It was a bewildering moment for Zach Jump, the American Lung Association鈥檚 national director of epidemiology and statistics. The numbers leaped off the computer screen and prompted an immediate question:
How could California, a leader in reducing lung cancer cases, fall so short on early diagnosis and treatment of the disease?
鈥淚t鈥檚 like you鈥檇 found the needle in the haystack of results,鈥� said Jump. 鈥淚 don鈥檛 know if anyone knew this was going to show up.鈥�
It was right there in the association鈥檚 annual 鈥溾�� report, published in November: California had the third-lowest rate of new lung cancer cases in the country, a laudable achievement. But among state residents diagnosed with the disease, nearly a quarter received no treatment 鈥� a dismal showing that landed California near the bottom of the heap. Worse, California screened high-risk patients at a lower rate than every state but Nevada.
Nationally, the report showed a dramatic increase in the five-year survival rate of people diagnosed with the disease. That finding was reinforced by an American Cancer Society showing that from 2016 to 2017, the U.S. experienced the in cancer mortality ever reported 鈥� driven by a decline in deaths from lung cancer.
California鈥檚 low rate of new lung cancer cases makes sense given its aggressive anti-tobacco laws and high taxes on tobacco products. Between of people who die of lung cancer in the U.S. were smokers, and 鈥淐alifornia is the poster child for tobacco control,鈥� said Jump.
But what explains the state鈥檚 dramatically weaker performance on early diagnosis and treatment?
The answer is complicated in a state as large as California, but lung cancer experts agree on the influence of several factors: the state鈥檚 , broad cultural and linguistic diversity, inconsistency of health care access by region 鈥� and neighborhood 鈥� and a financial reluctance by many medical professionals to treat poor people, who than those of the general population.
鈥淧eople aren鈥檛 getting screened in the places where the incidence of smoking is the highest,鈥� said Dr. Jorge Nieva, an oncologist with Keck Medicine of the University of Southern California.
A , the only recommended screening exam for lung cancer, is highly effective, research shows. In one large clinical trial, it among people at high risk, who were as those between ages 55 and 80 with a history of heavy smoking, even if they had quit within the previous 15 years.
The lung association study shows that just 4.2% of patients in the United States who are at high risk for lung cancer get screened for it 鈥� seen as an alarmingly low figure by those who work in the area of prevention. But compared with that low national figure, California鈥檚 screening rate is woefully inadequate: just 0.9%.
鈥� but only if insurance payments are high enough. Medi-Cal, the government-funded insurance program for low-income people that covers about a third of all Californians, has long paid rates
Not surprisingly, scans are performed much more commonly in areas where people are likely to have good private insurance. 鈥淯nfortunately, it鈥檚 the population that doesn鈥檛 have great insurance that needs the screening the most,鈥� said Nieva.
Medical experts say the state鈥檚 low screening numbers help explain why 24% of California鈥檚 diagnosed lung cancer patients , well above the national average of around 15%. Without adequate screening, lung cancer generally is discovered at later stages, when treatment is far less effective and many clinical trials aren鈥檛 offered.
Other factors weigh heavily on California鈥檚 ability to boost screening and treatment, according to people with deep experience in the field. Among them:
Cultural barriers. Especially among immigrant groups, 鈥渨e need culturally sensitive approaches that include materials, educational tools, awareness campaigns and doctors who can speak to people in their native languages,鈥� said Laurie Fenton Ambrose, president and CEO of the , a patient advocacy group.
Homelessness. As California鈥檚 unhoused population has swelled to health care providers have more difficulty reaching those in need of services. 鈥淢any of the 60,000 homeless in L.A. County would very likely be considered at risk for lung cancer, and they are not being screened,鈥� said Dr. Steven Dubinett, a pulmonologist at UCLA.
Access to primary care. 鈥淐alifornia has some uniqueness in how hard it is to see a doctor in lots of parts of the state,鈥� Nieva said. 鈥淭hat鈥檚 incredibly important when it comes to getting things early on, like that persistent cough you鈥檝e had for a few months.鈥�
Lack of statewide coordination. The state鈥檚 hasn鈥檛 been updated in almost a decade. 鈥淚t is inefficient and slow to improve. You don鈥檛 even have a plan that lays out its goals for fighting lung cancer,鈥� Fenton Ambrose said.
Numerous personal factors can also influence whether patients get screening and treatment, experts say. Some people may be reluctant to be tested for fear of learning they have a terrible disease 鈥� including medical problems unrelated to lung cancer that the exam might uncover.
Nieva and Fenton Ambrose said the stigma attached to lung cancer 鈥� the notion that patients caused it themselves by smoking 鈥� can contribute to a sense of fatalism in both patients and their doctors.
Dubinett favors rolling out screening programs throughout the state, especially in areas where access to health care is spotty. Given the effectiveness of the exams and follow-up treatment if lung cancer is detected early, the state might well improve upon its five-year survival rate for lung cancer patients, which 鈥� roughly matching the national average of 21.7%, according to the lung association.
Such an initiative may fall to the state, with help from academic medical systems including USC and UCLA.
Nieva noted that USC has begun an outreach program in South Los Angeles offering high-risk patients free rides to Keck Hospital for screening.
鈥淭his should be getting done everywhere, and at a 100% rate,鈥� Nieva said. The fact that it鈥檚 not is 鈥渁 real indictment of our health care system.鈥�
This story was produced by聽, which publishes聽, an editorially independent service of the聽.