Screening high-risk individuals for lung cancer with low-dose tomography is an effective and recommended approach for reducing mortality from the condition. That said, planning a lung cancer screening (LCS) program can be challenging, as a successful program requires strategic multidisciplinary collaboration.

Clinicians planning to start a new LCS program would do well to adhere to the new guide developed by the American Thoracic Society and the American Lung Association, particularly to the section on program implementation.

The section, Implementation Guide for Lung Cancer Screening, was written by Carey C. Thomson, MD, MPH, director of the Lung Cancer & Lung Nodule Care Program at Mount Auburn Hospital, Cambridge, Massachusetts, and Andrea McKee, MD, cochair of the Lung Cancer Screening Steering Committee at Lahey Hospital & Medical Center, Burlington, Massachusetts, and is available online.

In the “Planning an LCS Program” section of the guide, pulmonary experts from various successful LCS programs across the United States describe the strategies their institutions used to overcome commonly encountered implementation obstacles and ensure the success of an effective program. Here's what more some of them have to say on the process.

Establishing Resources and Program Structure

The first step in starting an LCS program is to secure resources to support a multidepartmental program.

“We engaged hospital leadership to emphasize the importance of developing an LCS program and ensure that the program had the appropriate infrastructure and staffing,” said Katrina Steiling, MD, MSc, cochair of the Lung Cancer Screening Committee at Boston University School of Medicine in Massachusetts.

Depending on the available resources, the governance structure of each LCS program can vary and is typically categorized as centralized, decentralized, or hybrid. A centralized structure places the majority of LCS responsibilities with the program, whereas a decentralized structure leaves most, aside from the actual exam and interpretation, to the provider. Most programs are governed by a hybrid structure, employing both centralized and decentralized processes.

“This [hybrid structure] means that referrals for LCS exams can be made from a patient’s primary care provider [decentralized referral] or from our Lung Nodule Clinic, where subspecialty providers conduct a shared decision-making visit with patients to review the potential benefits and harms of screening [centralized referral],” Dr. Steiling explained.

“One benefit to a hybrid structure is that patients have more options for discussing LCS with a health care provider and having the test ordered. Some patients may feel more comfortable talking with their primary care provider about their risk factors for lung cancer and whether LCS is right for them, and others might prefer to talk to a specialist,” Dr. Steiling added.

According to Kim L. Sandler, MD, codirector of the Lung Screening Program at Vanderbilt University Medical Center in Nashville, Tennessee, although a centralized structure requires more resources than the other structures, such as staff who can perform the shared decision-making visit, it can significantly decrease the burden on referring providers.

“We meet with every patient for 20 to 30 minutes to discuss all components of the shared decision-making visit, including providing smoking cessation counseling for our active smokers. This is time that our referrers may not have in their busy practices,” Dr. Sandler said.

“Another important component to ensure efficient and effective workflow and communication is regular review of program performance and quality metrics,” Dr. Steiling said.

Quality metrics commonly collected and followed in LCS programs include access to the program, smoking habits, radiology results, cancer detection rate, noninvasive procedures, and invasive procedures. Collecting data on these metrics is necessary for both reporting to an approved registry and tracking the quality of the program.

Building and Implementing a Successful Team

Regardless of the type of program structure, most experts agree that a program coordinator is critical for developing a successful program.

“I believe you have to have a program champion, 1 person who is willing to say, ‘This is my responsibility. I will make this happen.’ That doesn’t mean that the person does it alone, but they are accountable for making sure all the pieces are in place to get the program up and running. Then you rely on collaborations with people in other departments for their expertise,” Dr. Sandler explained.

In addition to a program coordinator who provides administrative attention to detail, a multidisciplinary steering committee is essential to guide program development. A steering committee often consists of leaders from diverse departments, including radiology, oncology, pulmonary medicine, thoracic surgery, and primary care.

“We established a multidisciplinary steering committee tasked with the development and implementation of the LCS program,” Dr. Steiling said. “This committee reviews performance data and quality metrics quarterly and discusses any operational opportunities and challenges.”

“High-quality requires attention to details to ensure that only eligible patients are screened, that referred patients get their screening exams, and that abnormal findings are evaluated in a timely manner. An LCS program coordinator and a patient navigator are the important links,” Dr. Steiling concluded.

Thomson CC, McKee A, Borondy-Kitts A, et al; American Thoracic Society, American Lung Association. Implementation guide for lung cancer screening. lung.org/assets/documents/lung-cancer/implementation- guide-for-lung.pdf. Accessed October 31, 2018.

Aberle DR, Adams AM, Berg CD, et al; National Lung Screening Trial Research Team.Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. doi: 10.1056/ NEJMoa1102873.

