ACR Bulletin

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Word of Mouth

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Lung cancer screening advocates are urging providers to share the message with their patients — low-dose CT saves lives.

Word of mouth is so much more powerful than something you see on a billboard.

—Samir J. Parikh, MD, MBA
October 01, 2019

The evidence that lung cancer screening (LCS) improves mortality has increased considerably in the past year — yet this lifesaving strategy continues to be underused. This assessment is the impetus for the ACR, many of its radiologists, and a supporting cast of healthcare professionals who are determined to break down the barriers between LCS programs and the patients who need them.

“The number of patients who have undergone low-dose CT (LDCT) lung screening has increased significantly, contrary to some of the headlines that say uptake is low,” says Ella A. Kazerooni, MD, FACR, a cardiothoracic radiologist and chair of ACR’s Lung Cancer Screening Registry and Lung-RADS® Committee. “The largest obstacle remains education of referring physicians and the public in general. We need to reach primary care providers (PCPs) about who is eligible for screening, when to screen, and how to establish a workflow for providing shared decision-making.”

Telling Numbers

The evidence that LDCT saves lives is difficult to dispute. The National Lung Screening Trial (NLST) — which launched in 2002, with findings reported in 2010 — looked at more than 50,000 people aged 55 to 74 who were current or former smokers with at least a 30 pack-year history of smoking (equal to smoking a pack a day for 30 years or 2 packs a day for 15 years). The NLST found that patients receiving annual CT screens had a 20% lower lung cancer mortality rate compared with individuals screened using standard radiography. The ACR believes NLST data also showed that annual LDCT scans were more cost-effective than other accepted cancer screening interventions, including breast, cervical, and colorectal.

More recent international findings show even greater benefits. The Nelson Study was presented last fall at the International Association for the Study of Lung Cancer’s World Conference on Lung Cancer and showed that LDCT in high-risk patients reduced lung cancer deaths by 26% in men and up to 61% in women (up to a 44% reduction overall if male and female cohorts were evenly split).

Based on the number of lung cancer deaths predicted by the American Cancer Society for 2018, widespread LCS could save up to 65,000 lives in the U.S. each year. Educating PCPs and their patients about these benefits is key when establishing LCS programs. And radiologists are vital to the long-term success of these programs by dispelling misconceptions about the risks versus rewards of LDCT.

Provider Pause

“Among the biggest concerns we’ve seen are over false positives,” says Charles S. White, MD, FACR, professor of radiology and director of thoracic imaging at the University of Maryland School of Medicine. “It’s the idea that you might subject patients to unnecessary additional testing or unnecessary procedures, particularly surgery,” he says. The perception that screening might lead to mortality, or at least morbidity, can cause pushback from providers and apprehension by patients — despite the demonstrated benefits of LCS, White notes. “One of the biggest challenges providers describe when treating patients who undergo LCS is what to do about incidental findings — those unrelated to lung nodules but found on the chest CT report.” To allay some of these concerns, the ACR LCS 2.0 Steering Committee is developing a one-page “quick guide” that identifies the most common incidental findings in LCS and guidelines for follow-up. The recommendations range from “typically no action required” to “follow-up imaging suggested” to “referral to specialist for further evaluation.” 

Getting PCPs on board and at ease is just good medicine because LCS cannot be done in isolation, says David E. Midthun, MD, director of the LCS program at Mayo Clinic. “I think that the majority of the referrals should come from primary care,” he says, not another specialist. “It is part and parcel of healthcare for PCPs to talk to patients to make sure they are up-todate with their colonoscopy, their mammogram, and their LCS, when it’s appropriate.”

Cohesive Cast

Getting (and keeping) PCPs involved in LCS requires constant and focused communication between multiple healthcare players. “As a coordinator, I try to periodically update the physicians on the criteria of our program,” says Tricia Coatie, RN, MSN, OCN, member of ACR’s LCS 2.0 Steering Committee and thoracic oncology clinic and LCS coordinator at Elkhart General Hospital in Indiana. “I
believe it is imperative to stress the importance of educating high-risk patients who are eligible for LCS.” 

Elkhart General Hospital formed its thoracic oncology clinic in 2012, recruiting leaders from radiology, cardiothoracic surgery, oncology, pulmonology, and other specialties to get involved in LCS and treatment. “Our physicians do an excellent job of informing and educating our patients about LCS, but there are still some patients who remain unaware of its importance, possibly because they choose not to see their doctor on a routine basis,” Coatie says. 

Coatie regularly collaborates with radiologists at the hospital to better understand and stay current on LDCT findings. “I sit down with the lead radiologist for our LCS program and he goes over the Lung-RADS assessment categories and recommendations,” Coatie says. 

According to Kazerooni, radiologists can help by reaching out and providing educational information to PCPs in their area. “Put educational material in your waiting rooms — including breast screening areas — where patients coming in are familiar with screening,” Kazerooni suggests. If they don’t want or need screening for themselves, they might still share the information with friends
and families, she says. 

“We as radiologists have to take the first step,” says Samir J. Parikh, MD, MBA, a radiologist at Henry Ford Allegiance Health in Jackson, Mich., who, in 2015, spearheaded a LCS clinic that has served nearly 2,500 patients to date. “Education is most important, but it’s not enough.” PCPs are busy, he says, and when something new is coming down the pipeline, “it can be difficult to wrap your head around.” It’s no different from when radiologists are faced with new technology, he adds. “Sometimes if it doesn’t seem immediately relevant to your practice, it’s difficult to make it a priority,” he says. 

Parikh has held meetings and talks with PCPs and other physicians for CME to encourage interest in LCS. While it is challenging to get them to respond to a meeting request, it isn’t because they don’t care about their patients, he says. “They want to learn more about LCS, but they are busy with other aspects of care. If you put together some kind of forum where they have their questions answered on the spot — not searching for answers — it is much better than sending them a flyer.” The goal is to get PCPs talking to as many patients as possible about LCS. “Patients may have certain behaviors or cultural beliefs that prevent them from getting checked — so we need to be mindful of our approach and response,” Parikh suggests.

For certain populations, LCS is as important as breast cancer screening, Parikh believes. Once you get a patient into your LCS program, encourage them to pass along what they have learned to their friends and family. Parikh points out, “Word of mouth is so much more powerful than something you see on a billboard.”

Author Chad Hudnall,  Senior Writer, ACR Press