Change in Programming
By Beth W. Orenstein
Vol. 22 No. 5 P. 14
Expanded lung cancer screening eligibility can help reduce deaths.
More people die from lung cancer in the United States than from cancers of the breast, colon, and prostate gland combined, according to the American Cancer Society. Lung cancer is the No. 1 cause of cancer deaths for both men and women, making up nearly 25% of all cancer deaths. “The mortality rate is high because most patients who develop symptoms already have advanced-stage disease,” says Jared Christensen, MD, MBA, vice chair of strategy in the department of radiology at Duke Health in North Carolina and chair of the ACR Lung-RADS Committee.
Early detection through lung cancer screening (LCS) allows for the diagnosis of lung cancer when it’s in its most treatable stage. When detected early, the five-year survival rate is about 90% compared with 16% in advanced-stage disease, Christensen says. Several clinical trials have shown that low-dose CT screening is the best test for finding early-stage lung cancers and reducing lung cancer–related deaths.
That’s why, in March 2021, when the US Preventive Services Task Force (USPSTF) recommended lowering the initial age and smoking history requirements for LCS, radiologists and oncologists rejoiced. The new recommendations lower the age that people start screening from 55 to 50 and reduce the number of pack-years of smoking history from 30 to 20. The USPSTF still recommends annual screening of high-risk individuals until age 80 and only includes individuals who currently smoke or people who have quit smoking within the past 15 years.
The USPSTF made its initial recommendations for annual LCS with low-dose CT in 2013 after the National Lung Screening Trial (NLST) found that participants who received CT had a 15% to 20% lower risk of dying from lung cancer than participants who received standard chest X-rays. The NLST, which enrolled 53,454 current or former heavy smokers aged 55 to 74, launched in 2002 and released its initial findings in late 2010.
The USPSTF’s changes to its recommendations, announced in March, could nearly double the number of people eligible for LCS, says Ella Kazerooni, MD, MS, FACR, chair of the ACR Lung Cancer Screening Registry and the National Lung Cancer Roundtable, which is facilitated through the American Cancer Society. The American Cancer Society predicts nearly 132,000 will die from lung cancer in the United States this year. More widespread screening could save 30,000 to 60,000 lives in the United States each year, Kazerooni says.
The changes are a “big deal,” according to Debra Dyer, MD, FACR, chair of the ACR Lung Cancer Screening Steering Committee. “The previous recommendations left out a lot of patients who are at high risk for lung cancer,” she says, “and there is research to back up that the changes will allow screening programs to pick up more lung cancers.”
Many are hoping that the changes in eligibility will increase LCS in two demographic groups in particular: African Americans and women, populations that are particularly vulnerable. Black men are about 15% more likely to develop lung cancer than white men.
“The Black community has a higher risk of lung cancer with a lower pack-year history than whites,” Kazerooni says. “By reducing the age and pack-year requirements, it increases the number of Black individuals who are now eligible for this life-saving screening test.”
Changes Not Enough
Men have historically had higher lung cancer rates than women, largely because of their smoking patterns. However, a study published in August 2020 in the International Journal of Cancer found that young women—those between the ages of 30 and 49—have a higher rate of lung cancer than men worldwide. The study, conducted in 40 countries across five continents, found women had a higher rate of lung cancer in six countries: Canada, Denmark, Germany, New Zealand, the Netherlands, and the United States. The increase seen in women was largely attributable to higher rates of adenocarcinoma, a type of lung cancer seen in individuals who smoke. However, this type of lung cancer is also the most common type found in nonsmokers and is more likely to occur in young women.
“The population of women who are at high risk for lung cancer and develop it earlier also should benefit from the USPSTF’s updated recommendations to screen people who are younger and who have smoked fewer cigarettes,” Kazerooni says.
However, Christensen, Kazerooni, and Dyer, all of whom run LCS programs at their respective institutions, say the changes alone are not enough. More needs to be done to encourage those who are eligible to take advantage and get screened, they say. The ACR estimates only about 15% of Americans who met the previous USPSTF LCS criteria are tested each year. The radiologists say it may be a little lower at their practices.
