December 10, 2018

LCS Q&A With Debra S. Dyer, MD, FACR

In this Physician Spotlight, we talk with Debra S. Dyer, MD, FACR, Chair of the Department of Radiology at National Jewish Health in Denver, CO, about how lung cancer screening is evolving, how her lung cancer screening (LCS) program has taken root and three actionable steps that radiologists can take to become LCS champions in their own organizations.
How are radiologists becoming the champions in establishing lung cancer screening programs?
I'm a thoracic radiologist at National Jewish Health, which is a chronic respiratory disease hospital, so LCS is a natural interest of mine. We have many patients who are prior or current smokers and are eligible for LCS. It is very concerning there has been such a low uptake of LCS on the national level, especially since it was finally approved by the U.S. Preventive Services Task Force and screening was recommended for high-risk patients. In January 2014 through the Affordable Care Act, commercial insurance began covering LCS without patient cost sharing, and Medicare came on board in 2015.

Unfortunately, unlike mammography and colorectal screenings, there are lots of hoops physicians must jump through to enable patients to get lung cancer screening, including the requirement for shared decision making and smoking-cessation counseling. Bottom line, there are a lot of barriers. We need to think creatively and maximize our resources. We have a perfect model in mammography with radiologists having leadership roles in screening. In mammography, radiologists manage the screening programs, make recommendations for follow-up and track patient compliance. So, I thought: Why don't we have more radiologists doing the same thing for LCS? What can the ACR do to empower radiologists to take the lead in their institutions or practices or communities — with the overall goal of increasing the adoption of low-dose CT lung cancer screening? I brought the idea to the ACR leadership, and the LCS 2.0 Steering Committee was born.

What is LCS 2.0 and what is the purpose of the committee?
If the first generation of LCS was advocating for approval of LCS and getting payers to reimburse for it, the next generation of LCS is to ensure that as many eligible patients as possible get screened. The LCS committee is exploring the barriers to adoption and trying to figure out the necessary resources and support to help radiologists become more engaged. With LCS 2.0, radiology as a specialty has an opportunity to demonstrate its contributions to value-based care and to population health.

Why are radiologists the right champions to get this off the ground?
Radiologists are the first to know that a patient has a lung nodule. We’re very good at identifying nodules, dictating that they're there and making recommendations for what should be done next. It's only logical that the radiologist should lead the effort in terms of guiding patients through the screening and follow-up process.

How did you get your LCS program started at National Jewish Health?
We actually started our program in 2011, before the National Lung Cancer Screening Trial was published. We developed a robust program for tracking incidentally detected lung nodules. When a nodule is identified, our radiologists dictate a tag phrase at the bottom of our reports to recommend follow up for the patient. This tag phrase can be data-mined by our homegrown automated system, which enters the patients into a local registry for incidental nodules. As a result, we're able to track when a patient gets the recommended follow up and we send letters to patients when they are overdue for their follow-ups. Since we had this process in place, it was fairly easy for us to implement LCS.

An important part of any LCS program is a multidisciplinary conference for review of suspicious nodules. We added a nodule conference onto our weekly multidisciplinary lung tumor conference that was already in place. One of our radiologists leads the nodule conference, which is easy to do since we've seen all the cases. It just makes sense. I coordinate the nodule conference with the help of our LCS navigator who assembles the list of patients with suspicious nodules (both screen-detected and incidental) identified over the past week. I email providers who have patients whose cases will be reviewed at the nodule conference and invite them to attend. Then the multidisciplinary group — which includes thoracic surgeons, pulmonologists, oncologists, radiation oncologists and radiologists — together decides the best next steps for each patient. After each conference, I send emails to the providers to let them know the recommendation from the multidisciplinary group. Now, our providers expect to hear from me and even email me to request that their patients be reviewed.

What are three actionable steps radiologists can take now to get an LCS program started?
First, many radiologists are already participating in tumor boards, so it’s easy to get started by adding a review of suspicious nodules onto those meetings. Radiologists can approach the tumor board leader and say, "Every week, we're finding suspicious lung nodules. Can we bring them to the conference for discussion?” All of the necessary people are already assembled, and the nodule cases usually don't take as long to discuss as a complicated known tumor — maybe three or four minutes. The wonderful thing is that we get everyone on the same page, and the group begins to look to radiologists for leadership, because we’re bringing the cases and our recommendations to them.

The second step is to identify key people in your institution who can help: thoracic surgery, pulmonary, IT, administration. Don’t try to do this alone. And, of course, you want to engage all of your radiologists who will be contributors to the program. Ask them to take turns leading the nodule conference. That way, multiple radiologists will be engaged and recognized as leaders in the effort.

Third, reach out to the ACR for help. Utilize Lung-RADS®, access all of the other ACR LCS resources, and share them with your colleagues. And, finally, consider joining the ACR LCS 2.0 Steering Committee to help us take LCS to the next level.

Debra S. Dyer, MD, FACR

Debra S. Dyer, MD, FACR, is a professor and chair of the Department of Radiology at National Jewish Health (NJH) in Denver, CO. She received her medical degree from George Washington University School of Medicine and did her residency at the University of Colorado Health. She has been in practice for more than 25 years.

Throughout her career, Dyer has been committed to quality improvement. She has implemented numerous quality improvement initiatives, including programs in radiation dose reduction, structured reporting in radiology and the appropriate utilization of imaging. She helped develop NJH’s lung nodule registry, the first of its kind in the United States.

With a special interest in LCS CT and lung nodule management, Dyer is the director of the LCS CT program at NJH. She is also a co-investigator in an LCS CT research study evaluating the utility of biomarkers along with screening CT. She is currently the site principal investigator for a multi-institutional national trial evaluating optimal follow-up protocols for incidental lung nodules.