Health Care Delivery
Original Contribution
Implementing Lung Cancer Screening Using Low-Dose Computed Tomography: Recommendations From an Expert Panel By Scott D. Ramsey, MD, PhD, Jennifer L. Malin, MD, PhD, Bernardo Goulart, MD, MS, Laurie F. Ambrose, Jeffrey P. Kanne, MD, Andrea B. McKee, MD, Shelby D. Reed, PhD, RPh, J. Sanford Schwartz, MD, and Sean D. Sullivan, PhD
Abstract Purpose: In December 2013, the US Preventive Services Task Force issued a final B-level recommendation indicating that individuals between the ages of 55 and 80 years who have a 30 – pack-year smoking history and have smoked within the past 15 years should receive annual low-dose computed tomography (CT) lung cancer screening. We convened a multidisciplinary panel of experts to create practical guidance for efficiently implementing effective CT lung cancer screening programs.
Results: The panel identified five main goals that must be achieved to maximize the efficiency and effectiveness of implementing CT lung cancer screening: one, accurately identify individuals eligible for screening; two, provide access to screening at qualified facilities for eligible individuals; three, ensure appropriate follow-up for positive and negative screening results; four, promote continuous quality improvement of screening programs and downstream care; and five, provide smoking cessation support for all current smokers. The panel proposed a series of stakeholder-specific recommendations for achieving these goals.
Methods: The lung cancer screening panel included 12 members, representing a broad range of stakeholders. The panel discussed clinical and system issues related to the implementation of CT lung cancer screening and developed recommendations for implementing CT lung cancer screening programs.
Conclusion: Implementation of effective and efficient population-based CT lung cancer screening will require involvement and coordination of stakeholders across the health care system to address the data and infrastructural needs that were identified.
Introduction
Methods
In December 2013, the US Preventive Services Task Force (USPSTF) issued a final recommendation that individuals at high risk for lung cancer receive annual low-dose computed tomography (CT) lung cancer screening. Individuals between the ages of 55 and 80 years who have a 30 –pack-year smoking history and have smoked within the past 15 years are considered eligible.1 The grade-B recommendation was based on a systematic evidence review, which was heavily influenced by the National Lung Screening Trial (NLST), a good-quality trial that found a 20% relative reduction in lung cancer mortality after 3 years of screening.2-6 Using models developed by the Cancer Intervention and Surveillance Modeling Network, the USPSTF extended its recommendation to include patients older than those in the NLST and annual screening beyond 3 years.7 CT lung cancer screening has the potential to save many lives if implemented properly, but there are numerous issues related to the implementation of LDCT that will influence its success in practice. To operationalize the USPSTF recommendations to achieve effective population-based CT lung cancer screening, we convened a multidisciplinary panel of experts to develop practical guidance for efficiently implementing highquality screening programs.
The lung cancer screening panel met on December 13, 2013. It included 12 members, representing health care providers, insurers, integrated delivery systems, health economists, and patient advocacy groups (Table 1). These members were selected to achieve a diversity of stakeholder representation, expertise, and experience with regard to clinical, administrative, policy, and patient issues surrounding implementation of CT screening for lung cancer (Table 1). The organizers tasked the panel with providing practical guidance for implementing lung cancer screening programs, without taking a position on the USPSTF lung cancer screening recommendations. The panel discussed clinical and system issues related to implementation of CT lung cancer screening, as well as factors influencing its economic impact. The meeting was divided into four main sessions: one, overview of lung cancer screening and USPSTF recommendations; two, implementation issues; three, financial impact and clinical outcomes; and four, developing recommendations. Each session consisted of a short panel-member presentation followed by a group discussion. Although guiding questions were provided for the group discussions, the conversation was open. The final session focused on developing a set of recommen-
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University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA; Wellpoint, Santa Monica, CA; Lung Cancer Alliance, Washington, DC; University of Wisconsin School of Medicine and Public Health, Madison, WI; Lahey Hospital and Medical Center, Burlington, MA; Duke Clinical Research Institute, Durham, NC; and School of Medicine, Wharton School, and Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
Recommendations for Implementing CT Lung Cancer Screening
Table 1. Panel Members and Affiliations Panel Member
Affiliation
Role
Scott D. Ramsey, MD, PhD
University of Washington, Seattle, WA
Clinician researcher
Jennifer L. Malin, MD, PhD
Wellpoint, Santa Monica, CA
Payer
Carolyn R. Aldigé
Prevent Cancer Foundation, Alexandria, VA
Patient advocate
Laurie F. Ambrose
Lung Cancer Alliance, Washington, DC
Patient advocate
Jeffrey P. Kanne, MD
University of Wisconsin School of Medicine and Public Health, Madison, WI
Clinician
Andrea B. McKee, MD
Lahey Hospital and Medical Center, Burlington, MA
Clinician
Shelby D. Reed, PhD, RPh
Duke Clinical Research Institute, Durham, NC
Researcher
Sean D. Sullivan, PhD
University of Washington, Seattle, WA
Researcher
Fred Hutchinson Cancer Research Center, Seattle, WA
J. Sanford Schwartz, MD
University of Pennsylvania, Philadelphia, PA
Clinician researcher
Christian G. Downs, JD, MHA
Association of Community Cancer Centers, Rockville, MD
Organization advocate
Tracy A. Lieu, MD, MPH
Kaiser Permanente Northern California, Oakland, CA
Researcher
Walter F. Stewart, PhD, MPH
Sutter Health System, Concord, CA
Payer
dations for CT lung cancer screening implementation, presented herein. The selection of participants, the agenda for the meeting, the discussions at the meeting, and the preparation of this report were not, in any way, suggested or influenced by the funder. S.D.R. and S.D.S. were responsible for every detail of the meeting, from participant identification to manuscript preparation.
