Lung Cancer Screening Winning Strategies for Program Development

November 2019 Lung Cancer Screening Winning Strategies for Program Development

IMAGING 3.0 IN PRACTICE IMAGING 3.0® Progress through Collaboration: The Lung Cancer Screening Implementation Guide

The United States Preventive Services Task Force recommends lung cancer screening for those considered at high risk, because if caught before it spreads, the likelihood of surviving five years or more improves to 56 percent. Implementing a screening program to support patients is complex, which may be contributing to the slow adoption of lung cancer screening programs in community hospitals and healthcare systems.

The American Lung Association worked with the American Thoracic Society to convene experts from diverse disciplines to develop the Lung Cancer Screening Implementation Guide. The Guide recognizes that a successful screening program requires careful coordination and offers an overview of the general structure of screening programs and topics for consideration, including pitfalls and resources.

Designed to help individuals quickly find the right information as they are tackling a particular issue, the interactive website includes sections on: • Initiating a Lung Cancer Screening Program • Radiology Requirements • Shared Decision Making • Referring Physicians • Program Navigation & Data Tracking • Resources

We know that lung cancer screenings have the potential to save an estimated 25,000 lives if every American at high risk were screened. The Lung Cancer Screening Guide is a bold step to expanding access to lung cancer screening across the country, giving more hope to those at risk of lung cancer.

See the full Guide at LungCancerScreeningGuide.org. November 2019

IMAGING 3.0 IN PRACTICE Case Studies

4 A Proactive Role for Radiology Lung Cancer Screening: In partnership with referring PCPs, radiologists in Boston built a life-saving lung cancer screening Winning strategies for program development program for high-risk patients across their hospital network. More people in the United States die of lung cancer than any other cancer. The disease’s mortality rate is high because it often goes 8 Breathe Easier undiagnosed until the later stages, when treatment is difficult. But Indiana radiologists work alongside care partners to create a successful lung cancer it doesn’t have to be that way — and we can change it. screening program that addresses a population Early detection is key, and the best way to find lung cancer before it becomes symptomatic health need. is through low-dose CT (LDCT) lung cancer screening. The results of the National Lung 12 Early Detection Matters Screening Trial showed that LDCT lung cancer screening saves lives, leading CMS to issue Radiologists in Michigan collaborate with a national coverage decision for eligible patients in 2015. administrators and care partners to develop a successful lung cancer screening clinic and Although CMS and most private insurers now cover lung cancer screening, the majority enhance population health. of the estimated 8 million eligible Americans are not enrolled in a screening program. We 16 Lung Screening in an Urban Setting must stand up to ensure patients have access to and are informed about this life-saving Radiologists in the Bronx lead a lung cancer care. The ACR Patient- and Family-Centered Care Commission’s Lung Cancer Screening screening program targeting an underserved, 2.0 Steering Committee is committed to empowering radiologists to lead screening high-risk urban population. programs. 23  Implementing an LCS Program Implementing a lung cancer screening program takes commitment, resources, and time. Your action plan for successful program development. But radiologists are well-positioned to manage these programs and ensure patients are guided into appropriate care pathways. It’s one more way we can leverage our expertise 20 Lung Screening Solutions to ensure patients receive the care they need, when they need it. It also gives us another North Dakota radiologists collaborate with referring physicians to administer lung CT opportunity to interact with patients and witness the meaningful impact of our work. screening for high-risk patients. The Imaging 3.0 case studies in this issue highlight how radiologists across the country 24 Patient Forward have led the development of successful lung cancer screening programs. Each article A multidisciplinary team invites patients and details the steps the radiologists took to build their programs and enroll patients, while their families to a weekly thoracic oncology also outlining the results and next steps. Along with these valuable stories, this issue conference at Elkhart General Hospital. includes resources you can use to start or advance your own lung cancer screening 27 Screen Time program. The nation’s flagship military hospital has developed an effective lung cancer screening Together, we must expand the availability of lung cancer screening to ensure all patients program for the Department of Defense. who need it are enrolled. With lung cancer accounting for 25% of all U.S. cancer deaths — lives depend on it. 30 Lung Cancer Screening Discussion Questions Debra S. Dyer, MD, FACR Jump-start a conversation about lung cancer Chair, ACR Lung Cancer Screening 2.0 Steering Committee screening. 31 Are you an LCS Novice or Ninja? Test your lung cancer screening knowledge. Imaging 3.0 Advisers Imaging 3.0 Staff ACR Press Staff Lyndsee Cordes Director of Periodicals Geraldine B. McGinty, G. Rebecca Haines VP, ACR Press Lisa Pampillonia Art Director Chris Hobson Imaging 3.0 MD, MBA, FACR Nicole Racadag ACR Bulletin Managing Editor Senior Communications Manager QUESTIONS? COMMENTS? Marc H. Willis, DO, MMM Chad Hudnall ACR Bulletin Senior Writer Contact us at [email protected] Jenny Jones Imaging 3.0 Managing Editor Jessica Siswick Digital Content Designer View online issues of Imaging 3.0 in Practice: Sabiha Raoof, MD, FACR Linda Sowers Consulting Editor Cary Coryell Publications Specialist acr.org/InPractice

All American College of Radiology Imaging 3.0 Case Studies are licensed under a Creative SHARE YOUR STORY Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. Based on Have a case study idea you’d like to share with the works at www.acr.org/imaging 3. Permissions beyond the scope of this license may be radiology community? To submit your idea, please visit available at www.acr.org/Legal. acr.org/Suggest-a-Case-Study.

Imaging 3.0 in Practice n November 2019 3 Case Study Published February 2019 A Proactive Role for Radiology In partnership with referring PCPs, radiologists in Boston built a life-saving lung cancer screening program for high-risk patients across their hospital network.

nly 16% of lung cancers are diagnosed implementing LDCT lung cancer screening Oearly, when the five-year survival rate can at BIDMC. KEY TAKEAWAYS be as high as 90%. The rest aren’t detect- “When the results of the trial were • After the National Lung Screening Trial ed until the disease reaches the advanced published in 2011, it gave the idea a new 1 proved that low-dose CT lung cancer stages. By the time lung cancer spreads and boost,” says Bankier, who is also a professor screening could reduce mortality rates, triggers symptoms, the five-year survival rate of radiology at Harvard Medical School and 2 a radiologist in Boston led develop- plummets to just 5% — giving it the highest chief of the cardiothoracic imaging section ment of a practical screening program. mortality of any cancer and accounting for and director of functional respiratory imag- 25% of all cancer deaths in the United States. ing in the radiology department at BIDMC. • Leaders of the screening program Fortunately, advanced screening technol- “But there wasn’t a lot of enthusiasm in the meet regularly with primary care physi- ogies can improve this prognosis through beginning because some members of the cians throughout the hospital network earlier detection of lung nodules. The hospital administration were concerned that to build trust and collect input for National Cancer Institute demonstrated this this would never be financially sustainable.” improving the program. with the National Lung Screening Trial (NLST) The idea gained traction at BIDMC be- • Automated patient qualification and (Learn more at bit.ly/Lungtrial), which started tween 2012 and 2014 as several professional enrollment, along with centralized in 2002 and revealed that participants groups — including the American Cancer administration and follow-up, reduce screened with low-dose CT (LDCT) were at Society, the American Thoracic Society, the the burden of patient management least 20% less likely to die from lung cancer.3 American Society of Clinical Oncology, the for referring physicians while keeping The NLST sparked one of the country’s first U.S. Preventive Services Task Force, and the them in the loop. LDCT lung cancer screening programs at Beth ACR — began recommending LDCT lung Israel Deaconess Medical Center (BIDMC), a cancer screening. The final piece of support Harvard Medical School Teaching Hospital came in 2015, when CMS issued a national in Boston. Since launching LungHealth® in coverage decision to reimburse LDCT lung March of 2016, radiologists at BIDMC have cancer screening. (Read the decision at bit.ly/ performed 2,200 LDCT exams to screen 1,390 CMSDecision) patients who are at high risk for lung cancer. “The confirmation of reimbursement from “Through this program, we are catching major insurance companies made it possible and detecting lung cancer earlier, at a stage to implement this idea in practice,” Bankier when patients can still undergo treatment says. “For the first time, we had reimburse- and survive,” says Alexander A. Bankier, MD, ment estimates, which helped us make the PhD, medical director of LungHealth at case that an LDCT lung cancer screening BIDMC. “So far, we’ve caught 25 cases of lung program made sense economically.” cancer, 24 of which were early stages, and I Bankier worked with the hospital’s stra- don’t think it’s overly immodest to say that tegic planning division to build a business we saved these patients’ lives. LDCT lung plan that illustrated the program’s potential. cancer screening shows how imaging can Together, they estimated the number of play a proactive role in disease prevention, high-risk patients within the healthcare not just detection.” system’s reach who would qualify for lung cancer screening based on Medicare’s Support for LDCT Screening eligibility criteria. (Learn more at bit.ly/ lungeligibility) Then, they calculated poten- Years before establishing LungHealth, BIDMC tial revenue from regular screenings, as well participated in the NLST as one of 33 trial as downstream revenue from positive find- screening sites that conducted exams for ings, incidental findings, and follow-up scans. the nationwide study. Bankier joined the “The administration wanted to see num- hospital around 2008 as the trial was ending bers to justify whether this program would and became committed to permanently

4 IMAGING 3.0 PHOTO COURTESY OF BIDMC. be economically viable,” Bankier says. “But there’s also a value aspect that you can’t put a dollar amount on, because you’re offering preventive care that can improve the health of your patients and potentially save lives.” The First Step By addressing the program’s economic po- tential and patient value, Bankier secured the approval of the hospital administration, with full support from the radiology department. The hospital provided funds to hire a program manager, which was a critical first step in the program’s development. “The one thing I learned from witnessing the final phase of the NLST was that the administration and patient management aspects of lung cancer screening are at least as important as the medical aspect,” says Bankier, noting that BIDMC added a full-time Through its lung cancer screening program, the radiology department at Beth Israel Deaconess Medical Center has administrative position for the duration of detected 24 lung cancers in the early stages, when the disease is still treatable. the NLST. “From the very beginning, I empha- sized the need for a dedicated person to run this program.” with PCPs to build buy-in while fine-tuning continuously in the communication loop so In late 2015, Lauren M. Taylor, RN, BSN, the details of the program. they didn’t lose contact with their patients.” joined the team as program manager, and to- The goal of these conversations was two- gether, she and Bankier began planning how fold: first, to educate referring physicians to run a screening program. Administratively, Collaborative Partners about the screening program so they could, Bankier and Taylor had to plan step-by-step After meeting with referring physicians within in turn, inform their patients; and second, to how to qualify eligible patients for enrollment the hospital, Bankier and Taylor worked their gather PCPs’ feedback and concerns. “A few (See bit.ly/BIDMCLung), order screening ex- way outward to reach referrers throughout of these physicians were enthusiastic about ams, discuss shared decision making, design BIDMC’s network, which spans 45 affiliate the idea of LDCT lung cancer screening, a structured reporting template, organize locations, including primary care practices but there was also a substantial number subspecialty reads, handle incidental findings, and community healthcare centers across of skeptics,” Bankier says. “We learned a lot and coordinate annual follow-ups through from these conversations, and the input the Greater Boston area. “The segment of ongoing patient management. from physicians helped us improve the our population that qualifies for LDCT lung program.” cancer screening often includes the same PCPs as Partners Most of the early concerns echoed the people who receive care at our community Bankier and Taylor quickly learned that imple- same risks that were documented in the NLST healthcare centers,” Bankier says. “A relatively menting a screening program was markedly findings and other research — such as overdi- high smoking population exists within these different than providing diagnostic imaging. agnosis of lung cancer and incidental findings groups, so there’s a proportionately higher “Preventive screening requires a completely unrelated to lung cancer. Many PCPs worried number of high-risk patients in these pockets.” different context, because we don’t see pa- that the program would add more administra- Bankier recognized that the community tients with symptoms,” Bankier says. “We see tive work and patient management duties to healthcare centers in BIDMC’s network would individuals who are at risk for a disease and their workloads, and others feared they’d lose be critical partners for the screening program. want to stay healthy.” control over patients who enrolled. “Nancy Kasen, the chief of the community Since ideal candidates for lung cancer “By knowing the referring physicians’ healthcare centers, was immediately onboard, screening typically don’t walk into the hospi- concerns, we were able to tailor the program because she understood the importance of tal seeking a diagnosis, Bankier had to reach on the front end to make them more com- screening these patients,” Bankier says. “From high-risk participants proactively — through fortable enrolling patients,” Taylor says. “We day one, the community healthcare centers their primary care physicians (PCPs). Early in realized how important it was to reduce their and the patients they represent were a strong the planning process, Bankier and Taylor met administrative burden, while keeping them pillar on which our program was built.”

