ACR Bulletin

Covering topics relevant to the practice of radiology

Increase Annual Screening to Nip Lung Cancer in the Bud

Ella A Kazerooni, MD, FACR, discusses the importance of LCS and the ACR Lung Cancer Screening Registry. 
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The ACR has a wealth of opportunities for engagement, including serving on panels or committees that are helping develop these tools and making them better for all stakeholders.

—Ella A. Kazerooni, MD, FACR
January 25, 2023

In this discussion, we dive into lung cancer screening (LCS) and the ACR® Lung Cancer Screening Registry (LCSR) with Ella A. Kazerooni, MD, FACR, professor of radiology and internal medicine and associate chief clinical officer for diagnostics at the University of Michigan Medical Group. She is also the founding chair of the LCSR and the new chair of the ACR National Radiology Data Registry (NRDR®) Committee.

What is the importance of LCS in the delivery of patient care?

Lung cancer has been the leading cause of cancer death in the U.S. among both men and women for over 30 years. To make an impact on cancer mortality in the U.S., it is imperative that we increase the uptake of LCS. Most people aren’t aware that lung cancer kills more people each year than cancers of the breast, colon and prostate gland combined.

Fortunately, we have a screening test that works: low-dose chest CT. We are already seeing what a difference screening programs can make, with a stage shift in lung cancer over the last decade from late-stage cancers to earlier-stage cancers. This is happening because the early-stage cancers commonly found with screening have a five-year survival of 80% to 90%, compared to symptom-detected cancers where it’s only 10% to 15%.1,2

In 2021, the U.S. Preventive Services Task Force changed its LCS recommendations to lower the starting age for screening from 55 to 50 and the smoking history requirements from 30 pack-years to 20 pack-years, which nearly doubles the eligible population for LCS from about 8 million up to over 14 million people. And, more importantly, it reaches a more diverse population, including Black Americans and women, who have a higher cancer risk at a younger age and with a less extensive smoking history.

It’s also important to know that the National Committee for Quality Assurance is embarking on the development of an LCS Healthcare Effectiveness Data and Information Set (HEDIS) measure. Like the HEDIS measure for breast cancer screening, this will likely revolve around the percentage of patients eligible for LCS who are being screened, something that radiology practices can directly impact. HEDIS performance measures are designed to provide purchasers and consumers with the information they need for reliable comparison of health plan performance and cover many measures that impact public health.

What is the LCSR and why is it an indispensable part of every quality and safety program?

The LCSR helps clinicians monitor and demonstrate the quality of LCS in their practices through detailed feedback reports, including peer and registry benchmarks. Because screening is performed on an asymptomatic population, there is an added responsibility for the medical community to ensure that risks and benefits are adequately measured and monitored. Contributing data to the LCSR not only helps clinicians improve their own quality of patient care, it also helps improve and refine LCS care for everyone at the national level.

As we were setting up the infrastructure for LCS at the ACR, one of the important things we wanted to do was learn lessons from prior cancer screening implementations, such as that for breast cancer. Because the fundamental foundation of all the ACR NRDR registries is quality improvement, we see the LCSR as a way for practices to enter their data about the population they are screening, including results, follow-ups and cancer diagnosis rates. This ensures they’re rolling out LCS with attention to quality and by benchmarking themselves against other practices. They can see how they’re performing, look for gaps in performance and engage in quality improvement work to change their screening practices for the better.

Tell us about new initiatives to use LCSR data for quality improvement.

One of the things we’ve been working hard on for the LCSR is making it easier for practices to look at and use their data. We wanted to make the interface more user-friendly and provide tools that can help practices do quality improvement (QI) projects using their own data. The dashboards have been significantly improved for ease of use, and we’ve started to use the format of key performance indicators where practices can focus attention. Importantly, the team of volunteers and ACR staff have developed the first batch of three practice QI project templates that take users step by step through their own data. The templates can help practices conduct gap analysis of their performance compared to the dashboard benchmarks. From there, they can go through a cycle of Plan-Do-Study-Act (PDSA) to improve their performance.

We wanted to make the interface more user-friendly and provide tools that can help practices do quality improvement (QI) projects using their own data.

—Ella A Kazerooni, MD, FACR

A key measure for which we have developed quality improvement templates this year is adherence to annual screening. To realize the benefit of screening, it’s important that patients come back annually, but adherence to annual LCS is under 25%.3 We need to do better if we’re going to save lives using LCS. So we developed a project template where registry participants can look at their data, see how they’re performing and go through actionable steps to identify patients they might target in trying to improve adherence to annual screening. By going through a PDSA cycle, they can then determine whether those tactics are making a difference — and then go through the PDSA cycle and check again. Each template has suggestions for who it might be important to include in a practice or facility when working on performance measures and outlines tactics it might be useful to implement.

