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LUNG CANCER SCREENING

IMPROVING LUNG CANCER SURVIVAL IN THE COMMUNITY SETTING

Scott Skibo, MD, FCCP

Haywood Regional Medical Center

Duke LifePoint

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PRACTICE LOCATION

159 Bed Hospital

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“At present, lung cancer is recognized late.

Opportunities to improve survival are through earlier

detection, accurate diagnosis, accurate localization,

and curative therapy…”

Carbone, PPNIH ConferenceAnnals of Internal Medicine (1970): 73:1003

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1. American Cancer Society: Facts and Figures 2013.

2. SEER Cancer Statistics Review; 1975-2008; National Cancer Institute, Accessed March 2013.

LUNG CANCER

SURVIVAL RATES

BY STAGE

AT DIAGNOSISat 10 years1

at 5 years2

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|

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DIAGNOSING LUNG CANCER EARLY

of new cases have

late-stage cancer.

(Stage III or IV)

of new cases have

Early-stage cancer.

(Stage I or II)

Current State Ideal State

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SCREENING FOR LUNG CANCER: EARLY DETECTION MATTERS

• 70% of patients found to have lung cancer in the LDCT arm of the

National Lung Screening Trial (NLST) were diagnosed in the early

stages1

• Only 320 LDCT screenings are needed to prevent one death1

• In the NLST, the mortality for patients at high risk receiving LDCT

screening was reduced by 20% vs. X-ray1

• LDCT screening costs $1631 per person, or $81,0000 per quality-

adjusted year gained in comparison with with no screening2

1. N Engl J Med. 2011;365(5):395-409

2. N Engl J Med. 2014;371:1793-1802

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SO HAS THIS HAPPENED?

• USPSTF updated guidelines in 2013 recommending yearly

screening for lung cancer using LDCT

• 2015 Medicare/Insurance reimbursed test

• The importance of detecting lung cancer early and

managing incidental pulmonary nodules is well known and

accepted.

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FEWER THAN 4% OF HIGH RISK PATIENTS GET SCREENED FOR LUNG CANCER- AND

NOT CHANGED BY USPSTF GUIDELINES

• 2010 National Health Interview Survey found that only 3.3% of high

risk smokers had been screened by LDCT the previous year

• 2015 National Health Interview Survey found that only 3.9% of high

risk smokers were screened by LDCT

• In 2015, 6.8 million current and former smokers were eligible for CT

screening- only 262,700 were actually screened.

JAMA Oncology 2017;3(9):1278-1281

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IN 2016 ONLY 1.9% OF 7.6 MILLION ELIGIBLE PATIENTS UNDERWENT LDCT SCREENING

• Only 1.6% of eligible heavy smokers in the South

underwent LDCT

• Region has the most accredited screening sites

(663/1796)

• Most eligible patients (3,072,095/7,612,975)

• In contrast- 65% of women age 40 or older underwent

mammography for breast cancer screening in 2015

• Pham DC, et al, ASCO 2018, Abstract 6504

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WHY IS THE RATE OF SCREENING HIGH RISK PATIENTS SO LOW?

(THIS IS AN EVIDENCE BASED, GUIDELINE RECOMMENDED, AND MEDICARE APPROVED TEST)

WHAT CAN BE DONE TO CHANGE THIS?

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WHY IS THE SCREENING RATE SO LOW?

• Are physicians not referring enough?

• Are eligible patients not wanting screening, even if they

know a test is available?

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WHY IS THE SCREENING RATE SO LOW?(PROVIDERS)

• Knowledge of, attitudes toward, and use of LDCT for lung cancer

screening among family physicians

• 98% felt LDCT increased odds of detecting cancer at an earlier stage

• 75% felt the benefits outweighed the harms

• 76% discussed risks/benefits of LDCT in some capacity with their

patients

• >50% reported making one or no screening

recommendations in the past year

Cancer 2016;122:2324-31

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WHY IS THE SCREENING RATE SO LOW?(PROVIDERS)

• LDCT screening practices and attitudes among primary care providers

at an academic medical center

• Few PCPs ordered lung cancer screening

• 21% X-ray, 12% LDCT, 3% sputum cytology

• <50% of PCPs knew three or more of the six guideline components

for screening, and 24% knew zero

• 30% of providers doubted effectiveness of LDCT in improving

outcomes

• This study was conducted at a medical center that

participated in the NLST

Cancer Epidemiol Biomarkers Prev 2015; 24(4): 664-70

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WHY IS THE SCREENING RATE SO LOW?(PROVIDERS)

• What are the factors associated with LDCT screening utilization?

• Lack of knowledge led to a 37% inappropriate referral rate from 2013 to 20151

• Almost 2/3 of physicians are unsure whether CMS covers the cost of LDCT2

• 82% of providers are interested in learning more about lung cancer screening1

1.Prev Med Rep 2017 Jun; 6 :17-22

2. Cancer 2016;122:2324-31

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WHAT HAS BEEN LEARNED?(PROVIDERS)

• There is a well documented disconnect in moving clinical research findings into clinical practice (1981 Beta-Blocker Heart attack Trial, etc)1 - This is a evidence based, guideline recommended, Medicare covered test.

