Originally published on Devex.com
Lung cancer continues to be a leading cause of cancer-related mortality in the United States — a statistic made more tragic by the fact that early-stage diagnoses carry an 80% cure rate. However, screening rates remain critically low — particularly within medically underserved communities — leading to a cycle where most patients are only diagnosed once the disease has reached an advanced, symptomatic, and less treatable stage.
Speaking with Devex, Dr. Drew Moghanaki, professor and chief of thoracic oncology at the University of California, Los Angeles School of Public Health’s Department of Radiation Oncology, discusses the evolution of lung cancer screening infrastructure, including how public-private partnerships are successfully translating clinical evidence into scalable, equity-focused solutions.
This conversation has been edited for length and clarity.
What factors most strongly contribute to disparities in lung cancer risk and diagnosis, and why is early detection such a critical intervention point for addressing them?
I have discovered that a key factor that influences lung cancer outcomes is largely tied to access to care. That is, patients who are adequately insured are more likely to receive timely diagnoses, access high-quality treatment, and ultimately achieve better outcomes than those who are uninsured or underinsured.
Another factor concerns the challenges that underresourced communities face in providing appropriate lung cancer screening and treatment expertise, regardless of individual patient insurance status. For example, a local hospital might not have high-quality surgery, radiotherapy, or medical oncology services. They might not even be committed to supporting a lung cancer screening, diagnosis, or treatment program due to competing priorities and limited resources.
Finally, I’ve come to appreciate the significant role of individual patient health literacy in lung cancer outcomes — particularly at the earliest stages of detection. Some patients may not fully understand that lung cancer, when caught early, can be treatable or even curable. This gap in understanding can lead to individual nihilism, which can contribute to missed appointments and incomplete evaluations, which can delay diagnosis and allow the lung tumor to spread and no longer be curable.
What are some of the lessons you learned from the VA-PALS implementation program that made it the most successful lung screening program across the VA, and how did it address healthcare disparities?
VA-PALS [the Veterans Affairs Partnership to Increase Access to Lung Screening] was a public-private partnership from 2017-2022 that was cosponsored by the VA Office of Rural Health and the Bristol Myers Squibb Foundation. It built a network of lung screening centers across the VA [Department of Veteran Affairs] by using an implementation approach that ensured all veterans — regardless of where they lived — were informed and counseled about the potential benefits of early detection.
The success of VA-PALS, in which we screened over 30,000 veterans, ultimately led the VA to establish the National Center for Lung Cancer Screening, which gave rise to enterprise-wide policies requiring that all veterans over the age of 50 be assessed for screening eligibility wherever they receive care. This now allows the VA to offer lung screening as standard of care for all veterans confirmed eligible, which truly minimizes disparities, given it supports the entire population receiving care through the VA.
A key lesson we learned through VA-PALS is that successfully implementing a new clinical program, such as lung cancer screening, requires a critical mass of engaged people, sufficient resources, and a genuine commitment from each hospital’s administration to enact the policy changes needed to sustain its growth. We learned that without those foundational elements, individual screening programs can become isolated and unsupported, leaving the people doing that work feeling alone and vulnerable to burnout and attrition.
These lessons ultimately led us to understand that when you build a team across diverse geographic locations around a shared mission that everyone feels a sense of ownership in, the team becomes passionate and, frankly, unstoppable. People show up differently when they understand they are part of something larger than themselves and that their work is directly saving lives. We have certainly carried this awareness into our latest lung screening implementation project, named CAL-PALS (California Partnerships to Increase Access to Lung Cancer Screening), where everyone involved is highly engaged and willing to make time to build new lung screening programs.
Why did you choose to get involved in building lung screening programs outside the VA?
Following my recruitment to UCLA in 2021 to lead our department’s lung cancer program, I recognized a significant gap in the state’s priority for lung screening. I learned the state of California was second to last in the nation in lung cancer screening, which, to me, was simply unacceptable for a state that is a leader in public health and first outlawed smoking in the 1990s.
