The pace of new lung cancer screening initiatives, published research and collective efforts of organizations and imaging specialists in the United States and across the world has, impressively, quickened. While Lung Cancer Awareness Month is officially on the calendar in November, the work of a broad, committed range of focused experts is a daily priority. From the comprehensive “Saved by the Scan” screening initiative and programs of the American Lung Association (ALA), whose “State of Lung Cancer 2022” report (issued after this issue was finalized, to be covered in January/February issue), to the work of the American Cancer Society’s National Lung Cancer Roundtable (NLCRT), and global efforts of the International Association for the Study of Lung Cancer (IASLC), there is a palpable and powerful sense of momentum. Here, then, the second in our ongoing series.
ACR Lung Cancer Screening Network
In early April, 2022, the American College of Radiology (ACR) selected 22 teams as the first cohort of the ACR Learning Network, a new initiative to improve diagnostic imaging through a learning health system approach. Funded by a grant from the Gordon and Betty Moore Foundation, four improvement collaboratives will address important areas of performance in cancer diagnosis.
“We are excited to roll up our sleeves and get the work underway with a remarkable group of facilities that have committed the time, resources and personnel to achieve meaningful improvement in one or more of these four important diagnostic areas,” said David B. Larson, MD, MBA, chair of the ACR Commission on Quality and Safety, and principal investigator and physician program director of the ACR Learning Network program. Facility teams will work together to solve the same problem at their respective institutions using a structured improvement process customized to their local environment.
The ACR announced details on facilities and physicians selected for the inaugural improvement collaboratives, noting that the Lung Cancer Screening Collaborative Leader selected is Neville Irani, MD, University of Kansas. Irani is also involved in the development and implementation of the Healthcare Quality Improvement Platform (HQuIP), a platform which connects facilities to solve common problems and make the best use of limited resources.
“We need to enable both patients and physicians to lead efforts that will measurably improve patient outcomes and experience, focusing on the things that matter most,” Irani said Irani in an ITN interview on screening initiatives.
About the Healthcare Quality Improvement Platform
HQuIP is a public charity formed by physicians, patients and family who have seen loved ones and friends suffer or even lose their battles to health concerns. Its coordinators note that in a complex health system, many patients experience miscommunication, poor outcomes, incorrect diagnoses or uncoordinated care, the platform works to address these issues.
HQuIP aims to improve patient experience and health outcomes, while seeking to design systems to prevent errors. Based in Leawood, Kan., the programs and resources provided through HQuIP are run by public support, as the coordinators try and make sure cost is not a barrier to improvement. Coordinators encourage imaging community professionals to reach out and explore ways the platform can support their efforts to expand screening, connect practitioners and patients for better outcomes, and develop a truly comprehensive lung cancer screening program with a focus on patient experience.
“With 90% of high risk patients not receiving lung cancer screening, the team at the Healthcare Quality Improvement Platform is proud to assist organizations in underserved, rural and high risk communities to triple their annual lung cancer screening volumes,” said HQuIP Program and Outreach Director, Debra Dougher.
National Lung Cancer Roundtable
Accelerating lung cancer screening uptake has long been a key priority of the American Cancer Society National Lung Cancer Roundtable. Its stated mission: NLCRT is a consortium of public, private and voluntary organizations that work together to fight lung cancer by engaging in research and projects that no one organization can take on alone. It is the NLCRT’s belief that working collectively and collaboratively will drive progress faster to reduce lung cancer mortality.
Launched in 2017, it has charged many of its strategic priority committees with addressing the challenges that contribute to the low rates of lung cancer screening across the country. The coalition of over 175 member organizations works to close gaps in cancer screening by connecting people, communities and systems to improve equity and access. Many of its signature initiatives have recently launched, including the LungPLAN resource forecasting model, with other deliverables in progress with key partners.
