding barriers: no primary care physician, limited insurance access, geographic isolation, and no awareness that lung cancer screening even existed. His case isn't an outlier. It is, tragically, a pattern.

The Evidence Base: Why Low-Dose CT Screening Works — and Why Access Matters

The case for lung cancer screening is robust. The National Lung Screening Trial (NLST), published in the New England Journal of Medicine in 2011, demonstrated that LDCT screening in high-risk individuals reduced lung cancer mortality by 20%. The NELSON trial, published nearly nine years later, showed a 26% mortality reduction in the high-risk population. These are significant, meaningful numbers.

The USPSTF formally recommended lung cancer screening in 2013, and CMS approved coverage in 2015. That is now more than a decade of policy support — and yet screening rates have failed to reflect it.

Part of the reason is structural. Lung cancer screening is not a simple one-step process. It requires a coordinated referral pathway involving primary care physicians, pulmonologists, radiologists, and sometimes oncologists. It requires standardized scan interpretation using structured reporting systems. It requires patient navigation to ensure individuals are not lost between steps — especially if a nodule is identified and follow-up is needed. Every added step is a potential point of failure for a patient already facing barriers.

Understanding the Barriers: System, Provider, and Patient Levels

The barriers to equitable lung cancer screening fall into three interconnected categories.

System-Level Challenges

System-level barriers include inadequate coordination infrastructure, the complexity of multidisciplinary referral pathways, and geographic limitations — particularly for patients in rural areas where screening-capable radiology centers may be hours away. Transportation, time off work, and financial costs compound these obstacles.

Provider Misconceptions

Physician-perceived barriers are significant and often underappreciated. A national survey found that approximately half of primary care physicians believed that some insurance plans still did not cover lung cancer screening or required prior authorization — a misperception rooted in inconsistent historical experiences. These perceived barriers translate into reduced referrals, even when coverage exists.

Patient-Level Barriers

Patient-level barriers include lack of awareness, smoking-related stigma, fatalism, and deep-seated mistrust of the healthcare system — particularly among minority and historically marginalized communities. In our own research, more than half of eligible patients in our community reported never having discussed lung cancer screening with their primary care provider (or did not recall doing so), and most were unaware that lung cancer screening existed at allor was covered by health insurance.

These aren't failures of individual patients. They are failures of a system that has not reached them.

A Community-Based Solution: Navigation, Awareness, and Local Champions

Recognizing these gaps, our team at Brown University launched a community-based navigator program in partnership with Blackstone Valley Community Health Center in Rhode Island, supported by a Robert A. Winn Excellence in Clinical Trials grant. The program focused on three core areas: provider and patient education and awareness, one-to-one patient navigation throughout the entire screening process, and community outreach with the development of local champions who could build trust within culturally specific communities.

We demonstrated a significant improvement lung cancer screening rates in our underserved population, with the integration of navigator in the process. While the numbersstill fall far short of where they should be, it represents a meaningful, demonstrable improvement.
Equally important was adherence. Among patients who completed their initial LDCT, we saw a tremendous improvement in adherence to follow-up screening with the support of the navigator — a metric that matters enormously, since annual screening is what makes the mortality benefit possible.

One notable finding: even within our already-underserved minority population, English-speaking patients were overrepresented among those who completed LDCT screening, and a higher proportion of patients who completed screening were white. This underscores that language barriers remain a meaningful obstacle even when translation services are available, and that cultural trust — not just linguistic access — must be actively addressed.

Clinical Implications and Practice Takeaways: How Providers Can Reduce Disparities

For clinicians seeking to reduce screening disparities in their own practice and community, several actionable strategies emerge from this work:
Identify your community's specific barriers. Disparities are not uniform. A rural community in South Dakota may benefit most from a mobile LDCT screening unit; an urban underserved population may need targeted awareness campaigns and dedicated navigators.

Leverage EMR-based tools. Automated identification of eligible patients and reminder systems within electronic health records can be highly effective for busy primary care providers managing extensive patient lists.