Results Primary Issues Influencing Clinical and Economic Impacts of Screening The panel identified five primary issues critical to implementing screening programs efficiently (Table 2). Discussion focused on the inherent difficulties involved in addressing these issues. Correctly identifying individuals eligible for screening. Screening only high-risk individuals will be critical for achieving realworld outcomes similar to those observed in the NLST. Screening can occur opportunistically, with eligible individuals identified through self-identification or by health care providers, or in a directed manner, where health systems use administrative data to target high-risk individuals for populationbased screening outreach programs. The latter approach would enhance screening access but require the availability of data enabling identification of the eligible population. Detailed smoking history data are not currently available in searchable electronic databases for most US adults. This is especially true for former smokers, who constitute the majority of lung cancer diagnoses.8 Therefore, it will be necessary to develop standardized methods to accurately ascertain and document patient smoking history.
high-quality care. The Affordable Care Act requires private insurers to cover preventive services with a USPSTF grade-A or -B recommendation at no cost to the patient. This will encourage the growth of screening centers, including those not following best practices. Hence, it will be essential to enable providers to refer patients to qualified facilities. Developing a process for accrediting lung cancer screening centers of excellence will also be beneficial. The American College of Radiology (ACR) has a CT accreditation program and is currently developing a module specific to lung cancer screening. The level of benefit from screening will also depend on adherence to the screening schedule. Therefore, developing programs that maximize long-term adherence will be necessary. Ensuring appropriate follow-up for positive and negative screening results. Because the US health care system is fragmented and often exhibits inconsistent continuity of care, developing guideline-based follow-up protocols may improve outcomes. The panel highly recommended that medical centers nationwide adopt a uniform structured reporting system that would integrate with existing electronic health record (EHR) systems, provide standardized radiology reports with guideline-based recommendations, and include messaging capabilities for coordinating care. Promoting continuous quality improvement. Improving screening program effectiveness over time requires tracking and refinement of program performance. Therefore, the panel Table 2. Primary Issues to Address During Screening Program Implementation
Providing access to screening at qualified facilities for eligible individuals. It will be important to provide access to screening at qualified facilities for eligible individuals (approximately 8 million in United States).9,10 Infrastructural and system issues must be addressed quickly to meet this demand while providing Copyright © 2014 by American Society of Clinical Oncology
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Issue Correctly identify individuals eligible for screening Provide access to screening at qualified facilities for eligible individuals Ensure appropriate follow-up for positive and negative screening results Promote continuous quality improvement of screening programs and downstream care Offer smoking cessation support for all current smokers
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Fred Hutchinson Cancer Research Center, Seattle, WA
Ramsey et al
suggested that patient registries be used, with the goal of promoting quality improvement and providing research opportunities. This work is currently under way with the ACR.11
Stakeholder-Specific Recommendations The panel developed a series of stakeholder-specific recommendations, recognizing that these efforts will require ongoing training and resources. Hospitals, medical centers, and clinics. On the basis of the USPSTF recommendations, the ACR is in the process of developing standards for CT lung cancer screening, along with a CT lung cancer screening accreditation module.11 The panel felt that centers should use these resources as a starting point for developing screening programs and consider becoming accredited. Additionally, a panelist from Lahey Hospital and Medical Center (Burlington, MA) noted that this institution has implemented a CT lung cancer screening program and would share screening-related materials with other interested facilities.20-22 The panel felt that an important first step for institutions developing screening programs is to appoint a multidisciplinary steering committee, including all stakeholders affected by the screening program. Developing a protocol to facilitate coordinated, guideline-based care throughout the health care system and training and collaborating with institutional staff involved in the screening process would be key responsibilities for the committee. For example, a hospital committee could work with the radiology department to ensure infrastructural needs were met and identify opportunities for improving quality and throughput, the multidisciplinary medical team to ensure appropriate follow-up, and the information technology department to contribute data to the patient registry and facilitate quality improvement initiatives. Education and collaboration with local primary care providers (PCPs) will also be important, because they will play a central role in the screening process. Once EHR data are available, enabling eligibility assessment, centers could also develop population-based outreach programs. The panel noted that infrastructural needs assessment and expansion are likely to be critical. The radiology department could help predict the business and infrastructural needs, based on projections of future demand relative to current and prior usage patterns. For example, Lahey has been able to perform all e46
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PCPs. PCPs are ideally situated to identify eligible patients, discuss lung cancer screening and smoking cessation, and refer patients to qualified screening facilities. Screening will be more efficient if PCPs develop methods to identify eligible patients during office visits, while recording smoking history data in the EHR to enable future population-based screening efforts. Others have recommended that documenting smoking history become a required part of routine practice in primary care.23,24 Recording current smoking status is one of the Centers for Medicare and Medicaid Services meaningful use core measures.25 Furthermore, as practices adopt EHRs, it will be important to capture detailed information regarding both current and past smoking history (ie, current-, former-, or neversmoker status; packs smoked per day; duration of smoking; and dates of cessation attempts) to enable patient identification for population-based screening approaches. Currently, much of these data are unavailable in EHR systems, meaning that eligible patients can only be identified opportunistically. Other specialists who frequently provide care to current and past smokers, such as pulmonologists, cardiologists, and diabetologists, may be able to enhance records with this information. The panel agreed with the USPSTF emphasis on adopting a shared decision-making approach when discussing screening with patients.1 Discussions with patients would likely incorporate the following: what CT lung cancer screening entails, its associated harms and benefits, and potential follow-up tests and procedures. The USPSTF has developed fact sheets and evidence syntheses discussing the lung cancer screening recommendations, which target a variety of audiences, including providers and patients.26 Understanding these issues may decrease patient anxiety, which is a potential harm of screening, and encourage high-risk individuals to be screened. Conversely, this may dissuade those at lower risk from being screened. Furthermore, these discussions can be used as an opportunity to assess patient willingness and eligibility to proceed with follow-up care; the USPSTF recommends against screening individuals who are unwilling or unable to undergo surgery or who have a serious comorbid illness.1 Finally, the panel recommended that providers only refer patients to facilities that provide multidisciplinary guideline-based care. The process of identifying and referring patients for screening provides numerous opportunities to motivate patients to quit smoking. The potential for increasing smoking cessation rates is one benefit of recruiting current smokers. As recommended by others, every current smoker should receive smoking cessation counseling.23,24 Health care informatics infrastructural suppliers and supporters. Establishing efficient screening programs nationwide will require the development and expansion of informatics infrastructure. The panel proposed adding fields to EHR systems for capturing detailed smoking history data, developing a uniform structured re-
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Offering smoking cessation support for all current smokers. Smoking cessation is fundamental in reducing the risk of lung cancer and is considered highly cost effective.12 Studies have suggested that the cost effectiveness of CT screening may be heavily influenced by its impact on quit rates among smokers.13,14 Panel members discussed concerns that screening programs may compete for funds with existing smoking cessation programs and that negative screening results may reinforce smoking behavior in current smokers. Alternatively, lung cancer screening could act as a teachable moment to encourage smoking cessation.15-19 Because it is not known whether CT screening has a positive or negative impact on smoking, approaches that systematically integrate smoking cessation interventions into screening programs should be evaluated.