LungPLAN is a free financial planning tool that helps healthcare professionals, financial experts and administrators model implementation costs and outcomes to demonstrate downstream value of a lung cancer early detection program (screening and nodule management), thereby ensuring these programs are successful and tailored to their patient population. According to the NLCRT, LungPLAN was created by a team of NLCRT clinical, navigation, health systems and financial experts, and was field-tested by health systems and provides a framework for predicting lung cancer screening and nodule management program costs, resources, staffing, volume and revenue. It is based on current evidence including data from the American College of Radiology Lung CT Screening Reporting & Data System (LUNG-RADS) and the Lung Cancer Screening Registry.
The NLCRT convened its inaugural Summit, “Accelerating Uptake of Lung Cancer Screening — A National Initiative,” this past July in Washington, DC. It reported that approximately 100 members of the multidisciplinary lung cancer community met to share knowledge and success stories, explore key barriers, develop and ultimately prioritize strategies and tactics to address the identified barriers to lung cancer screening. Noting that national lung cancer screening rates are below 6% for the eligible population, the Summit laid the foundation for developing a comprehensive strategic plan with actionable recommendations to accelerate the uptake of screening.
According to their summary report, this NLCRT priority aligns with recommendations from the President’s Cancer Panel as the single most effective approach to saving lives from lung cancer. The President’s Cancer Panel report concluded that increasing cancer screening rates represents a significant opportunity to reduce the burden of cancer across the United States. President Biden’s Cancer Panel members John Williams, MD, FACS (chair), and Edith Mitchell, MD, MACP, FCPP, FRCP attended the Summit.
The National Lung Cancer Roundtable also provided updates on the NLCRT-ACR Webinar and Podcast Series which continued into 2022, noting its partnership with the American College of Radiology (ACR) has resulted in a third season. The new six-part series, which started in July, focused on challenges and opportunities unique to established screening programs, showcasing methods and metrics for centers to use to accelerate uptake and adherence.
The NLCRT returns to in-person meetings with a December 5-6 Annual Meeting, in Washington, DC, its 6th such conference. The ITN editorial team will continue to report on the initiatives and reports emerging from this important group.
Low-dose CT in the Spotlight
In ongoing efforts to support strong lung cancer screening programs, companies like Philips are working to expand visibility and access to computed tomography (CT) scans to both physicians and patients. One such effort is its CT Experience Tour, planned across 16 cities. While there cannot be live scans conducted within the mobile environment, the company is looking to extend the opportunity for patients and customers to experience the look and feel of what a CT scanner experience entails, with the hope of eliminating much of the fear and apprehension of a CT scan procedure. Representatives from Philips note that this is a critical element to help overcome the challenge of recruiting patients into early lung cancer screening.
Philips announced in June, 2022, that it has teamed up with a Colorado-based diagnostic solutions company, Biodesix, Inc., to incorporate the results of the Biodesix Nodify Lung blood-based lung nodule risk assessment testing into Philips’ Lung Cancer Orchestrator patient management system. It reports that the incorporation of proteomics data — along with the radiologic and patient history data currently used to determine treatment decisions — can help create diagnostic efficiency for cancer care centers in the management of a growing number of lung nodule cases, via the contextual launch of Biodesix Nodify Lung application within Lung Cancer Orchestrator. Philips Lung Cancer Orchestrator solution enables health systems to operationalize lung cancer screening and lung nodule management programs at scale.
What are Key Solutions for the Future?
In a discussion with ITN, Ilya Gipp, MD, PhD, Philips Medical Officer — Oncology, who is involved with the NLCRT, shared his insights.
“The good thing is that there are many ways we see cancer care may be done better. The question is where to start. Much is being done already. The Biden-Harris Administration Cancer Moonshot is the proof of the fact that oncology is in the focus all the way from the highest level. Besides screening, our only chance for early cancer detection is a chance for catching it incidentally. Now, may we increase our chances? I think this is possible.”