Imaging 3.0 in Practice n November 2019 5 Alexander A. Bankier, MD, better chance of picking up lung cancer early PhD, professor of radiology at and treating it. It has saved lives and could Harvard Medical School and chief of the cardiothoracic save your life someday.” imaging section and director of Aronson says he’s never had a high-risk functional respiratory imaging patient decline his screening recommenda- at Beth Israel Deaconess Medical Center, developed an LDCT lung tion. He has enrolled about 20 patients into cancer screening program to the program since it launched. detect lung nodules as early When Marsha DiCesare’s primary care phy- as possible. As LungHealth Program Manager, Lauren M. sician told her about the screening program Taylor, RN, BSN, handles all during her annual physical, it seemed like patient management, tracking, and follow-up. a “no brainer.“ If you’re a former smoker, it’s always in the back of your mind, because we all know how bad smoking is for your health,”

PHOTO COURTESY OF BIDMC. OF COURTESY PHOTO says DiCesare, 59. “Lung cancer doesn’t usually present symptoms until it’s pretty advanced, so after smoking for many years, Relationship Building reminding them to get their annual scan. screening gives me peace of mind.” That’s valuable, because it’s very difficult For months before the program began in for doctors to keep track of each individual Workflow Design 2016, Bankier and Taylor met regularly with when they have so many patients.” With the goal of making the program referring physicians throughout the network. convenient for both referring physicians Since then, they’ve continued to check in and patients, Bankier and Taylor designed every few weeks. “In our experience, the Patient Enrollment a workflow focused on proactive patient most effective way to reach patients has Taylor and Bankier knew they needed to management and thorough follow-up. “Once been through regular in-person visits with make it easy for referring physicians to enroll enrolled in the screening program, every referring physicians,” Taylor says. “The referring patients into the program. To that end, they patient gets a shared decision-making phone physicians are our closest partners in terms worked with the hospital’s IT department to call from me that explains the benefits, risks, of educating patients about the program and develop an in-house tool that allows referring what to expect when they arrive for their getting them to enroll.” physicians to enroll qualified patients — exam, what to expect on their report, and Bankier emphasizes that these visits can’t those between the ages of 55 and 77 with a what happens if there’s a positive finding,” be phoned in or delegated, because relation- smoking history of at least 30 pack-years, who Taylor says. “We talk through all the steps, ships with referring physicians are critical either currently smoke or quit within the last and I introduce myself as the central contact to a screening program’s success. “The best 15 years — with just a few clicks. person who will help them through all of it.” advice I can give other radiologists is to seek “They developed a tool within our BIDMC offers screening exams at three as much personal contact with referring phy- ordering system that calculates a patient’s (soon to be four) locations throughout the sicians as possible,” Bankier says. “Referring smoking history in pack-years,” Aronson says. hospital network, and scans are read central- physicians delegate some of their responsi- “So, if a patient smoked half a pack a day for ly by a small group of subspecialty-trained bility to us in terms of patient management, 10 years, then a full pack a day for 15 years, radiologists. Technically, any CT equipment so it’s very important that they know to and then five cigarettes a day for the last can be programed with the low-dose proto- whom they’re entrusting their patients.” 10 years — the calculator determines the col, allowing for future expansion. Primary care physicians like Mark D. accumulated pack-years. Once they exceed When patients arrive for their initial LDCT Aronson, MD, appreciate knowing that the 30, they fall into the screening protocol, screening, they first meet privately with a ra- LungHealth team handles patient qualifica- and the system automatically prompts us to diologist to discuss the program. “Having the tion, education, tracking, and administration recommend the program.” conversation with the radiologist really put centrally, so referring doctors don’t have to Referring physicians just click the pop-up my mind at ease and made me feel comfort- spend time on those things. “The radiologists notification, and the system automatically able and well informed,” says DiCesare, who set up a system to track lung cancer screen- issues a screening exam order, auto-populat- had her first screening in the spring of 2017. ing candidates and take ownership of patient ed with the patient’s inclusion criteria. When management,” says Aronson, vice chair for Aronson sees the smoking history pop-up, quality in the department of medicine at he’ll tell the patient: “You fit into our lung Coordinated Care Decisions BIDMC and professor of medicine at Harvard cancer screening protocol. I recommend that Screening results are sent to patients and Medical School. “Once a patient’s enrolled you get screened, because studies show that their referring physicians within a week. Most in the program, I don’t have to worry about if we screen you regularly, we have a much screening results come back negative, Bankier

6 IMAGING 3.0 “We can make a multidisciplinary management decision based on our discussion,­ and then immediately organize the next steps.” —Alexander A. Bankier, MD, PhD

says, so the typical recommendation is for pa- keep them totally apprised of their patients,” tients to return in a year for annual screening. she says. “Sometimes I’ll just send an email, Some findings may require patients to return and then if it’s acute, I also call them. But in three to six months for a re-scan. More sus- we track it and order it all centrally, so we’re pect findings, however, require a collaborative taking that administrative burden off of the multidisciplinary discussion. referring physicians.” Every suspicious case (with nodules classified as 4B or 4X, according to ACR’s Growth Opportunity standardized LUNG-RADS® assessment cat- egories bit.ly/ACR_LungRADS) is discussed In addition to detecting lung cancer as early at a weekly thoracic oncology conference. as possible, the screening program is catch- During each conference, multiple disciplines ing other abnormalities, including cardiac related to thoracic disease come together, disease and abdominal issues. (Read the The screening program has been well-received by referring physicians like Mark D. Aronson, MD, vice chair including radiology, thoracic surgery, thorac- “Standardized Findings” case study at bit.ly/ for quality in the department of medicine at Beth Israel ic pathology, interventional pulmonology, StandardizedFindings to learn more.) Deaconess Medical Center and professor of medicine at respiratory medicine, nuclear medicine, Perhaps more importantly, patients Harvard Medical School. oncology, and radiation therapy. Bankier also enrolled in the program are more likely to re- invites referring physicians whose patients duce their smoking habits or stop altogether. ENDNOTES: are being discussed. Smoking cessation information and support At the conference, the reading radiologist 1. Knight SB, Crosbie PA, et al. Progress and prospects of early are offered through the program, and Taylor detection in lung cancer. Open Biol. 2017 Sep; 7(9): 170070. takes the lead — sharing the clinical findings even became a certified smoking cessation doi: 10.1098/rsob.170070. Published online 2017 Sep 6. of each case and then moderating the counselor to help patients stop smoking. “If 2. Seigel RL, Miller KD, et al. Cancer facts & figures 2018. CA: A discussion as various subspecialties chime we’re telling you that you’re at high risk for Cancer J Clin. 2018; 68:7-30. doi.org/10.3322/caac.21442 in about the upsides and downsides of po- lung cancer because of smoking, it’s a big in- 3. National Lung Screening Trial Research Team. Reduced tential next steps, including biopsy, surgery, lung-cancer mortality with low-dose computed centive to quit smoking,” says Aronson, who’s or simply waiting three to six months for a tomographic screening. N Engl J Med. 2011 Aug 4; noticed that all of his patients have stopped 365(5):395-409. doi: 10.1056/NEJMoa1102873. Published follow-up scan. “The advantage of this set- smoking since enrolling. online 2011 Jun 29. ting is that we can make a multidisciplinary To build on these positive results, Bankier management decision based on our discus- sion, and then immediately organize the has a vision to continue growing the Next Steps next steps,” Bankier says. “We can refer the screening program: expanding into new • Meet personally with referring patient to the thoracic surgeon, the referring affiliate healthcare sites, increasing patient physicians to share ideas about im- physician, or the specialist, all of whom are enrollment, and ultimately broadening the usually at the conference and already know program’s overall reach. “The program is plementing a lung cancer screening the patient’s history. That’s a huge advantage named LungHealth — not specific to cancer program that makes practical sense for for patient management.” but really about overall lung health,” Bankier everyone involved. If primary care physicians are unable to says. “In the future, we might be able to use • Encourage radiologists to take a more attend these conferences, Taylor takes notes the information we acquire, not only for proactive role in patient care by meet- and reports back to keep them informed. preventing cancer but also to look at other ing with participants before screening She also schedules any follow-up exams or respiratory diseases where early detection exams to discuss the process and allevi- appointments — whether it’s surgery, a rou- may benefit the patient. We want to be as ate concerns. tine screening, or a re-scan in several months comprehensive as we can to save as many — while maintaining ongoing contact with lives as possible.” • Build a multidisciplinary team to regu- referring physicians. “We try to be cognizant larly discuss complex cases and improve of the referring physician’s time, but also By Brooke Bily patient care through collaboration.

Imaging 3.0 in Practice n November 2019 7 Case Study Published November 2018 Breathe Easier Indiana radiologists work alongside care partners to create a successful lung cancer screening program that addresses a population health need.

ccording to the Centers for Disease Control Aand Prevention, 25.6% of Indiana resi- KEY TAKEAWAYS: dents smoked in 2011, and the state ranked • Radiologists at Elkhart General Hospital fifth in the nation for number of smokers. In (EGH) collaborated with referring the northern Indiana city of Elkhart alone, clinicians and administrative staff to smoking was so prevalent that many residents organize, market, and manage a lung identified it as a top concern in a 2011-2012 cancer screening program. community health assessment. These findings prompted radiologists and other providers • Since founding the program in 2012, at Elkhart General Hospital (EGH) to consider the EGH team has diagnosed 29 lung the dangerous effects of smoking on their cancers, more than 50% of which were community and act to address them. Stage 1. One of the most obvious impacts of smok- • Now, EGH is working with sister hos- ing is a high mortality rate. Lung cancer is a pitals within Beacon Health System to leading cause of cancer deaths in the U.S.1, develop similar lung cancer screening and research indicates that identifying high- programs at those institutions. risk patients and screening them for cancer Allison M. Lamont, MD, chair of radiology at Elkhart with low-dose computed tomography General Hospital, says that “old-fashioned dialogue” was

(LDCT) can reduce lung cancer mortality by critical to educating referring physicians about the benefits of lung cancer screening. up to 20% among smokers.2 Unfortunately, though, most at-risk patients do not undergo regular screening, and many patients go undiagnosed until Getting Started symptoms arise in the later stages of the dis- EGH’s lung cancer screening program began ease. By that point, the chances of effectively taking shape in 2012, after the hospital treating the disease are low. The five-year secured a CT scanner for the program. An survival rate for patients with early-stage oncology nurse proposed establishing lung cancer can be as high as 90%, while the the screening program during a quarterly late-stage survival rate is only 5%. Hoping to meeting of the hospital’s cancer committee, give its patients a better chance of survival, which includes representatives from the EGH partnered with its existing smoking departments involved in oncology care. The cessation group to establish a lung cancer radiologists, cardiologists, and pulmonolo- screening program six years ago. gists in attendance immediately supported Since then, the program has undergone the idea — recognizing that it would address many changes, but most importantly, it an urgent population health need. is getting results: EGH radiologists have “As a radiology department, we are diagnosed more patients with early-stage committed to offering new services that lung cancer than they did before imple- will improve patient health,” explains Albert menting the program. Of those diagnosed W. Cho, MD, vice chair of radiology at EGH. through the program, more than 50% had “We had been interested in developing a Stage 1 lung cancer. “It is critical to detect lung cancer screening program for a while to lung cancer early, before patients become address this public health crisis. Once we had symptomatic,” says Allison M. Lamont, MD, the scanner available and buy-in from other chair of radiology at EGH. “If patients become departments, we saw an opportunity to help symptomatic, it is often too late. This is a drive the implementation.” life-saving program.” To start, the radiologists met with specialty

8 IMAGING 3.0 partners, administrative staff, and care co- pulmonology, and oncology, and to hospital ordinators to construct a framework for the administrators during regularly scheduled program. “One of the most exciting aspects of meetings. “We helped others understand this program has been working with the other the criteria and the things that had to be specialties and with hospital administrators,” calculated for the program to work, such as Cho says. “There is often a view that special- the scheduling processes and patient flow ties, particularly radiology, are independent between the radiologists and the nurse prac- and operate on their own, but working titioner in charge of follow-up,” says William together has so many benefits, such as in- T. Molen, MBA, director of imaging services creased camaraderie throughout the hospital at EGH. and enhanced dialogue among specialties to While the program was not expected to better serve patients. It’s very rewarding.” generate a profit, everyone who heard the presentations unanimously supported the Building a Business Case effort. “If you step back to examine what’s best for the patient, you quickly realize that this One of the first things the team had to define program is a good thing,” Molen says. “If we was eligibility criteria for lung cancer screen- break even at worst, it’s easy to prioritize the ing patients. The Centers for Medicare and program.” Medicaid Services (CMS) had not yet issued guidelines for reimbursement of lung cancer Albert W. Cho, MD, vice chair of radiology at Elkhart Marketing the Program General Hospital, and his team developed the lung cancer screening, so the Elkhart team decided to screening program to address an urgent population follow the National Comprehensive Cancer Once the program was up and running in health need. Network’s screening guidelines, which state June of 2012, the team ran into two notable that high-risk eligible patients are between hurdles. The first involved enrolling patients cancer in the early stages, when it’s still treat- 50 and 74 years old with a history of smoking in the program. Initially, the team marketed able,” Lamont says. “Expanding participation at least 1.5 packs of cigarettes per day for 20 the program directly to smokers in Elkhart in the program really came down to old-fash- years or more. County. Radiologists and other physicians ioned dialogue.” From there, the team focused on the pro- worked a booth at the county fair, where they gram’s business case. Since CMS did not yet spoke to smokers about lung cancer screen- Covering the Cost cover lung cancer screening, the team had ing and distributed marketing materials. The second obstacle that radiologists faced in- to determine how much to charge for the Patients, however, were not immediately volved the cost of care. Even though the price service. They needed to cover the program interested in the program. costs without pricing out patients, partic- “It’s a need, but at the same time, it’s a bit the hospital charged for screening was low ularly low-income patients. “We wanted of a hard sell,” Molen explains. “Women know relative to the cost of the service, some pa- to market this as something that patients they should get mammograms because their tients could not afford it. Rather than turning would value and find important, while giving cancer risk naturally increases with age. With these patients away, the committee sought them some perspective on the cost of care,” smokers, it’s different because they know funding from the Elkhart Hospital Foundation Lamont explains. they are doing something that’s bad for their to cover their screening. The team ultimately decided to charge health, so they’re often reluctant to pursue An advanced practice nurse for oncology $199 out of pocket — the rough equivalent to screening.” services at EGH delivered a presentation to one and a half packs of cigarettes per day for a After realizing this, the team changed the foundation’s board about the benefits month, a fact they advertised to help patients course and began focusing most of its and cost-effectiveness of the program. After understand the value of this potentially marketing efforts on cardiologists and other hearing about the important role lung cancer life-saving service. While the price would just referring physicians who regularly treat smok- screening plays in saving lives, the board cover the program costs, the team deter- ers. Radiologists mentioned the program unanimously agreed to cover the cost of mined that the potentially life-saving benefits during tumor boards and quarterly staff meet- screening for individuals who met the pro- were more important, and they remained ings, as well as in conversations with referring gram requirements but could not afford it. steadfast in their desire to not financially physicians. By 2015, CMS began covering lung cancer overburden patients. Soon, primary care and other referring phy- screening for Medicare patients who meet With these details in hand, several radiol- sicians began inquiring about the program, specific guidelines, so the hospital foundation ogists and a nurse practitioner dedicated with cardiologists ultimately referring the no longer needed to subsidize the program time to gaining hospital administrator and most patients. “We took these opportunities for many patients. (Learn more at bit.ly/ physician buy-in for the program. They gave over the phone or in person to really educate CMSDecision) What’s more, the out-of-pocket presentations to physicians in cardiology, referrers about how screening can detect lung cost of screening at EGH eventually decreased

