Rethinking how mobile units can catalyze progress on lung cancer screening: a scoping review of what we have learned

Introduction

Lung cancer stands as the foremost cause of cancer-related fatalities among both men and women in the United States (US) and globally, largely due to the high prevalence of advanced-stage diagnoses (1). In 2024, it is estimated that there will be 234,340 new cases of lung cancer and 125,070 deaths attributed to the disease in the US alone, accounting for 12.2% of all incident cancers and 20.8% of all cancer deaths (1). The 5-year relative survival rate for non-small cell lung cancer (NSCLC) at stage I/II ranges between 56% and 90%, whereas in patients diagnosed with distant stage or metastatic disease (stage IV), it is extremely poor (5.2%) (2).

Lung cancer screening (LCS) via low-dose computed tomography (LDCT) represents a promising avenue for improving lung cancer outcomes by facilitating early detection (3). The United States Preventive Services Task Force (USPSTF) recommends annual LCS with LDCT for adults aged 50 to 80 years, who have a smoking history of at least 20 pack-years and currently smoking or having quit within the last 15 years (4). Although LCS via LDCT has been unequivocally proven to enhance early disease detection and subsequent outcomes, only 5.8% of the 14.2 million eligible US adults underwent screening in 2022 (5,6). In certain states, screening rates are reported to be as low as 1% (6). Multiple factors contribute to lower screening uptake in the US and worldwide including limited access to healthcare services, providers’ perception, fear of a cancer diagnosis, low perceived risk of lung cancer, stigmatization, cultural factors, and practical barriers of cost, insurance, transportation, and time off work (7,8).

The deployment of mobile LCS units represents a promising strategy to improve access to screening. Drawing on the implementation of mobile screening mammography units, which have resulted in increased screening rates among underserved populations (9,10), mobile LCS platforms have the potential to bring screening services directly to individuals in rural and underserved areas who might not actively seek out preventive care. This approach could further improve lung cancer outcomes, decrease downstream healthcare costs, and ultimately save lives (8,11). Through a scoping review approach, our objective is twofold: first, to delineate the extent and impact of mobile LCS platforms by offering an overview of current platforms; and second, to assess the multilevel factors that facilitate or impede the implementation of the mobile LDCT platforms themselves. We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-846/rc).

Methods

Literature search

We conducted a scoping review to identify studies that reported mobile LDCT screening platforms and their operations. We searched for studies published between January 2017 and December 2023, in the electronic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Embase, Scopus, and Web of Science. Search terms used were combinations of Medical Subject Heading (MeSH) and keyword terms (Table S1): “mobile health platform”, “LDCT”, “lung screening”, “lung cancer screening”, “lung cancer screening van”, “lung screening bus”, mobile lung cancer screening”, and mobile low-dose computed tomography screening”. We implemented the scoping review standards outlined by the five-step framework of Arksey and O’Malley (12), specifically to identify the research questions, identify the relevant studies, search and select the evidence, chart the evidence, and collate, summarize, and report the evidence.

The objective of this review was to address several research questions related to the implementation of mobile LDCT which vary widely in their approach. (I) What are the key patient- and system-level characteristics of the current mobile LDCT platforms? (II) How do mobile LDCT screenings compare with fixed hospital-based screenings in relation to downstream patient outcomes? (III) Whether there is an adequate return on investment (ROI) to justify the utilization of mobile LDCT platforms, considering that some programs focus on financial viability and demonstrating ROI, while others prioritize accessibility for underinsured and uninsured populations, often relying on grant funding to overcome financial barriers. We included English language articles and abstracts that addressed index LCS and adherence to annual follow-up. Studies were excluded if they did not involve a mobile LDCT LCS unit, had overlapping populations, or focused on cancers other than lung cancer.

Article selection

We identified a total of 1,005 articles from the original searches. After removing duplicate articles (n=355), we screened 648 articles against the inclusion and exclusion criteria by two independent reviewers using Covidence systematic review software, which resulted in the selection of 50 relevant articles for full-text review. Following this process, we included 10 published articles (10,13-21), and two were conference proceeding abstracts (22,23).

Data extraction

One author (J.D.) abstracted relevant information regarding study characteristics and results from the included articles and entered this information into a prepopulated study database. Another author (D.Y.) independently reviewed and verified the accuracy of collected data by cross-referencing it with the original articles. Any discrepancies were discussed, and resolved by consensus, and in consultation with the third reviewer (S.D.K.). The following information was summarized in the study database: the study design, publication year, data source, sample size, the location of the mobile LDCT platform, number of lung cancer cases, lung cancer detection rate, and other significant findings of the platform. Additionally, findings from US studies were summarized to investigate the sociodemographic characteristics of mobile platform users. Due to the descriptive nature of the review, publication bias and quality were not evaluated.

