Lung Cancer Screening: Key Updates for the Clinician
In this video roundtable discussion, Jaspal Singh, MD, MHA, MHS, interviews Jasleen Pannu, MD, Coral Giovacchini, MD, and Leisa Lackey about lung cancer screening, including revisions to the patients who qualify for screening, the barriers and cost of screening, and lung-RADS scores and why they matter. This is part one of a three-part series on lung cancer screening.
Additional Resources:
- Tanoue LT, Tanner NT, Gould MK, Silvestri GA. Lung cancer screening. Am J Respir Crit Care Med. 2015;191(1):19-33. doi:10.1164/rccm.201410-1777CI
- Van Haren RM, Delman AM, Turner KM, Waits B, Hemingway M, Shah SA, Starnes SL. Impact of the COVID-19 Pandemic on Lung Cancer Screening Program and Subsequent Lung Cancer. J Am Coll Surg. 2021;232(4):600-605. doi:10.1016/j.jamcollsurg.2020.12.002
- Lake M, Shusted CS, Juon HS, et al. Black patients referred to a lung cancer screening program experience lower rates of screening and longer time to follow-up. BMC Cancer. 2020;20(1):561. doi:10.1186/s12885-020-06923-0
- Meza R, Jeon J, Toumazis I, et al. Evaluation of the benefits and harms of lung cancer screening with low-dose computed tomography: modeling study for the US preventive services task force. JAMA. 2021;325(10):988-997. doi:10.1001/jama.2021.1077
- Haddad DN, Sandler KL, Henderson LM, Rivera MP, Aldrich MC. Disparities in lung cancer screening: a review. Ann Am Thorac Soc. 2020;17(4):399-405. doi:10.1513/AnnalsATS.201907-556CME
TRANSCRIPTION:
Jaspal Singh:
Welcome everybody to Consultant360. I'm your host, Dr Jaspal Singh. I'm a pulmonologist and critical care physician at Atrium Health in Charlotte, North Carolina. And with me today are three very esteemed guests talking today about our episodes on lung cancer screening and incidental lung nodule management. We'll start with Dr Jasleen Pannu, Jasleen?
Jasleen Pannu:
Hello and thank you so much for having me here. My name is Jasleen Pannu, I'm an interventional pulmonologist. I'm a director of interventional pulmonology translational research at the Ohio State University Medical Center. And I'm passionate about early detection of lung cancer. I dedicate a lot of time working with patients who are diagnosed with lung cancer early, as well as setting up several programs in our hospital to facilitate better care of such patients. So, I've led the setting up of the lung nodule program at the Ohio State University Medical Center in a comprehensive manner that includes a lung nodule clinic, includes AI software to assess lung nodules too. And we are hoping to continue to work on this further.
Jaspal Singh:
Fantastic. Leisa Lackey, would you mind introducing yourself?
Leisa Lackey:
Yeah. Hi, I'm Lisa Lackey. I oversee the lung screening and incidental lung nodule program for Atrium Health in Charlotte, North Carolina. We started our program back in 2017 with lung screening and added incidental lung nodules in 2021, and I'm delighted to be here today. Thank you.
Jaspal Singh:
Thank you for also joining and sharing your expertise. Dr Coral Giovacchini?
Coral Giovacchini:
Hi everybody. Thanks for having me also. I'm Coral Giovacchini. I'm an interventional pulmonologist and the director of clinical operations for our interventional pulmonary program at Duke Health. I also co-direct our lung cancer screening program and have led the growth of our thoracic and interventional pulmonary programs, including an incidental nodule clinic across several sites in our health system, leading predominantly the growth into Raleigh and our Wake County sites as our health system has grown and expanded into new territories.
Jaspal Singh:
Well, fantastic. That's great to have all three of you here. So, welcome to the first part of our three-part series. In the first part, we're going to focus on lung cancer screening. Jasleen, I'm going to start with you. Talk to us a little bit about lung cancer screening, the highlights of who qualifies, and how to get screened. And what have been the latest updates?
Jasleen Pannu:
So, lung cancer screening is recommended by the US Preventative Task Force as a mandatory screening now. Currently, the patients who qualify are patients above 50 years of age up to 80 years. Patients who have smoked more than 20 pack-years, and those who are either currently smoking or have quit smoking less than 15 years ago. This is an update because this criteria has been recently broadened. It was earlier applicable to patients older than 55 years of age, and those who smoked more than 30 pack-years. So, it has been broadened to cover a wider patient population to improve its access. So, those are the patients that currently qualify.