screening examinations during available downtimes, thus avoiding the need to purchase additional machines. It predicts that future demand at the institution will necessitate the addition of one 40-hour shift.22
Recommendations for Implementing CT Lung Cancer Screening
Insurance companies and integrated delivery systems. Although the USPSTF grade-B recommendation theoretically removes screening-related cost barriers, uncertainty remains. A Medicare coverage decision has not been finalized, but the Medicare Evidence Development and Coverage Advisory Committee voted against recommending national coverage on April 30, 2014.27 For the privately insured, implementation issues, such as billing coding, may affect access.28 The panel recommended that benefits be structured in a manner that encourages eligible individuals to be screened, notifies ineligible individuals that screening is not covered, and promotes the use of qualified facilities. However, this requires that health plans have access to valid and reliable data in searchable databases, enabling the identification of eligible individuals. The USPSTF also recommends (grade A) that clinicians ask all adults about tobacco use and provide smoking cessation interventions for current smokers. This enhances private coverage of smoking cessation interventions, which will enable their integration into the screening process.24 Copyright © 2014 by American Society of Clinical Oncology
Insurance companies also have an opportunity to develop population-based outreach programs to encourage high-risk individuals to participate in screening and to ensure that their networks provide access to high-quality, efficient screening centers. Many panelists recommended that insurers collect detailed data on current and prior smoking behavior during annual enrollment. Insurers could then develop population-based outreach strategies, such as mailing screening reminders to high-risk members or contacting PCPs to identify patients under their care who may qualify for screening. However, the panel acknowledged that under the Affordable Care Act, these data could also be used to raise insurance premiums for current smokers, which may have unintended negative consequences (eg, creating incentive for members to falsify smoking information).29 Employers. Employers could also collect detailed information on smoking history and encourage eligible employees to discuss screening with their PCPs. Providing smoking cessation programs may increase smoking cessation rates, although establishing smoking penalties may have unintended consequences. Employers could partner with health plans or local screening centers to develop innovative approaches for encouraging atrisk employees to be screened. Advocacy groups. Patient advocacy groups already actively support lung cancer screening, and they can continue to help in a number of ways. For example, advocacy groups could provide resources to help develop and identify qualified facilities and guide patients and referring physicians to these locations. Additionally, educational campaigns for patients and physicians could be used to increase awareness of CT lung cancer screening and promote smoking prevention and cessation. Furthermore, resources could be used to support screening-related research. State and national public health agencies. Lung cancer causes more deaths in the United States than any other type of cancer and is preventable through smoking avoidance and cessation.30 Public health agencies should consider implementing a national campaign, focusing on lung cancer awareness, screening, and prevention. Communicating the benefits of smoking cessation would be integral to this initiative. The benefits and harms of CT lung cancer screening could also be incorporated, along with education regarding lung cancer risk assessment and screening eligibility.
Discussion Implementation of effective CT lung cancer screening must be approached prudently, with the active participation of stakeholders across the health care system. We convened a multidisciplinary panel of stakeholders to identify key issues that could influence screening effectiveness and outlined recommendations for approaching these issues. The panel envisioned screening occurring opportunistically at first and, ultimately, in a population-based manner. The panel identified several issues to address to enable future population-based screening efforts, including the need for: one, standardized patient smoking history data collection; two, infrastructural needs assessment and expansion; integrated systems enabling collaboration and data
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porting system, establishing a patient registry, and ensuring that all systems are standardized and integrated appropriately. EHR systems that allow providers to record detailed smoking history will enable eligibility assessment for population-based screening programs. The Centers for Medicare and Medicaid Services meaningful use criteria for EHR systems require fields for current smoking status.25 However, data on pack-years and quit dates are also necessary for identifying eligible individuals. Therefore, the panel recommended that these fields be incorporated. These systems could also ease provider burden by allowing electronic entry of screening orders, automatically generating screening appointments, and activating follow-up reminders. A structured reporting system, which tracks patients and findings and links results to guideline-based recommendations, will facilitate appropriate follow-up. The panel highly recommended that a uniform system be developed and adopted nationwide. For example, one system that is being developed—LungRADS—is modeled on the ACR Breast Imaging Reporting and Data System used in breast cancer screening.20,21 Patient registries can be used both by screening programs, to monitor performance and conduct quality improvement exercises, and by researchers. To this end, existing registries can be coordinated and expanded. For example, the ACR is currently working on expanding the National Radiology Data Registry to include a national lung cancer screening database, which may fulfill this need.11 The panel envisioned the registry systematically collecting all data for screened patients, including eligibility criteria, screening results, incidental findings, clinical workup and followup, and histologies and stages of detected cancers. Finally, the panel felt that these systems should be integrated and standardized across the United States. This will enable data sharing, improve continuity of care and follow-up, and facilitate higher-quality research and reporting. Collaboration between health informatics entities and professional societies would help to ensure that these systems are developed in a manner that is clinically relevant and avoids duplication.
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over time. Finally, studies should examine the emotional impact of screening and identify methods of allaying patient anxiety. Implementing lung cancer screening will provide numerous research opportunities, which will help fill knowledge gaps regarding both lung cancer and lung cancer screening. Federal and private sector groups should consider funding research in this area. Acknowledgment Supported by Genentech (which convened the expert panel). We thank the following expert panel members who did not participate as authors in this report: Christian G. Downs, JD, MHA, Tracy A. Lieu, MD, MPH, Walter F. Stewart, PhD, MPH, and Carolyn R. Aldigé. We also thank Peter B. Bach, MD, MAPP, and Arliene Ravelo, MPH, for helpful comments, and Joanna C. Sanderson, PharmD, MS, for editorial support. Authors’ Disclosures of Potential Conflicts of Interest Although all authors completed the disclosure declaration, the following author(s) and/or an author’s immediate family member(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a “U” are those for which no compensation was received; those relationships marked with a “C” were compensated. For a detailed description of the disclosure categories, or for more information about ASCO’s conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment or Leadership Position: Jennifer L. Malin, WellPoint (C) Consultant or Advisory Role: Scott D. Ramsey, Genentech (C); Jeffrey P. Kanne, Parexel Informatics (C); J. Sanford Schwartz, Blue Cross and Blue Shield Associations Medical Advisory Committee (C); Sean D. Sullivan, Genentech (C) Stock Ownership: Jennifer L. Malin, WellPoint; J. Sanford Schwartz, General Electric (manufacturer diagnostic imaging equipment), General Electric (manufacturer diagnostic imaging equipment) Honoraria: Andrea B. McKee, Varian, Hospitals for Grand Rounds Research Funding: Sean D. Sullivan, Genentech Expert Testimony: Andrea B. McKee, MEDCAC for Centers for Medicare and Medicaid Services (U) Patents, Royalties, and Licenses: None Other Remuneration: None
Author Contributions Conception and design: Scott D. Ramsey, Jennifer L. Malin, Laurie F. Ambrose, Jeffrey P. Kanne, J. Sanford Schwartz, Sean D. Sullivan Financial support: Sean D. Sullivan Collection and assembly of data: Andrea B. McKee, Shelby D. Reed Data analysis and interpretation: Scott D. Ramsey, Jennifer L. Malin, Bernardo Goulart, Jeffrey P. Kanne, Shelby D. Reed, J. Sanford Schwartz Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Scott D. Ramsey, MD, PhD, Fred Hutchinson Cancer Research Center,1100 Fairview Ave North, M3-B232, Seattle, WA 98109-1024; e-mail: [email protected].
