December 07, 2022

Increase Annual Screening Uptake to Nip Lung Cancer in the Bud

In this issue, we discuss lung cancer screening 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 Lung Cancer Screening Registry at the ACR and the new Chair of the ACR National Radiology Data Registry (NRDR®) Committee.

What is the importance of lung cancer screening 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. In order to make an impact on cancer mortality in the U.S., it is imperative that we increase the uptake of lung cancer screening. Most people are not 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%.

In 2021, the U.S. Preventive Services Task Force changed its lung cancer screening recommendations to lower the starting age for screening from age 55 to age 50 and the smoking history requirements from 30 pack-years to 20 pack-years, which nearly doubles the eligible population for lung cancer screening from about 8 million up to over 14 million people. The lower starting age and pack-year threshold makes this an important life-saving test for more people than ever. And, 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.

As radiologists, we must do all we can to ensure patients are appropriately referred and have widespread access to lung cancer screening CT. Radiology practices play a critical part in their communities to identify individuals who are eligible for screening by helping to educate their patient population as well as their referring providers as to who is eligible, and to make it easy for them to come in for screening.

It's also important to know that the National Committee for Quality Assurance is embarking on the development of a lung cancer screening HEDIS® measure. Similar to the HEDIS measure for breast cancer screening, this will likely revolve around the percentage of patients eligible for lung cancer 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, including screening.

What is the Lung Cancer Screening Registry (LCSR) and why is it an indispensable part of every quality and safety program?
The LCSR helps clinicians monitor and demonstrate the quality of lung cancer screenings 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, but also helps improve and refine lung cancer screening care for everyone at the national level.

As we were setting up the infrastructure for lung cancer screening at the ACR, one of the important things we wanted to do is learn lessons from the prior cancer screening implementations, such as breast cancer, one of which is the importance of the quality of care in saving lives. Because the fundamental foundation of all of 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, their screening results, follow ups and, ultimately cancer diagnosis rates, to ensure they're rolling out lung cancer screening 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.

Improving patient outcomes is the overarching goal of the program, with a focus on smoking cessation and identifying lung cancer at the earliest possible stage and making sure that patients come back for their annual screening CT.

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 to make 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 quality improvement project templates that take users step by step through their own data to conduct gap analysis of their performance compared to the dashboard benchmarks, and go through a cycle of Plan-Do-Study-Act (PDSA) to improve their performance.

One of the key measures for which we have developed quality improvement templates this year is adherence to annual screening. In order to realize the benefit of screening, it's important that patients come back yearly, but adherence to annual lung cancer screening is under 25%. We need to do better if we're going to save lives using lung cancer screening. 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 if 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 tactics that they might find useful to implement.

The other two QI project templates for the LCSR are smoking cessation in the setting of lung cancer screening and radiation dose for lung cancer screening 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 being part of 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.

Of note, physicians can earn up to 20 CME by completing an LCSR PDSA project, and participation can count as a QI project for your ABR Part IV Maintenance of Certification credit.

To learn more about these QI opportunities using the LCSR, read the ACR Bulletin article Improving LCS Adherence in the November issue.

How can LCSR participants get started using these new QI templates?
In the NRDR Support Knowledge Base, we have resources where 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 really 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 real 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 also 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 quit program, as well as the specialist who will be seeing patients who have an abnormal screening test result, such as a pulmonologist and thoracic surgeon. If you don’t have the specialists in your health system or group practice, it’s important to make connections with them so you can streamline patient referrals and reduce the time to a cancer diagnosis so that treatment can begin.

As the new chair of the NRDR Steering Committee, tell us what’s new and next for NRDR?
I'm honored to be the new chair of the NRDR Steering Committee, 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, Dr. Margarita Zuley, 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, the most important thing is to be able to understand how to look at your performance and do the important work of quality improvement. 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 meaningfully.

What advice do you have for radiologists who want to become more involved and engaged in quality improvement initiatives?
It's important for radiologists to be proactive, engaged learners if they're interested in becoming more involved and engaged in quality improvement initiatives. The ACR has a wealth of opportunities for engagement in the activities, by 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 could I possibly make a difference as one person. Don't be afraid; the more you ask and learn, and the more you seek out and encourage people around you, the easier it'll become.

With November just passing, which is Lung Cancer Awareness Month, we've had a lot of focused activities and increased awareness about the importance of accelerating quality lung cancer screening. 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 lung cancer screening and to accelerate quality lung cancer screening in your practices. Participating in the ACR LCSR is an important way to bring high-quality lung cancer screening to your patients.

In the Spotlight

Ella A. Kazerooni, MD, MS, FACR

Ella A. Kazerooni, MD, FACR, is a Professor of Radiology and Internal Medicine at the University of Michigan Medical School, specializing in cardiothoracic radiology, and the Associate Chief Clinical Officer for Diagnostics at the University of Michigan Medical Group. After medical school and diagnostic radiology residency at the University of Michigan, she completed a fellowship in thoracic radiology at Massachusetts General Hospital/Harvard Medical School. She is past President of the American Roentgen Ray Society, the Association of University Radiologists, the Society of Thoracic Radiology and the Radiology Alliance for Health Services Research, a past Trustee of the American Board of Radiology and has served on the ACR Board of Chancellors.

Dr. Kazerooni is the current and founding Chair of the National Lung Cancer Roundtable (NLCRT) at the American Cancer Society. With a mission to create lung cancer survivors, early detection through both lung cancer screening and incidental lung nodule management programs is essential, together with bringing guideline-based care, including biomarker-based therapies, to patients with advanced lung cancer, and to do so in a patient-first manner, with a focus toward eliminating the stigma commonly faced by patients in their lung cancer journey. She is also the founding Chair of the ACR LCSR, led the development of the Lung-RADS® schema for the interpretation and management of lung cancer screening and is Vice Chair of the Lung Cancer Screening Guidelines group at the National Comprehensive Cancer Network.