Results

A total of 12 studies that met the inclusion criteria were included in the review. The selection process is outlined in Figure 1, and the characteristics of included studies are summarized in Table 1. The majority of studies were from the US (n=5) (10,14,16,20,22), the United Kingdom (UK) (n=3) (13,15,21), Japan (n=1) (17), China (n=1) (19), and Brazil (n=2) (18,23). All of the studies explored the utilization of a mobile LCS unit and the effectiveness of the platform. Two studies (15,20), compared outcomes between mobile sites and hospital-based screening, whereas the other 10 studies reported outcomes from mobile LDCT platforms. Participant inclusion criteria and targeted groups varied across the studies. Most of the studies focused on rural and underserved populations except for one study (20), that recruited patients from an urban site.

Figure 1 Flow diagram of the selection of studies to be included in the scoping review. CINAHL, Cumulative Index to Nursing and Allied Health Literature.

Patient- and system-level characteristics are considered when establishing a mobile LDCT platform

The three studies from the UK recruited participants at high risk to undergo LDCT screening (Table 1) (13,15,21). The Manchester study identified high-risk participants using the modified Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) Screening Trial, PLCO_M2012, with a 6-year risk threshold of ≥1.51% (13). Of the 2,541 patients offered lung health checks, 1,429 (56.2%) met the criteria for LCS according to the PLCO_M2012 risk model and among these patients 1,384 received LDCT screening. Another study used the PLCO_M2012 (6-year risk ≥1.51%) and/or the Liverpool Lung Project risk model version 2 (LLPv2) (5-year risk ≥2.0%) model (15). In this study, 1,542 lung health checks were conducted, with 1,159 patients identified as eligible for LCS based on the PLCO_M2012 risk model. Among those eligible, 1,145 underwent LDCT scans. The third study enrolled participants from the Yorkshire Lung Screening Trial, who were invited to the Lung Health Check following a telephone-based high-risk determination using the USPSTF 2013 criteria, the PLCO_M2012 model, or the LLPv2 model (21). Out of the 22,815 patients contacted, 7,958 were offered a lung health check after meeting the criteria for lung cancer risk assessment, and 6,650 of these patients underwent LDCT. Two studies from Brazil were included (18,23). One study invited high-risk participants of their smoking cessation integrative program to undergo LCS in their mobile LDCT unit. The study found promising preliminary results for future national models (18). The other study from Brazil (23), reports an initiative to improve screening in an underserved population of workers from a former asbestos manufacturing factory, with 89% directly involved in asbestos manufacturing.

In a 10-year screening period, a mobile computed tomography (CT) unit based in Shimane, Japan (17), prioritized LCS even before the publication of the National Lung Screening Trial (NLST) results (3). Over ten years, this program screened 25,189 patients ages 21 to 89 years, with 85% being over the age of 50 years. The program saw a steady increase in screening participants each year, with 4,052 participants screened in 2019. This program also offered LDCT screenings to participants who had never smoked, revealing a lung cancer incidence of 54.9% among individuals in this group (17). Another large study (n=12,360) conducted in China (19), also offered LDCT screening to individuals who never smoked. Among the 86 lung cancer cases, 68 (79.1%) cases were in this group.

Four of the five studies from the US (Table 2) emphasized the provision of services by mobile units to uninsured or underinsured participants (10,14,20,22). Three out of the five studies included diverse racial/ethnic groups (14,20,22). However, one study solely reported information on the White race (16), and another did not provide a breakdown of race/ethnicity (10). Across the studies, users of mobile LDCT included a higher proportion of Black (18–28%) (14,20,22) or Hispanic (3%) (14,22) or Asian (2.8%) (20) or Native American (0.5%) (14,22). One study highlighted in our review includes one of the first mobile LDCT programs in the US, based in North Carolina, which had a formidable impact and pioneering results. This program, designed without the goal of being financially profitable, exclusively screened uninsured and Medicaid patients. The study reported screening 550 participants, with a mean age of 61 years, and found that 70% of patients screened resided in rural areas (14). In addition to detecting lung cancer, these screenings also found that 16% of patients had moderate or severe coronary artery disease, and 27% showed vascular atherosclerosis (14). The same group expanded their outreach and conducted a 4-year follow-up study on 1,200 participants. Notably, 51% attended the 12-month repeat LDCT and 27% attended the third repeat LDCT scan (22).

Two pilot studies compared the mobile and the “brick and mortar” hospital settings (15,20). The study from Leeds, UK (15), reported that the median distance traveled to the hospital site was less than to the mobile site (3.3 vs. 6.4 km, P<0.01). Additionally, responders at the hospital site were found to have lower socio-economic status and were more likely to be individuals who currently smoke compared to those who had previously quit smoking. The study conducted in New York, US (20), compared screening sites and found that participants in mobile screening settings were significantly more likely to be younger (<55 years old), less likely to meet the 2013 USPTF guidelines, have lower smoking intensity, and receive baseline LDCT (99.5% vs. 40.6%) compared to those at fixed hospital sites.

