While 2020 will be recalled as the year a rogue virus brought the world economy to its knees, the lung cancer screening community will remember it as a year of deliberation by the United States Preventive Services Task Force (USPSTF) on whether to expand low-dose CT (LDCT) lung cancer screening (LCS) to include adults aged 50—down from 55—to 80 years of age with at least 20—down from 30—pack-years as recommended by the Cancer Intervention and Surveillance Modeling Network (CISNET) Lung Cancer Working Group Technical Report.

Organized radiology, including the Strategic Radiology coalition of privately owned independent radiology groups, thoracic surgery, and lung cancer advocacy groups made their cases in comment letters for expanded low-dose CT lung cancer screening guidelines, and on March 9, the USPSTF announced that the expanded criteria had been approved.

“As we have with done with our mammography screening programs, radiology has an opportunity to make a significant impact on population health by catching lung cancer at an earlier stage when it is treatable,” said Scott Bundy, MD, FACR, Strategic Radiology CEO. “Lung cancer is the number one cause of death by cancer, with nearly 80% of lung cancer patients diagnosed with metastatic disease. We can move the needle on that number if we overcome the challenges to reach more of the at-risk population.”

The broader criteria are expected to more than double the eligible LDCT LCS population from 6.4 million adults to 14.5 million adults, according to an editorial published in JAMA. [1] For Aaron Cann, MD, PhD, head of the chest imaging section at member practice Quantum Radiology, the expanded guidelines represent a return to more inclusive criteria in place 16 years ago, when Quantum Radiology initiated a lung cancer screening program for the Wellstar Hospital System in the Greater Atlanta Metropolitan Area.

“We actually started with Early Lung Cancer Action Program (ELCAP) guidelines back in 2007, long before the National Lung Screening Trial (NLST),” notes Dr. Cann. “Originally, we did this under an IRB using the ELCAP guidelines, which were much more permissive than the NLST guidelines. When NLST came out, we were screening second-hand smokers and patients 50 and up, and we actually had to adjust our guidelines down and screen fewer patients to fit those new guidelines.”

Another Frontier

Dr. Cann and colleagues published data [2] demonstrating that a significant number of lung cancer patients were second-hand smokers, people aged 50 to 55, and people with 15 packs. “The NLST guidelines were way too restrictive in my experience,” he said. “We have been huge proponents for a long time of what the USPSTF just did.”

Including second-hand smokers represents yet another opportunity to save lives with lung cancer screening, Dr. Cann believes. “Second-hand smoke is dangerous and the NLST guidelines still don’t properly reflect that, so that is another frontier,” he says. “People who lived in houses with spouses that smoked, people that worked on airplanes and in other environments where people smoked, the guidelines just don’t catch them.”

The good news is that the annual number of patients screened is on the rise, he reports. As of January 2021, Quantum Radiology’s program at Wellstar Health System in Atlanta performed 21,000 screening studies on ~8,000 unique patients since its inception. In 2020, 4,600 screening studies were performed, yielding 72 lung cancer diagnoses. “We started slow, and we’ve been ramping up over time,” Dr. Cann says. “Now it is becoming something of a tsunami.”

Slow Uptake

Overall, far fewer smokers and former smokers than eligible under the previous guidelines are participating in a screening program despite the reimbursement support for LDCT LCS examinations. In its comment letter to the USPSTF, Strategic Radiology noted that fact. “We acknowledge that patients who could benefit from Lung Cancer Screening have participated in the program in fewer numbers than we all had hoped. Recent studies estimate Lung Cancer Screening uptake in eligible populations to be between 3.8% and 14.4%. [3,4],” wrote SR Chair Emeritus A. Van Moore Jr, MD; Judith Amorosa, MD, Chair, Lung Cancer Screening Committee, SR–Patient Safety Organization (PSO), a chest radiologist with University Radiology, New Brunswick, NJ; and Lisa Mead, RN, CPHQ, Executive Director, SR­–PSO.