Jaspal Singh:
That's fantastic. So, we know the lung cancer screening, so it sounds like the US Preventive Task Force says it seems to be working, seems to be saving lives, and now they've expanded it. Talk to us a little bit about that if you don't mind.
Jasleen Pannu:
Absolutely. So, since the National Lung Screening Trial (NLST), there have been several other studies and all of them have indicated there's a significant benefit towards mortality. There is a decent amount of patients' lives that can be saved by a very reasonable amount of tests for every 320 screens. Then you can save one patient's life, which is pretty good compared with other screening tests like sometimes you have to do more than a thousand mammograms to detect one breast cancer, and close to 700 Pap smears to detect cervical cancer. And the screening test is noninvasive. It's a low-dose CT scan. It does not involve having a clinic appointment or having somebody get an invasive test for the patient. It just involves lying down to get a CT and it's over within sometimes 20 seconds. So, it's an easy-to-do test and it's also really effective in the sense that the amount of screens you need to do to detect one cancer is pretty small compared to like I said, colorectal cancer, mammograms for breast cancer, or Pap smear. So, it's a pretty effective test.
So, to make it more and more accessible to cover a wider population because it's not that only patients above 55 years of age get lung cancer. There have been increasing reports of lung cancer in patients who smoke lesser or who may not have smoked for that long. And we do not have enough data to exactly say how many pack-years increase the risk to that amount that you should exclude the lower ones. So maybe hopefully in the future, there will be further studies ongoing that may even broaden it further.
Jaspal Singh:
That's fantastic. That's very helpful to know. Now, it sounds like it's mainly for primary care for anyone considering ordering these tests and now I'm imagining all these people are getting screened, right? All these people have this sort of nodules, and abnormality is detected. We screen enough people. We start to find a lot of interesting findings. So, I'll talk a little about when a primary care doctor or somebody else orders a lung cancer screening test, a study of some sort, they might see a score like a Lung-RADS score or how to synthesize some of these findings, if you don't mind for us, Coral?
Coral Giovacchini:
Yes, specifically the scores that are most often, not necessarily always, but most often assigned to low-dose CT scans are referred to as Lung-RADS scores. This was developed by the American College of Radiology as a standardized scoring system and mostly it's an easy language, so it's a unified language between radiologists who are also specifically trained in this and a language that we can use as practitioners afterward to communicate to each other. It scores nodules based on their different characteristics from benign to suspicious looking and also based on size and then changes between CT scans if you're following a lung cancer screening program. I think the other thing that people forget about the Lung-RADS is actually that it's the rest of the RADS, the ADS is and data system. And so, it is also a data system for the radiologists to make sure that we have the data on the lung cancer screening nodules that we are appropriately tracking and assigning these a score and allows for appropriate updates to this.
So, Lung-RADS itself has been around for almost a decade now and has gone through several versions, and the ACR, American College of Radiology continually updates this and has a specific committee looking at all of these things to make sure that we're appropriately assigning these nodules for appropriate follow-up so that it's an easy language for practitioners to follow. I will say other scoring systems have been around and are occasionally used, but Lung-RADS is the most common that you see in the US and there's a big push to kind of standardize this as the predominant one.
Jaspal Singh:
Well, that is super helpful. So, we've talked about who gets in. Who gets this test? Who might be ordering? It might be anybody can order these tests, depending on whether the patient qualifies when we gather. They get the test, the test the CT scan, which is fairly easy to do as we heard. And then it goes into this secret sausage of figuring out how to score it, whatever scoring system we use. And then what happens afterward? The management, I'm just imagining a whole complex web of management questions. Who's picking up the ball? Who's interpreting the tests? Sort of like when people go through mammograms, it might be a systematic team managing it. Leisa, talk to us a little bit about this is kind of your space a little bit about what happens after that scan's done in this void or vortex of a complex health system.
Leisa Lackey:
It's important now that the patient's had a scan that there is some sort of tracking mechanism within the healthcare system that's offering the screening. And so, having a tracking registry is so important to lung screening not just for tracking a patient but also for making sure that the patient gets to the next level of care. A tracking registry can be an Excel spreadsheet. The American College of Radiology has a tool that can be used for manually tracking lung screenings. That seems a little bit labor-intensive, right? To be manually tracking that. It's an option, it's tedious, but for smaller hospitals maybe that makes sense, but it is very limiting concerning tracking compliance. Is a patient coming back? Are they being navigated to the next level of care? Ideally, what is important to think about is finding a software solution. Many out there manage lung screening registries.