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Screening high-risk individuals for lung cancer with low-dose tomography is an effective and recommended approach for reducing mortality from the condition. That said, planning a lung cancer screening program can be challenging, as a successful program requires strategic multidisciplinary.

Experts Give Advice on How to Plan a Successful Lung Cancer Screening Program

Clinicians involved in conducting lung cancer screening (LCS) with low-dose computed tomography (CT) are already at an advantage for optimized care.

LCS is beneficial, as it enables earlier detection of lung cancer in asymptomatic patients, thus allowing curative treatment and reducing mortality risk. However, to ensure that the benefits of LCS outweigh the risks of radiation exposure from the CT, it is critical that the administered radiation dose is as low as possible without compromising image quality.

Such detail is emphaized in the new guide developed by the American Thoracic Society and the American Lung Association, in an effort to help clinicians implement a standardized process and a structured reporting system during the CT.

The guide, entitled Lung Cancer Screening Implementation Guide, was written by Carey C. Thomson, MD, MPH, director of the Lung Cancer & Lung Nodule Care Program at Mount Auburn Hospital, Cambridge, Massachusetts, and Andrea McKee, MD, cochair of the Lung Cancer Screening Steering Committee at Lahey Hospital & Medical Center, Burlington, Massachusetts, and is available online.

“The most important thing is that all sites adhere to the dose limitations required by CMS,” stated Eric M. Hart, MD, chief of chest imaging at Northwestern University Feinberg School of Medicine, Chicago, Illinois, in an interview with MD Magazine

To confirm that LCS programs abide by the American College of Radiology and Society of Thoracic Radiology specifications, screening should follow a standardized and structured protocol. In the “During the CT: Reporting” section of the guide, pulmonary experts from diverse LCS programs describe how their institutions have successfully implemented this process.

LCS programs can standardize the milliampere (mA) dose administered during the CT by following either a fixed-mA or variable-mA approach. In order to ensure the dose administered is optimized for the individual patient, adjustments can be made based on the weight of the patient. For instance, when using a fixed-mA approach, the dose may need to be increased by 10 mA for heavier patients and decreased by 10 mA for patients who weigh less.

In addition to the mA dose, order tracking should be standardized in the program’s database. Most institutions have found it helpful to use an electronic health record system to accomplish this, as notification functions can be programmed to help orders move appropriately and entirely through the screening process, ensuring that abnormal results are reviewed in a timely manner.

According to Kim L. Sandler, MD, codirector of the Lung Screening Program at Vanderbilt University Medical Center in Nashville, Tennessee, all data are entered into the medical record as part of the institution’s LCS program, including components of the risk-prediction model from the shared decision-making visit and important demographic data. “This also makes reimbursement from insurance providers easier, as all information is located in 1 place,” Sandler said.

Ensuring Structured Reporting In addition to standardizing how orders are tracked through the program, reporting results in a structured manner is essential. Structured reporting is critical to guarantee that results are accurately communicated by the radiologist to the provider and that exam data are appropriately submitted to an approved registry for reimbursement.

Most LCS programs use Lung-RADS to interpret and report CT results. Lung-RADS is a classification system that categorizes exam results, thus standardizing the interpretation process.

If the radiologist determines that results are suspicious for lung cancer, a follow-up consultation with a pulmonologist is typically recommended; however, the personnel responsible for scheduling a referral or arranging necessary follow-up scans varies depending on the program’s governance structure.

“Abnormalities detected by LCS can be managed either by the patient’s primary care provider or through the centralized LCS and lung nodule clinic,” said Katrina Steiling, MD, MSc, cochair of the Lung Cancer Screening Steering Committee at Boston University School of Medicine in Massachusetts.

“Providers are always given the opportunity to do these things themselves, but we have found that they prefer for these things to be managed within the program,” Sandler said.

Most experts agree that a program coordinator is helpful for providing oversight for following clinical activity in patients’ charts, guaranteeing results are communicated to the provider and ensuring appropriate follow-up is scheduled with the patient.

“Because we have a dedicated program coordinator, we are able to arrange necessary follow-up for abnormal findings and schedule routine follow-up scans,” Dr. Sandler said. “In order to have a centralized program, you need to have a program coordinator.”

LCS requires multidisciplinary collaboration between radiologists, the multidisciplinary team, primary care providers, nurses, patients, and approved registries. Therefore, it is essential to use a structured reporting system to facilitate accurate communication of results.

Lung cancer screening requires multidisciplinary collaboration between radiologists, the multidisciplinary team, primary care providers, nurses, patients, and approved registries. Therefore, it is essential to use a structured reporting system to facilitate accurate communication of results.

Hannah Kent-Ritchie, PhD

Articles

Experts Give Advice on How to Plan a Successful Lung Cancer Screening Program

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