Lung Cancer Screening

Inside Lahey: A blueprint for high-volume, high-quality lung cancer screening that’s detecting cancer earlier—and helping to save lives

Andrea McKee, MD
Chairman, Division Chief Radiation Oncology, Lahey Hospital & Medical Center
Brady McKee, MD
Section Head of Thoracic Imaging and Cardiac CT in the Division of Radiology, Lahey Hospital & Medical Center
Sarika Ogale, PhD
Principal Health Economist, Health Economics and Outcomes Research (HEOR), Genentech, Inc

November marks Lung Cancer Awareness month, an important time to raise awareness about the world’s deadliest cancer. Government, industry thought leaders, healthcare providers, and manufacturers share in the common mission of improving outcomes through earlier detection. Lahey Hospital & Medical Center (Lahey) and Genentech are part of this collective movement, and have collaborated on the development of educational lung cancer screening (LCS) materials used by patients and providers.

This post is also part of that movement. It shares insight into Lahey’s and Genentech’s efforts, and how Lahey built a successful LCS program from the ground up so other health systems can join the fight against lung cancer and implement their own LCS programs.

Early detection is everything

If lung cancer is detected early, there is a higher probability of curative treatment. However, a significant challenge with lung cancer management was the absence of an effective method to screen for early-stage disease among the high-risk population. This all changed in 2011 when the National Lung Screening Trial (NLST) demonstrated a 20% reduction in lung cancer mortality with 3 rounds of annual low-dose CT lung screening (LDCT) compared with annual chest radiographs in asymptomatic current and former heavy smokers between 55 and 74 years old. The largest European LCS trial (NELSON trial) recently announced an even greater reduction in lung cancer mortality of 26% using 4 rounds of LDCT over 5.5 years in current and former heavy smokers between 50 and 74 years old.

What is low-dose CT?

A noninvasive scan that takes several detailed 3-dimensional X-rays of the lungs with less than 25% of the typical radiation dose. The 3-D images help detect early-stage lung cancers that may be too small to detect by traditional X-ray. Early detection can mean the difference between life and death.

Despite medical advancements, improvements in lung cancer outcomes remain poor

Simply stated—widespread uptake of LCS among high-risk individuals has been limited despite the proven ability of LCS to prevent thousands of lung cancer deaths per year.

According to the National Health Interview Survey (NHIS), only 2-4% of high-risk smokers received LDCT for lung cancer screening.

Since the landmark NLST, multiple organizations have established guidelines on the use of CT for LCS. However, each set of recommendations varies slightly, which can lead to confusion and different decisions for who should get screened. For example, some recommend that screening stop at age 74, while others extend the eligible age to 79 and 80. Variations also exist based on the length and intensity of the person's smoking history.

The LCS reimbursement landscape

While reimbursement has been historically a challenge, both private insurers and Medicare now offer coverage for LCS among eligible high-risk individuals who meet all the eligibility criteria. Medicare beneficiaries must meet all of the following criteria for LCS:

  • Age 55 to 77
  • Asymptomatic (no signs or symptoms of lung cancer)
  • Tobacco smoking history of at least 30 pack-years (one pack-year = smoking 20 cigarettes (one pack) per day for one year, or 40 cigarettes per day for half a year, and so on)
  • Be a current smoker or one who quit within the last 15 years
  • Receive a written order for LCS from a doctor following a shared decision-making visit

The Affordable Care Act requires private insurers to cover LCS for people at high risk who fit the criteria above and are between 55 and 80 years old.

Shifting the LCS paradigm

Lahey is a multidisciplinary thoracic oncology center that diagnoses and treats lung cancer with specialized teams of radiation and medical oncologists, diagnostic and interventional radiologists, thoracic surgeons, interventional pulmonologists, pathologists, oncology nurses, patient navigators, and nutritionists.

Lahey: a pioneer of early lung cancer detection

  • Began offering LCS in January 2012 as a community benefit program available to all patients at high risk for lung cancer
  • Originated the Lung-RADS system, managed by the American College of Radiology (ACR) and used worldwide for LCS reporting
  • Home-grown LCS database served as the model for one of the most popular commercially available LCS program management systems in use today
  • In conjunction with MeVis AG,* developed a LCS simulation environment “LungAcademy” to help train radiologists to read LCS exams using Lung-RADS
  • The first facility in the United States to be designated an accredited Lung Cancer Screening Center by the ACR and has one of the largest clinical LCS programs in the country
  • Has shared its experience and standards/protocols, and has provided assistance to over 700 lung screening centers worldwide
  • Since 2015, Lahey has consistently detected more stage I than stage IV lung cancers

*MeVis AG develops innovative software for the analysis and processing of image data, contributing to the early detection and diagnosis of cancer.