DOI: 10.1200/JOP.2014.001528; published online ahead of print at jop.ascopubs.org on December 9, 2014.
References 1. Moyer VA: Screening for lung cancer: U.S. Preventive services task force recommendation statement. Ann Intern Med 160:330-338, 2014
3. Infante M, Cavuto S, Lutman FR, et al: A randomized study of lung cancer screening with spiral computed tomography: Three-year results from the DANTE trial. Am J Respir Crit Care Med 180:445-453, 2009
2. Aberle DR, Adams AM, Berg CD, et al: Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365:395-409, 2011
4. Pastorino U, Rossi M, Rosato V, et al: Annual or biennial CT screening versus observation in heavy smokers: 5-year results of the MILD trial. Eur J Cancer Prev 21:308-315, 2012
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sharing; four, patient and provider education; and five, development, accreditation, and use of qualified facilities. Because of data and infrastructural gaps, which currently prevent identification of and access for eligible individuals, health care systems could consider a phased approach to population-based screening, first recruiting those with known or easily identifiable smoking status and expanding the scope over time by collecting more data on smoking history, educating physicians and patients, and actively reaching out to those who are potentially eligible. Focusing population-based screening efforts on eligible current smokers initially may have the greatest impact, partially because these individuals have the highest risk, and also because of the opportunity to encourage smoking cessation. To refine the process of CT lung cancer screening and maximize its benefits, the panel identified areas for further research. First, there is a lack of agreement regarding the threshold beyond which the benefits of screening outweigh its associated harms. Within the NLST sample, there was substantial variability in net benefit.31 There was also variability in the types of data used to support the USPSTF recommendation, because the decision to increase the screening age to 80 years was based on modeling work alone. Furthermore, many of the benefits and harms of implementing CT lung cancer screening in the general population remain unknown. The ideal screening duration is also uncertain, because the NLST only tested three consecutive annual CT screening scans. Therefore, the panel recommended research into real-world outcomes, screening duration, and the use of risk prediction models as tools to select individuals for screening. Development of less invasive diagnostic follow-up procedures would also improve the net benefit of screening. Future studies should explore the economic implications of screening and identify approaches that maximize its cost effectiveness. Another line of study could focus on identifying disparities in CT lung cancer screening with an eye toward addressing access barriers. Although it is widely believed that cancer screening has emotional and behavioral impacts on patients, their presence and management have not been well established in lung cancer. Studies should assess the combined impact of lung cancer screening and smoking cessation interventions and determine if and how to best integrate these programs. Factors relating to screening adherence have not been fully explored either. The panel felt it would be beneficial to investigate the impact of test results and other factors on screening adherence and to compare strategies to improve adherence. Strategies to engage patients in shared decision making should also be considered, given that this requires patients to understand relatively complex information. Quality assurance programs will also need to be designed and evaluated
Recommendations for Implementing CT Lung Cancer Screening
5. Saghir Z, Dirksen A, Ashraf H, et al: CT screening for lung cancer brings forward early disease: The randomised Danish Lung Cancer Screening Trial— Status after five annual screening rounds with low-dose CT. Thorax 67:296-301, 2012 6. Humphrey LL, Deffebach M, Pappas M, et al: Screening for lung cancer with low-dose computed tomography: A systematic review to update the US Preventive services task force recommendation. Ann Intern Med 159:411-420, 2013 7. National Cancer Institute, Cancer Intervention and Surveillance Modeling Network, Lung Cancer Working Group: Benefits and harms of computed tomography lung cancer screening programs for high-risk populations. Rockville, MD, Department of Health and Human Services, Agency for Healthcare Research and Quality, AHRQ Publication 13-05196-EF-2, 2013
18. 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 103:2154-2162, 2005 19. Ashraf H, Tønnesen P, Holst Pedersen J, et al: Effect of CT screening on smoking habits at 1-year follow-up in the Danish Lung Cancer Screening Trial (DLCST). Thorax 64:388-392, 2009 20. McKee BJ, McKee AB, Flacke S, et al: Initial experience with a free, highvolume, low-dose CT lung cancer screening program. J Am Coll Radiol 10:586592, 2013 21. McKee AB, McKee BJ, Wald C, et al: Rescue lung, rescue life. Oncol Issues 29:20-29, 2014. www.accc-cancer.org/oncology_issues/MA2014.asp 22. Lahey Health: Low-Dose CT Lung Cancer Screening. www.laheyhealth.org/ lungscreening
9. Ma J, Ward EM, Smith R, et al: Annual number of lung cancer deaths potentially avertable by screening in the United States. Cancer 119:1381-1385, 2013
23. Tobacco Use and Dependence Guideline Panel: Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD, US Department of Health and Human Services, 2008
10. National Comprehensive Cancer Network: NCCN Clinical Practice Guidelines in Oncology: Lung Cancer Screening. www.nccn.org/professionals/physician_gls/ f_guidelines.asp 11. American College of Radiology: Advances in CT Lung Cancer Screening. www.acr.org/Quality-Safety/eNews/Issue-05-March-2014/CT-Lung-Screening
24. US Preventive Services Task Force: Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: US Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 150:551-555, 2009
12. Feenstra TL, Hamberg-van Reenen HH, Hoogenveen RT, et al: Cost-effectiveness of face-to-face smoking cessation interventions: A dynamic modeling study. Value Health 8:178-190, 2005
25. EHR Incentive Program: Eligible Professional Meaningful Use Core Measures: Record Smoking Status. www.healthit.gov/providers-professionals/achievemeaningful-use/core-measures/record-smoking-status
13. McMahon PM, Kong CY, Bouzan C, et al: Cost-effectiveness of computed tomography screening for lung cancer in the United States. J Thorac Oncol 6:1841-1848, 2011
26. US Preventive Services Task Force: Lung Cancer: Screening. www. uspreventiveservicestaskforce.org/uspstf/uspslung.htm
14. Villanti AC, Jiang Y, Abrams DB, et al: A cost-utility analysis of lung cancer screening and the additional benefits of incorporating smoking cessation interventions. PLoS One 8:e71379, 2013 15. van der Aalst CM, van Klaveren RJ, van den Bergh KA, et al: The impact of a lung cancer computed tomography screening result on smoking abstinence. Eur Respir J 37:1466-1473, 2011 16. van der Aalst CM, van den Bergh KA, Willemsen MC, et al: Lung cancer screening and smoking abstinence: 2 year follow-up data from the Dutch-Belgian randomised controlled lung cancer screening trial. Thorax 65:600-605, 2010 17. Poghosyan H, Kennedy Sheldon L, Cooley ME: The impact of computed tomography screening for lung cancer on smoking behaviors: A teachable moment? Cancer Nurs 35:446-475, 2012
Copyright © 2014 by American Society of Clinical Oncology
