Guideline-Discordant Lung Cancer Screening: Emerging Demand and Provided Indications

Purpose: It is unclear whether patients and providers have started to knowingly request lung cancer screening (LCS) outside US guidelines and insurance coverage for risk factors besides a history of heavy smoking. The authors analyzed their institution's best practices advisory (BPA) clinical decision support system to determine whether providers knowingly order guideline-discordant LCS and the indications given.

Methods: CT examinations ordered for LCS at an academic medical center that triggered BPA alerts from November 2018 to December 2019 were reviewed. Alerts were triggered by attempts to order examinations outside Medicare coverage, which resembles most US guidelines. Providers can override alerts to order the examinations. Primary outcomes were the number of examinations performed using orders with overridden BPA alerts and indications given. Qualitative exploratory and directed content analyses identified motivators and decision-making processes that drove guideline-discordant screening use.

Results: Forty-two patients underwent guideline-discordant LCS, constituting 1.9% of all patients screened (42 of 2,248): 42.9% (18 of 42) were <54 or >77 years old, 14.3% (6 of 42) had never smoked, 40.5% (17 of 42) had quit >15 years earlier, and 31% (13 of 42) had smoked <30 pack-years; 45.2% (19 of 42) fell outside all US guidelines. The most common indication was a family history of lung cancer (21.4% [9 of 42]). Perceptions of elevated cancer risk from both patients and referring providers drove guideline-discordant screening use.

Conclusions: Referring providers knowingly ordered screening CT examinations outside Medicare coverage and US guidelines, including for never smokers, for indications including a family history of lung cancer. LCS programs may need tailored strategies to guide these patients and providers, such as help with cancer risk assessment.