It makes it much easier and it's automated. So once a patient has a scan, it's going into the software solution that helps you to track the patient, help you remind the patient, "Hey, you're due for your next screening." It also helps make sure any patient that has an abnormal finding that we can navigate that patient to the next level of care. So, for instance, what we currently have, we're able to track the patient, we're able to remind the patient, but then the navigation part is incredibly important. Some software solutions don't offer that navigation part.
I feel like it's important when you're looking at a solution, to make sure it has the navigation part. We have navigators on staff who are looking what is the next level of care for the patient. Is it another scan? We're going to do a six-month scan. Is it a pulmonary consult? Is it a biopsy? We're going to send them for a thoracic surgery consult. No, they're ready to go on to oncology if it's caught in a later stage or the patient's not appropriate for curative treatment like surgery. So, having that navigation tool has been incredibly important in us making sure that patient gets to the next level of care.
Jaspal Singh:
Well, that sounds pretty sophisticated. So, now we have an easy-to-do test. We have a standardized way of interpreting that test. We have a whole network and a whole team that Leisa leads to manage some of that work for some people who have the team it's great. All three of you have teams that help with a lot of this space, but yet just published our screening rates are so low in the country. Why is that? Talk to us a little bit about what your thoughts are and any of you just sort of why aren't they so low? Despite all these sorts of really major advancements?
Jasleen Pannu:
Yeah. That's a concern, but I am hopeful. I think one issue is that is one of the more recent screenings that has been introduced. So, there are a lot of unknowns about it and there are a lot of myths about it and uncertainties which sort of lead to that gap where the provider, the physician as well and the patient are a bit unaware of it. Sometimes I talk to patients about it and they haven't ever heard about it before. And the same for physicians. Well, they have heard about it, but they're not so aware of it, we all just mentioned they're not so aware of what to do once you order it, and what if you find something accidental or incidental? So, I think that uncertainty leads to some hesitation. So that's one big one that's an issue. And then the next part relates to, I mean, in my mind, I think a lot of stigma where it's the only one of the cancers where we very strongly associate it with smoking. When somebody comes to see us in the office, we say "Hello." And then the next question is, "Do you smoke?" So, it's a lot of subconsciously attaching blame to it. And patients also do that to themselves. They feel guilty and they almost feel like they would deserve something like this to happen for them even though it's not their fault. I mean, nobody could have predicted that in the future. But that makes this hesitation and sort of shame that is happening for the patients themselves. And even physicians and oncologists attest that they feel that the patients are judged and patients themselves feel that they're judged.
So, it keeps that sort of hesitation because they don't want to know the bad news, even though, even if they find cancer early, we find with lung cancer screening close to 60% of the time, most of the cancers will be in stage one that will be found with lung cancer screening. They expect something, they'll find out something bad. So, they want to avoid the bad news, but it may be good news that they're trying to stay away from, and it may become bad if they don't cater to it earlier.
Jaspal Singh:
So, it sounds like what you're saying is, I'm just going to summarize, you had a lot of stuff there. One of the reasons screening rates are about 5% right now in the country is because they should be higher, but education, a lot of hesitancy, maybe some mistrust even of this health system and sort of what the implications are. Maybe some fear and of course the stigma associated with smoking and such, and that's pretty accurate?
Jasleen Pannu:
Yeah.
Jaspal Singh:
And then with that, I'm going to give you a little bit of talk we heard a lot about some of the benefits of finding lung cancer early, but we also heard that other things might be found that we might find other things. So, we may go down a rabbit hole of biopsies and complex procedures on patients who had something that may not have bothered them or even super slow-growing cancers that might've not affected their overall health and life expectancy. And talk to us about this, what some people fear about over-diagnosis, or is that a real concern? Or what are your thoughts on that?
Coral Giovacchini:
Yeah. That's been also one of the major barriers. Overdiagnosis is a major barrier to the uptick of lung cancer screening, right? Even as we went through all the trials over decades, differential rates, even when you're talking about lung nodules, right? There's a nodule rate of about 24% per year in screening that's going to be benign. And so, we're going to pick up a lot of incidental findings, including other lung nodules that we may or may not have had to track down. I think it's also important to note that lung cancer screening is one of the only screening tests that requires a counseling visit. And so, providers, which I think is also a very good thing that we have to go through this counseling about incidental findings, but also probably a barrier to enrolling in lung cancer screening because it's an extra step for providers to do and a requirement for payment for it.
