What is the importance of early lung cancer detection in the delivery of patient care?
Dr. Kazerooni: Lung cancer is the leading cause of cancer death in the United States, and it kills more people than the second, third and fourth leading causes combined. From a population health perspective, it's arguably the most important cancer that radiologists can work on. While there have been lots of advances in lung cancer treatment and therapies in the last 20 years, the biggest change has been in early detection, primarily through lung cancer screening.
Dr. Wandtke: We've had great success in the last decade with the development of CT lung cancer screening programs. Many programs are now seeing a significant number of patients and are detecting large numbers of cancers in earlier stages than they've ever been detected before. We are saving thousands of lives and are shifting the epidemiology of lung cancer in this country.
Following on the success of lung cancer screening programs and the LCSR, what new opportunities are being recognized in the quest to save even more patient lives?
Dr. Kazerooni: Since its introduction in 2015, the ACR LCSR has been instrumental in helping radiology practices evaluate and demonstrate the quality of their CT lung cancer screening programs, including benchmarks from peers and the registry. Along the way we realized that, while we've been managing incidental pulmonary nodules (IPNs) for a very long time, this issue hasn't received the same attention and performance improvement measures that lung cancer screening has had. Today, we recognize that early detection is a combination of both screening and incidental pulmonary nodule management.
Dr. Wandtke: The problem is that more than half of lung cancers are diagnosed in patients that are not in lung cancer screening programs. In part, that’s because it's a risk-based screening program that requires a significant smoking history (which ignores the 15% of lung cancers found in non-smokers) and in part, because most screening-eligible patients are still not being screened. How we most commonly find pulmonary nodules is by detecting them incidentally on other imaging tests. So, if we've done the CT for another purpose, and we find these IPNs, we now have new knowledge that we can use to identify another group of patients at risk for lung cancer, namely those with worrisome lung nodules, and their management can be moved into an incidental pulmonary nodule track.
Tell us about the expansion of the ACR LCSR into the ELCDR. What’s new and how will it improve patient care?
Dr. Kazerooni: IPNs are the most common actionable incidental finding found on radiology exams and have become more common as imaging resolution improves. Unfortunately, an estimated 60% of patients with actionable IPNs don’t receive guideline-concordant follow-up imaging, leading to avoidable late-stage lung cancer diagnoses and much poorer survival. The reasons for this are numerous — an example of the “Swiss cheese” model of errors. Lack of appropriate recommendations for management, lack of communication about that follow up to patients and ordering providers, and lack of tracking that the recommendations are completed all lead to lack of adherence to follow-up recommendations.
Earlier this year, the ACR received an implementation grant to develop diagnostic performance feedback tools for actionable IPNs. In late 2025, the ACR will expand LCSR to support diagnostic performance feedback on management of actionable IPNs. This added capability broadens the established LCSR into an Early Lung Cancer Detection Registry capable of helping radiologists and other physicians increase early lung cancer detection and save more lives. Because we already have the background infrastructure in place as well as the registry fields and definition of terms for lung cancer screening, we can build on that and make it applicable to IPNs. In addition to the current performance feedback provided for LCS exams, the new ELCDR will help healthcare organizations improve management of IPNs through diagnostic performance feedback and benchmarking. The implementation was funded by a Gordon and Betty Moore Foundation grant overseen by the University of California at San Francisco and the Council of Medical Specialty Societies.
What role did the ACR Learning Network IPN collaborative play in developing those new measures?
Dr. Wandtke: I've been working with incidental findings and lung nodules for a decade now, but there hasn’t been a standard way to measure quality or performance around recommendations until fairly recently. When we started the ACR Learning Network, we focused one of the collaboratives on improving the early detection of lung cancer for incidentally detected pulmonary nodules. In our first two cohorts in the program, we developed ways to measure success that are clinically meaningful and can be performed in the real world.
The Learning Network settled on two metrics that we felt most represented quality in this area. The first measure is around the quality of the recommendations being made by the radiologist and their alignment with the Fleischner Society guidelines. Was the management the radiologist recommended from the beginning actually appropriate? This is important because if we make too many recommendations or bring patients back at too short of a time interval, it will lead to excess healthcare costs with limited benefit. If we bring patients back too late, we might not change their course of care and miss chances for earlier/lower stage lung cancer diagnoses, which are more treatable with better outcomes.
