The Lung Cancer Screening Implementation Guide

 was a product of collaboration among 25 experts from 16 institutions. But it was also a product of both the successes and failures of lung cancer screening (LCS) programs before it.

The new LCS guideline, from the American Thoracic Society and the American Lung Association, was developed on research into the experiences related to previously established LCS programs.

As guideline author Peter J. Mazzone, MD, MPH, of the Cleveland Clinic explained in an interview with MD Magazine®, no one system is right.

“Every site may have a different way to do it, but regardless of how you put the program together, there are certain elements to the structure of the program that are necessary to make sure you’re screening safely,” Mazzone said. “Many different structures of programs are outlined in the guide…[to] highlight all the different things you need to think about and how different programs have addressed those issues.”

Offering and Promoting Smoking Cessation Counseling

Most programs offer smoking cessation counseling as part of a shared decision making (SDM) visit and throughout the program. Some LCS programs also order pulmonary function studies for new patients to provide an overall picture of lung health.

The SDM visits provide time to discuss smoking cessation with patients to help them understand its importance. Resources for smoking cessation can be provided at SDM visits, at the time of the scans, in letters to patients confirming appointments,and in letters to patients with their test results.

According to a US surgeon general 2014 report, individuals who quit smoking experience lower all-cause and cancer-specific mortality.

 Therefore, including smoking cessation counseling in LCS programs provides opportunities to promote smoking behavioral changes, which can affect patient prognosis.

The results of a study from investigators at Mayo Clinic in Rochester, Minnesota, revealed that patients who received positive LCS results were more likely to quit smoking.

 Furthermore, the rate of quitting was directly proportional to the number of positive test findings.

Tracking Tobacco Use and Smoking Cessation

The SDM visit is an opportune time to discuss the patient’s tobacco use status and history. During the visit, health care providers record information related to packs/cigarettes per day/year, years smoked, and years since quitting, if a former smoker. Computed tomography technologists also ask about their current smoking status at each screening.

This information can then be cross-referenced with the patient’s electronic health record (EHR) to encourage follow-up. Based on the information gathered during the SDM, LCS program personnel will follow up with patients through phone- or web-based models or in person during annual visits.

It is also important to track whether smoking cessation counseling is provided in the LCS program. This can be done via documentation in the EHR as part of the order for the scan, via documentation in the LCS database, or through tracking of quality metrics, which may include:

The number of individuals screened for tobacco use and/or the number of individuals who present to an LCS screening site

The number of individuals who received or refused counseling to quit and/or the number of individuals identified as current tobacco users

Resources for Smoking Cessation in LCS Programs

The brief tobacco treatment model, which is consistent with the US Public Health Service’s Clinical Practice Guidelines for Treating Tobacco Abuse and Dependence, focuses on 5 steps: (1) asking patients about tobacco use, (2) advising patients to quit, (3) assessing quit readiness, (4) assisting with quitting, and (5) arranging follow-up. Physicians should provide patients with lists of resources, including links, to help facilitate smoking cessation.

Smoking cessation support can be incorporated into LCS programs in many ways. Resource lists can be included with patient letters; LCS program staff can call current smokers, discuss cessation options, and provide counseling; and LCS programs can offer telephone, in-person, and group counseling, as well as online support groups.

“In my specific program, I’ve found we have advanced practice providers who do these visits. They’ve been trained as smoking cessation counselors. They provide our patients with resources to help them quit and point to resources throughout the community that might be easier for them to access over time,” Mazzone explained.

He says there are insufficient data about the benefits of smoking cessation counseling during regular office visits compared with counseling provided as part of LCS programs.

However, research is ongoing to identify unique features in patients recommended for LCS screening for whom the smoking cessation message may prove more beneficial if conveyed outside of the regular office visit.

“When programs are being developed, everyone recognizes that this may be a captive audience. They’ve come in to be screened, there is some concern and understanding about the consequences of smoking, and so it may be a great time to engage the patient in smoking cessation activities,” Mazzone added.

Thomson CC, McKee A, Borondy-Kitts A, et al. American Thoracic Society, American Lung Association. Lung cancer screening implementation guide. lung.org/assets/documents/lung-cancer/implementation-guide-for-lung. pdf. Accessed November 12, 2018.

National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: US Centers for Disease Control and Prevention; 2014. ncbi.nlm.nih.gov/books/NBK179276/. Updated January 2014. Accessed November 5, 2018.

Townsend CO, Clark MM, Jett JR, et al. Relation between smoking cessation and receiving results from three annual spiral chest computed tomography scans for lung carcinoma screening. Cancer. 2005;103(10):2154-2162. doi: 10.1002/cncr.21045.

