ACR Bulletin

Covering topics relevant to the practice of radiology

No Patient Left Behind

Radiation oncologists and radiologists are changing the face of lung cancer screening for veterans.
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Based on the outcomes we will see through this program, we might be able to develop new screening methods, identify new risk factors to further refine eligibility criteria, and develop other quality indicators for radiologists to use in the future."

—Drew Moghanaki, MD, MPH
August 28, 2019

Each year, more people die of lung cancer than of colon, breast, and prostate cancers combined. Active duty and veteran military members have a significantly higher risk of developing lung cancer — due to exposure from carcinogenic chemicals on military bases and in the field of battle, as well as a higher rate of smoking.1 From 2006 through 2015, 77,930 veterans were diagnosed with non-small cell lung cancer. Unfortunately, the majority presented with advanced stages, which are often incurable and carry a survival rate of only 2–13%.1

These concerning statistics are why the U.S. Department of Veterans Affairs (VA) has been studying lung cancer screening (LCS) since as early as the 1950s. And the VA is doing more each year to make LCS available to every veteran at risk, says Drew Moghanaki, MD, MPH, section chief of radiation oncology at the Atlanta VA Medical Center. “At least once a week I see a patient with advanced lung disease. And when you are faced with this issue at least 52 times a year, you start trying to find any sort of solution that can reduce the rate of this happening,” says Moghanaki. In 2017, Moghanaki formed the VA Partnership to Increase Access to Lung Screening (VA-PALS) Implementation Network. Together with the International Early Lung Cancer Action Program (I-ELCAP), the Bristol Meyers-Squibb Foundation, and other collaborators, the project is working to ensure that VA LCS programs are using best practices.

The first phase of VA-PALS entails the installation of an open source screening software, adapted from the originally pioneered system that’s been in use by I-ELCAP since the 1990s. The newly adopted VAPALS-I-ELCAP software management system received the highest level of certification by the Open Source EHR Alliance in May of 2019 and is scheduled for deployment at ten VA medical centers throughout the country. The system borrows from I-ELCAP’s experience implementing LCS at over 80 institutions globally that has helped them define the way we screen today, says Moghanaki.1 The software, which will be installed on VA networks, will simplify the clinical workflow of LCS by reducing the need for manual data entry and automating alerts for clinicians when patients are overdue for their next evaluations. The program will track patients and develop a data set.

According to Moghanaki, because the software is open source, it can be deployed to other healthcare providers around the world — something that can help increase access to LCS globally. And with such a large population of patients and outcomes being tracked with a harmonized system — including the thousands of VA patients and the 75,000 patients already within I-ELCAP’s LCS registry — this software could lead to the largest global data set ever assembled to guide important changes in how we screen in the future. “Based on the outcomes we will see through this program, we might be able to develop new screening methods, identify new risk factors to further refine eligibility criteria, and develop other quality indicators for radiologists to use in the future,” says Moghanaki.

The implementation project also has a focus on training; ensuring quality low-dose CT image acquisition, interpretation, and reporting of findings; and patient management resources — including advanced practitioners serving as LCS navigators to counsel and track patients at risk for lung cancer, says Ian A. Weissman, DO, FACR, chair of the ACR GSER Network VA Subcommittee. Weissman, a radiologist at the Milwaukee VA (one of the implementation sites for VA-PALS), has already seen the impact of the program at his facility. “When we began the program, many of my colleagues were struggling to find effective ways to increase access to LCS, including successfully tracking patients,” he says. “But now that we’ve hired the LCS navigator, I’ve seen the results of this new VA-PALS initiative.”

For others wanting to get involved in LCS, both in the VA and private healthcare, the key to success is to make sure your LCS program is multidisciplinary — a strength of VA-PALS. “When we first began the program, we all wanted it to be an interdisciplinary partnership so that we could pull in as many experts and resources in the field as possible,” Moghanaki says. Without the support and resources of their institutions, LCS programs simply cannot flourish at the pace that’s needed to reach everyone at risk, he says. Moghanaki further likens those who get involved with LCS programs to volunteer firefighters and other emergency service personnel: “These individuals, like physicians, are very dedicated to saving lives. However, they can’t be successful without appropriate infrastructure supporting them. They need trucks, they need resources, and they need the backing of the city before they can safely run into burning buildings to save lives.” Through its software, training, and patient management, VA-PALS hopes to improve and provide continuous care for veterans throughout the entire LCS process: from screening, to diagnosis, to treatment and follow-up. “We cannot afford to lose any opportunity to save lives,” says Weissman. “No patient should be left behind.”



1. Moghanaki D. Veterans Affairs – Partnership to increase Access to Lung Screening (VA-PALS) [grant proposal]. Bristol-Meyers Squibb Foundation. 2017.

Author Meghan Edwards  Freelance Writer, ACR Press