Imaging 3.0 in Practice n November 2019 9 SSoo YYoouu’’rree

lung cancer, one was diagnosed with renal every one of those patients who has a serious ComComiingng iinn ffoorr cell carcinoma, and two were diagnosed with health condition or cancer, it can be a huge lymphomas. Many of these patients were difference between surviving and not surviv- u nn asymptomatic, so their cancers may have ing, and that makes everything worthwhile.” LLungng CCaa ccerer gone undiagnosed for some time, if not for It’s clear that lung cancer screening is the screening program. saving lives in the Elkhart community. EGH ccre nniingng Patients who are diagnosed through the physicians and administrators urge others to SS reee lung cancer screening program are invited to find ways to initiate these programs around participate in EGH’s thoracic oncology clinic. the nation. “We are just a little community (Learn more in the “Patient Forward” case hospital,” says Lamont, “but look at what we How effective is a CT scan? study on page 24.) Started as a way to deliver have done. We support each other, and we comprehensive, patient-centered care to lung encourage each other. Profound change can Because CT scans can detect even very small nodules in the cancer patients, the clinic gives patients and stem from that sort of teamwork.” lung, they are especially eective for diagnosing lung cancer at its earliest, most treatable stage. In fact, about 80 percent families a chance to meet in person with their By Chelsea Krieg of lung cancers are found at an early stage when there is a multispecialty care team to ask questions, good chance of a cure. Without screening, more than 70 review images, and discuss treatment options. percent of lung cancers are found at a late stage with little William T. Molen, MBA, director of imaging services at ENDNOTES Elkhart General Hospital, says that while the screening “Patients and families go into the thoracic chance of a cure. program didn’t initially generate much revenue, the oncology clinic and are in awe because there 1. American Cancer Society. Key Statistics for Lung Cancer. important thing is that it was saving lives. http://bit.ly/ACS_CancerStats Accessed Nov. 15, 2018. are so many people there to help them,” says 2. American Lung Association. Lung Cancer Fact Sheet. http:// Here’s the information you should How will the exam Cindie L. McPhie, vice president of operations bit.ly/ALA_CancerFacts Accessed Nov. 15, 2018. to $165 once the program started generating at Beacon Health System and EGH, where she know before undergoing a be performed? downstream revenue for the hospital. “We are has been involved in the lung cancer screen- low-dose CT scan. The technologist will position you, often lying flat, on the exam perfectly OK with doing the exam for a very ing program’s development from the start. Next Steps table. You will be asked to raise your arms over your head. low cost because it is an opportunity to bring “It gives them an amazing sense of comfort • View the most recent community health Then, the table will move more slowly through the machine as patients into our systems for care,” Molen when they realize they have something this the CT scan is performed. You’ll hold your breath while the assessment in your area and determine ut 5 to 10 seconds. This explains. “More importantly, it saves lives. valuable right in their backyard.” Should I be screened? machine is scanning, usually for abo what kinds of programs might be benefi- ensures that your lungs do not move, creating a more clear Currently, lung cancer screening is recommended and covered When you find cancers and find them early, cial to your area’s patient demographic. image. The entire exam should take around ten minutes total. everyone wins.” by most insurance plans and Medicare for specific high-risk Growing the Program individuals. A CT scan is currently covered for those who meet Program funding wasn’t the only thing that • Present new program ideas at tumor Based on the success of the lung cancer the following criteria: changed once CMS and other payers began boards or other regularly scheduled screening program at EGH, radiologists and ❋ Are age 55 to 77 What will happen after my scan? covering lung cancer screening. EGH also multidisciplinary committee meetings ❋ Currently smoke or have quit smoking within the last 15 years administrators are now helping EGH’s sister updated its eligibility criteria to meet the CMS to get buy-in and partners who will refer ❋ Have a tobacco smoking history of at least 30 “pack years” After your appointment, the radiologist will look at the results, search hospitals within Beacon Health System lung cancer screening guidelines and met the patients. (an average of one pack a day for 30 years, 2 packs a day for anything of concern, put together a report that discusses anything in Indiana develop screening programs for 15 years and so on) unusual that showed up in the images, and make recommendations requirements to become an ACR Designated • Seize opportunities to educate referring of their own. For example, collaborative for any follow-up care. The radiologist then sends the report to the Lung Cancer Screening Center, a designation efforts among imaging directors at EGH clinicians about the benefits of and physician who referred you for the screening. that includes minimum technical specifica- and Memorial Hospital in South Bend, Ind., opportunities that screening programs What are the risks and tions and ACR CT accreditation. (Learn more have led to a budding lung cancer screening afford. benefits of screening? at bit.ly/ACRLCSCenter) What if the radiologist program at Memorial. While achieving this designation required The CT combines special X-ray equipment with sophisticat- The growth opportunities in the sur- detects something? radiologists to alter the way they classify ed computers to produce multiple cross-sectional images of rounding hospitals encourage McPhie. “As the inside of the body. If the radiologist detects anything of concern, he or she will likely patients, they rose to the challenge to better we evolve more as a system, we will create Risks: Cancer screenings are not perfect. Many people who recommend a follow-up CT scan several months later to check that the serve patients. “We have adapted to every- avenues to help facilitate these programs in have smoked have small nodules (a relatively round area of nodule does not change in size. If you have an infection or any thing that has come down the pike,” Lamont inflammation in your lungs when you get your LDCT, you will likely be our other hospitals,” she says. “We have the abnormal tissue) in their lungs. Mostly, these are not lung says. “We have been willing to adjust, because cancer. Sometimes, a test appears to be abnormal, but no recommended to have a follow-up scan in about a month to make sure potential to serve more people and save more we care about the program and know it’s a lung cancer is found (this is called a false-positive finding). the issue went away and is not something else. For the small lives in our community through this program.” percentage of people with abnormalities that are concerning for lung valuable service that meets an important These findings may require additional testing, such as Molen agrees. “One of our mottos here at another CT (most likely) or a biopsy (less likely) to determine cancer, more immediate testing, such as a PET scan, may be community need.” EGH is putting the patient at the center of whether or not cancer is present. necessary, as well as a referral to a specialist such as a pulmonologist. Sometimes the scan will find something else that is not lung cancer everything that is happening,” he says. And his With a low-dose CT scan (LDCT) there is minimal risk of any but may be significant to your health. In most cases, these are not Seeing Results eects from radiation exposure. The machine uses about advice for others contemplating developing serious, but your physician may recommend additional tests such one-fifth the amount of ionizing radiation as a standard chest The team’s diligence has paid off. Between a lung cancer screening program is straight- as an ultrasound to get more information. Your physician may also CT scan. The amount of radiation from a LDCT scan is about refer you to a specialist. June of 2012 and June of 2017, EGH’s lung forward: “Know your doctors, community, and the same as an average American receives in six months cancer screening program served 941 health system, and build programs appro- from natural background radiation by living on planet Earth. patients. Of those, 29 were diagnosed with priately to fit your system. Be persistent. For Benefits: LDCTs are painless and noninvasive procedures ❋ Get information about lung cancer screening and other medical imaging at that can find lung cancer when it’s in early stages with a Radiologyinfo.org and the American Lung Association’s Lung.org. good chance for a cure. ❋ Visit ShouldIScreen.com to decide if lung cancer screening is right for you. 10 IMAGING 3.0 SSoo YYoouu’’rree ComComiingng iinn ffoorr LLuungng CCaannccerer SSccrereeenniingng How effective is a CT scan?

Because CT scans can detect even very small nodules in the lung, they are especially eective for diagnosing lung cancer at its earliest, most treatable stage. In fact, about 80 percent of lung cancers are found at an early stage when there is a good chance of a cure. Without screening, more than 70 percent of lung cancers are found at a late stage with little chance of a cure.

Here’s the information you should How will the exam know before undergoing a be performed?

low-dose CT scan. The technologist will position you, often lying flat, on the exam table. You will be asked to raise your arms over your head. Then, the table will move more slowly through the machine as the CT scan is performed. You’ll hold your breath while the Should I be screened? machine is scanning, usually for about 5 to 10 seconds. This ensures that your lungs do not move, creating a more clear Currently, lung cancer screening is recommended and covered image. The entire exam should take around ten minutes total. by most insurance plans and Medicare for specific high-risk individuals. A CT scan is currently covered for those who meet the following criteria: ❋ Are age 55 to 77 What will happen after my scan? ❋ Currently smoke or have quit smoking within the last 15 years ❋ Have a tobacco smoking history of at least 30 “pack years” After your appointment, the radiologist will look at the results, search (an average of one pack a day for 30 years, 2 packs a day for anything of concern, put together a report that discusses anything for 15 years and so on) unusual that showed up in the images, and make recommendations for any follow-up care. The radiologist then sends the report to the What are the risks and physician who referred you for the screening. benefits of screening? What if the radiologist The CT combines special X-ray equipment with sophisticat- ed computers to produce multiple cross-sectional images of detects something? the inside of the body. If the radiologist detects anything of concern, he or she will likely Risks: Cancer screenings are not perfect. Many people who recommend a follow-up CT scan several months later to check that the have smoked have small nodules (a relatively round area of nodule does not change in size. If you have an infection or any abnormal tissue) in their lungs. Mostly, these are not lung inflammation in your lungs when you get your LDCT, you will likely be cancer. Sometimes, a test appears to be abnormal, but no recommended to have a follow-up scan in about a month to make sure lung cancer is found (this is called a false-positive finding). the issue went away and is not something else. For the small These findings may require additional testing, such as percentage of people with abnormalities that are concerning for lung another CT (most likely) or a biopsy (less likely) to determine cancer, more immediate testing, such as a PET scan, may be whether or not cancer is present. necessary, as well as a referral to a specialist such as a pulmonologist. Sometimes the scan will find something else that is not lung cancer With a low-dose CT scan (LDCT) there is minimal risk of any but may be significant to your health. In most cases, these are not eects from radiation exposure. The machine uses about serious, but your physician may recommend additional tests such one-fifth the amount of ionizing radiation as a standard chest as an ultrasound to get more information. Your physician may also CT scan. The amount of radiation from a LDCT scan is about refer you to a specialist. the same as an average American receives in six months from natural background radiation by living on planet Earth. Benefits: LDCTs are painless and noninvasive procedures ❋ Get information about lung cancer screening and other medical imaging at that can find lung cancer when it’s in early stages with a Radiologyinfo.org and the American Lung Association’s Lung.org. good chance for a cure. ❋ Visit ShouldIScreen.com to decide if lung cancer screening is right for you. Case Study Published August 2019 Early Detection Matters Radiologists in Michigan collaborate with administrators and care partners to develop a successful lung cancer screening clinic and enhance population health.

