Defining Eligibility and Providing Counseling Key for Lung Cancer Screening Programs

Peter J. Mazzone MD, MPH

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 guide¹ 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.

Deciding Whom to Screen

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

Establishing Screening Systems

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.

Sharing Decision Making

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.

Scheduling the Screening

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.