Alabama

Understand lung cancer burden in Alabama by looking at the measures of incidence, survival rates, stage at diagnosis, surgical treatment and availability of screening centers.

Incidence Intro:

The rate of new lung cancer cases in Alabama is 66.7 and significantly higher than the national rate of 59.6. It ranks 37th among all states, placing it in the below average tier.

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.

Alabama ranked 36th (out of the 46 states with available data) with 18.9 percent of cases receiving no treatment. This is significantly higher than the national rate of 15.4 percent and puts Alabama in the below average tier.

Prevention

Screening:

Screening for lung cancer with annual low-dose CT scans among those at high risk can reduce the lung cancer death rate by up to 20 percent by detecting tumors at early stages when they are more likely to be curable.

High-risk is defined as:

• 55-80 years of age;
• Have a 30 pack-year history of smoking (this means 1 pack a day for 30 years, 2 packs a day for 15 years, etc.);
• AND, are a current smoker, or have quit within the last 15 years.

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.

In Alabama, 4.1 percent of those at high risk were screened, which was similar to the national rate of 4.2 percent. It ranks 30th among all states, placing it in the average tier.

Medicaid:

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. 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 and found that 4.8 percent of those at high risk had been screened in states where fee-for-service Medicaid plans covered screening, compared to 2.6 percent in states that did not cover screening.

Alabama was one of the 12 states whose Medicaid fee-for-service programs did not cover lung cancer screening as of January 2019.

Tobacco:

Tobacco use is the leading risk factor for lung cancer. Smoking and secondhand smoke both have been shown to cause lung cancer.

The smoking rate in Alabama is 20.9% and significantly higher than the national rate of 16.4%. It ranks 42nd among all states, placing it in the below average tier.

SOTC:

Each year the American Lung Association puts out the "State of Tobacco Control" report. The 2019 report grades all 50 states and the federal government on four key tobacco control policies: tobacco control and prevention spending, smokefree air, tobacco taxes, and cessation coverage. Alabama's 2019 "State of Tobacco Control" report grades are:

• "F" for Tobacco Prevention Program Funding;
• "F" for Smokefree Air;
• "F" for Tobacco Taxes;
• "F" for Access to Tobacco Cessation Treatments; and
• "D" for Tobacco 21 Laws.

For more information about smoking, visit Lung.org/stop-smoking.

Radon is the second leading cause of lung cancer. Radon is a colorless and odorless gas that can seep into homes and buildings. Some geographical areas have naturally higher prevalence of high radon levels than others, but any home can have elevated levels. The US EPA has set an action level of 4 pCi/L. At or above this level of radon, the EPA recommends you take corrective measures to reduce your exposure to radon gas.

• 13 counties in Alabama are considered Zone 1 which means they have predicted average indoor radon screening levels greater than 4 pCi/L.
• 33 counties in Alabama are considered Zone 2 which means they have predicted average indoor radon screening levels from 2 to 4 pCi/L.

For more information on radon testing and removal, visit Lung.org/radon.

Air Pollution is a known risk factor of lung cancer.

• One outdoor air pollutant found to cause lung cancer is year-round particle pollution. Each year the American Lung Association puts out the "State of the Air" report. The 2019 report grades U.S. counties on harmful particle pollution and ozone pollution recorded over a three-year period, and details trends for metropolitan areas over the past two decades. The report ranks also both the cleanest and most polluted areas in the country. View the Alabama report card.

For more information about air pollution, visit Lung.org/healthy-air.

Learn more about the other risk factors for lung cancer and how you can reduce your risk.

Stage

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.

Nationally, only 21.5 percent of cases are caught early when the five-year survival rate is much higher (57.7 percent). Unfortunately, most cases (48.5 percent) are not caught until a late stage when the survival rate is only 6.0 percent.

In Alabama, 20.6 percent of cases are caught at an early stage, which is significantly lower than the national rate of 21.5 percent. It ranks 36th among the 48 states with data on diagnosis at an early stage, placing it in the average tier.

State Intro:

The American Lung Association's "State of Lung Cancer" report explores how lung cancer varies by state. It does this by analyzing key lung cancer indicators including incidence, survival, stage at diagnosis, surgical treatment, lack of treatment and screening rates. Learn more about how lung cancer is affecting your state and contact your local officials to urge them to help save more lives by encouraging lung cancer screening.

Summary:

• Incidence Rate: Below Average Tier
• Five-Year Survival Rate: Bottom Tier
• Early Diagnosis Rate: Average Tier
• Surgical Treatment Rate: Below Average Tier
• Lack of Treatment Rate: Below Average Tier
• Screening Rate: Average Tier
• Fee-For-Service Medicaid Coverage of Screening: No

Despite the early diagnosis rate in Alabama falling into the average tier, the state still has a lot of work to do to make sure that more of those at high risk for lung cancer are screened. When this rate increases, we can anticipate that the surgery rate would increase, as surgery is often the recommended treatment for those diagnosed at an earlier stage. In addition, when cases are found earlier, we would expect the five-year survival rate to increase.

The Lung Association encourages all states to cover lung cancer screening based on recommended guidelines across all fee-for-service and managed care plans without any financial or administrative barriers in their Medicaid programs.

It is alarming that Alabama falls into the below average tier for percent of patients receiving no treatment. Some patients do refuse treatment, but issues such as fatalism and stigma can prevent eligible patients from accessing treatment that may save or extend their lives. All patients should work with their doctors to establish a treatment plan and goals.

Alabama residents can lower their risk of lung cancer, as well as the risk of those around them, through these steps:

• Talk to your healthcare provider if you meet the high-risk criteria, and encourage others who meet the criteria to do the same.
• If you or someone you know is ready to quit smoking, the Lung Association is here to help. Our Freedom From Smoking program has helped over a million people quit smoking for good.
• Higher tobacco taxes both encourage people to quit and prevent children and others from starting to smoke.
• Well-funded tobacco control programs are an important part of helping people quit and keeping potential new smokers from starting.
• Comprehensive coverage of all FDA-approved smoking cessation medication and the three forms of counseling, with no barriers to accessing them, leads to more successful quit attempts.
• Make your house and car clean air zones, with no smoking allowed. Avoid places that are not smokefree, and advocate for smokefree air policies in restaurants, bars, casinos or anywhere they are not in place.
• Test your house for radon, and take steps to reduce your risk if levels are too high.
• Reduce your exposure to unhealthy outdoor air:
• Stay indoors on unhealthy air days.
• Support clean air policies, including emissions limits and no vehicle idling zones.

Increasing lung cancer screening rates among those at high risk will help ensure that more patients undergo surgery during their initial round of treatment and survive the disease.

Survival Intro:

The percent of people still alive five years after being diagnosed with lung cancer (the survival rate) in Alabama is 16.8 percent, which is significantly lower than the national rate of 21.7 percent. It ranks 45th among the 45 states with survival data, placing it in the bottom tier.

Treatment Intro:

Lung cancer can often be treated with surgery as part of the first course of treatment if it is diagnosed at an early stage and has not spread outside of the lung and lymph nodes close to the lung. While surgery may not be an option for every patient, those who receive it as part of their initial treatment have higher survival rates than those who do not. 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.

Alabama ranked 36th (out of the 48 states with available data) with 18.0 percent of cases undergoing surgery as part of the first course of treatment. This is significantly lower than the national rate of 20.6 percent and puts Alabama in the below average tier.