Social Determinants In Lung Cancer Screening Compliance

Study uses questionnaire to identify patients’ unmet social needs


According to the American Cancer Society, more than 234,000 new cases of lung cancer are diagnosed each year in the U.S. Lung cancer is one of the leading causes of cancer-related deaths, claiming more than 154,000 lives annually.

“Prognosis is often poor, but early detection can lead to better outcomes,” said Donghoon Shin, MD, a radiology resident at Boston University. Dr. Shin and colleagues found that social determinants of health (SDH), including housing insecurity and insurance type, affect lung cancer screening utilization.

Lung cancer screening with low-dose CT is recommended by the United States Preventative Services Task Force for adults aged 50 to 80 with at least a 20 pack-year smoking history who currently smoke or have quit within the past 15 years. Of the 1,200 lung cancer screening CT appointments scheduled at Boston Medical Center (BMC) annually between 2015 and 2018, a third were canceled or missed.

“Studies have shown that missed care opportunities are associated with poor outcomes,” Dr. Shin said during an RSNA 2020 session.

The research team set out to determine if SDH factors were contributing to missed lung cancer screening CT appointments.

To measure the impact of SDH on the patient cohort, they used a screening tool developed at BMC called THRIVE. THRIVE is a simple questionnaire designed to help primary care clinicians understand and address patients’ unmet social needs in eight domains including housing, food, transportation, employment and education.

During the study period, 4,755 lung cancer screening CT appointments were scheduled for 2,801 patients. One third of these, 1,554, were canceled. A total of 1,147 patients, or 41% of the patient population, missed at least one CT screening appointment.

“Housing and insurance types were statistically and significantly associated with the odds of missing a CT screening appointment.”


Study Could Lead to Target Interventions

The patient population consisted of 1,728 male patients (61.7%). The race/ethnicity of the study cohort was 42.8% white, 36.1% Black and 14.2% Hispanic or Latino.

Insurance payors were 27% Medicare, 20.7% Medicaid and 21.7% private or other type of insurance.

Statistical analyses demonstrated that 90.4% of patients who were housing secure finalized their CT screening appointments compared to only 9.6% of the patients who were housing insecure.

Only 11% of patients who reported difficulty with transportation finalized their screening appointment, compared to 89% of patients without transportation difficulties.

A higher proportion of Medicare and privately insured patients were reflected in the group of patients able to finalize their appointments, compared to patients insured by Medicaid.

“Housing and insurance types were statistically and significantly associated with the odds of missing a CT screening appointment,” Dr. Shin said.

Additionally, the study results showed that transportation insecurity was associated with a 48% increase in the odds of missing a CT screening appointment.

Compared to patients with private insurance, the odds of missing a screening appointment were nearly six times higher for patients with Medicaid insurance. And compared to patients covered by Medicare, patients with Medicaid insurance were four times more likely to miss a screening appointment.

“We hope to apply this finding to target interventions to help improve health care utilization,” Dr. Shin said. “In the future, we plan to evaluate whether missed CT screening appointments led to clinically significant differences measured by Lung RADS score, pathology and survival.”

For More Information

View the RSNA 2020 session, “The Impact of Social Determinants of Health on Lung Cancer Screening Utilization,” at

See the RSNA News infographic on lung cancer screening. 

Read previous RSNA News articles on lung cancer screening: