Lung Screening Program Research Articles

Successes and challenges of implementing a lung cancer screening program in federally qualified health centers: a qualitative analysis using the Consolidated Framework for Implementation Research.

In recent years, studies have shown that low-dose computed tomography (LDCT) is a safe and effective way to screen high-risk adults for lung cancer. Despite this, uptake remains low, especially in limited-resource settings. The American Cancer Society (ACS) partnered with two federally qualified health centers and accredited screening facilities on a 2 year pilot project to implement an LDCT screening program. Both sites attempted to develop a referral program and care coordination practices to move patients through the screening continuum and identify critical facilitators and barriers to implementation. Evaluators conducted key informant interviews (N = 46) with clinical and administrative staff, as well as regional ACS staff during annual site visits. The Consolidated Framework for Implementation Research guided our analysis of factors associated with effective implementation and improved screening outcomes. One study site established a sustainable lung screening program, while the other struggled to overcome significant implementation barriers. Increased time spent with patients, disruption to normal workflows, and Medicaid reimbursement policies presented challenges at both sites. Supportive, engaged leaders and knowledgeable champions who provided clear implementation guidance improved staff engagement and were able to train, guide, and motivate staff throughout the intervention. A slow, stepwise implementation process allowed one site’s project champions to pilot test new processes and resolve issues before scaling up. This pilot study provides critical insights into the necessary resources and steps for successful lung cancer screening program implementation in underserved settings. Future efforts can build upon these findings and identify and address possible facilitators and barriers to screening program implementation.

Lung Screening Benefits and Challenges: A Review of The Data and Outline for Implementation.

Lung cancer is the leading cause of cancer-related deaths worldwide, accounting for almost a fifth of all cancer-related deaths. Annual computed tomographic lung cancer screening (CTLS) detects lung cancer at earlier stages and reduces lung cancer-related mortality among high-risk individuals. Many medical organizations, including the U.S. Preventive Services Task Force, recommend annual CTLS in high-risk populations. However, fewer than 5% of individuals worldwide at high risk for lung cancer have undergone screening. In large part, this is owing to delayed implementation of CTLS in many countries throughout the world. Factors contributing to low uptake in countries with longstanding CTLS endorsement, such as the United States, include lack of patient and clinician awareness of current recommendations in favor of CTLS and clinician concerns about CTLS-related radiation exposure, false-positive results, overdiagnosis, and cost. This review of the literature serves to address these concerns by evaluating the potential risks and benefits of CTLS. Review of key components of a lung screening program, along with an updated shared decision aid, provides guidance for program development and optimization. Review of studies evaluating the population considered "high-risk" is included as this may affect future guidelines within the United States and other countries considering lung screening implementation.

Mobile Lung Screening: Should We All Get on the Bus?

Despite favorable recommendations, national lung screening adoption remains low (2% to 3%). Patients living in rural areas have additional challenges, including access to lung screening programs. We initiated a mobile lung screening program to serve the rural patients at risk. This is what we learned from this 12-month feasibility project. Utilizing a multidisciplinary approach, we began an 8-month design and build schedule. This was the first build of this type. The operational team included a radiology technician, nurse practitioner, driver with a commercial driver's license, and program developer. Specialized software was used for data mining. Downstream revenue projections werebased on previously published Medicare claims data. Generally accepted accounting principles were used. The prototype bus was delivered January 2018. During the 12-month feasibility period, we performed 548 low-dose lung screenings at 104 sites. Mean patient age was 62 years, mean pack-years of smoking was 41; 258 (47%) were male. Five lung cancers were found in addition to a type B thymoma. Financially, we exceeded the break-even analysis by 28%. The 5-year pro forma using 1 year of actual data and 4 additional years of projected data demonstrated a net present value of 1 million, internal rate of return of 34.6%, and profitability index of 2.2-all highly dependent on downstream revenue. Although challenges exist, a commercially viable bus and a financially sound mobile program can be developed. However, without a centralized approach for incidental findings, the downstream revenue may be at risk as well as the financial viability of the project.

Deep Multi-task Prediction of Lung Cancer and Cancer-free Progression from Censored Heterogenous Clinical Imaging.

Annual low dose computed tomography (CT) lung screening is currently advised for individuals at high risk of lung cancer (e.g., heavy smokers between 55 and 80 years old). The recommended screening practice significantly reduces all-cause mortality, but the vast majority of screening results are negative for cancer. If patients at very low risk could be identified based on individualized, image-based biomarkers, the health care resources could be more efficiently allocated to higher risk patients and reduce overall exposure to ionizing radiation. In this work, we propose a multi-task (diagnosis and prognosis) deep convolutional neural network to improve the diagnostic accuracy over a baseline model while simultaneously estimating a personalized cancer-free progression time (CFPT). A novel Censored Regression Loss (CRL) is proposed to perform weakly supervised regression so that even single negative screening scans can provide small incremental value. Herein, we study 2287 scans from 1433 de-identified patients from the Vanderbilt Lung Screening Program (VLSP) and Molecular Characterization Laboratories (MCL) cohorts. Using five-fold cross-validation, we train a 3D attention-based network under two scenarios: (1) single-task learning with only classification, and (2) multi-task learning with both classification and regression. The single-task learning leads to a higher AUC compared with the Kaggle challenge winner pre-trained model (0.878 v. 0.856), and multi-task learning significantly improves the single-task one (AUC 0.895, p<0.01, McNemar test). In summary, the image-based predicted CFPT can be used in follow-up year lung cancer prediction and data assessment.

Internal-transfer Weighting of Multi-task Learning for Lung Cancer Detection.

Deep learning has achieved many successes in medical imaging, including lung nodule segmentation and lung cancer prediction on computed tomography (CT). Recently, multi-task networks have shown to both offer additional estimation capabilities, and, perhaps more importantly, increased performance over single-task networks on a "main/primary" task. However, balancing the optimization criteria of multi-task networks across different tasks is an area of active exploration. Here, we extend a previously proposed 3D attention-based network with four additional multi-task subnetworks for the detection of lung cancer and four auxiliary tasks (diagnosis of asthma, chronic bronchitis, chronic obstructive pulmonary disease, and emphysema). We introduce and evaluate a learning policy, Periodic Focusing Learning Policy (PFLP), that alternates the dominance of tasks throughout the training. To improve performance on the primary task, we propose an Internal-Transfer Weighting (ITW) strategy to suppress the loss functions on auxiliary tasks for the final stages of training. To evaluate this approach, we examined 3386 patients (single scan per patient) from the National Lung Screening Trial (NLST) and de-identified data from the Vanderbilt Lung Screening Program, with a 2517/277/592 (scans) split for training, validation, and testing. Baseline networks include a single-task strategy and a multi-task strategy without adaptive weights (PFLP/ITW), while primary experiments are multi-task trials with either PFLP or ITW or both. On the test set for lung cancer prediction, the baseline single-task network achieved prediction AUC of 0.8080 and multi-task baseline failed to converge (AUC 0.6720). However, applying PFLP helped multi-task network clarify and achieved test set lung cancer prediction AUC of 0.8402. Furthermore, our ITW technique boosted the PFLP enabled multi-task network and achieved an AUC of 0.8462 (McNemar test, p < 0.01). In conclusion, adaptive consideration of multi-task learning weights is important, and PFLP and ITW are promising strategies.

Prognostic effect of implementation of the mass low-dose computed tomography lung cancer screening program: a hospital-based cohort study.

Low-dose computed tomography lung cancer screening aims to detect early-stage lung cancers in order to decrease the incidence of advanced-stage lung cancers and to reduce lung cancer mortality. We analyzed the time trends of lung cancer stage distribution and mortality rates after the gradual implementation of the low-dose computed tomography lung cancer screening in a hospital-based cohort. Using the hospital-based cancer registry data on lung cancer number and death from 2007 to 2014, we aim to evaluate the trends in stage distribution and mortality rate after the gradual implementation of low-dose computed tomography lung cancer screening program over recent years. From 2007 to 2014, overall 2542 cases of lung cancers were diagnosed according to hospital-based cancer registry. For the 1-year mortality rate, the mortality rate decreased gradually from 48.16 to 37.04% between 2007 and 2014. For the 5-year mortality rate, the mortality rate decreased gradually from 88.49 to 69.44% between 2007 and 2014. There was a gradual decrease in stage IV lung cancer with the corresponding sharp increase in stage I early lung cancer after following the implementation of the large volume of the low-dose computed tomography examination between the years 2011 and 2014. In conclusion, these results suggest that the gradual implementation of low-dose computed tomography lung screening program could lead to a remarkable decrease in lung cancer mortality and a remarkable stage shift in the trend over time in this hospital-based cohort.