Part of the problem is that screening programs take time to develop, reminds Kurt Schoppe, MD, body imager with member group Radiology Associates of North Texas (RANT), Dallas-Fort Worth, and Radiology Relative Value Scale Update Committee Alternate Representative for ACR. “What people forget is that, historically, we didn’t start with robust breast cancer screening from the word go,” he says. “We still only screen a portion of the population that we should, and that is the most well-known screening program.”

An associated issue is that cancer screening programs require front-end investments in infrastructure and people to comply with registry reporting, scheduling, follow-up, and navigation. “Your technical expenses for doing screening with the registry responsibilities, scheduling, and navigation are higher than the non-contrast chest CT CPT code, and Medicare does not appropriately pay for it, even though the ACR has worked multiple times to try to get those expenses appropriately included in the technical portion of the code,” Schoppe notes. “A lot of hospitals inappropriately assumed they were going to make that up on the back end with procedures or surgeries, and that just really hasn’t panned out for most of them.”

As a result, many of the early programs have been dramatically scaled back or rolled intp larger cancer screening programs, diffusing responsibilities among existing full-time-equivalent employees.

Make it Easy

Dr. Schoppe, who serves as chair of radiology at a county hospital, has found success through automation despite the limited resources in public hospitals. “What we’ve done is try to make the process as automated as possible,” he explains. “We can do that because we have essentially a closed network of PCPs that refer into the county hospital. If we call something a Lung-RADS® 4 or above, that person automatically gets an appointment scheduled. It happens. Our PowerScribe reports use coded fields and automatically populate the registry and the databases that then get checked against scheduling appointments, scheduling follow-ups, and what have you. One of the things you take out of the loop is an overworked very busy PCP having to schedule this.”

PCP visits, pulmonologist visits, and recalls for 3 months, 6 months, or a year are automatically scheduled. “At our other hospitals, we just read the studies we don’t manage the program,” Dr. Schoppe reports. “At the county hospital, I have the IT and quality analyst in the department and therefore we can participate in, organize, and architect a program in an intelligent way as opposed to doing the bare minimum required to get the study reimbursed. The lung cancer screening program is run managed by our oncology service, which also keeps track of all of our other data statistics for other screening modalities. Lung cancer screening is actually considered a significant success on the county side as far as numbers being screened.”

Dr. Cann thinks that the Shared Decision Making (SDM) model under which the study is reimbursed has hampered uptake. Under SDM, patients must participate in a counseling session with their referring physician in which the benefits and harms of screening are explored. “The folks at the USPSTF over-emphasized the potential harms of screening and the Shared Decision-making Model is an example of that,” he says. “Nobody argues that patients shouldn’t make their care decisions, but the formal requirement for a separate billable code has done a huge amount to discourage lung cancer screening. I think that has to go.”

Notably, the American Academy of Family Physicians continues to maintain that the evidence is insufficient to recommend for or against screening for lung cancer with LDCT in persons at high risk of lung cancer based on age and smoking history. The American Association of Thoracic Surgeons recommended lowering the age to 50 for smokers and former smokers with an additional 5% risk of developing lung cancer over the following five years.

Addressing Disparities

In implementing the new guidelines, the USPSTF also addresses racial and gender disparities by providing greater access to lung cancer screening for African American and white female smokers. The fastidious demographic design of the NLST laid the groundwork for subsequent research that highlighted these disparities. Wrote Drs. Moore, Amorosa and Ms. Mead: “Denise Aberle, MD, NLST lead investigator, and her collaborators took extreme care to accurately reflect the demographics and ethnicities represented in the U.S. cigarette-smoking population when the NLST study was designed, relying on the Census Department’s Tobacco Use Supplement of the Continuing Population Survey for 2002–2004…. Lowering the pack-year threshold from 30 to 20 years and initiating screening at an earlier age could help address racial disparities in screening eligibility for a population at higher risk of lung cancer than the white population. Additionally, lowering the pack-year threshold is expected to increase access to lung cancer screening among white women, who accumulate a lower number of pack-years than white men over their smoking history.” [5,6]

Dr. Cann is hopeful that news of the new, expanded criteria will result in higher screening rates. “I hope that the message percolates to the community, and we get more of all eligible people, but in Atlanta, this will mean more minorities, which is a great thing,” he notes. “Hopefully the primary care community will hear about this and refer more people for lung cancer screening, because lung cancer screening saves lives.”

