Lung Cancer Screening in Head and Neck Cancer: An Opportunity to Increase Screening in Eligible Candidatess.

Patients and Methods
Patients were identified and enrolled in this study at the University of California, Davis Otolaryngology Head and Neck Cancer Clinic. Inclusion criteria required patients to be at least 18 years old and willingness to participate. Exclusion criteria included those who did not submit completed surveys. The study was exempt from review by the University of California, Davis Institutional Review Board.
Anonymous surveys were used to collect patient characteristics, cancer history, and details regarding each patient’s experience with lung cancer screening (Supplemental Appendix 1). The anonymous survey was administered between May 2024 and August 2024. A medical student administered the surveys and was available to answer any questions regarding the survey. Collected variables included age, biological sex, and smoking history, including current vs prior tobacco use, years since quitting, and total pack-years. Patients were also queried on the type of head and neck cancer for which they were being evaluated. Lastly, patients were surveyed regarding their awareness of lung cancer screening candidacy and personal experience with it. The survey was developed and approved by our multidisciplinary team to ensure clarity and readability. The survey was administered to the patient by a member of the research team (N.H.) upon arrival to outpatient appointments at the head and neck clinic. After the surveys had been collected, descriptive analyses were performed to characterize candidacy for screening, its use, and its outcomes.

Results
A total of 202 patients from the head and neck clinic were surveyed and met inclusion criteria. The response rate was at least 55%. The median respondent age was 66 years (interquartile range, 15 years), and men comprised slightly over half (n = 115 [58.9%]) (Table). Within this cohort, 77 (38.0%) previously smoked, and 15 (7.4%) were currently smoking. Of the 92 who had ever smoked, 73 (79.3%) carried a diagnosis of head and neck cancer. Of the patients with cancers of the head and neck, 16% were currently smoking vs 15% of patients who did not carry diagnoses of head and neck cancers. Those who formerly smoked had quit an average of 20 years (2 weeks-57 years) before completing the survey. Two of the patients in the cohort responded to 1 of the questions on the survey “not sure” and “unknown.”
Among all respondents, 23 (11.4%) met criteria for lung cancer screening according to the 2021 United States Preventative Service Taskforce recommendations.9 Seven (30.4%) of these patients were previously offered lung cancer screening and subsequently completed it. Two of these patients (28.5%) were diagnosed with lung cancer. Alarmingly, 16 (69.6%) of the patients who met criteria for lung cancer screening were not offered it (Figure). At the time of the survey, 18 patients (8.9%) did not meet criteria for lung cancer screening but had undergone lung cancer screening in the past. In total, 25 (27.2%) of those who had ever smoked underwent lung cancer screening, and 5 of these 25 patients (20%) were diagnosed with lung cancer.

Comment
This study demonstrates the significant proportion of head and neck cancer patients eligible for lung cancer screening at a comprehensive cancer center (11.4%). Although the rate of nonsmoker cases of head and neck cancer has increased over time, thought to be secondary to human papillomavirus, smoking remains a major risk factor for head and neck cancer. Despite 11.4% of patients in our cohort meeting criteria for lung cancer screening, only a small proportion are actually being screened for lung cancer, highlighting underuse of screening in this high-risk population. Our results corroborate those of Diaz and colleagues,8 who evaluated the use of lung cancer screening in a similar population in the Southern United States. The main difference between these two cohorts is 100% of patients who presented at MD Anderson Head and Neck Cancer clinic had a diagnosis of head and neck cancer vs 79% in this cohort.
Despite its proven mortality benefit within high-risk populations, lung cancer screening remains vastly underused compared with screening methods. Efforts have been made for insurance coverage for these tests with the goal of increasing use. In 2015, the Centers for Medicare and Medicaid Services instituted a national coverage determination within Medicare for lung cancer screening. Under these preventative service benefits, high-risk patients who qualified for LDCT had no out of-pocket expenses.
Primary care providers play a critical role in cancer screening because they are tasked with identifying eligible patients and making the necessary referrals. However, primary care physicians face several key barriers, including insufficient visit time and numerous medical issues that need to be addressed. This issue further supports the need to identify high-yield groups that would benefit from targeted education, with the goals of both educating primary care physicians and decreasing the burden on primary care physicians to individually identify eligible patients. The present analysis suggests that patients with head and neck cancer represent a suitable population for these targeted initiatives.
According to the National Comprehensive Cancer Network guidelines, some but not all head and neck cancer patients are recommended to undergo positron emission tomography or computed tomography chest imaging for initial staging purposes. For example, T1 or 2 glottic cancer does not require chest imaging. The role of chest computed tomography or positron emission tomography scan for surveillance postoperatively in head and neck cancer is controversial, and there is no uniform consensus.
One of the important take-home points from this study is the need to educate head and neck surgeons on lung cancer screening guidelines so they are equipped to appropriately refer patients who qualify for lung screening if they will not require annual cross-sectional imaging that would include the lung fields. We have, importantly, also identified an additional specialty of providers who may aid in the identification of eligible patients outside of the primary care setting. Prior literature has demonstrated lack of provider knowledge to be an important barrier to lung cancer screening.10 Future endeavors should focus on whether these barriers can be mitigated by broadening education to subspecialists who see a high proportion of patients eligible for lung cancer screening.
Based on our findings, we propose targeted initiatives to increase education for both providers and patients within the head and neck clinic. The link between head and neck cancer and lung cancer has been well documented. We recognize that patients with head and neck cancer have significantly different expected survival benefits than the patients initially represented by the National Lung Screening Trial. The diminished survival benefit is important to acknowledge, particularly when considering the full range of downstream effects of screening initiatives. However, the United States Preventative Services Task Force recommendations do not exclude patients with other malignancies. Further research is needed to better understand the role that lung cancer screening can have on survivorship within the head and neck cancer population. The present analysis did not intend to elucidate these survival benefits, but rather identify an appropriate and representative target population for engagement.
We recognize the present analysis has several limitations. Our study is survey-based and relies on patient’s ability to recall and provide accurate smoking history, cancer history, and screening history. There are inherent limitations to survey studies. including variable interpretation. To mitigate this potential obstacle, one of the investigatory team was present with each respondent while the survey was completed. Additionally, we recognize that this study was performed at a single, tertiary care, cancer center, optimizing the homogeneity of the cohort, yet with the trade-off of limiting the generalizability of the study outside an academic system. We acknowledge that patients within our health system may have more access to care than most head and neck cancer clinics within the United States.
Our study identified a substantial proportion of patients with head and neck cancer who meet criteria for lung cancer screening. Additionally, it highlights the significant underuse of screening among these patients. The present analysis adds to the growing literature that supports this population to be a suitable target for education and use of lung cancer screening.8 Future endeavors should focus on bridging the gap between specialties to aid in optimizing use of lung cancer screening.