“Despite a well-organized effort to educate physicians and patients, we are still only screening a small fraction, about 12%,” says Christensen, who is the imaging director of lung cancer screening at Duke.
Dyer, chair of radiology at National Jewish Health in Denver, estimates her program screens between 5% and 10% of eligible patients, as does Kazerooni, a professor of radiology and internal medicine and codirector of lung cancer screening at Michigan Medicine in Ann Arbor.
The proportion of US adults who get the generally recommended screenings for breast cancer (mammography) and colon cancer (colonoscopy) is much higher: about 67%. Radiologists don’t expect compliance with LCS recommendations to reach that high any time soon, but they would love to see it increase significantly.
“Honestly, the fact that patients are more willing to undergo a colonoscopy than a noninvasive LCS CT is mindboggling!” Christensen says.
Why does LCS lag? Part of the problem is the stigma surrounding lung cancer, Christensen says. Many believe, falsely, that smoking is the only cause of lung cancer and, thus, blame the patient’s habit for the diagnosis. To vastly increase the number of people who are screened for lung cancer, “we must remove the stigma associated with it,” Christensen says. Even when a screening study is ordered, only 60% of patients actually follow through and obtain a screening CT.
“Removing the ‘blame’ that can be attributed to patients is one step in normalizing LCS and expanding its reach,” Christensen says.
Another challenge: LCS is relatively new. The USPSTF made its initial recommendations in 2013, after reviewing evidence of the efficacy of low-dose CT, chest radiography, and sputum cytologic evaluation for LCS in asymptomatic persons who are at average or high risk for lung cancer (current or former smokers). Modern mammography, developed in the late 1960s, was first officially recommended by the ACS in 1976. The USPSTF first urged primary care clinicians to screen for colorectal cancer in December 1995; last fall, the USPSTF lowered the age at which it recommended starting screening for colorectal cancer from 50 to 45, especially for Blacks, who are at higher risk of dying from the disease. It takes time for any of the recommendations to be widely adopted and diligent education of primary care physicians, patients, and the public at large, Kazerooni says.
Yet another challenge is that the requirements for LCS with low-dose CT are more cumbersome compared with breast and colon cancer screening. “Unlike mammography where a woman can self-refer or even colon cancer screening where, if you’re age 50, you’re eligible, with LCS there are all these other requirements besides age and smoking history,” Dyer says.
The new USPSTF recommendations leave in place that patients have to be smoking currently or have quit within the last 15 years. “That means someone has to look at all these eligibility requirements and make sure the patient qualifies. It’s not as simple as sending someone for a CT,” Dyer says. Referring providers have to be “really aware of all the requirements.” Nationally, data suggest that only one-third of primary care physicians know the correct eligibility criteria for LCS, which limits the number of correct referrals, Christensen notes.
Dyer says some people may be fearful because a CT of the chest could turn up other issues, such as thyroid tumors and kidney masses. Their initial LCS “may end up requiring them to come back for additional imaging, such as an ultrasound for the thyroid if we found a mass, or further studies of the kidneys, if we see an abnormality.” Sadly, some patients see it not as the life-saving early detection it may be but rather as an intrusion, she says.
And then there’s the issue of false-positives. Originally, the NLST saw a high false-positive rate of 27%, meaning that the observed finding was not due to lung cancer. “What we found in the trial was a number of indeterminate nodules were identified that may or may not be cancer, so it really wasn’t a false-positive for cancer; it was just the discovery of a nodule,” Dyer says.
The ACR has since responded with a Lung-RADS system similar to the BI-RADS scoring system for mammography. Kazerooni, who served as the inaugural chair of the Lung-RADS committee, says it was very important to develop standardized, clear management guidelines for screen-detected abnormalities “to appropriately manage high-risk findings and avoid unnecessary additional testing and biopsies for lower-risk findings.”
The Lung-RADS classification system is based on the characteristics of the nodule on CT and risk stratification for malignancy. Categories 1 and 2 correspond to a very low risk of lung cancer, and patients are recommended to return for their next LCS exam in a year. Category 3 warrants a follow-up low-dose CT in six months, and category 4, which is split into 4A and 4B, recommends more aggressive follow-up, with shorter interval follow-up CT and possibly a PET/CT and/or biopsy.