ore people die of lung cancer than any Mother cancer. According to the American KEY TAKEAWAYS Cancer Society, lung cancer accounts for a • After numerous trials proved that low- quarter of all cancer deaths in the U.S.1 The dose CT lung cancer screening could good news is that when lung cancer is diag- reduce mortality rates, a radiologist nosed early, the five-year survival rate can be in Michigan spearheaded a dedicated as high as 90%.2 clinic in line with Imaging 3.0™ and Multiple research studies show that lung other leadership practices he learned cancer screening decreases lung cancer through the ACR’s Radiology Leader- mortality. Data from the National Lung ship Institute®. Screening Trial (NLST) in 2011, showed a 20% reduction in lung cancer mortality in • The lung cancer screening clinic has patients who received low-dose CT (LDCT).3 served nearly 2,500 patients to date, (Learn more at bit.ly/Lungtrial) Based on the with a 3% lung cancer detection rate study, the U.S. Preventive Services Task Force and a Stage 4 detection rate that is 8% made lung cancer screening with LDCT a better than the national average. public health recommendation in 2013. And • To encourage maximum participa- both CMS and private insurers now cover tion, the team focused on eliminating lung cancer screening for qualified individ- potential hurdles for both patients and uals — with no copay or cost-sharing by the referring physicians. patient. (See coverage qualifications at bit. ly/CMSDecision) Recognizing that radiology is central to lung cancer Despite these advances, millions of smok- screening, Samir J. Parikh, MD, MBA, a diagnostic ers and former smokers who qualify for lung radiologist at Jackson Radiology Consultants, collaborated with care partners to establish a dedicated cancer screening are not getting the preven- clinic. tative scans that could save their lives. So, a cadre of radiologists is stepping up to lead lung cancer screening programs that break down the barriers to patients getting the Stepping Up to Lead care they need before it’s too late. As the healthcare industry recognizes that One such radiologist is Samir J. Parikh, lung cancer screening saves lives, radiologists MD, MBA, who launched a lung cancer like Parikh are also positioning themselves to screening clinic in Jackson, Mich., in 2015. deliver more value-based care for patients. Since its inception, the clinic has served Trained in cardiopulmonary radiology with nearly 2,500 patients, with a 3% lung cancer a focus on lung diseases, Parikh immediately detection rate. The goal of the clinic is to recognized that radiology is central to lung detect lung cancer early, when there is still cancer screening and volunteered to lead a time for life-saving treatment — and it’s lung cancer screening program for his health working. At a national level, 44% of lung system, Henry Ford Allegiance Health. cancers are not detected until Stage 4. In “Lung cancer detection starts with a CT of Jackson County, the late-stage cancer rate is the lungs, so the radiologist is at the center just 36%. of the entire chain of care,” Parikh says. “As we Here’s how a dedicated team of caregivers began considering a lung cancer screening implemented this life-saving lung cancer program, I was also learning about Imaging screening program, enabling earlier detec- 3.0™ and other leadership practices through tion and treatment of this deadly disease. the Radiology Leadership Institute®. (Learn

12 IMAGING 3.0 more at acr.org/imaging3 and acr.org/RLI) health system created a fund with a contri- Learning about the importance of value bution from The Tony Open, a local charitable over volume and leadership best practices foundation seeking to make a difference in sparked me to ask the question, ‘How can I the community, to pay for lung cancer screen- make a difference in patient care?’” ing for qualified patients who couldn’t afford For Parikh, the answer was to ensure that it,” Parikh says. his practice was among those developing After lining up funding, the team began and implementing a lung cancer screening actively implementing the lung cancer program. Parikh is a diagnostic radiolo- screening program, including finding space gist at Jackson Radiology Consultants, a for the clinic and securing dedicated time small private practice serving Henry Ford to use the CT scanner. Parikh met with his Allegiance Health, a medium-sized commu- radiology group partners and proposed that nity hospital in Jackson County. He shared he would schedule a block of time each week his idea for the clinic with his colleagues for lung cancer screening patients. With their at the eight-radiologist practice, and they support, he schedules one morning a week, were immediately on board. from 7 a.m. to noon, for the clinic. Next, he approached Yacobucci and other Improving Population Health Results from the clinic demonstrate that when care administrators and requested the same ded- partners, like Mohan G. Kulkarni, MD, a thoracic surgeon icated time to use the CT scanner for lung Parikh is a member of the health system’s affiliated with Henry Ford Allegiance Health in Jackson, cancer screening. He also asked for a place multidisciplinary lung disease site team, a partner with radiologists and administrators, lung cancer can be detected more often, and at earlier stages. to meet with patients to discuss their scans group dedicated to improving care around and findings. “I need that dedicated space this particularly deadly cancer. As such, he and time, because I want to speak with every began talking with other care partners on patient,” Parikh says. “The hospital adminis- the site team, including pulmonologists, tho- “We can intervene at a point trator looked at the NLST trial data and our racic surgeons, and hospital administrators, demographics and realized it was the right about establishing a lung cancer screening where we can impact the thing to do for our patients.” clinic in 2015 as an adjunct to its existing Other care partners agreed that the face- lung nodule program. course of the disease and to-face conversations between the patient After reviewing the area’s demograph- save lives.” and radiologist were critical to the program’s ic data, the team determined that a lung success. “Dr. Parikh is not a typical radiol- cancer screening program was a particularly —Mohan G. Kulkarni, MD ogist who spends most of his time in the worthwhile endeavor for the patient popu- dark reading images and creating reports,” lation the health system serves. In Jackson Kulkarni says. “He wants to have patient County, 30% of the population smokes, interactions to ensure anxious patients with and in Jackson city, 35% of residents are potential findings of lung cancer don’t leave smokers — compared with 23% of residents With recognition of both need and oppor- without having a clear understanding of throughout the state of Michigan. “We have tunity, Parikh and Kulkarni came together what comes next.” a significantly higher number of smokers in with other clinicians and administrators our community than the rest of the state, from Henry Ford Allegiance Health to form so many people meet the criteria for lung the lung cancer screening program. Karen Breaking Down Barriers cancer screening,” Parikh explains. Yacobucci, administrative director of Henry To make the program work effectively, Parikh The team also found that, according to Ford Cancer Institute (HFCI), Central Region, and the team focused on eliminating poten- the Commission on Cancer registry, 44% of was the force behind the successful execu- tial hurdles for both patients and referring lung cancers in 2010 were not diagnosed tion of the program. physicians. For patients, the screening clinic until Stage 4 in the United States. “Based on provides an easy and seamless pathway our at-risk population, we felt like screening Putting Ideas into Action from undergoing the initial CT and receiving could detect lung cancer at an earlier stage,” tobacco counseling to reviewing results of says Mohan G. Kulkarni, MD, a thoracic When the group started its program in 2015, the scan and ordering follow-up imaging and surgeon affiliated with Henry Ford Allegiance CMS was not yet covering lung cancer screen- scheduling appointments. Health in Jackson and the physician co-chair ing, so an important first step in establishing Here’s how the process works: When a pa- of the lung disease site team. “As a result, we the screening clinic was to find funding to tient comes in for screening, a technologist can intervene at a point where we can im- cover the cost for patients. “Immediately rec- conducts the scan, and then the patient goes pact the course of the disease and save lives.” ognizing the clinic’s life-saving potential, the to see Carol Zawacki, RN, LMSW, a certified

Imaging 3.0 in Practice n November 2019 13 tobacco treatment specialist and health ed- coordinator, monitors annual screening ucator, while Parikh reads the scan. “I didn’t patients. Brow enters and tracks all results want patients to have to come back for sep- within the EMR’s lung screening dash- arate tobacco counseling,” Parikh explains. board and the HFCI database to ensure “The goal is to have everything happen on that patients have follow-up appointments the same day, which encourages people to within the appropriate timeframe. Brow also get the follow-up care they need.” generates and mails reminder letters to each Zawacki says that in-person counseling lung screening patient one month prior to and treatment is the most effective for their recommended screening. Before any facilitating tobacco cessation. “I talk briefly new or returning patients are scheduled into with patients about their relationship with the lung screening block, Brow verifies the tobacco: the physical addiction, plus the order, reviews the chart to ensure the patient psychological, emotional, social, and meets CMS criteria for lung cancer screen- behavioral aspects,” says Zawacki, who was ing, and then reaches out to the patient to invited to join the screening team based on schedule the exam. her ongoing efforts to counsel lung nodule When the findings are suspicious, Bartlett, patients about smoking cessation. “Most who is also the lung nodule nurse navigator, people have tried to quit. Most want to quit. contacts the referring provider for appropri- I’m a resource to offer support, empathy, Carol Zawacki, RN, LMSW, a certified tobacco treatment ate follow-up based on LUNG-RADS. She also understanding, and education.” specialist, counsels patients on smoking cessation while facilitates orders for Henry Ford Allegiance the radiologist is reading the scans. Evidence shows that patients have a 50% physicians to co-sign, ensures proper order greater chance of quitting smoking when authorization, and schedules follow-up they combine some type of counseling with appointments — most within 14 days. For a nicotine replacement therapy or medica- “I talk brief­ly with patients outside physicians, Bartlett contacts the tion.4 “While patients are here, I can submit physician’s office with results and recom- an order for that treatment and then follow about their relationship mendations, then watches to ensure an up with them afterwards about other sup- order for follow-up imaging is placed. port they need to quit,” Zawacki says. with tobacco: the physical For patients with findings that require The data shows this on-the-spot tobacco addiction, plus the follow-up, Bartlett stays in close touch to counseling is working. The overall smoking ensure they get the recommended scans. cessation rate for patients in the lung cancer psychological, emotional, “I reach out to them by phone,” she says. screening program has gone from 13% in “I call three times, and if I haven’t spoken 2016 to 15% in 2017. Even better, the quit rate social, and behavioral with them, I send a certified letter about the for screening patients with negative screening importance of keeping their appointments. results increased from 8% in 2016 to 14% in aspects.” That’s when many people realize it’s serious, 2017. According to Parikh, these results can be — Carol Zawacki, RN, LMSW and they need to come in.” attributed to Zawacki’s direct interaction with Bartlett also reports back to those patients’ patients as a tobacco cessation counselor. referring physicians, letting them know what’s happening and what exams and Empowering Patients appointments have been scheduled. “Our to 15 minutes, depending on how many ques- By the time a patient has finished speak- ordering physicians find it reassuring that tions the patient has for Parikh. Every patient ing with Zawacki, Parikh has read the scan, our clinic is facilitating all of it. As a result, the leaves the clinic with exam results in hand. compared it to previous scans, and applied referring physicians are more inclined to en- In instances in which the findings are the ACR LUNG-RADS® lexicon. (View the courage their patients to come for screening, negative, Parikh stresses that, while there lexicon at bit.ly/ACR_LungRADS) The patient so everybody wins.” then joins Parikh and Christi Bartlett, RN, BSN, is no indication of lung cancer, patients are Patients are also comforted to know that the screening program’s nurse navigator, in still at high-risk for developing the disease Bartlett is there to assist them through the the reading room, where Parikh reviews the and should quit smoking. Bartlett makes an screening process and that they can always images with the patient. appointment for annual screening and rein- reach out to her with questions. “It makes all In these shared decision-making consul- forces that patients should keep returning to the difference having someone there for the tations, Parikh orients the patient with the ensure they have a chance to catch develop- patients to guide them through and make anatomy, identifies any nodules, and de- ing lung cancer early. sure nothing is overlooked,” Parikh says. “Our scribes the findings. Each consultation takes 5 From there, Kayla Brow, lung program patients know someone is watching out for

14 IMAGING 3.0 “Our goal is to find cancers at an earlier stage and get that intervention, so we can save more lives.” —Mohan G. Kulkarni, MD

late,” says Bartlett. “But if we catch it when END NOTES it’s small, it’s not too late. We just need to get 1. American Cancer Society. Cancer facts & figures 2018. you in here, get you checked, and watch out Atlanta: American Cancer Society; 2018 bit.ly/ACS_Facts . for you. We can make a difference.” 2. Knight SB, Crosbie PA, et al. Progress and prospects of early detection in lung cancer. Open Biol. 2017 Sep; 7(9): 170070. With their strong record of success, the doi: 10.1098/rsob.170070. Published online Sep. 6, 2017. team is now focused on getting even more 3. National Lung Screening Trial Research Team. Reduced patients in for lung cancer screening. “We are lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011 Aug 4; For patients with suspicious findings, nurse navigator all passionate about reaching out to our com- 365(5):395-409. doi: 10.1056/NEJMoa1102873. Published Christi Bartlett, RN, BSN, obtains authorizations and munity — especially the lower socioeconomic online June 29, 2011. often schedules follow-up procedures before the patient population where smoking is more prevalent 4. Treating Tobacco Use and Dependence, Clinical Practice even leaves the clinic. — and encouraging people to get the screen- Guideline 2008 Update, U.S. Department of Health and Human Services, Public Health Service, May 2008. bit.ly/ ing that can save their lives,” says Parikh. TreatingTobacco To that end, Parikh asks patients to share them behind the scenes. It’s reassuring when their screening experiences with their they know the order has been placed for families and friends — knowing that people Next Steps them before they even leave the clinic.” who smoke usually know others who smoke. • Review findings directly with patients The team also conducts outreach at events, Finding Cancer Earlier and recognize that LDCT for lung cancer like Rotary or Lions Club meetings, and at screening is a teachable moment for Based on the clinic’s efforts to make screening the county fair, parades, festivals, health fairs, smoking cessation. as easy as possible for patients and referrers, it and industrial parks, as well as at the hospi- • While patients are in the clinic, order is making inroads in its goal of catching lung tal’s annual “Shine a Light on Lung Cancer” scans and set follow-up appointments cancer early. “One thing we’re all concerned event. to encourage patients to continue about is missing cancer until it’s too late, Additionally, the team regularly visits med- screening or treatment and take the when the treatment is harder and the progno- ical practices and referring physicians whose burden off of referrers. sis is worse,” says Kulkarni. “We tried to come patient populations include a high num- up with a program to capture people before ber of smokers to provide education and • Focus on patient outreach and engage- they come in with advanced disease. Our goal promote the screening program. “People are ment. Identify a strategy to reach the is to find cancers at an earlier stage and get starting to realize that every time a patient highest-risk patients, including those in that intervention, so we can save more lives.” comes in for a physical, their doctors need to lower socioeconomic groups. The results of the lung cancer screening look into their smoking history and promote program speak for themselves. Since the lung cancer screening,” Parikh says. program began, the team has seen nearly Kulkarni believes that having a collabo- 2,500 patients and has found a total of 53 rative team of people who believe in the cases with pathologically proven lung cancer power of lung cancer screening is the most at all stages. The program has also detected important factor in the success of their nine other potentially deadly cancers, includ- program. “When you have buy-in from ad- ing esophageal, kidney, adrenal, transverse ministration along with dedicated clinicians colon, abdominal, and lymphoma. and a forward-thinking radiologist coming In 2018, the cancer detection rate for the together with a focus to improve care for a lung cancer screening program was nearly particular cancer, miracles can happen,” he 3%. And the incidence of Stage 4 cancer was says. “The evidence shows that we can have just 36% in 2018 as compared to the national an impact when we work together.” average of 44%. “Many times, our patients think that when we catch cancer, it’s too By Linda G. Sowers

Imaging 3.0 in Practice n November 2019 15 Case Study Published September 2019 Lung Screening in an Urban Setting Radiologists in the Bronx lead a lung cancer screening program targeting an underserved, high-risk urban population. PHOTO COURTESY OF MONTEFIORE HEALTH SYSTEM.

