PERS PE C T IV E
Work Group on Medical Students in the
Expanded Lung and Colorectal Cancer Screening
Expanded Lung and Colorectal Cancer Screening
— Ensuring Equity and Safety under New Guidelines
Daniel M. Horn, M.D., and Jennifer S. Haas, M.D.​​
100
terviewing for medical education institutions
Class of 2022 Moving Across Institutions for
Interviews for Postgraduate Training. Recom-
mendations on 2021–22 residency season in-
I n 2021, the U.S. Preventive Ser-
vices Task Force (USPSTF) rec-
ommended major expansions of
the populations that should un-
dergo routine screening for lung
or colorectal cancer. Both recom-
mendations are evidence-based
and, if implemented effectively,
will most likely save lives. The
changes were made with an eye
toward reducing inequities in rates
of early cancer detection among
women and people who identify
as Black, Indigenous, or Latinx.
The guidelines, however, were re-
leased without adequate attention
to how they would be implement-
ed. Efforts to deploy complex,
highly personalized screening
methods using the patchwork
approach that is typical of the
U.S. health system could back-
fire, unless health care organiza-
tions, payers, and policymakers
invest in preventive care infra-
structure.
We believe regulatory and pol-
icy solutions are necessary to pre-
vent unintended consequences as-
sociated with these important
expansions in cancer-screening
eligibility. To combat systemic rac-
ism and promote safety in ambu-
latory care, health care systems
could collect and report data on
disparities in preventive care, and
they could design and deploy safe-
ty nets to ensure timely follow-up
after abnormal screening results.
In addition, we need policies
that explicitly support equity
and safety in preventive care.
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Reengineering GME in a Pandemic
.­org/​­wp​-­content/​­uploads/​­2021/​­08/​­Virtual​-­Rec
considering applicants from LCME-accred-
ited, U.S. osteopathic, and non-U.S. medical
schools. 2021 (https://physicianaccountability​
When layered atop an already
inequitable care delivery system,
a substantial increase in the vol-
ume of preventive screening could
exacerbate inequities in access
based on race and other factors
and lead to missed or delayed
cancer diagnoses because of in-
adequate follow-up. Twenty mil-
lion people between 45 and 49
years of age are newly eligible for
routine colorectal cancer screen-
ing under the guidelines. Anoth-
er 6.4 million people are newly
eligible for lung cancer screen-
ing. The recommended age for
starting lung cancer screening in
current or former smokers dropped
from 55 to 50 years, and the rec-
ommended number of pack-years
of smoking history before screen-
ing is initiated dropped from 30
to 20 — which nearly doubles
the population of eligible adults.1
Even before these changes, the
preventive care system wasn’t
functioning well. Under the pre-
vious USPSTF screening guide-
lines, only 5% of eligible people
received lung cancer screening,
and 69% of adults were up to
date for colorectal cancer screen-
ing. Eligible populations now in-
clude younger people, who have
historically had lower preventive-
screening rates, are more racially
and ethnically diverse, and are
more likely to be underinsured
than older people. Inequities in
screening rates, cancer incidence,
and mortality have persisted for
decades, in part because health
_COVID​-­Only_Final​.­pdf).
DOI: 10.1056/NEJMp2116760
Copyright © 2022 Massachusetts Medical Society.
Reengineering GME in a Pandemic
care systems haven’t invested in
preventing systemic racism in the
delivery of routine preventive care
and don’t have functional systems
to consistently follow up after test
results indicating moderate or
high cancer risk.2 Purposeful ac-
tion will be required to overcome
these challenges to meet the
goals of the expanded USPSTF
guidelines.
We believe the first step is for
health care systems to create equi-
ty dashboards that report data on
disparities in screening rates by
race and ethnic group, sexual
orientation and gender identity,
and language. Because we can’t
improve what we don’t measure,
equity dashboards tracking key
process and outcome measures
should become part of the stan-
dard performance-management
tools deployed throughout the
U.S. health system. Our perspec-
tive could then shift from caring
for only the individual patients
who come into our offices to hav-
ing a more complete understand-
ing of the health of our popula-
tions, so that we can begin to
systematically address the barri-
ers our patients experience and
promote the facilitators our pa-
tients need. Such an approach is
critical to delivering on the po-
tential of the new guidelines, and
it will be required to begin ad-
dressing systemic racism and other
inequities in our health care sys-
tems. Of course, reliable equity
dashboards will not be possible
PE R S PE C T IV E
unless health systems consistent-
ly ask patients to share key dem-
ographic data. This will require
proactive education and outreach
in close partnership with the com-
munity, as demonstrated in the
“We Ask Because We Care” cam-