27. Chustecka Z: Panel says no to Medicare coverage for lung cancer screening. www.medscape.com/viewarticle/824427 28. Centers for Disease Control and Prevention: Health plan implementation of U.S. Preventive Services Task Force A and B recommendations: Colorado, 2010. MMWR Morb Mortal Wkly Rep 60:1348-1349, 2011 29. Curtis R, Neuschler E: Tobacco rating issues and options for California under the ACA. www.ihps.org/pubs/Tobacco_Rating_Issue_Brief_21June2012.pdf 30. Siegel R, Naishadham D, Jemal A: Cancer statistics, 2012. CA Cancer J Clin 62:10-29, 2012 31. Kovalchik SA, Tammemagi M, Berg CD, et al: Targeting of low-dose CT screening according to the risk of lung-cancer death. N Engl J Med 369:245-254, 2013
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8. Centers for Disease Control and Prevention: Cigarette smoking among adults: United States, 2006. MMWR Morb Mortal Wkly Rep 56:1157-1161, 2007
Original Contribution
Implementing Lung Cancer Screening Using Low-Dose Computed Tomography: Recommendations From an Expert Panel By Scott D. Ramsey, MD, PhD, Jennifer L. Malin, MD, PhD, Bernardo Goulart, MD, MS, Laurie F. Ambrose, Jeffrey P. Kanne, MD, Andrea B. McKee, MD, Shelby D. Reed, PhD, RPh, J. Sanford Schwartz, MD, and Sean D. Sullivan, PhD
Abstract Purpose: In December 2013, the US Preventive Services Task Force issued a final B-level recommendation indicating that individuals between the ages of 55 and 80 years who have a 30 – pack-year smoking history and have smoked within the past 15 years should receive annual low-dose computed tomography (CT) lung cancer screening. We convened a multidisciplinary panel of experts to create practical guidance for efficiently implementing effective CT lung cancer screening programs.
Results: The panel identified five main goals that must be achieved to maximize the efficiency and effectiveness of implementing CT lung cancer screening: one, accurately identify individuals eligible for screening; two, provide access to screening at qualified facilities for eligible individuals; three, ensure appropriate follow-up for positive and negative screening results; four, promote continuous quality improvement of screening programs and downstream care; and five, provide smoking cessation support for all current smokers. The panel proposed a series of stakeholder-specific recommendations for achieving these goals.
Methods: The lung cancer screening panel included 12 members, representing a broad range of stakeholders. The panel discussed clinical and system issues related to the implementation of CT lung cancer screening and developed recommendations for implementing CT lung cancer screening programs.
Conclusion: Implementation of effective and efficient population-based CT lung cancer screening will require involvement and coordination of stakeholders across the health care system to address the data and infrastructural needs that were identified.
Introduction
Methods
In December 2013, the US Preventive Services Task Force (USPSTF) issued a final recommendation that individuals at high risk for lung cancer receive annual low-dose computed tomography (CT) lung cancer screening. Individuals between the ages of 55 and 80 years who have a 30 –pack-year smoking history and have smoked within the past 15 years are considered eligible.1 The grade-B recommendation was based on a systematic evidence review, which was heavily influenced by the National Lung Screening Trial (NLST), a good-quality trial that found a 20% relative reduction in lung cancer mortality after 3 years of screening.2-6 Using models developed by the Cancer Intervention and Surveillance Modeling Network, the USPSTF extended its recommendation to include patients older than those in the NLST and annual screening beyond 3 years.7 CT lung cancer screening has the potential to save many lives if implemented properly, but there are numerous issues related to the implementation of LDCT that will influence its success in practice. To operationalize the USPSTF recommendations to achieve effective population-based CT lung cancer screening, we convened a multidisciplinary panel of experts to develop practical guidance for efficiently implementing highquality screening programs.
The lung cancer screening panel met on December 13, 2013. It included 12 members, representing health care providers, insurers, integrated delivery systems, health economists, and patient advocacy groups (Table 1). These members were selected to achieve a diversity of stakeholder representation, expertise, and experience with regard to clinical, administrative, policy, and patient issues surrounding implementation of CT screening for lung cancer (Table 1). The organizers tasked the panel with providing practical guidance for implementing lung cancer screening programs, without taking a position on the USPSTF lung cancer screening recommendations. The panel discussed clinical and system issues related to implementation of CT lung cancer screening, as well as factors influencing its economic impact. The meeting was divided into four main sessions: one, overview of lung cancer screening and USPSTF recommendations; two, implementation issues; three, financial impact and clinical outcomes; and four, developing recommendations. Each session consisted of a short panel-member presentation followed by a group discussion. Although guiding questions were provided for the group discussions, the conversation was open. The final session focused on developing a set of recommen-
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University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA; Wellpoint, Santa Monica, CA; Lung Cancer Alliance, Washington, DC; University of Wisconsin School of Medicine and Public Health, Madison, WI; Lahey Hospital and Medical Center, Burlington, MA; Duke Clinical Research Institute, Durham, NC; and School of Medicine, Wharton School, and Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
Recommendations for Implementing CT Lung Cancer Screening
Table 1. Panel Members and Affiliations Panel Member
Affiliation
Role
Scott D. Ramsey, MD, PhD
University of Washington, Seattle, WA
Clinician researcher
Jennifer L. Malin, MD, PhD
Wellpoint, Santa Monica, CA
Payer
Carolyn R. Aldigé
Prevent Cancer Foundation, Alexandria, VA
Patient advocate
Laurie F. Ambrose
Lung Cancer Alliance, Washington, DC
Patient advocate
Jeffrey P. Kanne, MD
University of Wisconsin School of Medicine and Public Health, Madison, WI
Clinician
Andrea B. McKee, MD
Lahey Hospital and Medical Center, Burlington, MA
Clinician
Shelby D. Reed, PhD, RPh
Duke Clinical Research Institute, Durham, NC
Researcher
Sean D. Sullivan, PhD
University of Washington, Seattle, WA
Researcher
Fred Hutchinson Cancer Research Center, Seattle, WA
J. Sanford Schwartz, MD
University of Pennsylvania, Philadelphia, PA
Clinician researcher
Christian G. Downs, JD, MHA
Association of Community Cancer Centers, Rockville, MD
Organization advocate
Tracy A. Lieu, MD, MPH
Kaiser Permanente Northern California, Oakland, CA
Researcher
Walter F. Stewart, PhD, MPH
Sutter Health System, Concord, CA
Payer
dations for CT lung cancer screening implementation, presented herein. The selection of participants, the agenda for the meeting, the discussions at the meeting, and the preparation of this report were not, in any way, suggested or influenced by the funder. S.D.R. and S.D.S. were responsible for every detail of the meeting, from participant identification to manuscript preparation.