Also, the size of the nodule comes into play. “With time, we have been able to use the Lung-RADS system, which was started in 2014, and collect data,” Dyer says. “And now we only report a nodule’s presence if it’s 6 mm or larger because we have the data to show that smaller nodules have a very, very low incidence of lung cancer. With this system, we’ve been able to get the false-positive rate down to about 10% to 12%, not the 27% reported from NLST. And that’s a very big deal, too.” Most radiologists around the country have adapted to the Lung-RADS tool very well, Dyer says. “It’s a fabulous system and a tremendous advance.” Dyer says the key is to get patients to come for their first LCS and use the results as a baseline.
Christensen does not believe that patient access is a significant factor in his program, which offers screening at six sites with most patients within a less than 20-minute drive to a screening center, he says. Duke started its LCS program in 2011. “Our program has grown exponentially each year since that time,” he says. “In our first year, we screened 42 patients. We now screen over 2,400 patients annually.”
Kazerooni agrees. “Our major obstacles are patient and primary care physician education and awareness of who to screen,” she says.
Tips for Success
So what can radiologists do to make LCS as routine for those who need it as mammography and colon cancer screening? Recommendations include the following:
• Take advantage of technology. Christensen says it’s possible to utilize data within EHRs to allow the health system to notify the patient’s primary care provider that a patient may qualify for LCS. “The provider is presented with this alert during routine medical appointments,” he says.
• Educate providers. “We want providers to think of LCS as part of routine encounters with their patients,” Christensen says. Physicians are very busy and have limited time with each patient interaction. “Helping providers understand the benefits of LCS and sharing national society guidelines and recommendations around LCS are important,” he says.
• Educate patients. Through directed patient communication and marketing, “we try to inform patients of this important clinical service and encourage them to discuss LCS with their providers,” Christensen says. “Empowering patients to make informed decisions pertaining to their health or that of loved ones is an important step toward increasing acceptance of LCS.” Kazerooni says it’s also important to make patients understand that LCS is not a once-and-done exam. “LCS is only effective if you continue to screen every year until a patient is no longer eligible,” she says.
Not every LCS program needs to be centralized like Dyer’s, but, she says, it makes it easier to meet the requirements and provides all-around better care. Her centralized program has a nurse practitioner who meets with each patient and follows up on significant findings. “The patient and referring provider receive a letter summarizing the findings on the CT, and the nurse practitioner serves as an intermediary to clarify any next steps,” Dyer says. This system prevents patients from falling through the cracks.
Christensen says his program’s coordinator helps identify who is due for screening but does not yet have the exam ordered “and communicates with both patients and referring providers to help ensure that patients receive the full benefit of screening through adherence.”
Furthermore, Christensen says, his program has a weekly conference where all positive screens are reviewed to confirm the findings and ensure that appropriate follow-up is performed. At monthly meetings, they discuss issues related to provider and patient education, program expansion, outreach, research questions, and revenue management. Programs can earn Designated Lung Cancer Screening status through the ACR and “it’s a great place to start for practices looking to implement LCS,” Christensen says.
Smoking cessation is another significant part of LCS. “LCS is a teachable moment for smoking cessation,” Dyer says. In a centralized program, the patient meets with a nurse practitioner and talks about smoking cessation benefits and programs. “If a patient is a current smoker and not ready to quit, that’s fine,” Dyer says. “They don’t have to agree to quit, but they are made aware of smoking cessation resources.” All of the nurse practitioners in Dyer’s program are trained tobacco treatment specialists.
Private insurance companies have one year from the time the USPSTF issued its recommendations to cover LCS screening for those who qualify. “The Centers for Medicare & Medicaid Services [CMS] recognizes the need to update their LCS National Coverage Determination [NCD] to reflect the USPSTF changes, as well, and a multistakeholder request to reopen the NCD has already been received by CMS to do so,” Kazerooni says.
“If you can find cancer early through screening, you can fundamentally change the face of lung cancer to a survivable cancer,” Kazerooni says. “We’ve got to convince people that coming for screening is a good thing.”
— Beth W. Orenstein of Northampton, Pennsylvania, is a freelance medical writer and regular contributor to Radiology Today.