Gipp added, “In lung cancer, with close to 100 million CT exams performed annually in the US, roughly one-quarter of CT exams have lungs included into the scanning range. Just imagine that tens of millions of patients might get a chance of getting potentially meaningful lung nodules detected while getting cardiac, trauma, mediastinum and other lung exams. By all means, we cannot put extra workload on radiologists, but talking about the future — there are CAD tools already to analyze imaging data and offer time-saving while increasing detection rates and offer reporting with characterization; and feature extraction for risk assessment and even automated follow-up with notifications for scheduling and no-shows tracking. This won’t work without efficient data, worklists and patient management beyond just the diagnostic imaging department. Cancer care of the future in my view needs to be better connected, and with meaningful data across all stages, professionals and departments.”
Research into this focus area is ongoing. Two separate studies were published in as many recent months in the Journal of the American Medical Association (JAMA). The first focused on factors related to veterans’ screenings. In another, researchers measured the impact of the USPSTF screening eligibility criteria which emerged in 2021. A brief overview of each follows.
Factors Associated with Declining Lung Cancer Screening
In an August 16, 2022, JAMA-published study, researchers addressed this question: What factors are associated with veterans declining lung cancer screening (LCS)?
“Factors Associated with Declining Lung Cancer Screening After Discussion with a Physician in a Cohort of US Veterans” was authored by Eduardo R. Núñez, MD, Critical Care Medicine, Pulmonology, at Baystate Health, Springfield, MA, with Tanner J. Caverly, MD, MPH, Sanqian Zhang, PhD, et al. Their objective: To assess how frequently veterans decline LCS and examine factors associated with declining LCS. This study included VHA facilities that demonstrated regular use of the LCS clinical reminder in the EHR.
In this cohort study of 43,257 United States veterans offered LCS, 32% declined. Veterans who were older or had more severe comorbidity were more likely to decline screening, whereas Black and Hispanic veterans were more likely to accept it. The facility and physician offering LCS accounted for more variation in decisions than did patient factors.
The findings suggest that improving LCS discussions between patients and physicians could enhance patient-centered care and address disparities in LCS, wrote the authors, noting: These findings suggest that shared decision-making conversations in which patients play a central role in guiding care may enhance patient-centered care and address disparities in LCS. They further concluded: Lung cancer screening is underused in the US both inside and outside the VHA, in part owing to a lack of awareness of LCS among populations at risk. The goal of shared decision-making conversations is to educate patients about LCS and its harms and benefits, consider patients’ individual lung cancer risk, and incorporate patient preferences and values with regard to LCS to improve overall LCS uptake and patient-centered care.
Analysis of Eligibility for Lung Cancer Screening by Race
An “Analysis of Eligibility for Lung Cancer Screening by Race After 2021 Changes to US Preventive Services Task Force Screening Guidelines” was published September 2, 2022, in the Journal of the American Medical Association (JAMA). Authors included: Laura C. Pinheiro, PhD, MPH; Lauren Groner, DO; Orysya Soroka, MA; Ashley E. Prosper, MD; Kellie Jack, MPH; Rulla M. Tamimi, ScD; Monika Safford, MD; Erica Phillips, MD, MS.
The study’s objective was to assess the consequences of the changes in USPSTF low-dose computed tomography eligibility criteria for lung cancer screening between 2013 and 2021 among Black and White community-dwelling adults.
To that end, the researchers asked this question: What consequences have the 2021 changes to the US Preventive Services Task Force screening guidelines for lung cancer had for the racial gap in lung cancer screening eligibility between Black and White community-dwelling adults?
Why was this important? Lung cancer incidence and mortality have disproportionate consequences for racial and ethnic minority populations. The extent to which the 2021 changes to the US Preventive Services Task Force (USPSTF) screening guidelines have reduced the racial disparity gap in lung cancer screening eligibility is not known, they noted.