KEY TAKEAWAYS: • Inspired by the results of the National Lung Screening Trial, physicians at Montefiore Health System collabo- rated across disciplines to develop a lung cancer screening program to reduce mortality rates in their high-risk population. • Screening program directors meet regularly with referring physicians throughout the hospital network to raise awareness and build trust. • With automated enrollment forms and follow-up reminders in the EMR sys- tem, the screening program reduces the burden of patient management for Linda B. Haramati, MD, MS, FACR, director of cardiothoracic imaging, and Andrea C. Furlani, MD, a cardiologist and future radiologist, review a chest scan at Montefiore Health System. referring physicians.

avid Feliciano’s friend went to the doctor detected early, the five-year survival rate can Dfor what he thought was just a cough, be as high as 90%.2 Lung cancer screening but imaging revealed something much programs, like the one Feliciano is enrolled more serious: Stage 4 lung cancer. “By the in at Montefiore Health System in New York, time he finally got his lungs checked, it aim to increase survival by catching lung was too late, and four months later, he was cancer early. gone,” Feliciano says. “We have systems like mammography Feliciano, himself a former smoker, to detect breast cancer and colonoscopy learned a valuable lesson from his friend’s to detect colon cancer, but lung can- results: Lung cancer typically doesn’t cer always lacked a screening pathway present symptoms until the advanced until we introduced low-dose CT (LDCT),” stages, when the disease is more difficult says Chirag D. Shah, MD, director of the to treat and nearly impossible to cure. “You pulmonary and critical care fellowship at don’t want to wait until you have symp- Montefiore. “With a framework for lung toms to find out you need treatment. You cancer screening, we can really impact want to catch it right away,” says Feliciano, patient care.” who smoked for 40 years. “That’s why I get Montefiore is located in the Bronx, which checked every year.” has the second-highest smoking rate of When it comes to lung cancer, early New York City’s five boroughs. The hospital’s detection is lifesaving. Three-fourths of screening program targets an ethnically lung cancer cases aren’t diagnosed until the diverse, underserved urban population at disease has spread, reducing the five-year high risk for lung cancer. Since Montefiore’s survival rate to just 5%.1 But if lung cancer is program launched in December of 2012, the

16 IMAGING 3.0 Around the same time, the Centers for between the ages of 55 and 74 with a smok- Medicare and Medicaid Services selected ing history of at least 30 pack-years,” Haramati Montefiore as one of 32 Pioneer Accountable says. “The only real resource we needed from Care Organizations (ACO). (Learn more at bit. administrators was a special order in our ly/CMS_ACO) Under this model, Montefiore electronic medical record to enroll patients focused on providing enhanced care coor- who met the eligibility criteria. They bought dination and illness prevention for Medicare into it because the evidence showed that lung beneficiaries, so its administrators instantly cancer screening would benefit patient care.” saw the lung cancer screening program as a With approval for the special order, way to meet these goals and improve patient Haramati developed an intake questionnaire outcomes related to lung cancer. “Montefiore to ensure that patients referred into the pro- had just become an ACO, so it was a propi- gram met the screening criteria. She worked tious moment to get everyone on board with with the EMR’s tech team to set up the spe- a program like this,” says Haramati, who has cial order so that when referring physicians a joint appointment in the department of enrolled patients, the questionnaire popped medicine. up automatically to confirm their eligibility. Linda B. Haramati, MD, MS, FACR, director of With the goal of developing a lung cancer Next, Haramati turned her attention to cardiothoracic imaging at Montefiore, led implementation screening program, Montefiore’s head of a successful lung cancer screening program at developing a consistent method for report- Montefiore Health System. of pulmonary medicine initiated the first ing results. Since standardized guidelines meeting among physicians from the surgery, for lung cancer screening did not yet exist, oncology, radiology, and radiation oncology Haramati met with the chief of mammog- “Even with limited resources, departments. Although all of the physicians raphy to develop guidelines based on supported the idea of lung cancer screening, BI-RADS® — and then switched to LUNG- the radiologists took the lead, sharing the screening programs can still RADS when the ACR published its first set NLST data and other screening information of guidelines in 2014. (Learn more at bit.ly/ with their colleagues. improve patient care.” ACR_BIRADS and bit.ly/ACR_LungRADS) “The strong body of evidence support- —Linda B. Haramati, MD, MS, FACR To schedule exams and manage follow-up ing lung cancer screening generated a lot appointments, the screening program of enthusiasm among participants,” says needed a dedicated bilingual coordinator. Haramati, who’s also a professor of radiol- The radiology department agreed to move ogy at Albert Einstein College of Medicine. a half-time clerk into the role. The coordi- system’s radiologists have screened more “But we knew from mammography that nator, Aracelis Jimenez, now a pillar of the than 2,200 patients and detected 55 cancers image-based screening has to be done right program, called new patients to confirm — about half of them Stage 1 and 2 lung to be effective. We’re not doing diagnostic cancer. imaging; we’re screening healthy people, so “Early stage disease is the most likely to we had to find a way to target and track eligi- be cured,” says Linda B. Haramati, MD, MS, ble patients. Instead of starting from scratch, FACR director of cardiothoracic imaging at we decided to apply the lessons we learned Montefiore, who spearheaded the program’s from mammography to make this program development. “By participating in a screen- successful as a radiology-centered service.” ing program, people with a smoking history have an opportunity to get ahead of lung Initial Resources cancer and seek life-saving treatment.” In modeling the lung screening program after mammography, Haramati and the Support for Screening multidisciplinary committee identified three In 2011, the National Cancer Institute key resources they needed to launch the published the findings of the National Lung initiative: a special order in the electronic Screening Trial (NLST), which established the medical record, a system to report results evidence to support lung cancer screening. consistently, and a coordinator to manage (Learn more at bit.ly/Lungtrial) The results re- patients and data. vealed that annual LDCT screening could lead “First, we wanted to make sure that we Anna Shmukler, MD, a radiologist at Montefiore and co- to a 20% reduction in lung cancer mortality screened only eligible patients, which at director of the lung screening program, has been integral rates, compared to standard chest X-rays.3 the time were current and former smokers to the program’s outreach.

Imaging 3.0 in Practice n November 2019 17 that they met eligibility requirements before practical for referring physicians to ask the PHOTO COURTESY OF MONTEFIORE HEALTH SYSTEM. scheduling exams, and then manually right questions to determine who’s a good tracked their results and follow-up recom- fit for a CT scan, you’ll end up with a more mendations with assistance from medical consistent program,” Shah says. “Patients are students and residents, including Hannah going to be skeptical, so equipping their PCPs Milch, Mark Kaminetsky, Abraham Kessler, to explain the program face-to-face can build Robert Peng, and Edward Mardakhaev. trust and confidence.” It took the committee about a year to gath- When his PCP explained that screening er these initial resources. Montefiore screened could detect lung cancer early enough for its first patient in December of 2012. treatment, Feliciano agreed that an annual scan was important. He had his first exam in Patient Enrollment 2016 and hasn’t missed his annual visit since. “My doctor is always telling me we’ve got to As the program got underway, the commit- nip it in the bud,” says Feliciano, 65. “So it’s tee’s biggest concern was enrolling patients. good to have this exam done once a year They worried because Montefiore’s patients because of the amount of time I smoked.” differ dramatically from the NLST population. Initially, some referring physicians, like “The majority of patients in the trial were Shah, worried about the amount of paper- Judy Yee, MD, FACR, radiology department chair at more affluent than our patients in the Bronx Montefiore, is a big advocate for lung cancer screening. work and patient management the program — most of whom come from low socioeco- added to their already heavy workloads. “I nomic backgrounds and have limited access had to keep a list of all my patients who were to healthcare,” explains Anna Shmukler, MD, the program as clinical coordinator. “We getting screened, and then try to track them a radiologist at Montefiore and co-director of were lucky to get one of the most experi- down when it was time for their next screen,” the lung screening program. enced nurse practitioners in our institution,” Shah explains. To overcome these concerns, With CMS’ coverage determination still a Haramati says. “She has experience in tho- the screening program needed more robust few years away, Montefiore had to consider racic surgery and oncology and knows many resources. the cost of screening for its underserved of the referring physicians throughout the patient population. (Read the determination institution — personal relationships that are at bit.ly/CMSDecision) “We’re the poorest Added Resources extremely beneficial to our program.” county in New York’s 62 counties,” Haramati The first upgrade came in 2015, when Leveraging her relationships with referring says. “Hospitals in Manhattan were charging Montefiore adopted a new EMR that allowed clinicians, Serrano expanded the screen- between $400 and $700 per scan, but if our for a more automated enrollment process ing program’s outreach efforts. She and patients had to pay that much for exams, it to help referring physicians order screening Shmukler began visiting primary care sites would have been a huge burden on them. exams and track follow-up recommenda- throughout the system to present the lung So, if their insurance company wouldn’t cov- tions. The second boost came in 2017, when cancer screening program in weekly meet- er it, we charged a reduced rate of $75.” renowned abdominal radiologist, Judy Yee, ings and grand rounds, emphasizing that Even with the relatively low cost, the MD, FACR, became chair of the radiology the program adds little work for referring team worried about convincing patients to department. physicians. “Some referring physicians were join the program. “We were concerned that “Dr. Yee is a big advocate for image-based reluctant because they’re already over- we’d be catching the disease at a later stage screening, so even before she joined whelmed with paperwork,” Haramati says. because our patients tend to seek medical Montefiore, she met with me to discuss the “With our clinical coordinator, we have the care only after they’re already symptomatic,” need for additional resources in the lung resources to unburden them of some previ- Shmukler says. cancer screening program,” Haramati says. ous barriers to referring patients.” Haramati knew the best way to reach “After Dr. Yee started in her new role, one high-risk patients early was through their pri- of the first things she asked for was a nurse Shared Decision Making mary care physicians (PCPs). With this in mind, practitioner to serve as a clinical coordinator Montefiore’s radiologists began reaching out for our program.” Serrano and Shmukler also explain that to referring clinicians about the screening pro- Yee partnered with the chair of radiation referring physicians can decide how much gram. When PCPs ordered CT scans for patients oncology and the director of the Montefiore of the process they want to oversee. When with emphysema or a history of smoking, for Einstein Center for Cancer Care, who each ordering a screening exam, referring physi- example, Shmukler would call them back and agreed to fund half of the coordinator’s sal- cians can opt to either order a lung cancer explain how to enroll these high-risk patients ary. In 2018, Maria Serrano, ANP-BC, AOCN, screening CT for a patient they’ve already into the new screening program. who had more than 20 years’ experience as met with to discuss the benefits and potential “If the screening order makes it simple and a nurse practitioner at Montefiore, joined risks of screening, or they can order a shared

18 IMAGING 3.0 will simply say, “We are pleased to inform you understand how beneficial this program can that the results of your recent lung cancer be for their patients.” screening imaging are normal. See you next As Montefiore’s program continues to year,” and they’ll get a reminder to schedule grow, it models how effective lung cancer their annual exam 12 months later. screening can be — even in the inner-city. If the results are more suspicious (LUNG- “There are many resource-poor areas where RADS-3 or LUNG-RADS-4), Serrano follows lung cancer screening can be developed to up with a phone call to both the patient and benefit patients and save lives,” Haramati the referring physician and urges patients to says. “Even with limited resources, screening discuss the results with their ordering doctor. programs can still improve patient care.” For LUNG-RADS-3 results, the radiologists For patients like Feliciano, a quick annual typically recommend follow-up scans in six exam is a small price to pay for peace of months. They send Lung-RADS-4 results to mind. “Hopefully I never develop lung can- Montefiore’s weekly multidisciplinary tumor cer,” he says, “but if they do find something, board for discussion. at least they can find it early enough to start Since Serrano used to head the tumor treatment.” board when she worked in thoracic surgery, she takes the lead presenting abnormal lung By Brooke Bilyj screening results every week. “We can esca- ENDNOTES Maria Serrano, ANP-BC, AOCN, Montefiore’s lung cancer late cases so other departments can expedite 1. Knight SB, Crosbie PA, et al. Progress and prospects of early screening program clinical coordinator, leveraged her the patient referral,” Serrano says. “It helps detection in lung cancer. Open Biol. 2017 Sep; 7(9): 170070. relationships to expand the program’s outreach. facilitate patients getting appointments doi: 10.1098/rsob.170070. Published online Sept. 6, 2017. much sooner, usually within a week.” 2. American Cancer Society. Cancer facts & figures 2018. Atlanta: American Cancer Society; 2018 bit.ly/ACS_Facts. decision-making session with the program’s Growth Goals 3. National Lung Screening Trial Research Team. Reduced clinical coordinator. lung-cancer mortality with low-dose computed With robust resources now in place, tomographic screening. N Engl J Med. 2011 Aug 4; Regardless of which option the referring 365(5):395-409. doi: 10.1056/NEJMoa1102873. Published Montefiore’s lung cancer screening program clinician chooses, the screening staff receive online June 29, 2011. is poised for steady growth, with two main automated pop-up alerts, letting them know goals: capture more eligible patients and that a referrer wants to schedule an exam. ensure that enrolled patients return annu- From there, they call patients to ensure they Next Steps ally. “Ideally, we want 90% compliance with meet the screening criteria (which now aligns • Develop a lung cancer screening order follow-up recommendations, and we’ve been with CMS) before scheduling an appointment in your EMR to automate enrollment for hovering around 50%. Some patients come for either the exam or a shared decision-mak- high-risk patients, reducing the adminis- back late — 18 months or two years later, ing session with Serrano. (See the CMS trative burden for referring physicians. instead of annually. Some of them drop out guidelines at bit.ly/lungeligibility) of the system because they got one normal • Dedicate the clinical personnel to take During the shared decision-making ses- result and decided that’s good enough,” responsibility for patient and data sion, as required by CMS before patients are Haramati says. “It’s one of our major priorities management and outreach to referring screened, Serrano explains the risk factors to improve that compliance.” physicians. for lung cancer and describes what patients The screening team is increasing its out- can expect during and after the exam. If the • Collaborate with a multidisciplinary reach and follow-up with physicians to bring patient decides to proceed with screening, team of experts to discuss abnormal more eligible patients into the program Serrano then orders the LDCT. screening results and expedite patient and increase compliance. It recently started follow-up. working with Montefiore’s public relations Results Reports department to coordinate marketing emails, After a patient undergoes a screening exam, symposiums, billboards, and press coverage one of Montefiore’s six chest radiologists to raise awareness about lung cancer screen- interprets the scan, generally within 24 hours, ing, while Serrano and Shmukler continue to and the EMR automatically generates a letter meet with local medical groups to promote to the patient and the referring physician out- the program. “Informing physicians about lining the results. Serrano explains to patients the large body of evidence is important,” ahead of time that if their results are normal Shmukler says. “We emphasize that lung (LUNG-RADS-1 or LUNG-RADS-2), the letter cancer screening saves lives to help them