Lung cancer screening: where do we stand?

A screening program for cancer in selected patients population could be a very effective measure to reduce morbidity and mortality rates. Several trials analyzed the efficacy of screening programs in lung cancer patients but nonetheless a worldwide adopted screening tool is lacking to date. Several uncertainties still exist but the scientific evidence about the efficacy of lung screening programs is already available.

Potential lung cancer screening outcomes using different age and smoking thresholds in the ANRS-CO4 French Hospital Database on HIV cohort.

In most lung screening programmes, only subjects ≥55years old and smoking ≥30 pack-years are eligible to undergo chest low-dose computed tomography. Whether the same criteria should apply to people living with HIV (PLHIV) is uncertain, given the increased lung cancer risks associated with immunodeficiency and high rates of smoking. We assessed different outcomes obtained from simulating one round of lung cancer screening in PLHIV using different age and smoking thresholds for eligibility. Data from the French Agence Nationale de Recherche sur le SIDA et les Hépatites Virales (ANRS)-CO4 French Hospital Database on HIV (FHDH) cohort of PLHIV and a national representative survey of PLHIV in care in 2011 (the ANRS-VESPA2 [enquête sur les personnes atteintes] study) were used to estimate the maximum proportion of incident lung cancers occurring between 2012 and 2016 that would have potentially been detected by screening in 2011. Secondary outcomes were numbers of eligible subjects in the cohort and numbers of subjects needed to screen (NNS) to detect one lung cancer. Among 77819 PLHIV in 2011 (median age 46years; 66% men), 285 subjects subsequently developed lung cancer. Adoption of the US Preventive Services Task Force (USPSTF) recommendations (55-80years; ≥30 pack-years) would have detected 31% of lung cancers at most. Lowering the minimum age to 50 and 45years would have detected 49% and 60% of cancers, respectively, but would have greatly increased the number of eligible subjects and the NNS to detect one case of lung cancer. Use of the USPSTF criteria would have detected only a minority of lung cancers in a large French cohort of PLHIV in 2011. Screening PLHIV at younger ages (45 or 50years) and/or the use of lower smoking thresholds (20 pack-years) may be beneficial, despite the consequently higher numbers of eligible subjects and NNS to detect one case of lung cancer, and should be evaluated in future studies.

Longitudinal associations between BMI change and the risks of colorectal cancer incidence, cancer-relate and all-cause mortality among 81,388 older adults

BackgroundIt remains controversial whether weight change could influence the risks of colorectal cancer (CRC) and mortality. This study aimed to quantify the associations between full-spectrum changes in body mass index (BMI) and the risks of colorectal cancer (CRC) incidence, cancer-related and all-cause mortality among midlife to elder population.MethodsA total of 81,388 participants who were free of cancer and aged 55 to 74 years from the Prostate, Lung, Colorectal, and Ovarian (PLCO) screening program were involved. The percentage change of BMI was calculated as (BMI in 2006 - BMI at baseline)/BMI at baseline, and was categorized into nine groups: decrease (≥ 15.0%, 10.0–14.9%, 5.0–9.9%, 2.5–4.9%), stable (decrease/increase < 2.5%), increase (2.5–4.9%, 5.0–9.9%, 10.0–14.9%, ≥ 15.0%). The associations between percentage change in BMI from study enrolment to follow-up (median: 9.1 years) and the risks of CRC and mortality were evaluated using Cox proportional hazard regression models.ResultsAfter 2006, there were 241 new CRC cases, 648 cancer-related deaths, and 2361 all-cause deaths identified. Overall, the associations between BMI change and CRC incidence and cancer-related mortality, respectively, were not statistically significant. Compared with participants whose BMI were stable, individuals who had a decrease in BMI were at increased risk of all-cause mortality, and the HRs were 1.21 (95% CI: 1.03–1.42), 1.65 (95% CI: 1.44–1.89), 1.84 (95% CI: 1.56–2.17), and 2.84 (95% CI: 2.42–3.35) for 2.5–4.9%, 5.0–9.9%, 10.0–14.9%, and ≥ 15.0% decrease in BMI, respectively. An L-shaped association between BMI change and all-cause mortality was observed. Every 5% decrease in BMI was associated with a 27% increase in the risk of all-cause mortality (HR = 1.27, 95% CI: 1.22–1.31, p < 0.001). The results from subgroups showed similar trends.ConclusionsA decrease in BMI more than 5% shows a significantly increased risk of all-cause mortality among older individuals; but no significant association between increase in BMI and all-cause mortality. These findings emphasize the importance of body weight management in older population, and more studies are warranted to evaluate the cause-and-effect relationship between changes in BMI and cancer incidence/mortality.

Unexpected effect of smoking/drinking cessation among computed tomography lung screening consumers

Abstract Background Low-dose computed tomography (LDCT) screening is an innovated tool for lung cancer prevention. The findings of LDCT trials indicated that the screening could increase the motivation of smoking cessation for high-risk groups. However, none studies have investigated the associations between commercial LDCT lung screening and unhealthy behaviours among those customers. Methods We established a prospective observational study at a community hospital in Taiwan. In total, 1326 customers of the commercial LDCT lung screening without lung cancer history were recruited. At the day of screening, interviewers collected their baseline demographic information and smoking/drinking habits. Only 605 participants completed two follow-up surveys at the 3rd and 12th month. Screening findings were defined as ’normal’ if there were no nodules or only definitely benign nodules and as ’abnormal’ if any lung nodule or ground-glass opacity were found. We applied the generalised linear mixed model to estimate the effects of time and screening findings on daily smoking and weekly drinking. Results The rates of daily smoking (weekly drinking) decreased from 13.1% (15.5%), to 10.9% (12.9%) in the 3rd month, and 7.9% (12.4%) in the 12th month. The associations between abnormal screening findings and smoking (-0.25, 95% CI: -0.77,0.28) or drinking (0.13, 95% CI: -0.29, 0.56) cessation are not significant. The time effect on smoking cessation was persistent (-0.23 and -0.62 at the two periods, 95% CI: -0.39, -0.07 and -0.85. -.038), and the effect on stopping drinking was relatively small (-0.23 and -0.28 at the two periods, 95% CI: -0.43, -0.04 and -0.52, -0.04). Conclusions Commercial LDCT screening would decrease the rates of smoking more than drinking among these consumers, and the abnormal finding was not further associated with cessations. It implies that commercial screenings may be beneficial for decreasing unhealthy behaviours as a teachable occasion. Key messages Commercial LDCT lung screening program may have benefits for decreasing smoking and even drinking behaviours among the non-specific high-risk population. It might be a good moment for health providers and practitioners to conduct cancer-related health education during commercial screening programs.

Association of a Lung Screening Program Coordinator With Adherence to Annual CT Lung Screening at a Large Academic Institution

BackgroundDetection of early-stage lung cancer improves during subsequent rounds of screening with low-dose CT and potentially leads to saving lives with curative treatment. Therefore, adherence to annual lung screening is important. We hypothesized that adherence to annual screening would increase after hiring of a dedicated program coordinator. MethodsWe performed a mixed-methods study in a retrospective cohort of patients who underwent lung screening at our academic institution between January 1, 2014, and March 31, 2018. Patients with baseline lung screening examinations performed between January 1, 2014, and September 30, 2016, with Lung CT Screening Reporting & Data System 1 or 2 scores and a 12-month follow-up recommendation were included. We tracked patient adherence to annual follow-up lung screening over time (before and after hiring of a program coordinator) and conducted a cross-sectional survey of patients nonadherent to annual follow-up to elicit quantitative and qualitative feedback. ResultsOf the 319 patients who completed baseline lung screening with normal results, 189 (59%) were adherent to annual follow-up recommendations and 130 (41%) were nonadherent. Patient adherence varied over time: 21.7% adherence (10 of 46) before hiring a program coordinator and 65.6% adherence (179 of 273) after the program coordinator’s hire date. Patients reported the following reasons for nonadherence to annual lung screening: lack of transportation, financial cost, lack of communication by physicians, and lack of current symptoms. ConclusionsAdherence to annual lung screening after normal baseline studies increased significantly over time. Hiring a full-time program coordinator was likely associated with this increased in adherence.

Integration of smoking cessation and lung cancer screening.

The National Lung Screening Trial demonstrated a decrease in both lung cancer mortality and overall mortality in enrollees aged 55-74 with a 30 pack-year smoking history using low-dose computed tomography (LDCT). Lung cancer screening in high-risk groups is supported by the United States Preventive Services Task Force, the National Comprehensive Cancer Network, and multiple other organizations. Inclusion for any lung screening program requires a history of smoking, and many undergoing screening are currently smoking. Screened patients are not only at risk for developing lung cancer, but also carry the risk of developing a host of other smoking related diseases, and cessation at any point is beneficial. Counseling and pharmacotherapy are evidence-based strategies which are well known to help people quit smoking. However, as lung cancer screening is an emerging and evolving field, the integration of cessation resources in screening programs is not uniformly done, and when it is done, there is no standardized approach. The goals of this review are to discuss the rationale for integrating smoking cessation resources in lung cancer screening, review what types of resources may be effective, and discuss different strategies of how integration can be done. Ultimately, the overarching goal of any lung cancer screening program is not merely to find more nodules, or diagnose more cases of cancer, but to help screened patients live longer, better lives. Smoking cessation broadens the impact of any lung cancer screening program well beyond the endpoints of cancer diagnosis and cancer mortality to reduce risk from many other diseases, and can positively impact many more patients than the small percentage that have cancer.

"To know or not to know…?" Push and pull in ever smokers lung screening uptake decision-making intentions.

BackgroundIn the United States, lung cancer screening aims to detect cancer early in nonsymptomatic current and former smokers. A lung screening pilot service in an area of high lung cancer incidence in the United Kingdom has been designed based on United States trial evidence. However, our understanding of acceptability and reasons for lung screening uptake or decline in a United Kingdom nontrial context are currently limited.ObjectiveTo explore with ever smokers the acceptability of targeted lung screening and uptake decision‐making intentions.DesignQualitative study using semistructured focus groups and inductive thematic analysis to explore acceptability and uptake decision‐making intentions with people of similar characteristics to lung screening eligible individuals.Setting and participantsThirty‐three participants (22 ex‐smokers; 11 smokers) men and women, smokers and ex‐smokers, aged 50‐80 were recruited purposively from community and health settings in Manchester, England.ResultsLung screening was widely acceptable to participants. It was seen as offering reassurance about lung health or opportunity for early detection and treatment. Participant's desire to know about their lung health via screening was impacted by perceived benefits; emotions such as worry about a diagnosis and screening tests; practicalities such as accessibility; and smoking‐related issues including perceptions of individual risk and smoking stigma.DiscussionDecision making was multifaceted with indications that current smokers faced higher participation barriers than ex‐smokers. Reducing participation barriers through careful service design and provision of decision support information will be important in lung screening programmes to support informed consent and equitable uptake.

MTE22.01 Integration of Cessation and Lung Cancer Screening

Lung cancer screening with low dose computed tomography (LDCT) has been studied extensively and is recommended for individuals who are deemed to be at increased risk, typically with a smoking history of 30 pack-years or more. The National Lung Screening Trial (NLST) demonstrated that with a screening program, there was a 20% reduction in lung cancer mortality. The overall incidence of lung cancer in the NLST was around 2%. Unfortunately, an often overlooked, yet treatable condition in any lung cancer screening program is continued tobacco use. In the NLST, 48% of participants were actively smoking at the time of the screening, and in our institutional program 71% are actively smoking. Cessation in this group may be seen as a challenge, as many of these patients have a much greater than 30 pack-year history and have not quit despite being advised by their primary physician. However, the lung cancer screening program may interact with the patient in a 'teachable moment' and these patients receiving screening may have increased motivation and willingness to quit if given the right resources. External resources such as quitlines or referrals to external tobacco cessation programs require action and increased motivation on the aprt of the patient, while integrating resources in the workflow of the screening program deliver the resources to the patient as a standard part of practice. Furthermore, the lung cancer screening program may be able to interact with the patient over time (through annual follow up at least) and may be an optimal way to deliver cessation resources to these patients. This session will explore different programmatic strategies to deliver cessation resources to patients in the construct of a LDCT Lung Cancer screening program. The coordinator of our screening program is a Advance Practice Registered Nurse (APRN) who sought out training and certification as a certified Tobacco Treatment Specialist (TTS). Referrals to the LDCT screening program are initially contacted by phone for a scheduling phone call, which also includes the initial elements of counseling these patients regarding tobacco cessation. An initial intake phone call determines appropriateness for screening and also can include elements of the 5A framework: ASK, ADVISE, ASSESS, ASSIST, ARRANGE. Then on the day of the scan, the APRN coordinator meets with the patient face-to-face at the point of the scan, and has already established rapport by telephone prior to the visit. The day of the scan, the patient receives in person counseling as part of their visit, and a cessation strategy or "Quit Plan” is made which may include medications such as nicotine patches and/or gum. After the scan, telephone follow up is conducted to both discuss cessation and discuss scan results with a plan for follow up. Additionally, patients can be enrolled in a state Quitline program as a standard part of the workflow which provides them with ongoing support. Another option for patients is for the screening program to refer them to group counseling sessions. The American Lung Association's Freedom From Smoking is one such structured program. Patients may not independently seek these programs out, but as a lung screening program, developing ties to programs in the community with integrated referrals to group counseling programs can be another way to further the delivery of resources to these patients. As patients return for repeat scans to follow up indeterminate nodules, or return the following year for routine scans, further cessation support is delivered, and if they have quit, abstinence support is provided. Quitlines, group counseling, and nicotine replacement therapy have been shown to be cost effective strategies to help people who smoke to increase chances of quitting. A lung screening program may identify 2% of its participants with lung cancer, but if half (or in our case 71%) are smoking, and integrated cessation resources help those patients to reduce or quit smoking, the benefit of the lung screening program is greatly amplified, and patients can reduce risk for future cancers as well as cardiovascular and non-oncologic respiratory diseases. Smoking Cessation, Screening, tobacco

