Reply: Early Adherence to Lung Cancer Screening.

From the Authors:

We appreciate the letter from Dr. Zulueta and colleagues highlighting similarities between our recent findings on adherence to lung cancer screening (LCS) follow up and their previous study (1, 2). Both studies find that adherence to LCS is suboptimal. In their analysis of participants in a site of the I-ELCAP (International Early Lung Cancer Action Program) study between 2000 and 2003, they found that only 65% of participants returned for a directed second computed tomography scan within 18 months of their baseline computed tomography. In our study of a multicenter cohort of LCS participants in a clinical program between 2012 and 2017, we found only 47% of the cohort was adherent to follow-up recommendations.

We note some important differences in design that make directly comparing results challenging and may account for the lower adherence in our study. The cohort followed in Dr. Zulueta’s study was enrolled in a research study rather than undergoing guideline-recommended care. As participants in a research study, we would expect high rates of adherence in their study. Indeed, in the U.S. National Lung Screening Trial, adherence rates were greater than 90% (3).

The letter also draws attention to two important issues that are valuable comparisons. First, both studies find higher rates of adherence among those who have quit smoking than those who continue to smoke. As we point out in our article, this may reflect a fatalistic attitude on the part of ongoing smokers toward a cancer prevention intervention and is particularly concerning given these patients remain at the highest risk for incident lung cancers. This group may be particularly in need of ongoing interventions to encourage both smoking cessation and LCS follow up. Second, as mentioned in the letter by Dr. Zulueta and colleagues, his team found that a nursing intervention resulted in a threefold increase in adherence. Although this was in the context of a research study rather than clinical practice, it still highlights an important point with which we agree: an intensive patient-facing navigation intervention may be needed to improve longitudinal adherence to LCS. Both our current and future work is directed at building the components of such a successful navigation intervention to improve the efficacy of longitudinal screening in clinical practice.