Imaging 3.0 in Practice n November 2019 19 Case Study Published June 2019 Lung Screening Solutions North Dakota radiologists collaborate with referring physicians to administer lung CT screening for high-risk patients.

hen radiologists at Sanford Medical WCenter in Fargo, N.D., heard about their KEY TAKEAWAYS: hospital’s plan to offer low-dose CT (LDCT) lung cancer screening for high-risk patients • As part of a multidisciplinary team, in 2012, they were a bit apprehensive. The radiologists manage lung CT interpre- radiologists knew that lung cancer screening tation and nodule recommendations would require a great deal of coordination for a high-risk screening program. and were concerned about the time and com- • Through referring physician education plexity associated with monitoring patients about lung CT screening, Sanford Med- who enrolled in the program. ical Center was able to treat cancers “We recognized the immense potential of earlier and improve public health. screening to identify lung cancer in the early stages, when it’s most treatable. But without • Through lung nodule meetings and the right follow-up procedures in place to a dedicated lung nodule clinic with a make sure no one fell through the cracks, we nurse navigator, the team centralized thought we’d actually be doing our patients a a complex screening process for im- disservice,” says Martha S. Kearns, MD, radiolo- proved patient management. gist at Sanford Medical Center Fargo. To ensure lung cancer screening patients would receive the necessary longitudinal care, the radiologists partnered with a Martha S. Kearns, MD, radiologist at Sanford Medical multidisciplinary team of primary care and Center Fargo, led implementation of the hospital’s lung internal medicine physicians, nurse naviga- cancer screening program, which has served nearly 4,000 patients. tors, pulmonologists, radiation oncologists, and oncologists to establish a dedicated lung nodule clinic to track and monitor lung cancer “Working closely with family physicians screening patients. and other key specialists, we’ve been able to Now, with a dedicated nurse navigator, the detect lung cancer early, before symptoms even appear,” Kearns explains. “Lung cancer team manages patient exams, results com- screening is part of our role as radiologists munication, and follow-up, with radiologists now, and it saves lives.” providing clear and consistent recommen- dations based on custom guidelines that the radiologists founded in part on the ACR Starting the Program LUNG-RADS reporting system. (Learn more The idea to start a lung cancer screening in the “Managing Nodules” case study at bit. program at Sanford Medical Center began ly/ManagingNodules) ) With this approach, during a 2012 lung care oversight committee Sanford’s lung cancer screening program has meeting, when administrators asked physi- grown significantly over the years. ciansan important question: What can our Since the program began in 2013 — with a cancer center do to elevate its performance? hiatus in 2015 for proposed Medicare changes Radiation oncologists and oncologists at — over 300 different providers throughout the Sanford’s Roger Maris Cancer Center noted an region have referred more than 3,900 patients uptick in the number of lung cancer patients for lung cancer screening. Among these pa- they were seeing and suggested that lung tients, the radiologists have identified 44 cases cancer screening could help detect cancer of cancer, 24 of which were detected in Stages cases sooner, while also bringing more pa- 1 and 2, when the disease is still treatable. tients to the center.

20 IMAGING 3.0 They pointed to the National Lung to inform patients about the benefits of and monitoring patients through the continuum Screening Trial (NLST), which found that need for LDCT screening: It helps detect lung of care as part of the lung nodule clinic. “If patients who underwent annual LDCT cancer early, when it’s still treatable and is patients had abnormalities, like a lung mass, screening had a 20% lower lung cancer mor- recommended for as many as 15 years after a we agreed to help primary care triage them tality rate compared to those screened with patient quits smoking. Sanford also inte- to pulmonology or interventional radiology 1 chest X-rays. (Learn more about the trial at grated a flagging system for LCS eligibility or send them for subsequent CTs — wherever bit.ly/Lungtrial) One of Sanford Fargo’s sister within the electronic medical record (EMR) the patients needed to go,” Kearns says. “We locations in Sioux Falls, S.D., had recently so physicians could more easily identify high- became a safety net to make sure the patients launched its own lung cancer screening risk patients. were being taken care of, so the primary phy- program. “We knew that if we were going to The lunch and learns also gave referring sicians had one less thing to worry about.” keep up with other health systems and bet- physicians an opportunity to ask questions ter serve patients, we had to start our own and voice their concerns. Some referring Meeting CMS Requirements screening program,” says Sharri M. Lacher, physicians worried that the radiologists APRN, who eventually became the program’s wanted to commandeer their patients. But While the self-pay model brought in a moder- lung nodule nurse navigator. Kearns and Lacher assured them that the ate but steady stream of over 200 patients in As the lung care committee considered goal was to work collaboratively to provide 2014, 2015 was a different story. In February starting a lung cancer screening program, this enhanced patient care. “We were really of that year, CMS announced a national cover- members evaluated Sanford’s existing CT saying to them ‘Let us help you help your pa- age determination for Medicare beneficiaries technology for LDCT calibration and agreed tients; let us help you do your job better and who meet certain eligibility criteria.3 The de- that patients would need a referral from their make sure your patients get the care they cision also outlined specific dose parameters, primary care physicians (PCPs) to enroll in the program. They also decided on both the eligibility requirements and a self-pay fee of $150 for patients, since lung cancer screen- “We knew that if we were going to keep up with other health ing had not yet been approved for insurance reimbursement. systems and better serve patients, we had to start our own The team’s use of existing CT equipment and exam space kept the program’s operating screening program.” costs low. Given the program’s minimal over- — Sharri M. Lacher, APRN head — and high potential for patient benefit — hospital administrators wholeheartedly endorsed launching the screening program for high-risk patients in March of 2013. need,’” Kearns explains. “We assured them we weren’t trying to steal their patients.” Working with Referrers The outreach educated referring phy- Referrer involvement was critical to gener- sicians about the benefits of lung cancer ating a steady volume of eligible screening screening. “We understood that if a patient patients. Unfortunately, many PCPs and had at least a 25-year smoking history, we’d other family physicians did not understand send them for screening to catch nodules the significance of the landmark NLST or the earlier and potentially save lives,” says David potential benefits of lung cancer screening Glatt, MD, chair of the department of family for high-risk populations. To overcome this, medicine at Sanford Health. Sanford specialists partnered with Lacher Still, many PCPs felt ill-equipped to man- to educate referrers across the region about age the increasing volume of lung nodule screening and to encourage them to enroll patients that screening would identify. “We patients in the program. were concerned we were going to lose Lacher planned monthly lunch and patients to follow-up,” Glatt explains. “As learns for physicians and nurses. During the far as we were concerned, radiologists and events, Lacher and physicians from radiation pulmonologists were the nodule experts and oncology and oncology emphasized the im- had a much better understanding for where portance of documenting patients’ smoking the patients should go next.” Radiologists, who had similar concerns Sharri Lacher, APRN, clinical nurse specialist in Sanford’s histories to identify probable screening can- lung nodule clinic, helped spread the word about the didates and encouraged referring physicians about patient follow-up, committed to benefits of lung cancer screening for qualifying patients.

Imaging 3.0 in Practice n November 2019 21 standardized reporting requirements, and increase with its expanding presence in the ENDNOTES other conditions for reading radiologists and region and within referrers’ offices, with 1,211 1. The National Lung Screening Trial Research Team. Reduced participating imaging facilities. Sanford’s high-risk patients undergoing screening Lung-Cancer Mortality with Low-Dose Computed screening program — like other lung cancer in 2018. Over the duration of the program, Tomographic Screening, 2011. N Engl J Med; 365:395-409. screening programs nationwide — was numerous lung cancers — 24 of them early 2. CMS.gov. Decision Memo for Screening for Lung Cancer suspended until it met the new requirements stage — as well as additional cancers, were with Low Dose Computed Tomography (LDCT). bit.ly/ and CMS finalized its reimbursement codes. identified in 44 patients, increasing their CMSDecision Accessed April 19, 2019 From there, Sanford began implementing chances of survival via various treatments. new processes to meet the CMS require- For 2019, the Sanford lung nodule clinic ments for lung cancer screening, including has set a new goal: a 20% increase in scans Next Steps the institution of dose reduction techniques to induce earlier nodule detection and • Approach administrators with detailed as part of the ACR Lung Cancer Screening successful treatment for at-risk patients. findings of high-risk CT screening bene- Registry (LCSR) and patient flow improve- Lacher believes that into the next decade the fits, making a business case for treating ments within the lung nodule clinic. (Learn lung cancer screening program could grow lung cancer earlier for improved out- more about the registry at bit.ly/ACR_ through the use of videoconferencing and/ LCSRegistry) The on-staff radiologist would or even a mobile screening unit to service comes. interpret the CT, share the standardized additional areas. • Meet with potential referring physicians report with both the PCP — who would de- Kearns says that the program’s success liver the results to the patient — and Lacher, in your region to educate them about can be attributed in part to radiology’s who, as the nurse navigator, would monitor lung screening, the need for a dedicated consistency in process, open-mindedness the patient to ensure care continuation for program, and how radiologists can lead about applications, and a willingness to be subsequent scans. hands-on in a way that demonstrates the the effort to ensure continuity of care According to Glatt, this coordinated care specialty’s value. “Lung cancer isn’t going for at-risk patients. delivery has been vital to the screening program’s success. “Centralizing the complex, away,” she says. “As radiologists, it is our job • Access lung cancer screening resources multidisciplinary process of CT screening to find it early, so we can reduce mortality, to determine your ability to meet estab- and lung cancer screening is the best way for and subsequent lung nodule management lished criteria for the LCSR, creating an us to do that.” into a clinic has enabled Sanford to provide action plan for achievement. (See the true accountability and the highest level of By Kerri Reeves resources at bit.ly/ACRLCSResources) patient care for thousands of patients.” Expanding the Reach The referrer education outreach efforts along with integration of LCS eligibility within the EMR spurred a significant increase in the program’s patient volume. After Medicare “There’s a lot of reimbursement for lung cancer screening was approved in late 2015, the year brought 466 stigma about people patients into the program, followed by 681 who smoke, and a patients in 2016. As the program gained momentum, misconception that Lacher and Kearns began helping rural Sanford sites in the region adjust screening they caused their processes to meet Medicare’s requirements own disease so they for a covered LDCT program and participa- tion in the ACR LCSR. “I’ve met with various don’t deserve to get leaders of rural clinics to discuss what we’ve screening.” implemented here at Sanford and to help guide them in offering screening and fol- — Andrea Borondy Kitts, MS, MPH, low-up access for high-risk patients in rural “Clearing the Barriers” in the areas,” Kearns says. August 2019 issue of the ACR Bulletin Sanford Medical Center’s lung cancer screening volumes have continued to