The other two QI project templates for the LCSR are smoking cessation in the setting of LCS and radiation dose for LCS CT exams. Smoking cessation is the number one way to reduce cancer deaths, and we know that it can take eight or more quit attempts on average for a person to stop smoking. By providing information and connections to resources with each step in a screening journey, radiology practices play an important role in that quit journey. For radiation exposure, we use the low-dose chest CT technique for lung cancer screening, with just enough radiation exposure to get good-quality pictures of the lung tissue, with less importance to the noisier parts of the images that you might see in the body wall or soft tissues. Keeping the dose as low as possible for patients who may be screened annually for several decades of their lives is really important as a radiation safety measure.

In the NRDR Support Knowledge Base, participants can see these QI project templates as well as step-by-step instructions for how to use them to implement practice changes and analyze their data over time.

What are the actionable steps that radiologists should take now to use LCSR data to improve quality and safety in their organizations?

Whether you are new to the registry or have been submitting data as far back as 2015 when the LCSR first opened, I would encourage you to log in to the registry and look at your data. We want to see active engagement and encourage participants to use some of the tools that we’ve created in the dashboard and the QI templates. The value of your data is looking at your performance and figuring out what you can do to bring better care to your patients. It’s important to engage the right team of people in your practice, which might include a lead radiologist, CT technologist, front desk and scheduling staff, primary care physician advocates for screening, someone from a local tobacco cessation program or with your state program, as well as the specialist who will be seeing patients who have an abnormal screening test result, such as a pulmonologist or thoracic surgeon.

As the new chair of the NRDR Steering Committee, can you tell us what’s new and next for NRDR?

I’m honored to be the new chair, and it’s been wonderful to learn more about the history of each of the registries, what their goals are for the future and what challenges they are facing. Last spring, the prior NRDR Steering Committee chair, Margarita L. Zuley, MD, FACR, brought together NRDR registry chairs with the ACR registry and quality staff leadership at ACR headquarters, which was a great learning experience for all of us.

For me, one of the most important things is for practices to be able to understand how to use their data. Putting data into a registry is one thing, but once you have your data in a registry, you need to be able to understand how to look at your performance and do the important work of QI. We want to make the NRDR suite of registries highly user-friendly, so that radiologists and staff in their facilities who are contributing data can actually dig in and use their data.

What advice do you have for radiologists who want to become more involved and engaged in QI initiatives?

The ACR has a wealth of opportunities for engagement, including serving on panels or committees that are helping develop these tools and making them better for all stakeholders. I used to find quality work daunting and wondered how I could make a difference as one person. But the more you ask, the more you learn — and soon you’re ready to get started.

November is Lung Cancer Awareness Month, and in 2022 we had a lot of focused activities and increased awareness about the importance of accelerating quality LCS. The ACR, in collaboration with the National Lung Cancer Roundtable at the American Cancer Society, launched the first National Lung Cancer Screening Day on Nov. 12. There’s no time like the present to learn more about LCS and to accelerate quality screening in your practices. Participating in the ACR LCSR is an important way to bring high-quality LCS to your patients


1. Henschke CI, Yankelevitz DF, Libby DM, Smith J, Pasmantier M, Yip R. 20-Year Lung Cancer Survival Rates in the International Early Lung Cancer Action Program (I-ELCAP). Radiological Society of North American Annual Meeting, Scientific Abstract S4-SSCH02-3, Chicago, November 27, 2022.

2. Potter AL, Rosenstein AL, Kiang MV, Shah SA, Gaissert HA, Chang DC, Fintelmann FJ, Yang CFJ. Association of computed tomography screening with lung cancer stage shift and survival in the United States: Quasi-experimental study. Br. Med. J. 2022 Mar 30;376e69008 DOI: 10.1136/bmj-2021-069008.

3. Silvestri GA, Goldman L, Burleson J, Gould M, Kazerooni EA, Mazzone PJ, Rivera MP, Doria-Rose VP, Rosenthal LS, Simanowith M, Smith RA, Tanner NT, Fedewa S. Characteristics of persons screened for lung cancer in the United States: A cohort study. Ann. Intern. Med. 2022 doi: 10.7326/M22-1325.

Author Interview by Linda Sowers  consulting editor, ACR