The Impact of Downstream Procedures on Lung Cancer Screening Adherence

Objective: (1) Evaluate downstream procedures after lung cancer screening (LCS), including imaging and invasive procedures, in screened individuals without screen-detected lung cancer. (2) Determine the association between repeat LCS and downstream proMethods: Individuals receiving LCS between January 1, 2015, and November 30, 2020, from Optum's deidentified Clinformatics Data Mart Database were included. Individuals with lung cancer after LCS were excluded. We determined frequency and costs of downstream procedures after LCS, including diagnostic imaging (chest CT, PET, or CT using fluorine-18-2-fluoro-2-deoxy-D-glucose imaging) and invasive procedures (bronchoscopy, needle biopsy, thoracic surgery). A generalized estimating equation was used to model repeat LCS as a function of downstream procedures and patient characteristics. The primary outcome was repeat screening within 1 year of index LCS, and a secondary analysis evaluated the outcome of repeat screening with 2 years of index LCS. Results: In all, 23,640 individuals receiving 30,521 LCS examinations were included in the primary analysis; 17.7% of LCS examinations (5,414 of 30,521) prompted downstream testing, with chest CT within 4 months being most common (9.1%, 2,769 of 30,521). At multivariable analysis adjusted for patient characteristics, the occurrence of a downstream diagnostic imaging test or invasive procedure was associated with a decreased likelihood of repeat annual LCS (adjusted odds ratio, 95% confidence interval: 0.38, 0.340.44; adjusted odds ratio, 95% confidence interval: 0.75, 0.63-0.90, respectively). Discussion: Downstream imaging and invasive procedures after LCS are potential barriers to LCS adherence. Efforts to reduce falsepositives at LCS and reduce patient costs from downstream procedures are likely necessary to ensure that downstream workup after LCS does not discourage screening adherence.