Among 14,285 participants (mean [SD] age, 64.7 [7.5] years; 7675 men [53.7%]), 5,787 (40.5%) self-identified as Black and 8,498 (59.5%) as White. Based on the 2013 USPSTF guidelines, 1,109 of 5,787 Black participants (19.2%) and 2,313 of 8,498 White participants (27.2%) were eligible for lung cancer screening (difference, -8.06 percentage points; 95% CI, -9.44 to -6.67 percentage points). Based on the 2021 guidelines, 1667 of 5,787 Black participants (28.8%) and 2,940 of 8,498 White participants (34.6%) were eligible for screening (difference, -5.73 percentage points; 95% CI, -7.28 to -4.19 percentage points).
The 2013 difference in screening eligibility among Black vs White participants was -12.66 percentage points (95% CI, -14.71 to -10.61 percentage points), and the 2021 difference was -12.15 percentage points (95% CI, -14.37 to -9.93 percentage points), according to the reported findings issued by the research team.
What did they learn? After adjustment for individual characteristics and important social factors associated with health, screening guideline changes were associated with a difference in lung cancer screening eligibility among Black and White individuals of -12.7 percentage points in 2013 and -12.2 percentage points in 2021.
The findings, write its authors, suggest that although expansion of the lung cancer screening eligibility criteria was important to address racial differences in screening, without reform to policies with the explicit goal of eliminating structural factors such as residential segregation, changes in screening guidelines may only minimally improve existing racial gaps in eligibility.
The researchers noted that 2021 changes to the USPSTF lung cancer screening guidelines were associated with reductions in but not elimination of existing eligibility disparities in lung cancer screening among Black and White adults. The findings suggest that accounting for factors beyond age and pack-years of smoking is needed when tailoring guidelines to improve screening eligibility among groups at high risk of lung cancer.
Further, although expansion of the USPSTF lung cancer screening eligibility criteria was an important step to address racial differences in screening, without broader political and socioeconomic policy changes that address structural and systemic racism, the intended results of these changes may not be achieved.
Important and ongoing studies like these, and efforts of a wide range of committed experts, will continue to support lung health initiatives.
Increased commitment to lung cancer screening is also emerging on a global scale. The International Association for the Study of Lung Cancer (IASLC) is the only global organization dedicated solely to the study of lung cancer and other thoracic malignancies. Founded in 1974, the association’s membership includes nearly 7,500 lung cancer specialists across all disciplines in over 100 countries, forming a global network working together to conquer lung and thoracic cancers worldwide. The association also publishes the Journal of Thoracic Oncology, the primary educational and informational publication for topics relevant to the prevention, detection, diagnosis and treatment of all thoracic malignancies.
The IASLC 2022 World Conference on Lung Cancer was held in Vienna, Austria, Aug. 6-9, 2022. During the meeting, representatives from the Diagnostics Working Group of the IASLC Early Detection and Screening Committee announced an effort to outline the current obstacles and perspectives of lung cancer screening in low- and middle-income countries, and to propose guidance, recommendations and future research strategies. This group currently has six members from low- and middle-income countries from four continents (Brazil, China, Colombia, India, Serbia and South Africa) and 11 members from high-income countries from three continents (Canada, Germany, Hungary, Italy, Spain, South Korea, UK and the United States).
The Early Detection and Screening (ED&S) Committee has several ongoing initiatives that aim to address this issue. Working Group meetings have led members to observe that a systematic evaluation of screening status in and between low-to-middle-income countries would involve a comprehensive comparison of lung cancer incidence and mortality by stage at diagnosis.
“Broader discussion on this matter is globally important, both for low-to middle-income and high-income countries,” said Milena Cavic, MD, Institute for Oncology and Radiology of Serbia. In a summary of the IASLC World Conference, Cavic reported on multiple factors that give rise to challenges in LC screening implementation. She added, “Many countries are planning to introduce lung cancer screening, taking into account all the governmental, healthcare and population-specific parameters important for this delicate process, thus evidence-based guidelines are of outmost importance.”
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