Results Primary Issues Influencing Clinical and Economic Impacts of Screening The panel identified five primary issues critical to implementing screening programs efficiently (Table 2). Discussion focused on the inherent difficulties involved in addressing these issues. Correctly identifying individuals eligible for screening. Screening only high-risk individuals will be critical for achieving realworld outcomes similar to those observed in the NLST. Screening can occur opportunistically, with eligible individuals identified through self-identification or by health care providers, or in a directed manner, where health systems use administrative data to target high-risk individuals for populationbased screening outreach programs. The latter approach would enhance screening access but require the availability of data enabling identification of the eligible population. Detailed smoking history data are not currently available in searchable electronic databases for most US adults. This is especially true for former smokers, who constitute the majority of lung cancer diagnoses.8 Therefore, it will be necessary to develop standardized methods to accurately ascertain and document patient smoking history.
high-quality care. The Affordable Care Act requires private insurers to cover preventive services with a USPSTF grade-A or -B recommendation at no cost to the patient. This will encourage the growth of screening centers, including those not following best practices. Hence, it will be essential to enable providers to refer patients to qualified facilities. Developing a process for accrediting lung cancer screening centers of excellence will also be beneficial. The American College of Radiology (ACR) has a CT accreditation program and is currently developing a module specific to lung cancer screening. The level of benefit from screening will also depend on adherence to the screening schedule. Therefore, developing programs that maximize long-term adherence will be necessary. Ensuring appropriate follow-up for positive and negative screening results. Because the US health care system is fragmented and often exhibits inconsistent continuity of care, developing guideline-based follow-up protocols may improve outcomes. The panel highly recommended that medical centers nationwide adopt a uniform structured reporting system that would integrate with existing electronic health record (EHR) systems, provide standardized radiology reports with guideline-based recommendations, and include messaging capabilities for coordinating care. Promoting continuous quality improvement. Improving screening program effectiveness over time requires tracking and refinement of program performance. Therefore, the panel Table 2. Primary Issues to Address During Screening Program Implementation
Providing access to screening at qualified facilities for eligible individuals. It will be important to provide access to screening at qualified facilities for eligible individuals (approximately 8 million in United States).9,10 Infrastructural and system issues must be addressed quickly to meet this demand while providing Copyright © 2014 by American Society of Clinical Oncology
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Issue Correctly identify individuals eligible for screening Provide access to screening at qualified facilities for eligible individuals Ensure appropriate follow-up for positive and negative screening results Promote continuous quality improvement of screening programs and downstream care Offer smoking cessation support for all current smokers
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Fred Hutchinson Cancer Research Center, Seattle, WA
Ramsey et al
suggested that patient registries be used, with the goal of promoting quality improvement and providing research opportunities. This work is currently under way with the ACR.11
Stakeholder-Specific Recommendations The panel developed a series of stakeholder-specific recommendations, recognizing that these efforts will require ongoing training and resources. Hospitals, medical centers, and clinics. On the basis of the USPSTF recommendations, the ACR is in the process of developing standards for CT lung cancer screening, along with a CT lung cancer screening accreditation module.11 The panel felt that centers should use these resources as a starting point for developing screening programs and consider becoming accredited. Additionally, a panelist from Lahey Hospital and Medical Center (Burlington, MA) noted that this institution has implemented a CT lung cancer screening program and would share screening-related materials with other interested facilities.20-22 The panel felt that an important first step for institutions developing screening programs is to appoint a multidisciplinary steering committee, including all stakeholders affected by the screening program. Developing a protocol to facilitate coordinated, guideline-based care throughout the health care system and training and collaborating with institutional staff involved in the screening process would be key responsibilities for the committee. For example, a hospital committee could work with the radiology department to ensure infrastructural needs were met and identify opportunities for improving quality and throughput, the multidisciplinary medical team to ensure appropriate follow-up, and the information technology department to contribute data to the patient registry and facilitate quality improvement initiatives. Education and collaboration with local primary care providers (PCPs) will also be important, because they will play a central role in the screening process. Once EHR data are available, enabling eligibility assessment, centers could also develop population-based outreach programs. The panel noted that infrastructural needs assessment and expansion are likely to be critical. The radiology department could help predict the business and infrastructural needs, based on projections of future demand relative to current and prior usage patterns. For example, Lahey has been able to perform all e46
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PCPs. PCPs are ideally situated to identify eligible patients, discuss lung cancer screening and smoking cessation, and refer patients to qualified screening facilities. Screening will be more efficient if PCPs develop methods to identify eligible patients during office visits, while recording smoking history data in the EHR to enable future population-based screening efforts. Others have recommended that documenting smoking history become a required part of routine practice in primary care.23,24 Recording current smoking status is one of the Centers for Medicare and Medicaid Services meaningful use core measures.25 Furthermore, as practices adopt EHRs, it will be important to capture detailed information regarding both current and past smoking history (ie, current-, former-, or neversmoker status; packs smoked per day; duration of smoking; and dates of cessation attempts) to enable patient identification for population-based screening approaches. Currently, much of these data are unavailable in EHR systems, meaning that eligible patients can only be identified opportunistically. Other specialists who frequently provide care to current and past smokers, such as pulmonologists, cardiologists, and diabetologists, may be able to enhance records with this information. The panel agreed with the USPSTF emphasis on adopting a shared decision-making approach when discussing screening with patients.1 Discussions with patients would likely incorporate the following: what CT lung cancer screening entails, its associated harms and benefits, and potential follow-up tests and procedures. The USPSTF has developed fact sheets and evidence syntheses discussing the lung cancer screening recommendations, which target a variety of audiences, including providers and patients.26 Understanding these issues may decrease patient anxiety, which is a potential harm of screening, and encourage high-risk individuals to be screened. Conversely, this may dissuade those at lower risk from being screened. Furthermore, these discussions can be used as an opportunity to assess patient willingness and eligibility to proceed with follow-up care; the USPSTF recommends against screening individuals who are unwilling or unable to undergo surgery or who have a serious comorbid illness.1 Finally, the panel recommended that providers only refer patients to facilities that provide multidisciplinary guideline-based care. The process of identifying and referring patients for screening provides numerous opportunities to motivate patients to quit smoking. The potential for increasing smoking cessation rates is one benefit of recruiting current smokers. As recommended by others, every current smoker should receive smoking cessation counseling.23,24 Health care informatics infrastructural suppliers and supporters. Establishing efficient screening programs nationwide will require the development and expansion of informatics infrastructure. The panel proposed adding fields to EHR systems for capturing detailed smoking history data, developing a uniform structured re-
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Offering smoking cessation support for all current smokers. Smoking cessation is fundamental in reducing the risk of lung cancer and is considered highly cost effective.12 Studies have suggested that the cost effectiveness of CT screening may be heavily influenced by its impact on quit rates among smokers.13,14 Panel members discussed concerns that screening programs may compete for funds with existing smoking cessation programs and that negative screening results may reinforce smoking behavior in current smokers. Alternatively, lung cancer screening could act as a teachable moment to encourage smoking cessation.15-19 Because it is not known whether CT screening has a positive or negative impact on smoking, approaches that systematically integrate smoking cessation interventions into screening programs should be evaluated.
