“Lung cancer screening (LCS) is in a transition period right now,” says Debra S. Dyer, MD, FACR, chair of the department of radiology at National Jewish Health in Denver and chair of the ACR’s LCS 2.0 Steering Committee. “We have opportunities now because of the new eligibility guidelines, but also concerns about a resurgence of COVID-19 — which really halted our momentum just as we were starting to take off in early 2020.”
Earlier this year, the U.S. Preventive Services Task Force (USPSTF) updated their LCS guidelines to broaden LCS eligibility to individuals who are 50 to 80 years of age and who have a 20 pack-years or more smoking history. These guidelines apply to people who currently smoke or who have quit smoking in the past 15 years. The previous USPSTF eligibility age range was 55 to 80 years and 30-pack years. A pack year is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked (learn more about the new guidelines at bit.ly/screening-guidance).1
The change to the guidelines doubles the eligible population, and private insurers and groups, such as the American Academy of Family Physicians, are adopting and supporting the new guidelines. The USPSTF update may also help address healthcare disparities by reaching more Black patients who have a higher risk of lung cancer at a younger age and with a lower smoking history. A return to higher screening numbers, however, is still challenging, Dyer says. “This is especially the case for patients with no primary care provider (PCP) and those who are reluctant to return to screening because of COVID-19 safety concerns,” she says.
“We have concerns around the resurgence of COVID-19 this year and how it might impact screening volume,” Dyer says. “Fortunately, I have not encountered any resistance from patients to come in for screening or follow-up care — which was not the case last year. We are excited about the opportunities the USPSTF recommendations present.”
Expanded eligibility is a huge outcome of the updated guidelines, but there is still work to be done. “Here in Colorado, we are very pleased that our state Medicaid program was one of the first in the country to adopt the new guidelines,” she notes. Medicaid is a bit more flexible and nimble than Medicare, Dyer says. To that issue, the ACR and other physician groups are currently in talks with CMS, urging officials to apply the guidelines to Medicare patients and make LCS a covered benefit. The ACR has also asked the country’s largest private insurers to make changes to their plans reflecting the new guidelines.
“We are discouraging some of the current Medicare coverage requirements when it comes to screening, and optimistic that the talks are going well,” Dyer says. According to Dyer, the requirements mean that Medicare patients must go through a shared decision-making visit with their PCP before they can get a CT for early detection.
Some people do not have PCPs, Dyer points out. That’s a challenge for the overall healthcare system, she says. Optimizing opportunities — such as starting a LCS conversation when a patient comes in for screening mammography — is critical. “Those patients are already aware of the importance of screening and may be more receptive to a discussion about LCS and smoking cessation programs (if applicable),” Dyer says.
“One of the things I have been most frustrated by in my career is the lack of hope among lung cancer patients and their providers,” says Michael R. Gieske, MD, a PCP and director of LCS at St. Elizabeth Medical Center in Edgewood, Ky., and east division physician director of primary care. “The outcomes for lung cancer, really until the last five years or so, have been pretty dismal.”
Traditionally, lung cancer has been caught through symptomatic and incidental pathways, Gieske says. “Now we have a mechanism to go after it — to screen people early just like we have done with breast and colon cancer,” he says. If lung cancer is detected in stage 1, the literature suggests a 70% to more than 90% chance of curing the cancer through surgery, chemotherapy, or immunotherapy intervention, Gieske says.2
“We are on track to roll out and follow the USPSTF 2021 recommendations by January of 2022,” Gieske says. Promoting the significance of LCS and the expanded eligibility pool can only be accomplished through better communication with potential patients and their providers. “It is incumbent upon providers to, at some point, tell their patients that this quick and painless CT scan exists,” he says.
“You also need public service announcements and marketing — and partnering with like-minded organizations helps,” Gieske says. His group is involved with the Kentucky Health Collaborative, a state-based healthcare initiative, for LCS outreach and advocacy. Radiologists need to use the resources available to them now through collaboration with other organizations, Gieske says.
Person-first language can translate into patients thinking of LCS as just another screening test — without the stigma of smoking as the catalyst.