MS16.04 National Lung Screening Program in Taiwan

MS16.04 National Lung Screening Program in Taiwan

The enduring legacy of black lung: environmental health and contested illness in Appalachia.

Over the past twenty years there has been a deadly resurgence of coal workers' pneumoconiosis (CWP), commonly known as black lung disease. While increased prevalence of the disease is alarming, these data only capture cases where CWP has been officially recognised. We argue that many more cases of the disease are going unreported. Drawing from contested environmental illness literature, we examine issues surrounding diagnostic uncertainty and medical surveillance. We draw from qualitative data on black lung that includes in-depth interviews, observation and document analysis. Findings indicate ongoing ambiguity and contestation over diagnosis of the disease, ranging from clinical and legal debates to concerted efforts to limit official recognition. While health screenings are currently available to miners, our results indicate low participation rates based on disincentives for early detection, logistical problems, and economic fears. Miners fear workplace discrimination and retaliation for participation in black lung screening programmes. Implications for public health policy and future research are discussed.

The cytokinesis-blocked micronucleus assay as a novel biomarker for selection of lung cancer screening participants.

Despite the promising results of the National Lung Screening Trial in reducing lung cancer mortality among high risk smokers, several challenges remain to be addressed. These include the high false positive rates and the large number of smokers screened in order to prevent one lung cancer death. In addition, host genetic susceptibility has not been integrated into selection of who should be screened. These challenges highlight the need to develop robust ways to identify susceptible smokers for appropriate screening. We used the cytokinesis block micronucleus (CBMN) assay to assess smoking induced genetic instability among NLST participants. Blood cultures were prepared at time of entry into the screening study and DNA damage was recorded as the frequency of binucleated nucleoplasmic bridges and micronuclei. Low dose CT (LDCT) and chest X-ray (CXR) image findings were available upon unblinding of the NLST study and imaging data were merged with blood marker data for statistical analysis. A total of 641 participants were included in this study. The frequency of the CBMN endpoints at time of entry into the study was significantly higher among study participants who had a positive finding during the 3-year screening or reported lung cancer at the end of the follow-up period as compared to participants who were negative. Growth curve models were used to compare trajectories of change in CBMN endpoints between entry into the study and end-of-screening period. A statistically significant increase was predicted for CBMN endpoints among the study participants who were positive versus those who remained negative at the end-of-screening period (P<0.001). Genetic instability biomarkers have the potential of facilitating the identification of genetically susceptible high-risk smokers who would benefit from targeted lung screening programs.

NCCN Guidelines as a Model of Extended Criteria for Lung Cancer Screening.

