Key Findings

While we have seen advancements in personalized treatment thanks to biomarker testing, targeted and immunotherapies, as well as a method of early detection, the burden of lung cancer is not the same everywhere. Treatment, exposure to risk factors, and use of screening vary from state to state. To save lives, it's critical to prevent lung cancer when possible and diagnose the disease as early as possible.

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

Most lung cancer cases are diagnosed at later stages when the cancer has spread to other organs, treatment options are less likely to be curative, and survival is lower.

The stage at which someone is diagnosed with lung cancer varies significantly by state. The early diagnosis rate was highest for Wyoming at 28.1 percent and lowest for Alaska at 16.6 percent.

Lung cancer is more likely to be curable if the tumor can be removed through surgery, and surgery is more likely to be an option if the diagnosis is made at an early stage before cancer has widely spread. Nationally, 20.6 percent of cases underwent surgery as part of the first course of treatment, ranging from 30.5 percent in Massachusetts to 13.5 percent in New Mexico.

Patients who are not healthy enough to undergo the procedure or whose cancer has spread too far 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.

Not every patient receives treatment after being diagnosed with lung cancer. This can happen for multiple reasons, such as the tumor having spread too far, poor health, or refusal of treatment. 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. Dismantling these and other barriers is important to reducing the percent of untreated patients.

Some lung cancer patients will not receive any form of treatment for legitimate medical or personal reasons, but the wide gap in lack of treatment rates between states suggests additional factors may contribute, like stigma, fatalism and access issues.  The percent of patients who receive no treatment is 15.4 percent nationally, ranging from 8.0 percent in North Dakota to 30.4 percent in Arizona.

If everyone currently eligible were screened, close to 48, 000 lives could be saved. For those ages 55-80 with a 30 pack-year history who still smoke or have quit within the last 15 years, screening with annual low-dose CT scans can reduce the lung cancer death rate by up to 20 percent by detecting tumors at early stages when the cancer is more likely to be curable.

For screening to be most effective, more of the high-risk population should be screened – currently, screening rates are very low among those at high risk. This may be because of a lack of access or low awareness and knowledge among patients and providers. As rates vary tremendously between states, it is clear that more can be done to increase screening rates.  Screening rates among those at high risk were 4.2 percent nationally, ranging from 12.3 percent in Massachusetts to 0.5 percent in Nevada.

Medicaid beneficiaries are disproportionately affected by lung cancer, yet standard Medicaid programs are one of the only healthcare payers not required to cover lung cancer screening. If screening is covered, Medicaid programs may use different eligibility criteria, require prior authorization or charge individuals for their scans.

As of January 2019, 31 state Medicaid fee-for-service programs covered lung cancer screening for those at high risk, 12 did not, and seven had no information available. In states where fee-for-service Medicaid plans covered screening, 4.8 percent of those at high risk had been screened, compared to 2.6 percent in states that did not cover screening. Coverage may also vary between fee-for-service and managed care plans within a state's Medicaid program.

The Lung Association urges all state Medicaid programs to cover lung cancer screening based on evidence-based guidelines across all fee-for-service and managed care plans and to remove any financial or administrative barriers that limit access to this lifesaving service.

Over the last decade, the rate of new lung cancer cases has decreased 19 percent, but it still remains the leading cause of cancer death in the United States.

Over the same period, the five-year survival rate has increased 26 percent, but remains one of the lowest among leading cancers.

Only 21.5 percent of lung cancer cases are diagnosed early, when survival rates are five times greater.

Lung cancer screening with low-dose CT scans has been recommended for those at high risk since 2013, but only 4.2 percent of those eligible were screened in 2018.

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.

Keys to prevention include raising awareness about tobacco use, exposure to radon gas, air pollution, and secondhand smoke, all of which are known to cause lung cancer. Despite understanding of these risk factors, for some patients, the cause of lung cancer is not clear. If you have concerns about your risk, such as if others in your family have or ever had lung cancer, it is important to mention this to 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 percent 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 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" report 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 radon rates than others, but any home can have elevated levels. The U.S. Environmental Protective Agency (EPA) has set an action level of 4 pCi/L (picocuries per liter of air). At or above this level of radon, the EPA recommends you take corrective measures to reduce your exposure to radon gas. The report highlights counties and their predicted average indoor radon screening level.
• Exposure to year-round particle pollution in the air has been shown to cause lung cancer. Each year the American Lung Association puts out the "State of the Air" report. The 2019 report grades U.S. counties on harmful particle and ozone pollution recorded over a three-year period and details trends for metropolitan areas over the past two decades. The report also ranks both the cleanest and most polluted areas in the country.