Systemic Challenges to Lung Cancer Screening in the Safety-Net Setting: Care and Informatics Fragmentation.

Abstract

Despite being the leading cause of cancer death, <20% of eligible, at-risk Americans undergo lung cancer screening. Lung cancer risk is concentrated in lower-income populations, but Medicaid-insured populations consistently have the lowest screening rates across cancers. To improve lung cancer screening rates and outcomes, we must understand the systemic challenges of orchestrating a complete episode of multidisciplinary care, from radiographic screening to treatment, in the resource-limited, safety-net environment. We performed a qualitative case study of purposively sampled imaging-based cancer screening programs in safety-net organizations serving high-need populations in Los Angeles County, identified by geospatial techniques. Using a semistructured guide, organizational screening experts were prompted in hour-long telephone interviews between November 28, 2023, and February 12, 2024, to describe their organization's imaging-based "screening pipeline," including how they interfaced with external organizations to complete multidisciplinary screening to treatment. Audio was securely recorded, transcribed, and analyzed, using inductive thematic analysis. Four diverse organizations provided insight. Respondents highlighted two main resource-intensive systemic challenges: (1) fragmentation of care across multiple organizations and (2) siloed health information, particularly imaging. These interrelated challenges precluded simplification or automation of screening processes, prompting organizations to resort to manual, labor-intensive workarounds to partially overcome these systemic issues. Care and informatics fragmentation particularly deplete safety-net resources and cause organized cancer screening programs to be unduly labor-intensive in this setting. These challenges were prevalent even in well-established screening programs, like breast, reinforcing that comprehensive, equity-based screening solutions transcend individual organizations.