Articles

The Lung Cancer Screening Implementation Guide was a product of collaboration among 25 experts from 16 institutions. But it was also a product of both the successes and failures of lung cancer screening programs before it. 

Smoking Cessation Counseling in Lung Cancer Screening Programs

Setting up a lung cancer screening (LCS) program can be a challenge in a multitude of ways. Through detailing past programs and discussing how they've each addressed their own challenges, the American Thoracic Society and the American Lung Association's new LCS guide

 can help clinicians design, implement, conduct, and streamline lung cancer screening (LCS) programs, Peter J. Mazzone, MD, MPH, of Cleveland Clinic in Ohio, and author on the guidelines, said in an interview with MD Magazine

“If you’re trying to improve your program or if you’re starting up a program, you get to see and learn from others who’ve been there before,” Dr. Mazzone added.

The CMS and the US Preventive Services Task Force suggest yearly screenings for individuals who are at risk of lung cancer and provide the necessary eligibility recommendations, such as upper age bracket and smoking history. When determining whom to screen, program steering committees consider eligibility criteria and provide the following considerations:

Additional evaluation prior to denying screening to patients who are medically inoperable

A 5-year disease-free cutoff period before screening patients with prior malignancy

A 12-month waiting period before enrollment of an individual who had a recent diagnostic chest computed tomography (CT) scan

Delayed screening for patients presenting with respiratory symptoms prior to scheduled testing until their symptoms resolve

Determining clear eligibility criteria is crucial during the development of an LCS program. These criteria should balance the risks and benefits of screening and help primary care providers (PCPs) identify individuals who may qualify for LCS.

“You have to be sure you’re selecting the right group—a group that’s at enough risk of developing lung cancer to benefit but not so sick that they won’t be able to tolerate any evaluation or treatment for things that are found,” Dr. Mazzone explained.

To identify patients who meet the screening criteria, LCS programs must educate PCPs through in-person meetings, presentations that describe the characteristics of high-risk patients, and/or educational packets. Most LCS programs reach out to eligible patients identified by PCPs via letters, emails, or community programs.

Most LCS programs have systems in place to ensure compliance with the eligibility criteria before an exam is scheduled and a scan is performed. For patients who do not meet the eligibility criteria but still wish to undergo a CT scan and are willing to pay out of pocket, most hospitals have provisions. These patients may or may not be part of the LCS program.

Depending on the structure of the LCS program, patients who are deemed eligible for screening receive counseling about testing from either their PCP or a member of the LCS program.

“Many, many patients are bound to have lung nodules. Most of those aren’t cancer, but they might make your patient rather nervous,” Dr. Mazzone said.

This prescreening counseling, called shared decision making (SDM), is critical because it helps clinicians educate patients about the benefits and harms of the process and eases their anxiety about anticipated results.

The SDM visit helps the patient “make an informed decision, be prepared for the results, potentially participate in smoking cessation, and build a relationship with the team,” Mazzone said.

Perceived barriers to SDM from a patient’s perspective include fear of lung cancer death and stigma. For a physician, barriers include lack of organizational support, lack of decision aids, and lack of time.

If time is limited (eg, less than 5 minutes) for the SDM session, patients are provided SDM tools to review prior to the visit. Scheduling the exam and the SDM visit on the same day helps ensure that patients will adhere to the program.

Most LCS programs use an electronic health record (EHR) system to schedule exams. PCPs schedule exams for programs that use decentralized ordering, whereas coordinators and navigators schedule exams at institutions that follow a centralized program. In hybrid programs, both scheduling options are available.

Most EHR systems cannot make the distinction between an LCS follow-up CT and a diagnostic CT; therefore, programs must monitor this process, and different options for monitoring are used. Some programs rely on the radiologist to make the distinction, others use database check points to ensure the correct order is placed, and in some cases, an LCS program physician reviews reports to confirm that tests have been ordered appropriately.

“The benefit of screening is seen by a minority of everybody who is screened,” Mazzone explained. “By structuring the program around some key principles, whether centralized or decentralized, you can help to guarantee the highest-quality screening for your patients.”

Thomson CC, McKee A, Borondy-Kitts A, et al; American Thoracic Society, American Lung Association. Lung cancer screening implementation guide. lung.org/assets/documents/lung-cancer/implementation-guide-for-lung. pdf. Accessed November 5, 2018.

Through detailing past programs and discussing how they've each addressed their own challenges, the American Thoracic Society and the American Lung Association's new lung cancer screening guide can help clinicians design, implement, conduct, and streamline lung cancer screening programs.

Vijayalakshmi Iyer, PhD

Articles

Smoking Cessation Counseling in Lung Cancer Screening Programs

Defining Eligibility and Providing Counseling Key for Lung Cancer Screening Programs