In response, a collaboration was established between leading implementation scientists at UCLA from the schools of medicine and public health, who drew on lessons from VA-PALS to develop a partnership with two regional community hospitals that had expressed interest in developing lung screening programs but had not yet moved forward with a concrete plan. We felt that if we could launch two new lung screening programs in regional hospitals, we could later replicate the implementation approach statewide by leveraging the network of the University of California healthcare systems and help get the state back into a leading position in driving down lung cancer mortality beyond smoking cessation strategies.
With a generous grant from the BMS Foundation, we helped kick-start each local hospital’s hiring of a full-time advanced practice provider and supported them in building the clinical workflows necessary to reach patients at risk for lung cancer and to get those eligible screened. Our team at UCLA is now providing each of these hospitals, which are both part of CommonSpirit Health, with expertise in public health, implementation science, lung cancer screening, and treatment to help them accelerate their development.
You previously shared that cancer outcomes within the VA have a narrow, or even potentially nonexistent, racial disparity gap compared to what we see in the general population. Can you tell us more about this?
Our research teams in the VA had observed over the years, through a growing body of published literature, that Black veterans receiving care through the VA were achieving similar cancer outcomes as compared to non-Black veterans. This stands in stark contrast to what we see in the general U.S. population, where disparities between racial groups persist — and, in many cases, are not narrowing.
Our research team investigated this by analyzing the body of literature published over the past decade on outcomes for veterans with cancer to determine whether this was true. What we found was that race did not predict worse outcomes among those with different cancer types, which implies that integrated healthcare systems like the VA, which provide near-equitable access to comprehensive cancer care, have the potential to substantially reduce or even eliminate racial disparities in cancer outcomes. Our research report was recently accepted and will be published soon.
Smoking history often carries a social stigma that prevents people from seeking help. How does your team approach patient outreach to make screening feel like a proactive health step rather than a judgment?
We are acutely aware that the public at large has long marginalized people who smoke. We consider this an unintended consequence of smoking cessation programs that, for more than half a century, have used fear, guilt, and shame as motivational tools to discourage people from starting and to encourage those currently smoking to quit. Unfortunately, the stigma this creates carries over whenever a person who is or was addicted to cigarettes later develops lung cancer, which can affect not only their well-being but also their willingness to pursue treatment.
This issue is real, and something we address head-on in the VA, where there is a culture that aims to never discriminate against any of our veterans to embody the military culture of leaving no one behind, regardless of their circumstances, including a history of smoking addiction. I wish every healthcare system had a similar culture, as I believe it is absolutely critical to destigmatize the smoking component of lung screening eligibility if we want to reach all patients who need this preventive service.
As you look ahead, how do programs such as CAL‑PALS point toward a future “gold standard” for lung cancer screening, and what would it take to replicate this model in other high‑burden communities nationwide?
Our CAL-PALS implementation project is actually quite straightforward. It partners a high-resource institution, such as UCLA, that has expertise in public health and lung cancer screening, diagnosis, and treatment, with a pair of highly motivated community hospitals with strong administrative support that want to make a meaningful and measurable difference in their patients’ lives. I encourage all healthcare environments to seek similar partnership opportunities as we aim to build more robust lung screening programs nationwide.
I also recommend that community hospitals explore emerging software technologies that are now available to simplify the implementation and maintenance of early detection programs. Particularly through commercially available software tracking systems that are now implemented in hundreds of hospitals across the country and are successfully leveraging artificial intelligence and computational linguistics to scan electronic medical records, review radiology reports, flag incidental findings, and automate care coordination to ensure that patients who receive a diagnosis are transitioned promptly into workup and treatment. Our CAL-PALS partner hospitals have already installed one of these systems, and it is helping us build our programs even more efficiently than we did during the VA-PALS program.
Visit Strengthening Care Systems — a series in collaboration with the Bristol Myers Squibb Foundation on raising awareness of the scale of the global lung cancer burden and the systems-level changes required to address it.