The second measure is around the timeliness and completion of follow-up imaging. Timing is very important with lung nodules. It's critically important that we identify lung cancer at early stages. There's about a 50% 10-year survival rate if we identify a stage one or two lung cancer, and only about a 5% or 10% long-term survival rate with a stage three or four lung cancer. So programs ensuring lung nodules are appropriately followed can have a tremendous impact on patient outcomes and make a major difference in population health.
The ELCDR registry will provide performance measures for IPNs that focus both on the quality of radiology report recommendations and timely follow-up completion rates.
What are the benefits of participating in this expanded registry and why is it an indispensable part of every quality and safety program?
Dr. Kazerooni: Actionable incidental findings are found on radiology studies across every body part and every modality: X-ray, CT, MR, ultrasound, nuclear medicine, everything that we do. IPNs represent a staggering 40% of all actionable incidental findings that require follow up. Couple that fact with lung cancer being the leading cause of cancer death by a large margin. If radiology practices had to pick one area to make the biggest impact on saving patient lives, leveraging the ELCDR and improving the quality of how we manage actionable IPNs, easily rises to the top of the list. Our own IPN program tracks all IPNs with actionable follow-up recommendations to ensure they are completed and is a combination of using our electronic health record to track these patients and nurse navigation to work with our referring clinicians and patients in collaboration with our radiologists and supported by our medical group practice.
Dr. Wandtke: I've been the director of our CT lung cancer screening program for over three years, and we rely heavily on the data that comes out of the LCSR to guide our program. The registry provides valuable information that you cannot otherwise obtain, which allows you to conduct performance improvement projects and make your program exceptional. Any organization that is looking to be exceptional in lung cancer care and in early diagnosis of lung cancer should be participating in the LCSR and the upcoming ELCDR. You will impact more patients by participating in both of those programs. You're going to get the data that tells you how you’re doing compared to others around the country. For IPNs, we will have national benchmarks for how you are doing in terms of making recommendations appropriately and making sure patients are coming back on time consistently.
Our practice has had an incidental findings tracking program in place for about a decade now. In talking to many other organizations, including nearly two dozen that have worked with us in the ACR Learning Network, the sites that have IPN quality improvement solutions are getting many benefits. First, they're identifying potential cancers at an early stage, which is improving patient outcomes, our primary goal. Second, they reduce malpractice risk for radiologists, referring providers and healthcare systems. You're also bringing back patients that have appropriate indications for imaging tests that have not been getting those imaging tests previously. The revenue associated with that additional imaging typically funds the program and often generates enough revenue to support other patient-centered projects that do not support themselves financially. Tracking your actionable recommendations makes the organization financially stronger while improving the quality of care in your community.
What role can the ELCDR play in helping radiologists take a leadership role in patient care and population health?
Dr. Wandtke: Inconsistency of IPN management is a big blind spot for most organizations. Addressing early detection of lung cancer is probably the most impactful thing you can do to contribute to population health given that lung cancer is the leading cause of cancer-related mortality for both men and women. Radiologists should not overlook the role we can play in tackling this major challenge. While this is not a radiologist-only problem, radiologists have taken the lead in early lung cancer detection and are saving patient lives. Radiology will be the only specialty to have developed a registry specific to lung nodules. We are demonstrating leadership in population health and finding ways to add value to patient care outside of simply creating radiology reports, which will help us fight the commoditization of radiology.
How can practices get started participating in the ELCDR?
Dr. Kazerooni: Sites that are already registered for the LCSR can participate in the ELCDR without additional fees as soon as it’s launched. They’ll see a familiar layout on the interactive user registry dashboard they’ve already been using, with their own data shown in comparison to national, regional and practice types that match their own. For sites not yet participating in LCSR, we recommend they begin now in order to get familiar with the registry process and prepare for IPN measures. There are also no additional fees for LCSR participation if a site is currently participating in either the Dose Index Registry or the General Radiology Index Registry.
What other resources are available for practices expanding early lung cancer detection programs?
Dr. Kazerooni: The ACR is a member of the American Cancer Society National Lung Cancer Roundtable, which I chair, and we've got a number of radiologists working with us from the ACR. We’ve developed and published online resources for early lung cancer detection, related both to IPNs and screening. The Best Practice Guide for Building Lung Cancer Early Detection Programs has valuable tools and an introductory webinar to help build effective programs across the entire care pathway — from primary care to radiologists and, importantly, nurse navigators.