ALA, ATS Seek Increase in Lung Cancer Screenings With New Healthcare Guide

November 13, 2018

An estimated 25,000 Americans who are at high risk for developing lung cancer would be saved annually through low-dose computed tomography (CT) scans, but only 5% of people who qualify are screened. In an effort to increase the number of people getting screened, the American Lung Association (ALA) and the American Thoracic Society (ATS) unveiled a Lung Cancer Screening Implementation Guide during Lung Cancer Awareness Month.

An estimated 25,000 Americans who are at high risk for developing lung cancer would be saved annually through low-dose computed tomography (CT) scans, but only 5% of people who qualify are screened. In an effort to increase the number of people getting screened, the American Lung Association (ALA) and the American Thoracic Society (ATS) unveiled a Lung Cancer Screening Implementation Guide during Lung Cancer Awareness Month.

The step-by-step guide is intended to help community hospitals and healthcare systems design, implement, and conduct low-dose CT screening programs for lung cancer. The guide was developed though a panel of experts convened by the ALA and ATS and includes detailed, question-and-answer style information about starting a lung cancer screening program, radiology requirements, shared decision making, requirements for program navigation and data tracking, and other details.

Andrea McKee, MD, one of the authors of the guide, discussed the screening issue in an interview with The American Journal of Managed Care®. There are a number of hurdles to overcome in setting up such a program, and the guide is intended to give concrete advice to overcome those barriers to screening, she said.

“It’s a pretty big endeavor,” said McKee. “It touches on so many areas of the organization.” That includes different business units for areas such as radiology, surgery, pulmonary, cardiology, internal medicine, oncology, and pathology, which may be more attuned to working in silos as opposed to collaborating in a broad screening program.

McKee, the division chief of radiation oncology at Lahey Hospital and Medical Center in Burlington, Massachusetts, noted that 430 people a day die from lung cancer, the number one cause of all cancer deaths in the United States. The 25,000 who could be saved each year assumes that they would have access to lung cancer screening, which is not the case.

While the number of designated lung cancer screening centers increased from an estimated 203 in 2014 to 1748 in early 2017, according to the CDC, large swaths of the country do not have access to such a center within a 30-minute drive. Some of those geographic areas correspond to regions that have high lung cancer mortality, but also have low access to screening centers.

Who qualifies for screening?

Lung cancer screening is recommended for those considered at high risk, which includes anyone age 55 to 80 who is a current smoker or who quit smoking in the last 15 years and smoked the equivalent of 30 pack years (defined as 1 pack a day for 30 years, 2 packs for 15 years, or any combination of years and packs that equals 30).

Many people who receive a diagnosis of lung cancer think it automatically has a deadly prognosis, McKee said. However, she likened lung cancer screening to mammography for breast cancer. “Like mammography, the earlier [the cancer] is found, the more easily cured it is,” she said.

Because most patients with lung cancer are not diagnosed until it is advanced, the survival rate at 5 years is poor—about 17% or 18%. But in a screening center population, rates are improved, she noted. About 85% of lung cancers discovered via screening are found at stage I or stage II; at stage I, there is a 90% cure rate, she said.

However, there are “a lot of moving parts” in a screening program, starting with first training a primary care provider about having a conversation with a patient at high risk for lung cancer about screening, McKee said.

Lahey came up with a “best practice alert” that is integrated into electronic health records because primary care doctors “need those prompts and supports” to alert them when the patient standing before them is a screening candidate, she said.

The age range for screening is different, depending on whether the payer is Medicare, Medicaid, or a commercial payer. For government programs, the age range is from 55 to 77, and for commercial insurers, the cutoff extends until age 80. For qualifying patients, there is no copay.

Screening programs must have patient navigators involved, as well as a system to capture program metrics and data and ensure patient follow up.

Reimbursement and next steps

One of the challenges for LCS centers is poor reimbursement, McKee said, as she noted that reimbursement from CMS keeps dropping, from $112.49 in 2016 to $59.84 in 2017 to $52.56 in 2018. It is unlikely that a stand-alone screening center can be financially viable in that environment, which is why most are contained in larger healthcare systems or multispecialty accountable care organizations, where any tumors that are found can also be treated.

“A center only doing the screening is really going to struggle,” she said. “We really need leadership on reimbursement.”

Looking ahead, McKee is hoping that screening criteria will become more liberal in the United States, following the September release in Europe of the NELSON screening trial results. In that study, 15,792 individuals were randomized 1:1 to either the study arm or the control arm. The control arm consisted of no screening whatsoever, which McKee said is more analogous to the US screening situation. In the NELSON study arm, participants were offered CT screenings at baseline and at 1, 3, and 5.5 years after randomization.

Participants age 50 to 75 were included in the study if they were current smokers or quit within the past 10 years, or had a 15-pack year history (10 cigarettes a day for 30 years) or had an 18.75 pack year history.

The CT screenings led to a 26% reduction in lung cancer deaths for men, and in women, up to a 61% reduction. By comparison, the US trial that led to the screening guidelines—the National Lung Screening Trial—compared low-dose CT scans with chest X-rays, and shoed a 20% relative reduction in overall mortality.

Smoking cessation is part of the process

Smoking cessation counseling is a required component of the screening process if the patient is still an active smoker. At multiple points of contact, encouragement to quit smoking and resources to do so should be provided, the guide says.

About 42% of US adults smoked in the 1960s; that percentage has dropped to about 15.5.% today, according to the CDC. Older Americans who are now eligible for screening (those 55 and older) are the same ones who saw smoking popularized in advertising and in the media in the 1940s through the 1980s, the guide notes.