Background: This review assessed the performance of patients in NCCN high-risk group 2 in a clinical CT lung screening (CTLS) program. Methods: We retrospectively reviewed screening results for all patients from our institution undergoing clinical CTLS from January 2012 through December 2016, with follow-up through June 2017. To qualify for screening, patients had to meet the NCCN Guidelines high-risk criteria for CTLS, have a physician order for screening, be asymptomatic, be lung cancer-free for 5 years, and have no known metastatic disease. We compared demographics and screening performance of NCCN high-risk groups 1 and 2 across >4 rounds of screening. Screening metrics assessed included rates of positive and suspicious examinations, significant incidental and infectious/inflammatory findings, false negatives, and cancer detection. We also compared cancer stage and histology detected in each NCCN high-risk group. Results: A total of 2,927 individuals underwent baseline screening, of which 698 (24%) were in NCCN group 2. On average, group 2 patients were younger (60.6 vs 63.1 years), smoked less (38.8 vs 50.8 pack-years), had quit longer (18.1 vs 6.3 years), and were more often former smokers (61.4% vs 44.2%). Positive and suspicious examination rates, false negatives, and rates of infectious/inflammatory findings were equivalent in groups 1 and 2 across all rounds of screening. An increased rate of cancer detection was observed in group 2 during the second annual (T2) screening round (2.7% vs 0.5%; P=.005), with no difference in the other screening rounds: baseline (T0; 2% vs 2.3%; P=.61), first annual (T1; 1.2% vs 1.7%; P=.41), and third annual and beyond (≥T3; 1.2% vs 1.1%; P=1.00). Conclusions: CTLS appears to be equally effective in both NCCN high-risk groups.

Lung Cancer Screening in the Community Setting

Lung cancer has high incidence and high mortality burden, particularly because it is typically diagnosed in later stages. The National Lung Screening Trial demonstrated a lung cancer-specific mortality benefit in high-risk current and former smokers with yearly low-dose chest computed tomography (CT). Lung cancer screening is thus recommended, but it is unclear whether the results of the National Lung Screening Trial can be replicated in community settings. A retrospective review was performed of the lung screening program over its first 5 years, 2012 to 2016. Patients' demographics, initial screening results, follow-up, and management results were analyzed in relation to the National Lung Screening Trial results. Annual adherence was defined as returning for imaging within 1 year+ 90 days. A total of 1,241 persons underwent initial screening over the 5-year period; 78.6% of findings were benign, and only annual repeat low-dose chest CT was recommended. A total of 29 cancers were identified in 26 participants (2%), of which 72% were stage I. The annual adherence rate to repeat imaging after a low-risk baseline scan was 37%, and the any follow-up rate was 51% despite programmatic efforts to follow screening recommendations. When positive findings required more intensive evaluation, most commonly by repeat chest CT scan, adherence was 88%. A total of 1.1% of all participants had invasive biopsies for benign results. Complications of biopsy were minimal. This review demonstrates that a community-based program can approximate the results of the National Lung Screening Trial in detecting early lung cancers. Further study of the adherence phenomenon is essential.

Adherence to Radiology Recommendations in a Clinical CT Lung Screening Program

BackgroundAssess patient adherence to radiologist recommendations in a clinical CT lung cancer screening program. MethodsPatients undergoing CT lung cancer screening between January 12, 2012, and June 12, 2013, were included in this institutional review board–approved retrospective review. Patients referred from outside our institution were excluded. All patients met National Comprehensive Cancer Network Guidelines Lung Cancer Screening high-risk criteria. Full-time program navigators used a CT lung screening program management system to schedule patient appointments, generate patient result notification letters detailing the radiologist follow-up recommendation, and track patient and referring physician notification of missed appointments at 30, 60, and 90 days. To be considered adherent, patients could be no more than 90 days past due for their next recommended examination as of September 12, 2014. Patients who died, were diagnosed with cancer, or otherwise became ineligible for screening were considered adherent. Adherence rates were assessed across multiple variables. ResultsDuring the study interval, 1,162 high-risk patients were screened, and 261 of 1,162 (22.5%) outside referrals were excluded. Of the remaining 901 patients, 503 (55.8%) were male, 414 (45.9%) were active smokers, 377 (41.8%) were aged 65 to 73, and >95% were white. Of the 901 patients, 772 (85.7%) were adherent. Most common reasons for nonadherence were patient refusal of follow-up exam (66.7%), inability to successfully contact the patient (20.9%), and inability to obtain the follow-up order from the referring provider (7.8%); 23 of 901 (2.6%) were discharged for other reasons. ConclusionsHigh rates of adherence to radiologist recommendations are achievable for in-network patients enrolled in a clinical CT lung screening program.