ROI and improvement in treatment outcomes to justify the use of mobile LDCT platforms

In Tennessee, a mobile LDCT unit was launched, and the results of a 12-month feasibility period were reported (16). During this period, the unit traveled to 104 sites and screened 548 participants, with a mean age of 62 years. Lung nodules greater than 2 mm were found in 232 (42%) of patients screened, and five lung cancers were detected. Additionally, the study conducted a break-even analysis, utilizing data from the first year alongside four additional years of projected data based on conservative estimates. Surpassing their break-even cost analysis by 28%, the program demonstrated financial viability despite only conducting screenings for 10 out of the 12 months. The program assessed its profitability by year 2, which was sustained over the next four years. This evaluation factored in downstream revenue from incidental findings and compared the costs associated with managing early-stage (stage 1 and 2) versus late-stage (stage 3 and 4) lung cancer.

LDCT outcomes reported from mobile platforms

In the US studies (10,14,16,20,22), and one study from Brazil (18), LDCT was assessed using the Lung Imaging Reporting and Data System (Lung-RADS) classification system (24), while other studies reported the results as pulmonary nodules, positive scans, or suspected lung cancer. Sampaio et al., reported pleural plaques or nodules in 19% of individuals, with a median exposure time of 13.5 years to asbestos (23). Five individuals exhibited moderate or marked signs of pulmonary fibrosis, and one was diagnosed with early-stage lung adenocarcinoma, none of which were suspected under standard care (23).

The lung cancer detection rate ranged from 0.33% to 3%, reflecting variations in participant recruitment methods. For example, the study from Japan (17), conducted over a 10-year screening period, enrolled participants without a smoking history, and out of the total 25,189 participants, only 82 (0.33%) were diagnosed with lung cancer (17). While, participants selected using the PLCO_M2012/LLv2 models reported a higher lung cancer detection rate with a range of 2.5% to 3% (13,15). Despite variations in overall detection rates, the studies consistently found a higher detection rate of early-stage lung cancers, ranging from 50% to 100% of the lung cancers identified.

Discussion

This scoping review highlights the impact of different mobile LDCT platforms on accessing underserved communities. The review included 12 studies examining LDCT mobile platforms across various countries including Brazil, China, Japan, the UK, and the US. In the US, the majority of participants in mobile LCS programs originated from rural areas (10,16) and were either uninsured or underinsured (14,20,22). Additionally, a significant proportion of participants belonged to racial/ethnic minority groups, notably African Americans and others (25,26) with considerably higher representation compared to hospital-based screening programs (20).

Studies in the UK (13,15,21), and China (19), focused on rural areas, and the 10-year study in Japan (17) focused on areas that were deficient in medical institutions. In Brazil, two distinct populations were studied: workers from an asbestos factory (23) and high-risk participants of tobacco cessation programs (18). Mobile LDCT platforms have the potential to bridge gaps in healthcare access and reach underserved communities. However, a large study by Crosbie et al. highlighted lower participation rates among individuals with current smoking status and socio-economic deprivation and emphasized the critical need for research to guarantee equitable access to screening (21). In addition, despite the demonstrated benefits of LCS over time (3), expanding its accessibility in communities with limited screening access can significantly impact the early detection and treatment of lung cancer among high-risk populations.

Furthermore, a significant finding from the current review underscores the success of mobile platforms in identifying a substantial number of early-stage, treatable lung cancers, especially among high-risk populations (27). Consistently across the reviewed studies, there was an increased rate of early-stage lung cancer detection. Early detection of lung cancer is crucial owing to its enhanced manageability and markedly improved prognosis compared to later stages. This not only underscores the immediate advantages of mobile LDCT screening in enhancing patient outcomes but also underscores its pivotal role in public health by facilitating timely and efficient treatment. Additionally, the economic advantages of early detection are noteworthy. Treating early-stage lung cancer incurs substantially lower costs per patient, estimated at $300,000 to $400,000 for six stage I–II cases, compared to over $2,000,000 for six late-stage cancers in the United States (14). This cost-effectiveness strengthens the financial argument for deploying mobile LDCT units, given the subsequent savings resulting from more favorable treatment outcomes.

Two studies compared screening conducted at mobile and fixed sites (15,20). Pua et al. (20) noted a significantly higher presence of uninsured patients and individuals from lower income brackets at mobile screening sites in contrast to hospital-based facilities. Additionally, the majority of LDCT imaging studies performed at the mobile unit were baseline examinations, constituting a notably larger proportion than those in the fixed-site cohort. In a separate study, Balata et al. (28) (not included in the review), observed that individuals who currently smoke and from the lowest deprivation quartile were less inclined to attend a hospital-based screening program. Travel-related barriers emerged as the most frequently cited obstacle to participation (28). These findings imply that mobile screening sites are particularly adept at reaching and involving individuals who have not previously undergone LCS, underscoring the potential of mobile units to enhance accessibility to essential healthcare services for marginalized populations.

