Lung Cancer Key Findings

While we have seen advances in personalized treatment thanks to biomarker testing and targeted immunotherapies, and saved more lives through the introduction of lung cancer screening, the burden of lung cancer is not the same everywhere. Treatment, exposure to risk factors, and use and coverage of screening vary from state to state. To save more lives, it’s critical to prevent lung cancer when possible and diagnose the disease as early as possible. Additionally, everyone should have access to therapies that may extend or improve the quality of their life.

By better understanding the impact of lung cancer at the state level, we can encourage interventions to save and extend lives. This report considers the following measures of lung cancer burden by state: new cases, survival, early diagnosis, surgical treatment, lack of treatment, screening and prevention, racial disparities and Medicaid fee-for-service program coverage of screening and identifies where each state ranks on each of these measures.

Our policymakers must do more to protect and expand quality and affordable healthcare coverage and improve access to lung cancer screening and treatment.

Close to 236,000 people will be diagnosed with lung cancer this year, with the rate of new cases varying by state. The report finds that Utah has the nation’s best lung cancer rate while Kentucky has the worst at almost 2.4 times the incidence rate of Utah. Over the last five years, the rate of new cases decreased 10% nationally.

There are a variety of risk factors associated with lung cancer, including smoking, exposure to radon gas, air pollution and secondhand smoke. Radon testing and mitigation, healthy air protections, and reducing the smoking rate through tobacco tax increases, smokefree air laws and access to comprehensive quit smoking services are all ways to help prevent new lung cancer cases.

Lung cancer has one of the lowest five-year survival rates because cases are often diagnosed at later stages, when the disease is less likely to be curable. The national average of people alive five years after a lung cancer diagnosis is 23.7%, which is a 14% improvement over the last five years. Connecticut ranked best at 28.8%, while Alabama ranked worst at 18.4%.

Nationally, only 24% of cases are diagnosed at an early stage when the five-year survival rate is much higher (60%). Unfortunately, 46% of cases are not caught until a late stage when the survival rate is only 6%. Early diagnosis rates increased 36% over the last five years nationally and were best in Massachusetts (30%) and worst in Hawaii (19%).

Lung cancer can often be treated with surgery if it is diagnosed at an early stage and has not spread. Nationally, 20.7% of cases underwent surgery, which was a 3% improvement over the last five years. Rates ranged from best at 30.9% in Massachusetts to worst at 13.1% in New Mexico.

Patients who are not healthy enough to undergo the procedure or whose cancer has spread too widely may not be candidates for surgery. Other treatments may be recommended instead of or in addition to surgery, such as chemotherapy, radiation, targeted therapy or immunotherapy. This report focuses on surgical treatment because it is more likely to be curative.

There are multiple reasons why patients may not receive treatment after diagnosis. Some of these reasons may be unavoidable, but no one should go untreated because of lack of provider or patient knowledge, stigma associated with lung cancer, fatalism after diagnosis, or cost of treatment. Nationally, 21.1% of cases did not receive any treatment. Treatment rates improved 8% over the last five years and were best in North Dakota (13.8%) and worst in Arizona (32.5%).

Lung cancer screening gives us hope in the fight to defeat lung cancer and represents an opportunity to save lives. Screening with annual low-dose CT scans can reduce the lung cancer death rate by up to 20% by detecting tumors at early stages when the cancer is more likely to be curable. 

Based on new research, in March of 2021, the United States Preventive Services Task Force (USPSTF) expanded its recommendation for screening to include a larger age range and more current and former smokers. This dramatically increased the number of women and Black Americans who are considered at high risk for lung cancer.

High risk is defined as:

Screening rates in this report are from before the guidelines were updated and do not yet reflect screening among those newly eligible.

For screening to be most effective, more of the high-risk population should be screened annually—currently screening rates are very low among those at high risk. Nationally, only 5.7% of those at high risk were screened. Massachusetts has the best screening rate at 17.8%, while California and Wyoming have the worst at 1.0%.