“We have created a number of educational tools, webinars series, and podcasts on LCS,” Dyer says, and the ACR Education Center recently updated its online screening course to include Lung-RADS®. The ACR Lung Cancer Screening (LCS) Registry® is also a great resource. “In my role at ACR, I think the best thing the LCS Steering Committee, and the College as a whole, can do is help provide radiologists with the tools they need to feel comfortable with recommending and scanning for lung cancer as eligibility expands,” Dyer says.
Choosing the right language is perhaps a less-considered way to facilitate LCS and care across the lung cancer continuum, says Ella A. Kazerooni, MD, MS, FACR, chair of the ACR Lung-RADS Committee and LCS Registry. The International Association for the Study of Lung Cancer recently put together a language guide on how to change one’s language to help eliminate blame and end the stigma associated with lung cancer towards one of healing and hope.
“A person is not defined by their condition,” Kazerooni says. “We need person-first, non-blaming language that doesn’t describe people as something — a smoker, for example, is an individual who smokes. A lung cancer patient is a patient with lung cancer. This type of language is catching on, Kazerooni says, and lets patients know that they are patients first “Person-first language can translate into patients thinking of LCS as just another screening test — without the stigma of smoking as the catalyst,” she says.
Just as patients need to understand what LCS actually is, providers too need education on the LCS process, Kazerooni says. “We’ve got to educate and develop systems to help our PCPs identify eligible patients,” she says. “Usually, an IT department can help with that by tracking at-risk patients. Unfortunately, pack-years are not readily available in most EMRs to do this easily yet. PCPs must also implement the shared decision-making process, and discuss smoking cessation too.”
LCS is not just a CT scan, Kazerooni says. “It’s a process. Another component to this is educating your hospital or practice administrators,” Kazerooni says. “Take the numbers to them on your local population at risk for lung cancer, and educate them on the process and the resources needed to support your program. It’s not only the right thing to do for patients who can be saved from a lung cancer death, but like breast cancer screening, it makes sense financially as well.”
Beyond radiologists and PCPs, connecting with the community is vital to the success of an LCS program, she says. “There may be a lung cancer survivorship group in your community, for example, or an advocacy group through organizations like the GO2 Foundation for Lung Cancer, the American Cancer Society, or the American Lung Association that works with state and local health departments to promote screening,” Kazerooni says.
Beyond radiologists and PCPs, connecting with the community is vital to the success of an LCS program. “There may be a lung cancer survivorship group in the community, for example, and the Lung Cancer Alliance works with state and local governments on promoting screening,” Kazerooni says.
Many imaging centers and radiology departments have recovered somewhat from the outbreak of COVID-19 in the spring of 2020, ending the year with no growth in LCS over 2019 nationally, Kazerooni says. “Now we’re seeing the trajectory for the number of screenings slowly rising,” she says. “We are hopeful it will continue to grow through the end of the year.”
“Over the past year we have seen about 85% to 90% of our patients coming back,” Dyer says. That is in no small part thanks to navigators, she adds. Frontline navigators and program coordinators help manage the care continuum for LCS. “They talk to patients on the phone, reassure them that we have safety protocols in place, and work to ensure follow-up care,” says Dyer.
“A lot of our approach to lung cancer centers around the way in which we deal with patients — and really with one another as providers and comrades,” Gieske says. “We have this routine scan available to us for early detection. It is no longer a hopeless situation, and we are starting to catch this earlier — the same as breast or colon cancer.”
“We have been successful in building partnerships to get the word out,” Gieske says. “Our program at St. Elizabeth Medical Center has been collecting solid, homegrown data. When your program is successful, you minimize patient risk and you cause a stage shift that greatly increases survivability.”
“If we do our due diligence, encourage vaccination, and maintain a safe environment for staff and patients, I’m optimistic that we can keep patients coming in for screening,” Dyer says. Last year, for the patients who came in for LCS, Dyer’s group found only one case of lung cancer that was not stage 1. “Screening works,” she says, “and you will find it leads to some very grateful patients.”