But a part of that counseling is talking about these incidental findings. So certainly, are we saving lives? Yes. We know the data points that will we find incidental things. Yes. And that's an important part of the discussion to have with patients. My personal bias on this is that you can usually counsel around once you find this incidental finding with an appropriate coordinated screening team, what needs to be followed, what needs to be tracked down, and sort of mitigate some of those unnecessary procedures within a structure. But it is a bulky thing to have to deal with as a provider.
Jaspal Singh:
Yeah. Absolutely. It sounds like a very complicated issue, but we need experts like you all to help us with that. Leisa, turn to you a little bit, about these programs and your navigators, and it's a really interesting program. As you're thinking through that, one of the benefits that was found was things like smoking cessation or rates have improved. Talk to us a little bit about the other aspects of lung cancer screening that we don't normally think of potentially.
Leisa Lackey:
Sure. Yeah. I think that we know that smokers are aware that it can cause cancer, right? And so, I think once they have a lung screening, we're hopeful that they'll choose to stop smoking and be able to connect them to resources to help them quit. Here at Atrium Health, we can connect patients. We have a program where we're able to connect those patients with smoking cessation services. We have a variety of advanced providers that are trained to provide that one-on-one counseling. Nicotine dependence is a chronic disease, and so we treat it would hypertension or diabetes. So, we schedule one-on-one visits with APP providers, we feel like they're best suited for that type of work. So yes, we find that there are cases where we have patients who are ready to quit, and we can connect them to the care.
There are other times when we find that patients might have an abnormal finding and we need to get them set up with a pulmonary consult or they don't have transportation, or they don't have anybody in the family that can be a part of a biopsy procedure. You have to have somebody there when you're having a biopsy or surgery. And so, we've found that our team has been able to connect to community resources to make sure we're taking care of the whole patient, right? Not just that lung nodule, but the other things that maybe we haven't identified before, but now it's something we need to make sure of. And that navigation team, I can't stress how important that is. We have a team that's made up of data registry folks, so those are the folks that are tracking the lung screenings. We also have the nurse navigators and then we have care coordinators. We want to make sure that the care coordinators and navigators are taking care of whatever the patient's needs are. And so, they work collaboratively together to take care of whatever that patient needs.
Jaspal Singh:
That sounds great. So, it sounds like to summarize where we're at. It sounds like Coral, you were mentioning a lot about these complex findings, these complex discussions after what we find can lead to a very nuanced discussion, but it sounds like skilled people like yourself can manage them. They just take a lot of trust and a lot of skillset development, but very doable from what you're telling me.
And then Leisa, it sounds like you're talking about sort of screening is just a part of a bigger picture of this gets them to attention of health of other issues from smoking cessation, maybe under covering things like COPD or other things that they might be high risk for. And then we start thinking about some of the social drivers that might be involved here. The ability to go through navigation through a system, the care coordination involved, and all the sort of elements that, yeah, your team does a lot of that and has learned a lot in the space. For those that don't have those teams per se though, there are probably some lessons to be paid attention to, but the care coordination, the navigation, and the other aspects of a strong screening program, does that sound right?
Leisa Lackey:
Yes.
Jaspal Singh:
All right. Anyone else? I just want to say thank you. I know we can talk about lung cancer screening forever for hours, but for our clinicians who are busy practitioners for a quick update, it sounds like we've covered a lot of things from the who's eligible, which has been revised. We've brought in who's eligible for screening. We've talked about some of the key aspects of what happens from ordering the test to the test itself being relatively easy, but then the interpretation being standardized to the follow-up care coordination, the navigation, and potential benefits. It does save lives. It can be extremely helpful. Many people don't know about it, and our screening rates are not great nationally, but we're trying to get them better. We remain hopeful, to use Jasleen's words, remain hopeful that with a combination of education, attention to some of the barriers, and attention to some of the complexities of how to understand and manage such patients, we think we can get those screening rates way up and we need everyone's help to do that. Does that sound about right?
Leisa Lackey:
Yes.
Jasleen Pannu:
Yes.
Jaspal Singh:
All right. Well, on behalf of Consultant360, I want to thank you all for your expertise on this first episode of our three-part series. Again, I'm your host, Dr Jaspal Singh. I want to thank you all for joining us today.
Jasleen Pannu:
Thank you.
Jaspal Singh:
Have a great day everybody.
Leisa Lackey:
Thank you.