paigns deployed by numerous
U.S. health systems over the past
decade.
Plans to address inequities in
preventive care could be mandat-
ed by the Joint Commission, the
National Committee for Quality
Assurance, and other credential-
ing bodies. Health care systems
will then need to focus on solu-
tions for advancing equity, such
as employing preventive care navi-
gators, offering after-hours screen-
ing and diagnostic services to
enhance access, supporting com-
munity-based screening sites, and
broadly deploying programs offer-
ing home-based screening meth-
ods, such as fecal immunochem-
ical testing or fecal DNA testing
for colorectal cancer. By setting
explicit goals regarding equitable
access to preventive care and track-
ing improvement, we can avoid
exacerbating health disparities
and begin leveraging the USPSTF
guidelines to correct long-stand-
ing inequities.
As health care systems reap
the financial rewards of conduct-
ing the various diagnostic evalu-
ations and surveillance tests that
frequently follow screening, they
could also be mandated to invest
in a comprehensive cancer-screen-
ing safety-net program. Such a
program could include registries
and workflows to ensure that
follow-up of abnormal test re-
sults is completed in a timely
and highly reliable manner for
all patients. Very few programs
for colorectal cancer screening
in the United States have a high-
reliability system to track all pa-
tients who don’t follow up after
n engl j med 386;2  nejm.org  January 13, 2022
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Expanded Lung and Colorectal Cancer Screening
an abnormal screening result.
Although accredited facilities for
lung cancer screening that bill
Medicare are required to submit
data to the Centers for Medicare
and Medicaid Services using a
registry, there’s no requirement
that the registry then be em-
ployed to close the loop and en-
sure that follow-up occurs. An
ideal cancer-screening safety-net
program would track all patients
for various preventive services,
regardless of insurance status.
The goal of implementing equi-
table and safe cancer screening
throughout the population will be
difficult to achieve without pay-
ment and regulatory reform. Sev-
eral types of reform would be
beneficial. First, payers could rec-
ognize the role of health naviga-
tors as crucial members of the
care team. Once navigators are
funded, either by means of a fee-
schedule adjustment or as part
of a primary care subcapitation
model, they could engage with
the most marginalized patients
in their communities to address
social barriers to care, facilitate
shared decision making, and or-
der and schedule indicated tests.
Navigators would also manage
cancer-screening safety-net regis-
tries and perform patient outreach.
Second, the United States lacks
the type of well-organized na-
tional screening program that
has been adopted in many Euro-
pean countries.3 To address this
gap, the federal government and
state governments could enter
into collaborative agreements with
health care organizations to es-
tablish interoperable preventive
care and safety-net registries that
would allow the preventive-screen-
ing records of patients who move
from one health care system or
geographic region to another to
be readily accessible to any clini-
cian they see. Third, mandating
that employers provide paid leave
for preventive care is key to en-
suring uptake among the young-
er populations that are included
in the expanded USPSTF guide-
lines.4
Fourth, Congress could pass
legislation that compels both
commercial and government pay-
ers to immediately cover services
that receive grade A or B recom-
mendations from the USPSTF.
The current 1-year lag before
commercial payers must begin
reimbursing providers for recom-
mended services delays screening
uptake and could therefore delay
the diagnosis of new cancers. Fi-
nally, Medicaid expansion under
the Affordable Care Act has driv-
en substantial improvement in the
provision of preventive care. We
believe all efforts should be made
to induce the 12 states that haven’t
yet expanded Medicaid to do so.5
The expansion of eligibility for
lung and colorectal cancer screen-
ing outlined by the USPSTF rep-
resents an opportunity for the
United States to promote health
equity, create safety-net registries
to ensure adequate follow-up af-
ter screening, and implement reg-
ulatory and payment reform that
facilitates rapid adoption of these
and other preventive care guide-
lines. Given that we are building
on a shaky foundation, all policy
and regulatory levers should be
pulled to generate incentives for
the U.S. health system to invest
in a more equitable and safer ap-
proach to preventive care.
Disclosure forms provided by the authors
are available at NEJM.org.
From the Division of General Internal Medi-
cine, Massachusetts General Hospital and
Harvard Medical School, Boston.
This article was published on January 8,
2022, at NEJM.org.
1. Henderson LM, Rivera MP, Basch E.
Broadened eligibility for lung cancer screen-
ing: challenges and uncertainty for imple-
101
 PERS PE C T IV E Expanded Lung and Colorectal Cancer Screening

