Simple Prompt at Lung Screening Visits Could Close Breast Cancer Screening Gap in High-Risk Women

A routine chest CT scan may soon do more than check the lungs of women at high risk for cancer. Researchers at Thomas Jefferson University report that patients enrolled in a lung cancer screening program could be nudged toward another potentially life-saving test with a remarkably simple intervention: a reminder about mammograms built into the visit itself. The idea rests on a straightforward observation about how preventive care is delivered. People who show up for one recommended screening test are already engaged with the health system, already sitting in an intake room, and already answering questions about their health. Adding a prompt about another relevant screening at that moment costs almost nothing, yet it could reach precisely the patients who are most likely to have fallen through the cracks.

The study, led by clinicians within a lung cancer screening program directed by Julie Barta, MD, an associate professor at Sidney Kimmel Medical College, focused on women between the ages of 50 and 75 who were current smokers or had a significant smoking history. Current guidelines call for people in this group to undergo an annual chest computed tomography scan to look for early signs of lung disease, including lung cancer, which remains the leading cause of cancer death in the United States. But the same population carries elevated risk for other malignancies as well. Smoking is a well-established risk factor across many cancer types, and as Meghan Maceyko, MD, a fourth-year general surgery resident and one of the researchers, puts it plainly: smoking is a risk factor in all cancers. For older women with substantial smoking histories, that includes breast cancer, one of the most common diagnoses in this age group and one for which mammography screening has repeatedly been shown to save lives when tumors are caught early.

To understand how well these women were keeping up with breast cancer screening, the team took a retrospective look at their electronic health records. The question was simple: had each woman received a mammogram in the two years before her lung cancer screening scan, a window consistent with standard recommendations for breast cancer screening in this age range? The records allowed the researchers to go beyond a single adherence number and examine patient characteristics associated with being overdue. What emerged was a pattern that clinicians who work in preventive care will recognize with frustration. Women with a greater smoking history were more likely to be overdue for mammography, and so were women who had previously been diagnosed with cancer.

That second finding is the one that gives the study its urgency. Patients with a prior cancer diagnosis are, by definition, among the highest-risk people in any screening population. They have already faced one malignancy, they are monitored closely for recurrence, and many are at increased risk for secondary cancers, whether because of shared risk factors such as smoking, the late effects of treatment, or genetic susceptibility. Yet the Jefferson analysis suggests that these very patients were among the least likely to be current on breast cancer screening. In other words, the women who stood to benefit most from a routine mammogram were the ones least likely to be getting one. The researchers describe this as a critical gap in preventive care, and the phrase is not an exaggeration. Screening programs are designed to concentrate resources where risk is highest, so an inverse relationship between risk and adherence signals that something in the delivery system is failing the patients who need it most.

Why might the highest-risk patients be the least well screened? The study did not set out to answer that question directly, but several plausible mechanisms fit the data. Patients with extensive smoking histories often carry a heavier burden of chronic disease overall, from cardiovascular disease to chronic obstructive pulmonary disease, and their medical visits may be dominated by the management of immediate symptoms rather than preventive planning. A prior cancer diagnosis can complicate the picture further. Survivorship care is frequently fragmented between oncologists and primary care providers, and responsibility for routine screening can fall into the space between them. Some survivors may also experience avoidance or anxiety around testing that recalls their original diagnosis. Whatever the individual explanations, the aggregate result is the same: the patients with the most to gain from screening are the ones most likely to slip past it unnoticed.

The proposed remedy is deliberately modest in its technical demands. Rather than building new programs or requiring additional visits, the researchers suggest embedding a breast cancer screening prompt into the intake process that lung screening patients already complete. For medical centers that operate lung cancer screening programs, such as Jefferson Health, the infrastructure is already in place. Patients are scheduled, registered, asked structured questions about their health, and seen by nursing staff before their scan. The next step, Maceyko notes, is simply to choose an easy and effective prompt. That could take the form of a pop-up reminder embedded in the screening questionnaire, or a single added question posed by the intake nurse. Either way, the intervention targets the moment of maximum engagement, when a high-risk patient is physically present and the health system has her attention.

The elegance of this approach lies in what it does not require. It does not require new imaging equipment, additional staffing, or a separate outreach campaign with mailings and phone calls. It does not require patients to navigate a new appointment or a new department. It piggybacks on a visit that already exists for a population that is already identified as high-risk by virtue of enrollment in lung screening. In implementation science, this kind of design is often described as leveraging existing touchpoints, and it is one of the most reliable ways to improve adherence at scale. A prompt that takes seconds to deliver can convert an otherwise missed screening into a completed one, particularly when it is paired with a clear pathway for scheduling the mammogram before the patient leaves.

The implications extend well beyond the pairing of chest CT and mammography. The same logic applies to any setting in which patients at elevated risk for one condition are seen for the surveillance of another. A patient arriving for colonoscopy could be asked about cervical screening; a patient in a dermatology surveillance program could be prompted about breast or colorectal testing. The researchers point out that further work in this area may open additional avenues for improving adherence, including prompts about other cancer screenings and the creation of pathways for electronic health records to automatically flag overdue tests. Modern EHR systems already track due dates for preventive services, but turning that data into action at the point of care remains inconsistent. A flag that surfaces during check-in, or a question scripted into the intake workflow, closes the distance between knowing that a test is overdue and actually getting it done.

There is also a broader lesson in the study’s central paradox. Health systems tend to assume that patients who are engaged enough to participate in one specialized screening program are likely to be current on their other preventive care, but the Jefferson data show that this assumption cannot be relied upon. Enrollment in lung screening identifies a high-risk population, yet within that population, adherence to mammography varies in ways that track with smoking history and cancer history rather than with engagement. Screening status for one test is simply not a reliable proxy for screening status across the board. That is precisely why an explicit prompt matters: it replaces an assumption with a question, and a question asked at the right moment can be answered, acted upon, and documented.

For the women at the center of the study, the stakes are concrete. Lung cancer screening exists because early detection changes outcomes in a disease that is usually found too late; mammography exists for the same reason in breast cancer. A patient who receives both screenings on schedule is protected twice, at a combined cost of two imaging appointments a year. If a pop-up reminder or an extra intake question can move even a fraction of overdue patients into compliance, the intervention will have earned its place in the workflow. The Jefferson team’s contribution is to show where the gap lies, who falls into it, and how small the fix could be. The next phase of research will determine which prompts work best and how far the principle can be extended, but the direction is already clear: the most efficient place to catch a missed screening is at the appointment the patient was already going to attend.

Subject of Research: Breast cancer screening adherence among women enrolled in a lung cancer screening program

Article Title: Boosting cancer screenings in high-risk groups

Article References: Boosting cancer screenings in high-risk groups. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: lung cancer screening, mammography, breast cancer, smoking, preventive care, screening adherence, electronic health records, Thomas Jefferson University, high-risk patients, cancer survivors, chest CT, health care intervention