Getting the Word Out

Nonetheless, more needs to be done to optimize the public health benefits of screening eligible patients for lung cancer. “Right now, most of our patients are referred to us by primary care physicians in the Wellstar Medical Group,” Dr. Cann shares. “Sometimes the hospital does a marketing push, and I am proposing that because of the expanded criteria, it should be on billboards all over town.”

Dr Cann recommends that radiology groups collaborate closely with their health systems and hospitals to get the word out. “There needs to be a public health outreach on this,” he believes. “This threat comes from many different locations: veterans, for instance, and flight attendants from the 1960s and 1970s have sky-high lung cancer risk. We work with the airlines to get their patients in for screening. Back then, airplanes were full of cigarette smoke, so unfortunately flight attendants have very high cancer rates.”

Just as radiologists partnered with hospitals, family care physicians, and other medical specialties during the past 45 years to implement multidisciplinary Breast Cancer Screening programs, the same pathways will need to be developed for Lung Cancer Screening. “There is a well-established road to breast cancer screening with Gynecology, Internal Medicine, and Family Practice referrers,” wrote Drs Moore, Amorosa, and Ms. Mead in their comment letter to the USPSTF. “More women of color need to be in this program. A similar road to Lung Cancer Screening needs to be developed with Family Practice, Internal Medicine, Gynecology, Urology (lung cancer and bladder cancer both are attributed primarily to cigarette smoking), and other surgical subspecialties.”

They also emphasized that in addition to time, screening programs require significant resources to flourish. “These programs require infrastructure, people, and other resources to be built over time,” they wrote. “Some Breast Cancer Screening programs have begun to explore the potential to leverage existing infrastructure for the purpose of engaging eligible female populations in LDCT lung cancer screening programs. [7] Public policymakers could help improve lung cancer screening uptake by supporting and funding national community-based awareness campaigns to make smokers and ex-smokers aware of these programs and the benefits of screening in finding lung cancer at earlier, treatable stages.”

Dr. Schoppe is not optimistic that radiology can increase awareness on its own. “I don’t think we will have a lot of impact there,” he says. “The impact we can have is that when we do get people screened, we have to make it easy and we have to make it understandable, and that comes down to your communications—clear form letters used to communicate with both the patients and the referring physicians, sensible reports, and make the process easy.”

References

1. Henderson LM, Rivera MP, Basch E.  Broadened Eligibility for Lung Cancer Screening: Challenges and uncertainties for implementation and equity. JAMA. 2021;325(10):939-941. doi:10.1001/jama.2020.26422 https://jamanetwork.com/journals/jama/article-abstract/2777223

2. Miller DL, Mayfield WR, Luu TD et al. Multidisciplinary computed tomography screening program improves lung cancer survival. Ann Thorac Surg. 2016;May;101(5)1864-9.

3. Zahnd W, Eberth J.M. Lung cancer screening utilization: A behavioral risk factor surveillance system data analysis. Am J Prev Med. 2019; 57: 250-255

4. Jemal A, Fedewa S. Lung Cancer screening with low-dose computed tomography in the United States—2010 to 2015. JAMA Oncol. 2017; 3: 1278-1281.

5. Aldrich MC, Mercaldo SF, Sandler KL, et. al. Evaluation of USPSTF lung cancer screening guidelines among African American adult smokers. JAMA Oncol. 2019;5(9):1318-1324.

6. Pinsky PF. Racial and ethnic differences in lung cancer incidence: how much is explained by differences in smoking patterns? (United States). Cancer Causes Control. 2006;17:1017-1024.

7. Eberth JM, Ersek JL, Terry LM et al. Leveraging mammography setting to raise awareness and facilitate referral to lung cancer screening: a qualitative analysis. J Am Coll Radiol. 2020;17: 960-969. Published online: Feb. 26, 2020.