Experts Provide Guidance on Reporting During Lung Cancer Screenings

Eric M. Hart, MD

Clinicians involved in conducting lung cancer screening (LCS) with low-dose computed tomography (CT) are already at an advantage for optimized care.

LCS is beneficial, as it enables earlier detection of lung cancer in asymptomatic patients, thus allowing curative treatment and reducing mortality risk. However, to ensure that the benefits of LCS outweigh the risks of radiation exposure from the CT, it is critical that the administered radiation dose is as low as possible without compromising image quality.

Such detail is emphaized in the new guide developed by the American Thoracic Society and the American Lung Association, in an effort to help clinicians implement a standardized process and a structured reporting system during the CT.¹

The guide, entitled Lung Cancer Screening Implementation Guide, was written by Carey C. Thomson, MD, MPH, director of the Lung Cancer & Lung Nodule Care Program at Mount Auburn Hospital, Cambridge, Massachusetts, and Andrea McKee, MD, cochair of the Lung Cancer Screening Steering Committee at Lahey Hospital & Medical Center, Burlington, Massachusetts, and is available online.

“The most important thing is that all sites adhere to the dose limitations required by CMS,” stated Eric M. Hart, MD, chief of chest imaging at Northwestern University Feinberg School of Medicine, Chicago, Illinois, in an interview with MD Magazine^®.

To confirm that LCS programs abide by the American College of Radiology and Society of Thoracic Radiology specifications, screening should follow a standardized and structured protocol. In the “During the CT: Reporting” section of the guide, pulmonary experts from diverse LCS programs describe how their institutions have successfully implemented this process.

Standardizing the Screening Process

LCS programs can standardize the milliampere (mA) dose administered during the CT by following either a fixed-mA or variable-mA approach. In order to ensure the dose administered is optimized for the individual patient, adjustments can be made based on the weight of the patient. For instance, when using a fixed-mA approach, the dose may need to be increased by 10 mA for heavier patients and decreased by 10 mA for patients who weigh less.

In addition to the mA dose, order tracking should be standardized in the program’s database. Most institutions have found it helpful to use an electronic health record system to accomplish this, as notification functions can be programmed to help orders move appropriately and entirely through the screening process, ensuring that abnormal results are reviewed in a timely manner.

According to Kim L. Sandler, MD, codirector of the Lung Screening Program at Vanderbilt University Medical Center in Nashville, Tennessee, all data are entered into the medical record as part of the institution’s LCS program, including components of the risk-prediction model from the shared decision-making visit and important demographic data. “This also makes reimbursement from insurance providers easier, as all information is located in 1 place,” Sandler said.

Ensuring Structured Reporting In addition to standardizing how orders are tracked through the program, reporting results in a structured manner is essential. Structured reporting is critical to guarantee that results are accurately communicated by the radiologist to the provider and that exam data are appropriately submitted to an approved registry for reimbursement.

Most LCS programs use Lung-RADS to interpret and report CT results. Lung-RADS is a classification system that categorizes exam results, thus standardizing the interpretation process.

If the radiologist determines that results are suspicious for lung cancer, a follow-up consultation with a pulmonologist is typically recommended; however, the personnel responsible for scheduling a referral or arranging necessary follow-up scans varies depending on the program’s governance structure.

“Abnormalities detected by LCS can be managed either by the patient’s primary care provider or through the centralized LCS and lung nodule clinic,” said Katrina Steiling, MD, MSc, cochair of the Lung Cancer Screening Steering Committee at Boston University School of Medicine in Massachusetts.

“Providers are always given the opportunity to do these things themselves, but we have found that they prefer for these things to be managed within the program,” Sandler said.

Most experts agree that a program coordinator is helpful for providing oversight for following clinical activity in patients’ charts, guaranteeing results are communicated to the provider and ensuring appropriate follow-up is scheduled with the patient.

“Because we have a dedicated program coordinator, we are able to arrange necessary follow-up for abnormal findings and schedule routine follow-up scans,” Dr. Sandler said. “In order to have a centralized program, you need to have a program coordinator.”

LCS requires multidisciplinary collaboration between radiologists, the multidisciplinary team, primary care providers, nurses, patients, and approved registries. Therefore, it is essential to use a structured reporting system to facilitate accurate communication of results.

Thomson CC, McKee A, Borondy-Kitts A, et al; American Thoracic Society, American Lung Association. Implementation guide for lung cancer screening. lung.org/assets/documents/lung-cancer/implementation- guide-for-lung.pdf. Accessed October 31, 2018.