Lahey continues to detect proportionately more early-stage cancers than late-stage cancers each year

  • A screen-detected stage I lung cancer diagnosis is associated with a 5-year survival rate of 90%
  • Without screening, over 70% of lung cancer is found at a late stage (stage III or IV), which is associated with a 5-year survival rate of only 5%
  • Of the more than 5,400 patients screened at Lahey since 2012, 193 have been diagnosed with lung cancer. 70% were detected at stage I, the earliest and most curable stage of the disease
  • Within the screened population, Lahey diagnosed stage IV less than 10% of the time vs 57% in the unscreened population

“This shift from [diagnoses of] late to early stages has tremendous implications for survival rate and patient care overall.”

—Andrea McKee, MD, Chairman of Radiation Oncology, LHMC

For Lahey, more screening means more lives saved

The Lahey way: success factors for LCS

With the right plan, LCS challenges can become opportunities. Lahey developed a specialized approach to building and implementing a LCS program. Always multidisciplinary—Lahey developed a hybrid program, which combines centralized quality control and decentralized referral for the target population. The program’s success can be attributed to several critical factors:

1
Resource determination

Lahey did not have substantial financial resources prior to starting the LCS program, and did not participate in any lung cancer screening trials. Therefore, Lahey needed to build its own LCS infrastructure from the ground up. It was also essential to quantify the affected population, perform a financial and infrastructure assessment, and assess the operational and financial feasibility of the program prior to implementation.

Lahey provided the lung cancer screening program as a community benefit at no cost to high-risk patients (per NCCN® guidelines and several Lahey criteria).

2
Multidisciplinary alignment

A cornerstone of the Lahey approach has been multidisciplinary alignment and buy-in. The complicated nature of lung cancer care requires a high level of coordination among many providers and specialists, all of whom play a pivotal role in treatment. Lahey ensured that a multidisciplinary approach was taken to create specific aspects of the program.

It was essential to establish partnerships between primary care physicians (PCPs) and radiology. The program requires the primary care team and/or referral base to partner with radiology to identify, inform, and follow all eligible patients through the screening process. This keeps the primary care team invested, informed, and motivated to continue referring patients to LCS.

3
Centralized tracking and decentralized referral

Enrollees in LCS programs may undergo dozens of examinations over a period of decades. A centralized program management system helps ordering physicians keep track of patients, and is one of the primary responsibilities of the program’s operational staff. Lahey’s lung screening database was used as a model for the development of a commercially available LCS program management system, which alerts staff when appointments are due or have been missed, and enacts protocols to notify patients and referring physicians of results and appointments.

In order to improve performance of radiologists, technologists, and the system as a whole, the team at Lahey developed Lung-RADS (a structured LDCT reporting system designed to ensure uniform reporting, efficient communication, and accurate data tracking of LCS findings which enables a centralized review process) following the BI-RADS model developed for breast cancer screening. At Lahey, the supervising radiologist regularly checks all reading radiologists’ reporting metrics to identify outliers, which could indicate a need for additional training.

Since a multidisciplinary care team cannot see every patient, the role of PCPs in the LCS process cannot be overstated. The PCP provider base represents an established and experienced, decentralized preventive care network that is essential to operating a low-cost, high-volume screening program.

4
Radiologist training/credentialing

Lung-RADS also facilitates structured, focused training. Comprehensive training for radiologists to correctly read and code LCS findings was also a critical component of ensuring the high quality of Lahey’s program. This is facilitated by the Mevis AG LungAcademy software platform, which requires scored reviews of over 100 LCS cases derived from the Lahey LCS program, as well as a series of multiple-choice questions based on included reading material and video lectures. Radiologist reading metrics such as rate of negative, positive, and suspicious cases are reviewed quarterly. At Lahey, radiologists interpreting LCS must read over 150 cases per year to maintain their credentials.

