The American Thoracic Society and American College of Chest Physicians recently developed a policy statement on the successful implementation of comprehensive low-radiation-dose CT (LDCT) lung cancer screening programs that are safe, effective, and sustainable. This type of screening has been shown to reduce risks for lung cancer-related mortality. However, there is a continued need for guidance in this area. LDCT screening is a complex process, and few healthcare providers have experience managing the challenges that come with starting these programs.
“There is an important need for an infrastructure for the initial screening CT scan as well as for the evaluation of pulmonary nodules and other abnormalities that are commonly detected on screening,” says Renda Soylemez Wiener, MD, MPH, who helped develop the policy statement document. “There is also a need to be prepared to treat any cancers that may be detected.” The policy statement refers to three phases of LDCT lung cancer screening program development: 1) planning, 2) implementation, and 3) maintenance.
“For the planning phase, we recommend the coordination of a multidisciplinary steering committee to oversee the screening program,” says Dr. Wiener. “This includes representation from pulmonology, thoracic surgery, radiology, primary care, medical center leadership, oncology, and radiation oncology. We also recommend educating and engaging primary care providers to ensure they understand the nuances of lung cancer screening. In most cases, primary care providers will be the ones who need to offer lung cancer screening to their patients. They will also need to be involved in the shared decision-making process required by Medicare.”
Dr. Wiener explains that obtaining buy-in from local leadership is important in order to ensure they will be supportive of LDCT screening programs. “It can be an expensive undertaking,” she says, “and establishing a business model with leadership’s support can help provide a sense of the financial implications of starting a program. It’s also important in the planning phase to market the program, within the medical center and perhaps to the public, so that they know it’s available.”
For the implementation phase, the policy statement recommends establishing systems for ensuring that screening is offered only to eligible patients. “It’s also important to establish a system for shared decision making,” says Dr. Wiener. “Tools, such as patient decision aids, should be available to facilitate shared decision making by explaining the pros and cons of lung cancer screening [Table].”
The policy statement recommends standardizing the entire process, including:
- Use of a low dose of CT scans used for screening.
- A template for radiologists to report CT results.
- A process for evaluating any nodules or abnormalities detected on CT scans.
- A method for ensuring that patients adhere to the follow-up process.
- An approach for reporting screening results to patients.
The maintenance phase focuses on monitoring the LDCT cancer screening program to ensure it meets quality standards. “It’s important to have a method for tracking any pulmonary nodules that are detected and ensuring that evaluation is appropriate,” says Dr. Wiener. “While Medicare requires this information be submitted to a registry, evidence suggest that a registry alone may be insufficient for ensuring follow-up. A dedicated person is needed to oversee the whole process and make sure all parties recognize who is responsible for following up on nodules.”
The most obvious benefit of LDCT lung cancer screening is the potential to decrease lung cancer-related mortality, but Dr. Wiener says there are other benefits to consider (Table). “This screening can reassure anxious patients and provide a teachable moment to encourage people to quit smoking,” she says. “However, it’s also important to consider the harms associated with LDCT screening, including the high false positive rate of lung cancer screening, physical complications from biopsy or surgical resections, and the emotional distress related to ongoing surveillance. Other possible harms include radiation exposure, potential false reassurance, and over-diagnoses of clinically insignificant tumors.”
The policy statement is directed mostly for helping medical personnel develop safe and effective LDCT lung cancer screening programs, according to Dr. Wiener. However, it also includes tools that are helpful in daily practice. “These tools include patient decision aids and offer physicians pragmatic advice about the whole lung cancer screening process.”
Renda Soylemez Wiener, MD, MPH, is an Assistant Professor of Medicine for The Pulmonary Center at Boston University Medical Center; an Adjunct Faculty member at The Dartmouth Institute for Health Policy & Clinical Practice; and a Core Investigator for the Center for Healthcare Organization & Implementation Research at Bedford VAMC.
Renda Soylemez Wiener, MD, MPH, has indicated to Physician’s Weekly that she has no financial interests to disclose.
Readings & Resources (click to view)
Wiener R, Gould M, Arenberg D, et al. An official American Thoracic Society/American College of Chest Physicians policy statement: implementation of low-dose computed tomography lung cancer screening programs in clinical practice. Am J Resp Crit Care Med. 2015;192:881-891. Available at www.atsjournals.org/doi/abs/10.1164/rccm.201508-1671ST#.ViaBGH6rRph.
Aberle D, Adams A, Berg C, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409.
Detterbeck F, Mazzone P, Naidich D, Bach P. Screening for lung cancer. Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143:e78S-e92S.
Moyer V. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160:330-338.