mentation and equity. JAMA 2021;​325:​939-
41.
2. Doubeni CA, Simon M, Krist AH. Ad-
dressing systemic racism through clinical
preventive service recommendations from
the US Preventive Services Task Force. JAMA
2021;​325:​627-8.
3. Basu P, Ponti A, Anttila A, et al. Status of
screening in the European Union Member
States — summary results from the second
European screening report. Int J Cancer
2018;​142:​44-56.
4. Ko H, Glied SA. Associations between a
New York City paid sick leave mandate and
health care utilization among Medicaid bene-
ficiaries in New York City and New York State.
5. Fedewa SA, Yabroff KR, Smith RA, Goding
Sauer A, Han X, Jemal A. Changes in breast
and colorectal cancer screening after Medic-
aid expansion under the Affordable Care Act.
Am J Prev Med 2019;​57:​3-12.
DOI: 10.1056/NEJMp2113332
Copyright © 2022 Massachusetts Medical Society.
Expanded Lung and Colorectal Cancer Screening

Slack Tide
implementation and organization of cancer JAMA Health Forum 2021;​2(5):​e210342.

RUNNER - UP IN THE 2 0 21 NEJM MEDIC AL FIC TION CONTES T

Slack Tide
C. Alessandra Colaianni, M.D.​​

T he house on the river was not a beach house,

David had insisted, but a “cove house,” some-
thing infinitely more precious. A beach house was
a luxury; a cove house implied a level of means that
Lena hadn’t even considered before accepting Liam’s
first weekend invitation. But the house itself was
modest; she could imagine the owners, Liam’s
grandparents, casually calling it a “camp,” the way
her other Northeastern friends referred to their
own families’ summer homes. They were always
situated on a lake, or a river or, as a last resort, a
pond. The proximity to water was important, she
had gathered, even if the homes were less than
grand; slight shabbiness was in fact a badge of
honor — a visible signal, perhaps, of how grounded
the owners had remained in spite of their wealth.
The nine of them had gathered each June since
the first year of medical school, establishing an an-
nual respite from the sweltering Baltimore sum-
mers, when the sun would bake the smell of stale
urine into the air just after dawn and make even a
short walk an unbearable ordeal. Now they’d scat-
tered to begin their work as real doctors — they
were all on track to finish intern year — with the
diplomas and battle stories to prove it. Seb had
flown all the way from Washington State for the
reunion, David from Texas, Liam and the rest from
Boston, and Lena had finagled a way to swap one
of her allotted golden weekends at the last minute,
pressing a bottle of wine into her co-intern’s hands
with gratitude approaching supplication.
The sign at the state line announced that she
was entering “Vacationland,” a word that, for Lena,
conjured visions of a theme park. A Maine summer
park would not be garish, she imagined, but would
throb with understated patrician splendor: it would
boast lobster bakes and nautical-themed shorts, se-
rene forest walks and bird-watching; discreet fum-
bling with swimsuit bottoms, goosebumps after
morning ocean swims; a hostess named Elizabeth
but called “Bootsy.”
She exhaled only after her car cleared the bor-
der. Intern year had, if anything, made her more
superstitious — more apt to recognize flocks of
birds as omens of death, to never use the word
“quiet” on a call night, to hold her breath when she
drove through a tunnel or over a bridge, or as now,
across a boundary. Someone in her childhood had
promised that any wish she made while holding
her breath would come true, and she had believed
it long enough for the habit to form. Lately, though,
Lena hadn’t been able to muster the desire to wish
for anything in particular, emitting instead a kind
of wordless, soundless vibration, that she would
make it through. To where, she did not know.
Cove house weekends typically hummed with an
unseen, soul-filling energy entirely distinct from
the pleasures of tradition and togetherness; Lena
believed, but would never admit, that it had some-
thing to do with the tides. David had once told her
that the tides at the house were backward because
of the particular positioning of the cove’s point,
the way the river flowed back to the ocean. Though
he was prone to hyperbole and sometimes even
outright falsehood if it served his story, she had
never checked him on it, preferring to believe that
the cove’s magic was part of its geography, con-
nected irrevocably to the moon.
The dogs, two Boston terriers, ran to her car as
she pulled up the gravel driveway; Seb tumbled out
of the house after them, all elbows and knees. A
peal of unexpected laughter escaped her, and she
stepped out onto the solid ground, smelling pine.
Seb pulled her into a long hug. “You look gaunt,”
he said finally. “Are they letting you eat?”
“She looks great,” Paul chimed in, appearing be-
hind her and picking her up, swinging her around
like a child. “You’re just in time for oysters!”

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