5
Extensive educational campaign outreach (CME) for in-network physician groups

The current low rate of LCS in the United States may be further evidence why PCPs are so important to the screening process. A recent study of PCPs from a wide range of practice settings demonstrated a knowledge gap in familiarity with lung cancer screening guidelines, which could also be a barrier to successful LCS program implementation. Understanding LCS guidelines was found to be associated with a higher likelihood of discussing LCS with patients, utilization of LCS, and referral to a LCS program.

Lahey’s CME consisted of:

  • Conducting face-to-face CME events with local PCP groups
  • Presenting facts from the NLST
  • Detailing the risks and benefits specific to LCS
  • Explaining opportunities to integrate smoking cessation counseling
6
Effective and collaborative PCP/patient engagement and utilization of patient navigators

Shared decision-making (SDM) is a collaborative process that allows patients and providers to make healthcare decisions together, taking into account the best scientific evidence available, as well as the patient’s preferences and values. Evaluation of SDM models include patient-reported satisfaction and patient adherence to recommendations.

The Lahey post-examination survey offered to all patients after baseline screening found a 98% overall likelihood to recommend screening to others. In addition, annual screening compliance at Lahey approaches 90%.

Another critical factor in Lahey’s program design was employing a patient navigator, who plays a pivotal role in screening and coordination of services:

  • Works directly with physicians and patients to provide needed resources
  • Acts as a point person for patients
  • Helps usher patients through the screening process
7
Employing effective and timely communication tools

Lahey and Genentech collaborated to develop communication tools for Think. Screen. Know., a coalition dedicated to raising LCS awareness and reducing stigma associated with lung cancer.

Community outreach is also utilized as a decision aid. Presentations at regional councils on aging, veteran’s groups, military bases, professional firefighters associations, semiprofessional baseball events, rotary clubs, chambers of commerce, health fairs, cancer walks, and lung advocacy events are all part of Lahey’s community outreach efforts.

8
Integrated smoking cessation

LCS helps people quit smoking. Approximately 50% of individuals at high risk for lung cancer are active smokers and can benefit from smoking cessation. Smokers who quit for more than 15 years have an 80% to 90% reduction in their risk of lung cancer compared with those who continue to smoke. A crucial by-product of LCS screening is its effect on smoking cessation rates:

  • Many view LCS as a teachable moment that can improve smoking cessation rates
  • Smoking cessation rates in Lahey’s screening program is 2 to 3 times the national average
  • Offering smoking cessation interventions as part of annual lung screening is estimated to improve overall screening cost-effectiveness by 20% to 45%
  • It has been shown that interventions as brief as 3 minutes can increase cessation rates significantly

CONCLUSION

The healthcare landscape is rapidly evolving. By studying successful LCS programs and learning from their experiences, it is possible to collectively accelerate the learning curve, detect more early-stage cancers, and help save lives.

Raising awareness

Lung cancer causes significantly more deaths in the United States than the next three leading types of cancers combined, all of which already have established screening interventions. Increased awareness and vigilance are needed to screen the appropriate people, including smokers and other high-risk patients.

“The bottom line is that [lung cancer] screening needs to increase among high-risk patients and the criteria used to identify high-risk are still not inclusive enough.”

—Andrea McKee, MD, Chairman of Radiation Oncology, LHMC

Educating PCPs regarding LCS guidelines may improve utilization of LCS for high-risk current and former smokers. The good news is that the majority of PCPs (80%) were interested in receiving additional education about LCS. The general population also needs to be aware of the option of LCS. The Lung Health Barometer, a recent survey among high-risk Americans, found that 84% were unfamiliar with LCS screening and its availability.

Momentum is building for improved outcomes

Successful screening programs like Lahey have demonstrated that as screening volume increases, so does the chance of effectively detecting early-stage versus late-stage lung cancer. The difference can be lifesaving.

In recognition of Lung Cancer Awareness Month this November, and the over 9,000,000 people that are at high risk in the United States, the time is now to shift the LCS paradigm further. It only takes a few pioneers and a team-oriented approach to make meaningful differences in earlier lung cancer detection and start a movement to save lives.

To learn more about lung cancer screening and to access supporting process flows and other educational materials, please visit Lahey Hospital & Medical Center and Genentech’s Think.Screen.Know. program.

Resources

Sponsored by Genentech, Inc.