Key Aspects for Implementing a Lung Cancer Screening Program

Michael A. Pritchett, DO, MPH

For clinicians who see patients at risk of developing lung cancer, a new guide on the implementation of lung cancer screening (LCS) programs has been developed by a panel of experts from the American Lung Association and the American Thoracic Society (ATS).¹ In this pragmatic guide, experts from a variety of US institutions provide a toolkit for how to design, implement, and conduct LCS programs.

“The problem is that 75% of lung cancers are found at stage III or stage IV, where we can’t do surgery, and unless [patients] have some rare molecular mutation, they usually progress and die from lung cancer,” said Michael A. Pritchett, DO, MPH, of FirstHealth of the Carolinas and Pinehurst Medical Clinic in Pinehurst, North Carolina, in an interview with MD Magazine^®.

“Several years ago, the National Lung Screening Trial found that we can [reduce] mortality [by 20%] by doing low-dose screening with CT [computed tomography] scans,” Dr. Pritchett said. “All the major societies have agreed that this is useful and can really create what’s called a stage shift. We want to shift that and flip those numbers, so at least 75% of patients are found at stage I or stage II [and] we can do surgery or just radiation therapy.”

The document was compiled using information from a survey designed to address real-world approaches to common problems encountered in LCS and program implementation for which guideline or consensus statements may not exist.

Screening Criteria

Annual LCS for individuals at risk of developing lung cancer is recommended by major medical organizations, including CMS and the US Preventive Services Task Force. According to Dr. Pritchett, patients have to be 55 to 77 years, with a 30-pack-per-year history of smoking. They also must be asymptomatic and cannot have had a CT scan in the last year.

“When we started this, we were getting everyone sent for LCS. [But] if they don’t meet the criteria, CMS won’t pay for it. The primary care physicians have to learn the criteria, know where patients can be scanned, and know we can take care of it [if they find something],” Dr. Pritchett said.

Core Domains of Lung Cancer Screening Programs

Policy statements from the American College of Chest Physicians and the ATS addressed who is screened, CT performance, reporting, lung nodule management, smoking cessation, patient and provider education, and data collection to ensure that the benefits of LCS outweigh potential harms as it is implemented.

LCS programs should collect data on lung cancer development risk for all enrolled subjects. The program must confirm an existing policy regarding individuals who will be offered screening, with the requirement that ≥90% of all screened subjects match this policy's criteria.

A low-dose CT for LCS should be performed based on American College of Radiology and Society of Thoracic Radiology specifications, and programs should collect data to verify that the average radiation dose complies with these recommendations.

A structured reporting system is recommended, and LCS programs should collect data related to compliance. Each program should confirm that at least 90% of CT screen reports are following the reporting system.

Regarding lung nodule management algorithms, programs should incorporate the following steps:

• Clinicians who have expertise regarding lung nodule management and lung cancer treatmentA nodule-characterization method and management tracking
• A communication approach between the ordering provider and the patient
• Data collection on the use and outcomes from surveillance and diagnostic imaging and biopsies for management

LCS programs must be integrated with a smoking cessation program, and data should be collected regarding the interventions offered to active smokers.

Clinicians must be educated to discuss the risks and benefits of screening with patients. LCS programs must list educational strategies used to educate providers and demonstrate the availability of standardized educational material.

LCS programs are required to collect data related to each component, testing outcomes, and cancer diagnoses, and these data must be reported annually to an oversight body. The program must respond to concerns from this oversight body to maintain accreditation.

“The key takeaway is to know the parameters, and for every patient who meets those parameters, I want them to be sent for a LCS CT scan, and then we can take care of the rest,” Dr. Pritchett said. “We understand the primary care doctors are overwhelmed, and yes, we are asking for 1 more thing. But this 1 more thing can save somebody’s life.”

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 October 31, 2018.