State Medicaid programs are one of the only healthcare payers not required to cover lung cancer screening for the traditional Medicaid population. If screening is covered, Medicaid programs may use different eligibility criteria, require prior authorization or charge individuals for their scans.

The American Lung Association analyzed lung cancer screening coverage policies in state Medicaid fee-for-service programs to assess the current status of lung cancer screening coverage for the Medicaid population. We found that 40 Medicaid fee-for-service programs cover lung cancer screening, seven programs do not provide coverage, and three states did not have information available on their coverage policy.

Keys to prevention include limiting exposure to tobacco use, radon, air pollution and secondhand smoke, all of which are known to cause lung cancer. Despite having a good understanding of these risk factors, it is not always possible to identify the cause of an individual patient’s lung cancer. If you have concerns about your risk, because of your exposures or your family history, it is important to share this with your doctor.

This report contains information and data on exposures to these risk factors on the state level:

• Tobacco use is the leading risk factor for lung cancer, accounting for 80 to 90% of cases. While we have seen historic decreases in the national smoking rate, not all Americans or regions of the country have benefited equally.
• Secondhand smoke has also been shown to cause lung cancer. There is no safe level of exposure to secondhand smoke. The “State of Lung Cancer” report highlights that making homes, workplaces and public spaces smokefree air zones, with no smoking allowed, can reduce the risk of exposure. This report’s sister, “State of Tobacco Control,” grades states for efforts to protect public spaces from secondhand smoke.
• Radon, a naturally occurring radioactive gas, is the second leading cause of lung cancer and the leading cause among nonsmokers. Radon is a colorless and odorless gas that can seep into homes and buildings. Some geographical areas have naturally higher average radon rates than others, but since any home can be at risk for elevated levels, the only way to know is to do a test. If testing shows interior radon levels at or above the U.S. EPA action level of 4 pCi/L (picoCuries per liter of air) or higher, it is recommended you take corrective measures to reduce your exposure to radon gas. Such measures should also be considered at levels at or above 2 pCi/L. The report highlights the percent of indoor radon tests at or above the EPA action level by state.
• Exposure to year-round particle pollution in the air has been shown to cause lung cancer. Each year the American Lung Association releases the “State of the Air” report. The 2021 “State of the Air” report found that more than 20.7 million people lived in counties that had unhealthy levels of air pollution in all categories from 2017 to 2019.

• The lung cancer survival rate increased 14.5% over the last five years nationally to 23.7% yet remains significantly lower among communities of color at 20.0% and Black Americans at 18.0%.
• In addition to lower survival rates, people of color who are diagnosed with lung cancer face worse outcomes compared to whites, including: less likely to be diagnosed early, less likely to receive surgical treatment and more likely to receive no treatment.
• Nationally, only 24% of cases are diagnosed at an early stage when the five-year survival rate is much higher (60%). 
• Lung cancer screening with low-dose CT scans has been recommended for those at high risk since 2013, but only 5.7% of those eligible were screened in 2020.
• The analysis in the “State of Lung Cancer” serves as a baseline against which future data can be compared, which may be especially beneficial as progress is made on the implementation of lung cancer screening.

As the American Lung Association works toward defeating lung cancer, the goal of the “State of Lung Cancer” report is to empower the public to learn more about lung cancer in their state and take action to improve lung cancer patients’ access to quality and affordable health care.

The report looks at key lung cancer measures to highlight the burden and examine opportunities to better address lung cancer at the state level. The report found that lung cancer rates for every measure vary significantly by state, and that every state can do more to defeat lung cancer, such as increasing the rate of screening among those at high risk, addressing racial disparities that impact lung cancer outcomes, decreasing exposure to radon and secondhand smoke, and eliminating tobacco use. 

This report provides unique information for federal and state officials, policymakers, researchers and those affected by lung cancer and emphasizes the need for resources and action to decrease the toll of lung cancer across the country.