Background
Lung cancer is the most prevalent and deadly malignancy worldwide [
1]. Research indicates that global cancer costs will reach $25.2 trillion over the next 30 years, with lung cancers, tracheal, and bronchus comprising the largest proportion at 15.4% ($3.9 trillion). China will bear the largest economic costs of cancers in absolute terms, accounting for 24.1% of the total global burden [
2]. According to the latest data released by the National Cancer Center (NCC) in 2016, China had an incidence rate of 59.89 per 100,000 for lung cancer, with the mortality rate being 47.51% [
3].
The timing of clinical diagnosis greatly impacts the health outcomes of lung cancer patients, with lower 5-year survival rates associated with later stages. Stage I patients exhibit a 5-year survival rate of 55.5%, while the rate for stage IV patients is only 5.3% [
4]. However, the majority of lung cancer cases in China are diagnosed at advanced stages (III-IV), constituting 64.6% of the total cases [
4]. With broad agreement reached on that early screening for high-risk population is of paramount importance in the management of lung cancer, more attention has been paid to the development of screening technique and nationwide implementation.
There is compelling evidence that Low-Dose Computed Tomography (LDCT) lung cancer screening significantly reduces mortality rates in patients [
5‐
8]. Many countries and organizations recommend LDCT as the primary method for early lung cancer screening and matched policy has been proposed [
9‐
11]. In March 2021, the United States Preventive Services Task Force (USPSTF) updated their lung cancer screening guidelines [
12]. According to the latest recommendations, 14.5 million Americans will be eligible for screening, which is an increase of 6.5 million individuals compared with the previous guidelines [
13,
14]. However, even in this context, less than 5% of the eligible population has undergone LDCT screening as required [
15]. The geographic location of institutions providing service and public compliance have been identified as major influencing factors [
8].
With increasing lung cancer disease burden, the central government of China has incorporated lung cancer screening in several nationwide public health projects. The more prominent ones are the National Major Public Health (NMPH) program in 2005 and the Urban Cancer Early Detection and Early Diagnosis (UCEDED) program in 2012 [
16]. These initiatives have demonstrated gradual improvements in compliance rates for lung cancer screening in China [
17]. However, the LDCT screening rate in most cities remains below 50% [
18‐
21], with significantly lower participation rates in rural areas, while rural areas are often where lung cancer vulnerable groups are more concentrated. To efficiently alleviate lung cancer disease burden as well as improve health equity as proposed in the national “Healthy China” strategy, promoting LDCT coverage and reducing urban-rural disparities is crucial. In China, healthcare resources are unevenly distributed with gathering centers clustered in developed areas [
22‐
25]. Being one of the typical high-value healthcare equipment, Computed Tomography (CT) scanners which are essential for LDCT are usually owned by large-scale hospitals that have sufficient need and technicians for CT services. The inadequate and uneven availability of CT scanners has been proved to significantly impact the accessibility of LDCT services and lung cancer screening in China, especially in rural areas of the western region [
23,
26].
The convenience of overcoming geographical barriers and receiving healthcare services is known as spatial accessibility and is gaining increasing attention by researchers and policy makers [
27]. Based on annual data from China’s rural poverty monitoring reports, geographical barriers have surpassed economic burdens as the primary obstacle hindering timely access to healthcare services [
28,
29]. Apart from allocation of healthcare resources which was being widely studied [
30,
31], healthcare seeking behavior from the demand side is also essential for accurate assessment of spatial accessibility, which includes the preference of healthcare institutions, travel mode, as well as travel impendence. Given the growing burden of lung cancer, and urgent requirement for extension of LDCT in China, a pilot study was carried out in the fifth-largest Sichuan Province. Actual practice and preference for LDCT were investigated through questionnaire. Then, the results were integrated into the Nearest Neighbor Method to assess the rationality of LDCT resource allocation. Based on this, political guidance was proposed to further promote the coverage of lung cancer early screening and diagnosis.
Discussion
Actual practices and preferences for LDCT lung cancer screening in Sichuan Province were studied through a province-wide cross-sectional survey. The results were integrated into spatial accessibility models to reveal the current rationality of CT resource allocation. The findings indicate that further efforts are needed to enhance awareness and compliance with early and regular screening among the high-risk population for lung cancer. The spatial coverage of LDCT services in Sichuan Province is generally satisfactory, but more effort is required to improve equity, especially in the less developed rural western regions.
The current spatial distribution of LDCT resources in Sichuan Province is relatively reasonable, which provides favorable bases for future nationwide lung cancer management strategies. Under the strategic framework of the national “Healthy China” action plan, the National Cancer Center actively implements cancer prevention and control strategies, including promoting screening and early diagnosis and treatment of malignant tumors such as lung cancer. With increasing recognition of LDCT for lung cancer screening, the availability of sufficient and convenient CT scanners is essential for the widespread implementation of early lung cancer screening [
34]. This research shows that more than 95% of the high-risk populations can access LDCT within 60 min through driving/taking public transportation, and 16.56% can walk to the nearest LDCT institution within 30 min, representing generally convenient access to LDCT services.
