It was a bewildering moment for Zach Jump, the American Lung Assn.’s national director of epidemiology and statistics. The numbers leaped off the computer screen and prompted an immediate question:
How could California, a leader in reducing lung cancer cases, fall so short on early diagnosis and treatment of the disease?
“It’s like you’d found the needle in the haystack of results,” Jump said. “I don’t know if anyone knew this was going to show up.”
It was right there in the association’s annual State of Lung Cancer report, published in November: California had the third-lowest rate of new lung cancer cases in the country, a laudable achievement. But among residents diagnosed with the disease, nearly a quarter received no treatment — a dismal showing that landed the state near the bottom of the heap. Worse, California screened high-risk patients at a lower rate than every state but Nevada.
Nationally, the report showed a dramatic increase in the five-year survival rate of people with the disease. That finding was reinforced by an American Cancer Society report released last month showing that a decline in lung cancer deaths from 2016 to 2017 fueled the country’s largest single-year drop in cancer mortality ever reported.
California’s low rate of new lung cancer cases makes sense given its aggressive anti-tobacco laws and high taxes on tobacco products. Between 85% and 90% of people who die of lung cancer in the U.S. were smokers, and “California is the poster child for tobacco control,” Jump said.
But what explains the state’s dramatically weaker performance on early diagnosis and treatment?
The answer is complicated in a state as large as California, but lung cancer experts agree on the influence of several factors: the state’s large income inequality, broad cultural and linguistic diversity, geographic inconsistency of health care access, and a reluctance by many medical professionals to treat poor people, who smoke at higher rates than those of the general population.
“People aren’t getting screened in the places where the incidence of smoking is the highest,” said Dr. Jorge Nieva, an oncologist at USC’s Keck School of Medicine.
A low-dose CT scan, the only recommended screening exam for lung cancer, is highly effective, research shows. In one large clinical trial, it reduced lung cancer deaths by 20% among people deemed to be at high risk based on their age and smoking history.
The lung association study shows that just 4.2% of patients in the United States who are at high risk for lung cancer get screened for it — a figure seen as alarmingly low by those who work in the area of prevention. But California’s screening rate is far worse: just 0.9%.
Performing the exam can be profitable if insurance payments are high enough. Medi-Cal, the government-funded insurance program for low-income people that covers about a third of all Californians, has long paid rates far below the national average.
Not surprisingly, scans are performed much more commonly in areas where people are likely to have good private insurance. “Unfortunately, it’s the population that doesn’t have great insurance that needs the screening the most,” Nieva said.
Medical experts say the state’s low screening numbers help explain why 24% of California’s lung cancer patients receive no treatment at all after they are diagnosed. Without adequate screening, lung cancer generally is discovered at later stages, when treatment is far less effective and many clinical trials aren’t offered.
Other factors weigh heavily on California’s ability to boost screening and treatment, according to people with deep experience in the field. Among them:
Cultural barriers. Especially when communicating with immigrant groups, “we need culturally sensitive approaches that include materials, educational tools, awareness campaigns and doctors who can speak to people in their native languages,” said Laurie Fenton Ambrose, president and chief executive of the GO2 Foundation for Lung Cancer, a patient advocacy group.
Homelessness. As California’s unhoused population has swelled to more than 150,000, health care providers have more difficulty reaching those in need of services. “Many of the 60,000 homeless in L.A. County would very likely be considered at risk for lung cancer, and they are not being screened,” said Dr. Steven Dubinett, a pulmonologist at UCLA.
Access to primary care. “California has some uniqueness in how hard it is to see a doctor in lots of parts of the state,” Nieva said. “That’s incredibly important when it comes to getting things early on, like that persistent cough you’ve had for a few months.”
Lack of statewide coordination. The state’s Comprehensive Cancer Control Plan hasn’t been updated in almost a decade. “It is inefficient and slow to improve,” Fenton Ambrose said. “You don’t even have a plan that lays out its goals for fighting lung cancer.”
Numerous personal factors can also influence whether patients get screening and treatment, experts say. Some people may be reluctant to be tested for fear of learning they have a terrible disease — including medical problems unrelated to lung cancer that the exam might uncover.
In addition, the stigma attached to lung cancer because of its link with smoking can contribute to a sense of fatalism in patients and their doctors.
Dubinett favors rolling out screening programs throughout the state, especially in areas where health care access is spotty. Given the effectiveness of the exams and follow-up treatment if lung cancer is detected early, the state might well improve its five-year survival rate for lung cancer patients, which stands at 21.5%. (The national average is 21.7%, according to the lung association.)
Such an initiative may fall to the state, with help from academic medical systems.
Nieva noted that USC has begun an outreach program in South Los Angeles offering high-risk patients free rides to Keck Hospital for screening.
“This should be getting done everywhere, and at a 100% rate,” he said. The fact that it’s not is “a real indictment of our health care system.”