22 IMAGING 3.0 Actions for Implementing a Lung Cancer Screening Program

Understand the need for screening Select a program structure Hire a nurse navigator/program coordinator in your area An LCS program structure will or borrow time from an existing research Research smoking statistics in your depend on the type of institu- program coordinator, navigator, or nurse to community: tion, available resources, and the manage longitudinal patient care • What percentage of area residents specialty and/or population of Consider someone with experience in smoke? the practice. Learn more at bit.ly/ thoracic surgery, oncology, or related • What are the demographics of LCSImplementationGuide specialty: smokers in your area? • Centralized LCS Program • Train the navigator/coordinator to confirm patient eligibility and • What percentage of lung cancers • Decentralized LCS Program schedule screenings in your area are currently diag- • Hybrid LCS Program-Decentralized nosed at a late stage? Access/Centralized Tracking Model • Empower the navigator/coordina- tor to ensure patients receive the Identify your internal resources Establish a program framework required screening and follow-up • Involve the navigator/coordinator Collaborate with clinical programs: Ensure you have the right team and in program outreach and marketing • Primary Care processes in place • The ACR Lung Cancer Screening efforts • Pulmonary Medicine Registry™ (LCSR) is currently the • Provide referring physicians and • Interventional Pulmonary only CMS-approved Qualified patients with a direct phone • Medical Oncology* Clinical Data Registry that enables number to reach the navigator/ • Thoracic Surgery* providers to meet quality-reporting coordinator requirements for receiving Medi- • Radiation Oncology* • Allow the navigator/coordinator to care CT LCS payment deliver results to primary care and • Pathology • Decide which radiologists will other referring physicians • Tumor board and/or lung nodule read exams and train them to read committee screening exams Conduct marketing, outreach, and (*If no onsite oncology, thoracic surgery, or ra- • Apply for ACR CT Accreditation engagement among referring physicians diation therapy exists, identify a regional center • Adopt a structured reporting sys- and patients for referrals.) tem, such as LUNG-RADS Create educational and marketing Engage with important institutional • Develop a process for managing material: partners/allies/departments: incidental findings • Identify a strategy to reach out to • Scheduling Coordinators • Create a system for notifying pa- the highest risk patients • Admissions Specialists tients of results • Use LCS as a teachable moment • CT Technologists • Identify process/person for report- for current smokers about smoking • Informaticists ing data to ACR Registry cessation • Health Information Management • Identify process to gather program • Collaborate with existing screening metrics programs in your practice, such • PACS Experts as mammography and colorectal • EMR Specialists Involve a smoking cessation counselor in the screening, to schedule patients • Finance Utilization Management program • Understand and anticipate provider • Marketing/Web Team Develop a process for patients to concerns (such as incidental find- see the counselor at the time of ings management) screening: • Develop clinical relationships and • Smoking cessation is a key com- workflows to review scan findings ponent of a comprehensive lung with patients cancer screening program • Track the impact of counseling over time to measure the smoking This action plan courtesy of the ACR Lung cessation rates Cancer 2.0 Steering Committee.

Imaging 3.0 in Practice n November 2019 23 Case Study Published September 2016 Patient Forward A multidisciplinary team invites patients and their families to a weekly thoracic oncology conference at Elkhart General Hospital. PHOTO COURTESY OF ELKHART GENERAL HOSPITAL s retired nurse Robyn Shank searched for Athe right place to begin her lung cancer KEY TAKEAWAYS: treatment journey, she selected a place • Leaders from radiology, cardiothoracic based on the experience of someone close surgery, and other specialties involved to her. “When a close acquaintance was in lung cancer screening and treatment diagnosed with cancer, her community hos- at Indiana’s Elkhart General Hospital pital in Tennessee had a tumor board where partnered to create a multidisciplinary physicians reviewed patients’ cases, and the thoracic oncology conference. patients were involved in the process,” Shank • Patients and family members have a seat says. “I wanted that same level of involve- at the table, participating with doctors in ment in my cancer treatment program.” their course of treatment. Shank, 59, searched the Internet and • The hospital’s cancer committee initiated found Elkhart General Hospital’s (EGH) mul- Lung cancer patient Robyn Shank and her husband, Fred, the program to address a public health tidisciplinary thoracic oncology conference. listen intently as Robyn’s doctors discuss her CT scan and Started in 2012, the program incorporates potential course of treatment as part of Elkhart crisis involving the area’s high percentage General Hospital’s Thoracic Oncology Clinic. The weekly of smokers, as compared to the rest of low-dose CT (LDCT) technology for lung can- conferences give patients and their family members a Indiana. cer screening and brings together all of the seat at the table to plan their care. medical professionals involved in a patient’s lung cancer treatment for weekly confer- nurses, a research nurse, director of oncology ences with their patients. The lung cancer services, case managers, physician assistants, screening occurs first, and then the patient is cancer registrars, nurse navigators, and palli- referred to the thoracic oncology conference. ative care staff. (Read about Elkhart’s lung cancer screening Most importantly, the patient is there program in the “Breathe Easier” case study on with a family member, sitting at the head page 8.) of a U-shaped conference table. This aspect Shank and her husband make the 45-min- of the program is so well-received that ute drive from their home in Sturgis, Mich., organizers had to limit the number of family to the hospital in Elkhart, Ind., to attend the members attending conferences. “With lung conferences. Patients typically attend an cancer management, patients are at the initial conference immediately following center,” says Samir B. Patel, MD,FACR, founder their lung cancer diagnosis. Upon comple- and director of the value management pro- tion of their treatment plan, patients attend gram at Radiology, Inc., in Mishawaka, Ind. a second session, during which they see a Including families in these conferences comparison of their CT scans before and improves the patient experience, he says. “No after treatment. patient comes alone,” Patel continues. “Lung cancer is a life-altering disease and, with Inviting Patients that, patients want to have as many support- ers with them as possible. It improves the Held from 7 to 8 a.m. every Thursday, the experience for the patients to have family conference’s early hour doesn’t deter partic- members with them, not only for support ipants from attending. Each session includes but also to listen and ask questions.” a team of physicians from thoracic surgery, radiology, interventional radiology, pathol- Related Content ogy, medical oncology, radiation oncology, Addressing a Public Health Crisis and pulmonology, along with an oncology Patel is also a member of the EGH’s board of Patient Forward nurse practitioner. Other participants can directors. He and the interventional and diag- Video: bit.ly/openingtopatients include registered dietitians, registered nostic radiologists of Radiology, Inc., helped

24 IMAGING 3.0 establish the thoracic oncology conference says Albert W. Cho, MD, vice chair of radiol- Developing a Treatment Plan at a time when the community was facing a ogy at Elkhart, who was also involved in the In addition to Lenfestey, interventional significant public health issue. creation of the lung screening program. “We radiologists have a great deal of contact with According to the Centers for Disease didn’t want to expose patients to high doses the patients, providing minimally invasive Control and Prevention, Elkhart County, an of radiation for a screening exam. There need- options. With that level of involvement, Patel area known for its recreational vehicle man- ed to be a balance. The low-dose technology says interventional radiology is a key partici- ufacturing industry, has a high percentage provided that.” pant in the thoracic oncology program. Nearly of smokers, compared to the rest of Indiana. all of the patients in the program have seen In response, EGH’s cancer committee, along Overseeing the Program an interventional radiologist for procedures, with senior-level executives and administra- Leading the day-to-day operations at the such as image-guided biopsy, prior to their tive personnel, initiated efforts to address conference is Jackie S. Lenfestey, MSN, FNP, lung cancer diagnoses. Having a “familiar face” this crisis. APRN-BC, the program’s point of contact at the conference goes a long way to optimiz- The cardiothoracic surgeons and for both physicians and patients. Within five ing the patient experience. radiologists teamed up to give multiple pre- days of a patient’s CT scan, Lenfestey calls the One of the clinic’s participating doctors, sentations to the hospital’s senior leadership, patient to discuss the results and next steps. interventional radiologist Nazar H. Golewale, presenting a vision for what would eventual- “I tell patients that the goal of the clinic is MD, receives a list of cases in advance of each ly become the thoracic oncology conference. to pull together all of the doctors and hospi- weekly conference. During the conference, The cardiologists were seeing patients who tal personnel working on their case, to agree he posts the patient’s images on a large had heart disease, but many of their patients on the stage of their cancer, and to give the screen and uses layman’s terms to explain had similar risk factors for lung cancer. At the patient the best options for their treatment,” the anatomy. “In many cases, patients have program’s onset, the cardiologists were the she says. “Throughout the process, we keep never seen CT scans before attending one of greatest advocates for lung cancer screening. the patient at the forefront of care.” the conferences,” Golewale says. “You can talk With the introduction of LDCT technology, Lenfestey also answers patients’ questions. about cancer and what it does to the body, which reached Elkhart in 2012, the hospital “The most frequent question I get is, ‘Is it ok but you really get a feel for it when you see felt comfortable launching the thoracic to ask questions?’” she says. “Patients are sur- the scans.” oncology conference. LDCT was a safe way to prised that they, along with their family, can Shank doesn’t shy away from the details address the community health crisis involv- actively participate in the dialogue between of her disease and, in fact, relishes being ing heavy smokers. the specialists and safely ask questions to closely involved in her treatment process. “We had to weigh the risks of radiation better understand their cancer and options “Once doctors reviewed the CT scans with us, dose versus the benefits of CT lung screening,” for management.” explaining everything we saw on the screen,

Doctors, nurses, and other hospital representatives meet weekly with lung cancer patients who are at the center of the thoracic oncology conference. They review CT scans, discuss treat- ment options, and study treatment effectiveness. PHOTO COURTESY OF ELKHART GENERAL HOSPITAL GENERAL ELKHART OF COURTESY PHOTO

Imaging 3.0 in Practice n November 2019 25 we came up with a treatment plan,” she says. “The doctors explained what the treatment “We’re fortunate with our scenario, in that we take a collegial would entail and, when they were done, asked if that was still the course I wanted to approach to problem-solving even though we come from take. They took as much time as I needed to different disciplines and are not employed by the hospital.” explain everything.” —Albert W. Cho, MD Building a Strong Team

A cohesive staff is imperative to develop- about our program through the community, associated with the disease, with patients of- ing a multidisciplinary program like this. and they want to come to Elkhart for their ten feeling like this is something they brought Organizing such a group can be challenging, treatment and to be a part of the program.” on themselves through lifestyle choices. though, as some physicians are employed by Cho is encouraged to see patients inter- For Shank, however, talking about her a hospital or multispecialty group, and other ested and involved in their own care, instead disease was a no-brainer. “My mother was physicians work on contract. Such is the case of being passive recipients of it from their a school teacher, so I think it’s up to me to at Elkhart, which contracts with Radiology, doctors. When the lung cancer screening teach everyone how good a program like Inc., for its radiology services. The synergy program started at Elkhart General, it was im- this can be,” Shank says. between the interventional and diagnostic portant to allow patients to self-refer into the radiologists of Radiology, Inc., and their By Kathy Knaub-Hardy program. Because cost could be a barrier for collaborative partnership with physicians in some patients, program organizers sought other specialties, is key to the success of the Next Steps thoracic oncology program. and received a grant from Elkhart General “We’re fortunate with our scenario, in that Hospital’s foundation to cover the cost of • Bring together physicians from multiple we take a collegial approach to problem- scans for low-income individuals. disciplines throughout the hospital to solving even though we come from different share knowledge and best practices disciplines and are not employed by the Eliminating Stigma with each other and with hospital administration. hospital,” Cho says. “We discuss together Involvement in the thoracic oncology con- what we need and how to get something ference not only helps patients learn more • Once the program is established, main- done. It’s a win-win for us and the patients. about their disease and treatment plan, but tain patient data not only for reporting And the hospital is addressing a health crisis also gives them a place where they feel they purposes, but for use in presentations at in the community.” can openly discuss their condition, sharing medical meetings where the program’s their fears and concerns. Lung cancer patients benefits can be promoted. Spreading the Word are often hesitant to discuss their disease, • Incorporate LDCT imaging into the pro- As of January of 2016, 443 unique patients more so than patients with other forms of gram to reduce the risk-to-benefit ratio have been imaged through the lung cancer cancer, Lenfestey says. There’s a certain stigma for lung cancer patients. screening program, and 14 lung cancers were diagnosed as a result. All but one of these PHOTO COURTESY OF ELKHART GENERAL HOSPITAL diagnoses included completed staging in- formation, such as the extent of the patient’s cancer, the tumor size, and whether or not the disease had spread to lymph nodes or other organs in the body. All 14 patients went on to participate in the thoracic oncology conference. The success of the lung cancer screening program and the thoracic oncology confer- ence spreads mostly through a grassroots, word-of-mouth campaign. “I get phone calls from people who live an hour to an hour- Interventional radiologist Nazar H. Golewale, MD, prepares to present patient and-a-half away,” Lenfestey says. “I talked to Robyn Shank’s lung CT during a conference someone who heard about our program from with Shank and the other physicians and medical staff involved in her treatment at someone at their church. People who have Elkhart General Hospital. been diagnosed with lung cancer are hearing

26 IMAGING 3.0 Case Study Published November 2015 Screen Time The nation’s flagship military hospital has developed an effective lung cancer screening program for the Department of Defense.