However, equity in accessing LDCT services remains a major concern for policymakers in Sichuan Province. Equal and accessible comprise the two main goals of healthcare resource allocation in China’s recent government reports, but disparities between rural and urban areas, as well as the more developed eastern and less developed western regions of Sichuan Province, are significant. From the quantity aspect, travel time is generally shorter in better-developed urban areas in the eastern region. From the quality aspect, the difference of spatial access to higher-level healthcare institutions is larger than lower-level healthcare institutions. Moreover, the disparity between urban and rural areas is closely related to the degree of transportation limitations, with greater differences in LDCT services accessibility between urban and rural areas in regions with more restricted transportation options.
Conflict exists between LDCT resource allocation among different levels of healthcare institutions and public preference. Our findings reveal that in Sichuan Province, high-level healthcare institutions at the municipal and provincial levels provide only 22.89% CT accessibility, which is often concentrated in urban areas. In contrast, county-level medical institutions offer 38.70% CT accessibility. Although county-level healthcare institutions and other healthcare institutions (mostly private hospitals) make significant contributions to ensuring LDCT coverage, more than 90% of participants preferred municipal and above level healthcare institutions for screening service. The actual 87.02% of respondents accepting LDCT services at municipal and above level healthcare institutions confirmed the selection biases.
In addition, adherence to annual lung cancer screening among high-risk populations is suboptimal. In Sichuan, lung cancer has the highest incidence rate among all malignancies. However, survey data reveals that only 34.72% of those at high risk are undergoing the recommended yearly screenings, a trend consistent with results from other regions in China [
18‐
21]. Although this rate exceeds that of the United States in 2017 (14.4%, 6.5–18.1%) [
34], the economic benefits of LDCT screening need to be based on a participation rate as high as 95% according to research from the National Lung Screening Trial (NLST) in the US [
6].
It is important to consider the undiscovered lung cancer burden in LDCT resource allocation in China. Recent research revealed a rising incidence of lung cancer in rural Sichuan, which is resulted from improved healthcare access and early detection initiatives in rural settings. Meanwhile, in urban areas, incidence of lung cancer is experiencing a decline due to heightened awareness about lung cancer risks in cities [
35]. Studies show that that individuals who undergo physical examinations, have a family history of lung cancer, or receive chest X-rays or LDCT are more knowledgeable about lung cancer and aware that LDCT can effectively detects early-stage lung cancer [
36]. With social development, the presented incidence of lung cancer in rural area will keep rising, while demand for LDCT screening in both rural and urban area will increase.
Meanwhile, challenges faced by ethnic minorities should be emphasized. Even in sparse populated ethnic minority regions, ethnic minorities are mostly distributed in vast rural area with underdeveloped public infrastructures. Because of the sparse population distribution and lower economic level, healthcare institutions in ethnic minority areas are usually government owned, comparatively lower in level, and fewer in number. Coupled with insufficient health awareness among ethnic minority residents, incidence of lung cancer among ethnic minority groups is a great challenge. Special attention should be paid to improving LDCT coverage in ethnic minority regions.
In summary, regional inequality in lung cancer screening is an important factor contributing to persistent disparities in lung cancer incidence and mortality rates. More efforts should be devoted to correctly guiding the public to both improve accessibility and enhance resource efficiency. Recommendations for the government aimed at improving LDCT screening and thus relieving the lung cancer disease burden were proposed as follows. Firstly, service capacity of LDCT screening in grassroot healthcare institutions should be improved by strengthening topical training and standardized management, meanwhile, health education to the public should be promoted widely to improve compliance among high-risk patients and enhance trust in lower-level healthcare institutions, to promote efficiency of CT resources in county level hospital represented low level healthcare institutions. Secondly, new techniques such as mobile CT vehicle and regular government leaded community-based lung cancer screening activities should be carried out especially in sparsely populated resource-limited rural areas and ethnic minority areas to address the issue of uneven spatial allocation of CT scanners [
26]. Thirdly, efforts should be made to improve public infrastructure, such as public beneficial “rural buses” in remote areas to enhance mobility and facilitating access to LDCT services.
This study is the first exploration of spatial accessibility of lung cancer screening services in China. We utilized CT scanner information from government databases and conducted a representative cross-sectional survey to gain insights into residents’ preferences and willingness to access LDCT services. The innovative use of Nearest Neighbor Method provided valuable information on the spatial accessibility of LDCT services. However, our study has several limitations. Firstly, Sichuan Province was taken as a representative of China, but comparison with other regions within and outside of China was not included due to data limitation. Secondly, we assumed that participants in the cross-sectional survey have equal opportunities to access LDCT services, without considering potential disparities among different socioeconomic groups, non-spatial factors such as service quality, insurance types, and reimbursement schemes that may also affect spatial accessibility and should be considered in future research [
25]. Thirdly, the service capacity of CT scanners as well as availability of LDCT doctors was not considered in this study due to data limitation.
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