screening examinations during available downtimes, thus avoiding the need to purchase additional machines. It predicts that future demand at the institution will necessitate the addition of one 40-hour shift.22
Recommendations for Implementing CT Lung Cancer Screening
Insurance companies and integrated delivery systems. Although the USPSTF grade-B recommendation theoretically removes screening-related cost barriers, uncertainty remains. A Medicare coverage decision has not been finalized, but the Medicare Evidence Development and Coverage Advisory Committee voted against recommending national coverage on April 30, 2014.27 For the privately insured, implementation issues, such as billing coding, may affect access.28 The panel recommended that benefits be structured in a manner that encourages eligible individuals to be screened, notifies ineligible individuals that screening is not covered, and promotes the use of qualified facilities. However, this requires that health plans have access to valid and reliable data in searchable databases, enabling the identification of eligible individuals. The USPSTF also recommends (grade A) that clinicians ask all adults about tobacco use and provide smoking cessation interventions for current smokers. This enhances private coverage of smoking cessation interventions, which will enable their integration into the screening process.24 Copyright © 2014 by American Society of Clinical Oncology
Insurance companies also have an opportunity to develop population-based outreach programs to encourage high-risk individuals to participate in screening and to ensure that their networks provide access to high-quality, efficient screening centers. Many panelists recommended that insurers collect detailed data on current and prior smoking behavior during annual enrollment. Insurers could then develop population-based outreach strategies, such as mailing screening reminders to high-risk members or contacting PCPs to identify patients under their care who may qualify for screening. However, the panel acknowledged that under the Affordable Care Act, these data could also be used to raise insurance premiums for current smokers, which may have unintended negative consequences (eg, creating incentive for members to falsify smoking information).29 Employers. Employers could also collect detailed information on smoking history and encourage eligible employees to discuss screening with their PCPs. Providing smoking cessation programs may increase smoking cessation rates, although establishing smoking penalties may have unintended consequences. Employers could partner with health plans or local screening centers to develop innovative approaches for encouraging atrisk employees to be screened. Advocacy groups. Patient advocacy groups already actively support lung cancer screening, and they can continue to help in a number of ways. For example, advocacy groups could provide resources to help develop and identify qualified facilities and guide patients and referring physicians to these locations. Additionally, educational campaigns for patients and physicians could be used to increase awareness of CT lung cancer screening and promote smoking prevention and cessation. Furthermore, resources could be used to support screening-related research. State and national public health agencies. Lung cancer causes more deaths in the United States than any other type of cancer and is preventable through smoking avoidance and cessation.30 Public health agencies should consider implementing a national campaign, focusing on lung cancer awareness, screening, and prevention. Communicating the benefits of smoking cessation would be integral to this initiative. The benefits and harms of CT lung cancer screening could also be incorporated, along with education regarding lung cancer risk assessment and screening eligibility.
Discussion Implementation of effective CT lung cancer screening must be approached prudently, with the active participation of stakeholders across the health care system. We convened a multidisciplinary panel of stakeholders to identify key issues that could influence screening effectiveness and outlined recommendations for approaching these issues. The panel envisioned screening occurring opportunistically at first and, ultimately, in a population-based manner. The panel identified several issues to address to enable future population-based screening efforts, including the need for: one, standardized patient smoking history data collection; two, infrastructural needs assessment and expansion; integrated systems enabling collaboration and data
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porting system, establishing a patient registry, and ensuring that all systems are standardized and integrated appropriately. EHR systems that allow providers to record detailed smoking history will enable eligibility assessment for population-based screening programs. The Centers for Medicare and Medicaid Services meaningful use criteria for EHR systems require fields for current smoking status.25 However, data on pack-years and quit dates are also necessary for identifying eligible individuals. Therefore, the panel recommended that these fields be incorporated. These systems could also ease provider burden by allowing electronic entry of screening orders, automatically generating screening appointments, and activating follow-up reminders. A structured reporting system, which tracks patients and findings and links results to guideline-based recommendations, will facilitate appropriate follow-up. The panel highly recommended that a uniform system be developed and adopted nationwide. For example, one system that is being developed—LungRADS—is modeled on the ACR Breast Imaging Reporting and Data System used in breast cancer screening.20,21 Patient registries can be used both by screening programs, to monitor performance and conduct quality improvement exercises, and by researchers. To this end, existing registries can be coordinated and expanded. For example, the ACR is currently working on expanding the National Radiology Data Registry to include a national lung cancer screening database, which may fulfill this need.11 The panel envisioned the registry systematically collecting all data for screened patients, including eligibility criteria, screening results, incidental findings, clinical workup and followup, and histologies and stages of detected cancers. Finally, the panel felt that these systems should be integrated and standardized across the United States. This will enable data sharing, improve continuity of care and follow-up, and facilitate higher-quality research and reporting. Collaboration between health informatics entities and professional societies would help to ensure that these systems are developed in a manner that is clinically relevant and avoids duplication.