• Physician knowledge is not optimal

• Physician belief that LDCT is valuable for early detection, but a lower proportion believe that LDCT reduces lung cancer mortality2

• Physicians believe lung cancer screening to be less efficacious than other cancer screenings2

1. N Engl J Med. 2003;349:868-874

2. Cancer Epidemiol Biomarkers Prev. 2015;24:664-670

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WHY IS THE SCREENING RATE SO LOW?(PATIENTS)

• 60% of patients that qualify for LDCT screening adhered to recommendation

• Younger, white, and female patients show a trend towards better adherence1

• No difference for cancer history, residential area, level of education, type of insurance, occupation, or provider location1

• 79% of the patients that did not go through with their prescribed LDCT wanted to do one in the future1

• Fatalistic beliefs, fear of radiation exposure, and anxiety related to CT scans2

• Those who quit smoking or smoke less are more likely to be adherent1

• (smokers are less likely to seek out care for lung cancer)3

1. Prev Med Rep. 2017 Jun;6:17-22

2. Lung Cancer. 2012;77(3):526-531

3. Thorax. 2016 (PubMed PMID: 26911574)

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WHY IS THE SCREENING RATE SO LOW (PATIENTS)

Those who quit smoking or smoke less are more likely to be

adherent1

• (smokers are less likely to seek out care for lung cancer)3

• Patients may perceive screening-detected lung cancer as confirmation

of a poor lifestyle choice2

1. Prev Med Rep. 2017 Jun;6:17-22

2. Pham DC et al. ASCO 2018, Abstract 6504

3. Thorax. 2016 (PubMed PMID: 26911574)

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WHAT CAN BE DONE TO IMPROVE SCREENING RATE?

• Provider Education

• Most (82%) were interested in learning more about LDCT1

• 59% stated an on-line lecture was the preferred method1

• Focus on mortality reduction, CMS coverage

• In office decision aides

• Patient Education

• Decision aids reduce the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication2

• Community outreach

1. Prev Med Rep. 2017;6:17-22

2. Cochrane Database Syst Rev. 2014;1:CD001431

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SHARED DECISION AIDS IMPROVE ADHERENCE TO LDCT SCREENING

Providers who discussed the benefits of LDCT screening with the use of shared decision aids increased screening participation from 10% to 95%1

• 1. Asian Pac. J. Cancer Prev. 2015;16(15):6293-6298

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SHARED DECISION MAKING MATERIALS

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PHYSICIAN OUTREACH/EDUCATION

= Individual practices visited

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COMMUNITY OUTREACH/EDUCATIONNEWSPAPERS

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COMMUNITY OUTREACH/EDUCATIONLOCAL TV

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COMMUNITY OUTREACH/EDUCATIONCOMMUNITY EVENTS

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LUNG CANCER SCREENING OUTCOMES

• 2016

• 96 total screens

• LR-3 10

• LR-4 6

• Diagnosed Cancer 2

• 2017

• 269 total screens

• LR-3 22

• LR-4 18

• Diagnosed Cancer 3

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0

5

10

15

20

25

30

35

40

2016 & 2017 LDCT Screenings

2016 2017

January December

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2018 – THROUGH JULY WE HAVE SCREENED 277 PATIENTS

96 269 474

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LUNG CANCER DIAGNOSED BEFORE AND AFTER PROGRAM DEVELOPMENT (SYSTEM

WIDE)

• 2014 (Pre- ENB) • 2015 (Post-ENB)

10%

10%

32%

48%

N= 31 (20% Stage 1 and 2)

Stage 1

Stage 2

Stage 3

Stage 4

29%

27%18%

26%

N=92 (56% Stage 1 and 2)

Stage 1

Stage 2

Stage 3

Stage 4

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54% OF OUR PATIENTS DIAGNOSED

WITH NSCLC IN 2017 EITHER UNDERWENT SURGICAL RESECTION OR STEREOTACTIC RADIOSURGERY (SBRT)

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NEXT STEPS

• Improve adherence to LDCT

• QI program launched to improve efficiency of scheduling

process (automation)

• Piloting a program for same day screening.

• Revisiting primary care programs/improved shared

decision making materials

• Expand availability of LDCT screening exams beyond our

immediate market

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DIAGNOSING LUNG CANCER EARLY

56%of new cases have

early-stage cancer.

(Stage I or II)

85%of new cases have

Early-stage cancer.

(Stage I or II)

Current State Ideal State

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POLICY CHANGE IS NEEDED TO IMPROVE ADHERENCE NATIONALLY

• Make lung cancer screening a national quality health

measure for healthcare systems by CMS to optimize

reimbursement

• In 2008 CMS made mammograms for breast cancer and

colonoscopies for colorectal cancer national areas of

improvement

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QUESTIONS?