ACR Bulletin

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Clearing the Barriers

How can radiologists take charge to improve awareness, decrease stigma, and challenge the uptake rate when it comes to lung cancer screening?
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We read these scans. We need to step up at our institutions, hospitals, and practices and champion LCS. But we can’t do it alone. We have to have partners: pulmonologists, primary care providers, oncologists, and thoracic surgeons.

—Debra S. Dyer, MD, FACR
August 07, 2019

Lung cancer is by far the leading cause of cancer death among both men and women. In fact, each year more individuals die of lung cancer than of colon, breast, and prostate cancers combined. This amounts to approximately 390 deaths per day.

The U.S. Preventive Services Task Force began recommending lung cancer screening (LCS) for current and former heavy smokers of at least 30-pack years, ages 55–80, in December 2013. By January 1, 2015, LCS was covered by commercial health insurance plans. By February 5, 2015, Medicare coverage was in place. However, uptake rates have remained astonishingly low, says Debra S. Dyer, MD, FACR, chair of the department of radiology at National Jewish Health in Denver and chair of the ACR’s Lung Cancer Screening 2.0 Steering Committee. Despite evidence of its effectiveness in the National Lung Cancer Screening Trial and the recently-released results of the European NELSON and MILD trials, LCS faces a slew of challenges related to stigma, who can get screened, and reimbursement. This new committee was created to help make LCS as successful as mammography and colon cancer screening — and grew out of mutual frustration among radiologists that LCS was not being utilized to help improve care.

Understanding the Statistics

The National Lung Cancer Screening Trial showed a 20 percent reduction in lung cancer mortality with targeted low-dose CT (LDCT) for LCS. However, according to a 2018 study based on data from the ACR’s National LCS Registry, only 1.9 percent of eligible individuals underwent LDCT in 2016. Encouragingly, a recent analysis of 2017 behavioral risk factor surveillance data across 10 states indicated 14.4 percent of those eligible had a CT scan to check for lung cancer in the previous 12 months, with significant state-to-state variation. But we are still missing a lot of people at risk, notes Dyer. Dyer and others believe several issues, related to stigma and the CMS requirements, may be keeping LCS from being as successful as its screening counterparts.

Today’s society has less empathy for patients who haven’t quit smoking, says Andrea Borondy Kitts, MS, MPH, JACR® associate editor and a lung cancer and patient advocate, consultant, and patient outreach and research specialist at Lahey Hospital and Medical Center. According to Borondy Kitts, it’s easy to forget that tobacco companies targeted heavy smokers when they were just teenagers, spending billions of dollars on advertising campaigns. “There’s a lot of stigma about people who smoke, and a misconception that they caused their own disease so they don’t deserve to get screening,” says Borondy Kitts. “It’s really a difficult situation.”

Stigma is not the only barrier to increasing LCS uptake. “There are a number of barriers to LCS that don’t exist for mammography and colon cancer screening,” says Dyer. The requirement of a shared decision-making visit for patients undergoing LCS is one of the more onerous LCS-specific CMS rules. It means patients must meet with their primary care provider to discuss the benefits and risks of LCS, as well as receive counseling on smoking risks and cessation services. This shared decision-making is not required for any other screening service, such as mammography.

“Physicians are so overwhelmed with the number of patients they see,” says Borondy Kitts. “They may not be talking to patients about LCS for many complex reasons. Maybe they only have five minutes and have to decide between many important topics they could discuss.” Dyer believes that the shared decision-making was a fine idea in theory, but wonders, “Wouldn’t it be great if primary care doctors could do this with every patient for every issue? Instead, this has turned out to be a great barrier.”

When CMS approved LCS it decided to do things a little differently, says Dyer, who notes it was perhaps an experiment, though no one knows for certain. CMS also mandated several other requirements for patients undergoing LCS. For instance, each patient must be entered into a national registry. The College has the only CMS-approved registry for LCS. But this means someone needs to be responsible for entering the data. “To pull all of this together and offer LCS at your practice takes a team,” says Dyer.

Improving the Uptake

That’s why the College founded the new LCS Steering Committee. “Radiologists need to have more of a leadership role in screening,” says Dyer. “We read these scans. We need to step up at our institutions, hospitals, and practices and champion LCS. But we can’t do it alone. We have to have partners: pulmonologists, primary care providers, oncologists, and thoracic surgeons.” The committee is working with stakeholders and patient advocacy groups to spread awareness and promote screening, she notes.

To start, the committee has established several working groups, each charged with its own overarching task to tackle: general outreach to primary care physicians and patients, implementation of LCS, economic issues, and incidental findings. The latter is another major issue for LCS. “We don’t just find nodules,” Dyer says, “we find other abnormalities that require attention, and we need to provide clear recommendations on next steps.” She adds that the committee is creating a one-page reference document for primary care providers and nurse navigators on managing incidental findings, as well as one for LCS program coordinators on economics and billing issues.

The goal is to educate more individuals about the benefits of LCS and how to navigate any challenges and complications, Dyer says. “We want to empower the radiologist, and provide tools to increase the uptake of LCS.”

Author Alyssa Martino,  Freelance Writer, ACR Press