Our review has several limitations worth noting. Firstly, our analysis was confined to published literature on mobile LDCT units. Additionally, there may be other mobile units operating globally, including established platforms in New York and future platforms planned for other US states, whose outcomes have not yet been published or presented. Consequently, our review might not fully encompass the breadth of mobile LDCT initiatives worldwide. Secondly, most of the studies from the United States that we included focused on the southeastern regions. As a result, the findings from these US-based studies might not apply universally across the entire country. Thirdly, the inclusion criteria varied among the studies we reviewed, which could impact the comparability of results and the conclusions drawn from different research projects.

Despite these limitations, our findings, particularly the elevated screening rates in these communities and the identification of early-stage lung cancer—affirm that mobile LDCT platforms are a feasible and impactful strategy for improving access to LCS (29). The utilization of mobile LDCT platforms stands to substantially enhance LCS uptake, especially among high-risk individuals in underserved regions who face challenges in accessing medical facilities (7). This effort could lead to improved health outcomes for diverse communities by facilitating earlier detection and treatment of lung cancer.

Conclusions

Mobile LDCT programs offer a potential solution to increase the uptake of LCS and address disparities in LCS rates (27). Efforts to enhance screening uptake should focus on individuals from low-income backgrounds, those with limited educational attainment, residents of rural areas, individuals with limited access to healthcare services, and those without health insurance coverage. To improve screening completion for lung cancer and promote thorough evaluation of abnormal scans (30), it is vital to implement initiatives in a culturally sensitive manner. Risk assessments should consider an individual’s racial or ethnic background (8). Community education efforts should highlight the quality of mobile screening services, emphasize the significance of follow-up appointments, and provide information about an individual’s specific lung cancer risk.

Acknowledgments

We acknowledge the assistance of Lauren Adkins, Pharmacy Liaison Librarian, at the University of Florida at Health Science Center Libraries for assistance with the literature search.

Funding: This work was supported by funding from the National Institutes of Health/National Cancer Institute (Nos. R01CA249506, R01CA284646, and P30CA247796), supported by the UF Health Cancer Center, and supported in part by state appropriations provided in Fla. Stat. § 381.915. The funder did not play a role in the design of the study; the collection, analysis, and interpretation of the data; the writing of the manuscript; or the decision to submit the manuscript for publication.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-846/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-846/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-846/coif). E.R. has received honoraria for CME Lectures from OncLive and Advisory Boards from Daiichi, Janseen/Johnson and Johnson, Astra Zeneca, Pfizer, Boehringer Ingelheim, and Oncohost, related to lung cancer treatment, but not lung cancer screening. J.E.G. has received honoraria and is board member for AbbVie; AstraZeneca; Blueprint Medicines; Coherus; Daiichi Sankyo; EMD Serono; Genentech; Gilead Sciences, Inc.; IDEOlogy Health; Janssen Scientific Affairs, LLC; Jazz Pharmaceuticals; Loxo Oncology Inc.; Merck & Co., Inc.; Novartis; OncoCyte Biotechnology; Regeneron; Spectrum ODAC; Takeda Pharmaceuticals; Triptych Health Partners; and Zai Lab (US) LLC. J.E.G. also has leadership or fiduciary roles, including ASCO Board of Directors Member, ASCO Education Committee Ex-Chair, IASLC Board of Directors Member and SWOG Lung Committee Chair and has received support for attending meetings and/or travel from AbbVie; OncoCyte; Spectrum Pharmaceuticals; and Coherus. J.E.G. has received grants/contracts from AstraZeneca; Boehringer Ingelheim; Bristol-Myers Squibb; Eli Lilly; EMD Serono-Merck KGaA; Genentech; Gilead Sciences: G1 Therapeutics; Ludwig Institute of Cancer Research; Merck & Co., Inc.; Novartis; Panbela Therapeutics; Pfizer; and Regeneron. JG has received consulting fees from AbbVie; AstraZeneca; Blueprint Medicines; Coherus; Daiichi Sankyo; EMD Serono; Genentech; Gilead Sciences, Inc.; IDEOlogy Health; Janssen Scientific Affairs, LLC; Jazz Pharmaceuticals; Loxo Oncology Inc; Merck & Co., Inc.; Novartis; OncoCyte Biotechnology; Regeneron; Spectrum ODAC; Takeda Pharmaceuticals; Triptych Health Partners; and Zai Lab (US) LLC. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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