or decades, the U.S. military included Fcigarettes in its rations—ready-to-eat KEY TAKEAWAYS: meals issued to service members in the field. • Walter Reed National Military Medical With access to these free cigarettes, military Center’s radiology team worked with personnel in stressful combat situations of- a multidisciplinary group to develop ten smoked. Recognizing the adverse health a lung cancer screening program for effects associated with smoking, the military military service members and other pulled cigarettes from its rations in 1975. But beneficiaries who are at high-risk for with inexpensive cigarettes widely available lung cancer. overseas and stress a constant factor, service members continue to take up smoking at a • More than 260 patients are currently higher rate than the general population.1 As enrolled in the screening program, a result, military service members and vet- which has a lung cancer detection rate erans may be at a greater risk of developing of more than 5%. lung cancer than their civilian counterparts. • Now seen as setting a standard for In 2012, radiologists at Walter Reed military treatment facilities, the National Military Medical Center program goes beyond screening to (WRNMMC) in Bethesda, Md., took action to help patients quit smoking and obtain address the issue and improve patient care proper follow-up care. by working with a multidisciplinary team to develop a lung cancer screening program for military service members, veterans, and Walter Reed National Military Medical Center has other beneficiaries. The program follows developed a successful lung cancer screening program. the success of the radiology team’s CT colonoscopy screening program, which has provided more than 20,000 exams since its care physicians and other providers can refer inception in 2004. Inspired by the National patients who meet certain criteria for routine Lung Screening Trial (NLST), a decade-long LDCT screening and coordinated follow-up study that showed a 20% reduction in lung care. Patients can also self-refer to the cancer mortality with low-dose CT (LDCT)2, program in much the same way that women WRNMMC’s lung cancer screening program self-refer for mammography screening. “If we has had a lung cancer detection rate of find a tumor, we can deal with it at an early more than 5%. “We suspect that we have a stage and have curative intent,” Prezioso says. “That makes a big difference in a patient’s life.” high-risk population, and we’re slowly dis- covering that is indeed the case,” says Cmdr. Elena Prezioso, director of the lung cancer The Ground Work screening program and physician assistant WRNMMC began developing its lung cancer in pulmonary medicine at WRNMMC. “We’re screening program after the NLST results were saving lives through this program.” released in 2011. A multidisciplinary team, Before WRNMMC established its lung including physicians from radiology, oncol- cancer screening program, patients who did ogy, pulmonary medicine, primary care, and not have symptoms of lung cancer or another preventative medicine, led the effort. “We had abnormality that required a chest CT were a group of people who had already worked not routinely screened. Therefore, the chance together on tumor boards and on other lung of detecting a patient’s lung cancer early was cancer–related programs, so lung cancer relatively low. With the program, primary screening was a natural outgrowth of that

Imaging 3.0 in Practice n November 2019 27 group,” says Cmdr. Joel A. Nations, MD, chief as asbestos, radon, agent orange, or silica/ team wanted to do more than simply scan of medicine and a pulmonary and critical care silicon. “The big thing is enrolling high-risk patients and send them on their way. To en- physician at WRNMMC. The hospital’s lead- patients into the program and making sure sure patients get the most out of the program, ership supported the team. “Our leadership that they qualify based on the criteria that the radiology team adjusted its workflow to wanted us to pioneer the screening program we set,” Liotta says. provide preliminary reads of the screening at our hospital and set a standard for other Once the patient criteria were determined, studies. Prezioso discusses these initial results military treatment facilities,” explains Cmdr. WRNMMC’s radiology department devel- with patients before they leave the hospital, Robert Liotta, MD, deputy director for clinical oped a schedule and ordering process for and final reads are issued soon thereafter. “We support and a cardiothoracic radiologist the CT screenings. It designated Tuesdays recognize that patients want their imaging at WRNMMC. as lung cancer screening days and created results as quickly as possible,” Prezioso says. The team began building the program a special order form for the program. “We “Radiology stands by to give initial reads so by establishing a set of criteria for patients created a new order in the computer that that patients can go home with preliminary who should be screened for lung cancer. It would pop up in our radiology information results and some peace of mind. It’s part of opted to follow two criteria based on the system, so we would know that the order our commitment to patient-centered care.” National Comprehensive Cancer Network’s was for the lung cancer screening program, Patients whose CT scans reveal incidental (NCCN) screening guidelines. Criteria one, and we would know how to protocol it ap- findings can see a pulmonologist which correlates closely with the Medicare propriately,” Liotta explains. The radiologists that day. reimbursement guidelines for lung cancer also developed a new dictation template to Additionally, the lung cancer screening screening, opens the program to patients ensure that they dictate their lung cancer team partnered with WRNMMC’s smok- 55-80 who have at least a 30 pack-year screening reports consistently. “By doing ing cessation coordinator to encourage history of smoking and who currently smoke that, the patient gets continuity of care and screening participants to quit smoking. or who quit smoking fewer than 15 years the referring physician knows exactly where Immediately following the scan, a patient in ago. Criteria two opens the program to to look on the report for specific informa- the program can see the smoking cessation patients 50 and older who have at least a tion,” Prezioso notes. coordinator to develop a plan or to follow 20 pack-year history of smoking and who up on an existing regimen to quit smoking. have one additional risk factor, such as a Focus on the Patient So far, 109 lung cancer screening patients family history of cancer, pulmonary fibrosis, While LDCT is at the heart of the lung cancer have participated in the smoking cessa- or past exposure to toxic chemicals, such screening program, WRNMMC’s radiology tion program, and of those, 30% have quit

28 IMAGING 3.0 COURTESY OF WRMMC COURTESY smoking. That’s higher than the national quit The Greatest Good rate of 25% for smokers who use smoking High Risk: Age 55–80 and 30 pk-yr and As WRNMMC prepared to roll out its screening Smoking/Tobacco cessation <15 yr cessation medications alone.3 The holistic program in November of 2012, in coordina- OR approach addresses all of a patient’s issues Age >50 and >20 pk-yr and one additional tion with Lung Cancer Awareness Month, risk factor other than second-hand smoking with smoking at the same time, Liotta says. it began educating referring physicians (Occupational Exposure, HEENT CA Hx, “We wanted to provide these services to give about the program. As part of these efforts, FHx of Lung CA 1st degree relative, Chronic Lung Disease) patients a one-stop shopping experience on Prezioso visits referring physicians’ offices to the same day as the scan,” he says. “Patients talk to them about the screening program. • RISK FACTORS • really like that.” During these visits, she distributes pock- Occupational Exposure: Radon, Another way the lung cancer screening et-sized laminated cards that outline the Asbestos, Agent Orange, Silica/Silicon team engages patients in the program is program’s patient criteria. She also hands Cancer Hx: Lung, HEENT, Lymphoma, Cancer related to smoking through direct communication. When a pa- out provider intake forms to help referring Family Hx: 1st degree relative with tient is due or overdue for a follow-up scan, physicians determine whether patients Lung Cancer qualify for the program. “We want to make Prezioso calls him or her to discuss schedul- Chronic Lung Disease: COPD, ing an appointment. “We didn’t want people sure we’re sticking with the criteria and not Pulmonary fibrosis just getting a chest CT and then not being just screening willy-nilly,” Prezioso explains. Questions Call: “The idea is to do the greatest good for the Pulmonary Front Desk followed up,” Liotta says. “So we actually largest number of patients possible, with (301) 295-4191 and have a system in place where our program ask for CDR Prezioso the least harm.” u Reference National is reaching out to patients and encouraging Comprehensive Cancer The lung cancer screening team also Network Guidelines

LUNG CANCER SCREENING CARD (NCCN.org) them to come in for their follow–up exams.” markets the program through promotional While Prezioso has been making these calls, videos, direct-to-patient outreach efforts, Walter Reed Military Medical Center has taken multiple the radiology department will take over and informational events. One video the steps to promote lung cancer screening directly to this outreach effort soon. “We’re looking at team produced to encourage referring patients. having a radiology nurse or one of our clinic physicians to talk to their patients about the nurses help run the program,” Liotta explains. program has been distributed throughout “Doing so will raise radiology’s profile be- the Military Health System. The team also cost standpoint and a patient care perspec- cause patients will receive calls directly from created a webpage where patients can tive. If we can avoid exposing patients to our department.” access information about the program, along the toxicities associated with chemother- with a questionnaire to help them determine apy, then we’ve done them a tremendous whether they should enroll in the program. service.” Additionally, the lung cancer screening team hosts two annual events, one a CME event, By Jenny Jones that includes informational booths and lectures about lung cancer awareness, pre- ENDNOTES vention, screening, and research. The events 1. Brown DW, Smoking prevalence among US Veterans, J Gen attract hundreds of referring physicians, Intern Med., 2010 Feb; 25(2): 147-149. medical staff, and patients. 2. National Cancer Institute. National Lung Screening Trial 2014. http://bit.ly/Lungtrial Accessed Oct. 14, 2015. These marketing and outreach efforts 3. American Cancer Society. A Word About Success Rates for have paid off. Currently, more than 260 Quitting Smoking. bit.ly/ACS_QuitSmokingGuide. Accessed patients are enrolled in screening and 14 Oct. 22, 2015. patients have been diagnosed with lung cancer through the program, with about half of those cases being early stage. Next Steps The team is currently enrolling about six • Assemble a multidisciplinary team to new patients per month. Maj. Christina build a robust lung cancer screening Brzezniak, DO, assistant service chief of program. hematology and oncology, says that the • Collaborate with smoking cessation and program improves patient care and reduces Radiologists at Walter Reed National other partners for focused patient care. Military Medical Center worked with a healthcare costs. “When we detect lung multidisciplinary team to develop a lung cancer early, we can avoid having to subject • Consult with referring physicians and cancer screening program for service patients to systematic chemotherapy,” patients to educate them about the members, veterans, and other beneficiaries. Brzezniak says. “That is huge from both a program.

Imaging 3.0 in Practice n November 2019 29 Lung Cancer Screening Discussion Questions Jump-start a conversation about lung cancer screening.

1. What percentage of your community’s population smokes? How does that compare to state and national levels?

2. What percentage of your patient population is eligible for lung cancer screening?

3. How many lung cancers are detected in your community? How many are detected at Stage 4 vs. an earlier stage? How do these numbers compare to state and national levels?

4. Which care providers can you partner with to develop a lung cancer screening program?

5. What additional staff do you need to support your program? How can you fund these positions?

6. How can you secure dedicated time on your CT scanner for lung cancer screening?

7. What can you do to educate patients and referring physicians about lung cancer screening?

8. How can you reassure referrers that a lung cancer screening program will not result in radiologists commandeering their patients?

9. How can you integrate smoking cessation into your lung cancer screening program?

10. Where can you meet with patients to review their findings and scans?

11. How can you monitor patients to ensure they receive recommended follow-up care?

12. How can you encourage eligible patients to return annually for lung cancer screening?

30 IMAGING 3.0 Are you an LCS Novice or Ninja? Test Your Lung Cancer Screening Knowledge

1. CMS guidelines state that patients 7. All of the following are known risk factors for Scoring: Novice to Ninja between which age range are eligible for lung cancer, except: lung cancer screening? a. Tobacco smoking How did you score? Give yourself a. 60-75 b. A personal or family history of lung one point for every correct answer. b. 55-77 cancer c. 48-62 c. Exposure to radon, asbestos, or other If you scored from 0-4: You are an LCS d. 62-85 carcinogenic agents Novice, and you should contact the d. Pet dander, pollen, and other allergens ACR LCS team at bit.ly/LCSQuestions 2. The American Lung Association estimates to learn more about how you can that ____ people in the United States are 8. Evidence shows that patients have a ___ boost your knowledge and start a LCS at high-risk for lung cancer: greater chance of quitting smoking when program in your community. a. 3 million they combine some type of counseling b. 8 million If you scored from 5-8: You are an LCS with a nicotine replacement therapy or c. 12 million Enthusiast who recognizes that radiol- medication. d. 16 million ogists are central to LCS, and you are a. 50% probably well on your way to partnering b. 63% 3. Which cancer is the leading killer of both with other care providers to establish an c. 80% men and women in the United States? LCS clinic in your community. d. 199% a. Colon b. Breast If you scored from 9-12: You are an 9. True or False: Radiology practices must c. Throat LCS Ninja. You really know your stuff invest in special CTs for lung cancer d. Lung and have already stepped up as a lead- screening? er in your community to facilitate and a. True 4. Lung cancer accounts for what percentage promote life-saving LCS. b. False of all cancer deaths in the U.S.? Whatever your score, there’s a lot to a. 8% 10. ACR LUNG-RADS state that a patient with learn from the LCS leaders profiled b. 15% a nodule that is probably benign should: in these case studies and from the c. 25% a. Schedule a follow-up LDCT in six . Take the next step d. 37% ACR LCS resources months toward enhancing patient care in your b. Immediately undergo a second LDCT community. Start or strengthen your 5. Before patients enroll in lung cancer c. Continue annual screening LCS program today! screening, CMS requires that they: d. Undergo a biopsy to confirm it’s (Learn more at acr.org/lungresources) a. Undergo a pulse oximetry test benign b. Meet with a smoking cessation Answers

expert

15 b. 11. When lung cancer is diagnosed early, the 12.

c. Schedule a shared decision-making 90% d.

five-year survival rate can be as high as 11. visit months six

___. Schedule a follow-up low-dose CT in in CT low-dose follow-up a Schedule a. 

d. Determine their family history for 10. a. 40% screening. cancer lung

lung cancer

b. 65% for required dose low the for calibrated

False — Any modern CT scanner can be be can scanner CT modern Any — False

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d. 90%

(NLST) in 2011, showed a ___ reduction allergens Pet dander, pollen, and other other and pollen, dander, Pet d.

in lung cancer mortality in patients who 7. 20% c.

12. Screening should be discontinued once a 6. received low-dose CT (LDCT). visit

person has not smoked for __ years.

Schedule a shared decision-making decision-making shared a Schedule  c.

a. 2% 5.

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b. 5%

Lung d.

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Imaging 3.0 in Practice n November 2019 31 Lung Cancer Screening Resources You Can Trust

The American College of Radiology (ACR®) offers resources to help radiologists provide safe, effective lung cancer screening, including Lung Cancer Screening Education, toolkits and key patient information.

Using the website listed below, access quality assurance tools, such as the CT Quality Control Manual, as well as patient education handouts on making informed choices, how to prepare for a screening and much more.

Visit acr.org/lungresources

Q&A Support Do you have questions about lung cancer screening implementation? Our experts are ready to help. Scan this QR code to submit your questions easily with your smartphone or visit acr.org/lungresources. 11.19