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over time. Finally, studies should examine the emotional impact of screening and identify methods of allaying patient anxiety. Implementing lung cancer screening will provide numerous research opportunities, which will help fill knowledge gaps regarding both lung cancer and lung cancer screening. Federal and private sector groups should consider funding research in this area. Acknowledgment Supported by Genentech (which convened the expert panel). We thank the following expert panel members who did not participate as authors in this report: Christian G. Downs, JD, MHA, Tracy A. Lieu, MD, MPH, Walter F. Stewart, PhD, MPH, and Carolyn R. Aldigé. We also thank Peter B. Bach, MD, MAPP, and Arliene Ravelo, MPH, for helpful comments, and Joanna C. Sanderson, PharmD, MS, for editorial support. Authors’ Disclosures of Potential Conflicts of Interest Although all authors completed the disclosure declaration, the following author(s) and/or an author’s immediate family member(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a “U” are those for which no compensation was received; those relationships marked with a “C” were compensated. For a detailed description of the disclosure categories, or for more information about ASCO’s conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment or Leadership Position: Jennifer L. Malin, WellPoint (C) Consultant or Advisory Role: Scott D. Ramsey, Genentech (C); Jeffrey P. Kanne, Parexel Informatics (C); J. Sanford Schwartz, Blue Cross and Blue Shield Associations Medical Advisory Committee (C); Sean D. Sullivan, Genentech (C) Stock Ownership: Jennifer L. Malin, WellPoint; J. Sanford Schwartz, General Electric (manufacturer diagnostic imaging equipment), General Electric (manufacturer diagnostic imaging equipment) Honoraria: Andrea B. McKee, Varian, Hospitals for Grand Rounds Research Funding: Sean D. Sullivan, Genentech Expert Testimony: Andrea B. McKee, MEDCAC for Centers for Medicare and Medicaid Services (U) Patents, Royalties, and Licenses: None Other Remuneration: None
Author Contributions Conception and design: Scott D. Ramsey, Jennifer L. Malin, Laurie F. Ambrose, Jeffrey P. Kanne, J. Sanford Schwartz, Sean D. Sullivan Financial support: Sean D. Sullivan Collection and assembly of data: Andrea B. McKee, Shelby D. Reed Data analysis and interpretation: Scott D. Ramsey, Jennifer L. Malin, Bernardo Goulart, Jeffrey P. Kanne, Shelby D. Reed, J. Sanford Schwartz Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Scott D. Ramsey, MD, PhD, Fred Hutchinson Cancer Research Center,1100 Fairview Ave North, M3-B232, Seattle, WA 98109-1024; e-mail: [email protected].
DOI: 10.1200/JOP.2014.001528; published online ahead of print at jop.ascopubs.org on December 9, 2014.
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sharing; four, patient and provider education; and five, development, accreditation, and use of qualified facilities. Because of data and infrastructural gaps, which currently prevent identification of and access for eligible individuals, health care systems could consider a phased approach to population-based screening, first recruiting those with known or easily identifiable smoking status and expanding the scope over time by collecting more data on smoking history, educating physicians and patients, and actively reaching out to those who are potentially eligible. Focusing population-based screening efforts on eligible current smokers initially may have the greatest impact, partially because these individuals have the highest risk, and also because of the opportunity to encourage smoking cessation. To refine the process of CT lung cancer screening and maximize its benefits, the panel identified areas for further research. First, there is a lack of agreement regarding the threshold beyond which the benefits of screening outweigh its associated harms. Within the NLST sample, there was substantial variability in net benefit.31 There was also variability in the types of data used to support the USPSTF recommendation, because the decision to increase the screening age to 80 years was based on modeling work alone. Furthermore, many of the benefits and harms of implementing CT lung cancer screening in the general population remain unknown. The ideal screening duration is also uncertain, because the NLST only tested three consecutive annual CT screening scans. Therefore, the panel recommended research into real-world outcomes, screening duration, and the use of risk prediction models as tools to select individuals for screening. Development of less invasive diagnostic follow-up procedures would also improve the net benefit of screening. Future studies should explore the economic implications of screening and identify approaches that maximize its cost effectiveness. Another line of study could focus on identifying disparities in CT lung cancer screening with an eye toward addressing access barriers. Although it is widely believed that cancer screening has emotional and behavioral impacts on patients, their presence and management have not been well established in lung cancer. Studies should assess the combined impact of lung cancer screening and smoking cessation interventions and determine if and how to best integrate these programs. Factors relating to screening adherence have not been fully explored either. The panel felt it would be beneficial to investigate the impact of test results and other factors on screening adherence and to compare strategies to improve adherence. Strategies to engage patients in shared decision making should also be considered, given that this requires patients to understand relatively complex information. Quality assurance programs will also need to be designed and evaluated
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13. McMahon PM, Kong CY, Bouzan C, et al: Cost-effectiveness of computed tomography screening for lung cancer in the United States. J Thorac Oncol 6:1841-1848, 2011
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14. Villanti AC, Jiang Y, Abrams DB, et al: A cost-utility analysis of lung cancer screening and the additional benefits of incorporating smoking cessation interventions. PLoS One 8:e71379, 2013 15. van der Aalst CM, van Klaveren RJ, van den Bergh KA, et al: The impact of a lung cancer computed tomography screening result on smoking abstinence. Eur Respir J 37:1466-1473, 2011 16. van der Aalst CM, van den Bergh KA, Willemsen MC, et al: Lung cancer screening and smoking abstinence: 2 year follow-up data from the Dutch-Belgian randomised controlled lung cancer screening trial. Thorax 65:600-605, 2010 17. Poghosyan H, Kennedy Sheldon L, Cooley ME: The impact of computed tomography screening for lung cancer on smoking behaviors: A teachable moment? Cancer Nurs 35:446-475, 2012
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27. Chustecka Z: Panel says no to Medicare coverage for lung cancer screening. www.medscape.com/viewarticle/824427 28. Centers for Disease Control and Prevention: Health plan implementation of U.S. Preventive Services Task Force A and B recommendations: Colorado, 2010. MMWR Morb Mortal Wkly Rep 60:1348-1349, 2011 29. Curtis R, Neuschler E: Tobacco rating issues and options for California under the ACA. www.ihps.org/pubs/Tobacco_Rating_Issue_Brief_21June2012.pdf 30. Siegel R, Naishadham D, Jemal A: Cancer statistics, 2012. CA Cancer J Clin 62:10-29, 2012 31. Kovalchik SA, Tammemagi M, Berg CD, et al: Targeting of low-dose CT screening according to the risk of lung-cancer death. N Engl J Med 369:245-254, 2013
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