Trends and outcomes of lung cancer screening among people with and without HIV in the US

In the United States (US), lung cancer is the leading cause of cancer-related mortality among people with HIV (PWH). Compared to the general population, PWH are more likely to be diagnosed with lung cancer at an advanced stage and less likely to receive curative treatment, ultimately leading to elevated mortality rates. Strategies to reduce lung cancer related mortality among PWH are needed. Annual lung cancer screening (LCS) using low-dose computed tomography (LDCT) is recommended for high-risk patients for early detection of lung cancer. Given the disproportionate burden of lung cancer in this population, PWH are likely to benefit from LDCT-based LCS. However, empirical outcomes data of LCS delivery, including uptake, follow-up, and outcomes, such as false positives and rates of invasive diagnostic procedures, are largely lacking in the context of living with HIV. These data are needed to develop tailored LDCT-based screening interventions for PWH to ensure they are receiving available preventive services with benefits that outweigh the potential harms of LDCT. To address this gap in scientific knowledge, we propose a two-pronged approach where we will (1) leverage a novel electronic health record (EHR)-based linkage of multiple health care systems across the Southeastern US, covering over 21 million patients and 70% of adults living in Florida, called OneFlorida+; and (2) partner with community clinics serving PWH across FL to include and prioritize insights regarding LCS delivery and decision-making processes from PWH eligible for LCS. OneFlorida+ presents a novel, unprecedented context to characterize LCDT-based LCS trends in PWH given Florida has among the highest rates of lung cancer in the US, low rates of LCS based on general population estimates and one of the highest HIV incidence rates in the US. Our aims include Aim 1: Characterize patterns of LDCT-based LCS (1) uptake, (2) outcomes, (3) follow-up after a positive finding, and (4) longitudinal adherence to LCS comparing PWH to adults without HIV eligible for LDCT; Aim 2: Estimate the direct and indirect effects of individual-, healthcare-, and contextual-level factors on LCS uptake and follow-up adherence among LCS-eligible people with and without HIV; and Aim 3: Examine patients’ decision making experiences with lung cancer screening through in-depth interviews with PWH eligible for LCS (without cancer) and PWH with lung cancer. The successful completion of our proposed project will: (1) provide novel and urgently needed evidence describing the trends in LCS utilization and outcomes among PWH; (2) advance our understanding of the mechanisms through which multiple factors contribute to cancer preventive behaviors in the context of LCS adherence among PWH; (3) inform the development and testing of multi-level intervention designs targeting actionable factors impacting LCS behaviors for future studies; and (4) create a large EHR-based cohort of PWH that can be longitudinally tracked to support future HIV studies on cancer screening as well as cancer-related outcomes.