Invest in patient navigation. One-to-one navigator support — from referral through follow-up — demonstrably increases both uptake and adherence.

Build local champions. In communities with significant mistrust or cultural barriers, trusted community members who advocate for screening can be more effective than institutional messaging alone.

Correct provider misconceptions. Active education of primary care physicians around current insurance coverage and referral pathways is essential to closing the gap at the referral stage.

Consider risk-based screening models for higher-risk populations that may be underserved by current eligibility criteria alone.

What Patients Need to Know About Lung Cancer Screening

If you are between the ages of 50 and 80, have smoked at least 20 pack-years, and currently smoke or quit within the last 15 years, you may be eligible for a yearly lung cancer screening scan — a low-dose CT scan that is non-invasive, quick, and covered by most insurance plans including Medicare and Medicaid. This scan can find lung cancer early, when it is most treatable.

Many people who qualify for this screening have never been told about it. If you haven't spoken with your doctor about lung cancer screening, ask about it at your next visit. If you don't have a primary care doctor, a community health center in your area may be able to help connect you to screening resources. Early detection saves lives — and you deserve access to it.

Key Takeaways

• Lung cancer screening saves lives, with LDCT reducing lung cancer mortality by 20–26% in high-risk populations (NLST and NELSON trials), yet national screening rates remain at only 15–18%.
  
• Disparities in screening are multilayered, spanning race, ethnicity, socioeconomic status, geography, language, education level, and insurance type — and often intersect in compounding ways.
  
• Awareness gaps are profound: in one Rhode Island community, 46% of eligible patients were unaware that lung cancer screening existed, and 60% did not recall discussing it with their provider.
  
• Community-based navigation works: implementation of a dedicated patient navigator increased screening rates from under 3% to over 12% in an underserved population and improved follow-up adherence.
  
• Local, tailored strategies are essential: each community has a unique set of barriers, and effective interventions must be designed with those specific barriers — and community trust — in mind.
  

References and Resources

1. National Lung Screening Trial Research Team. (2011). Reduced lung-cancer mortality with low-dose computed tomographic screening. New England Journal of Medicine, 365(5), 395–409.
   
2. de Koning HJ, et al. (2020). Reduced lung-cancer mortality with volume CT screening in a randomized trial (NELSON). New England Journal of Medicine, 382(6), 503–513.
   
3. U.S. Preventive Services Task Force. (2021). Lung cancer screening: Recommendation statement. JAMA, 325(10), 962–970.
   
4. American Lung Association. (2023). State of Lung Cancer Report. Available at: lung.org
   
5. Centers for Medicare & Medicaid Services. Lung Cancer Screening Coverage Information. Available at: cms.gov
   
6. National Health Interview Survey (NHIS) / Behavioral Risk Factor Surveillance System (BRFSS), 2023 Data.
   

About the Author

Dr. Hina Khan completed her medical training in India before pursuing her residency and fellowship in New York City. She is currently a thoracic oncologist at Brown University, where she specializes in lung cancer and mesothelioma. Dr. Khan is the recipient of a Robert A. Winn Excellence in Clinical Trials Award for her work in expanding equitable lung cancer screening access across underserved and diverse populations.

Frequently Asked Questions About Lung Cancer Screening

Q1. Who is eligible for lung cancer screening?

Adults aged 50–80 with a 20 pack-year smoking history who currently smoke or quit within the past 15 years may qualify for annual LDCT screening.

Q2. What is a low-dose CT (LDCT) scan?

LDCT is a quick, non-invasive imaging test that uses low radiation to detect lung cancer early, when it is most treatable.

Q3. Why are lung cancer screening rates so low?

Barriers include lack of awareness, limited access to screening centers, provider misconceptions, and systemic healthcare inequities.

Q4. Does insurance cover lung cancer screening?

Yes, most insurance plans, including Medicare and Medicaid, cover LDCT screening for eligible individuals.

Q5. How can screening disparities be reduced?

Strategies include patient navigation programs, community outreach, provider education, and improved healthcare system coordination.