Dr Michael Gieske on Successes and Challenges in Increasing Lung Cancer Screening in Rural Regions

Michael Gieske, MD, director of lung cancer screening at St. Elizabeth Health Care, speaks to the success of the Rural Appalachian Lung Cancer Screening Initiative, along with challenges to implementing increased lung cancer screening.

Michael Gieske, MD, director of lung cancer screening at St. Elizabeth Health Care, speaks to the success of the Rural Appalachian Lung Cancer Screening Initiative, along with challenges to implementing increased lung cancer screening.


Can you share some successes of increased screening recommendations within your practice in Kentucky or within the Alliance. How were you able to achieve these results?

The success of our lung cancer screening is really well-known, and that's part of why I became involved in the Rural Appalachian Lung Cancer Screening Initiative—to bring some of the success and the experience that we've had in our program through St. Elizabeth Health Care in Northern Kentucky to this region. For example, we've done over 36,000 lung cancer screenings now since we started our program in 2013, and we're presently doing about 750 lung cancer screenings per month. We did 8200 lung cancer screenings last year, and we're on track to probably hit about 9000 screens this year. So, we have a wealth of experience when you just simply look at the numbers that we've done. But it's not so much the numbers that we've done, it's the results that we've achieved. We're finding now, over the last year and a half, or almost 2 years now 70% of the lung cancers that we're finding are in stage I, when you can have greater than 90% chance of curing the lung cancer. We're finding 80% of the lung cancers we discover in stage I or stage II, which are considered the early stages of lung cancer. We're finding 1 lung cancer for every 28 patients that we screen. So, we're targeting a very high-risk population. We've had our program in place long enough, and we've gotten good enough now in our program where we're really starting to get patients back for their annual screens. And when you do that, you really start to see the really impressive impact of lung cancer screening. Lung cancer screening is to be done every year until either at eight years of age, or until it's been 15 years since you smoked. And when you have these patients come back year after year after year, you're going to be much less likely to see late-stage lung cancer—stage III or stage IV—if they're adherent with the program. So we're finding 80% to 100% of lung cancers, and patients that have come back for their fourth, fifth, and sixth lung cancer screened in stage I.

Did you encounter any barriers or challenges along the way?
When you when we talk about lung cancer screening, there's a lot of barriers, and some of them unfortunately been put upon us by Medicare. We are obligated to do shared decision-making for the baseline lung cancer screening that we do, and we have a decentralized program, so anybody in our program can order lung cancer screening and do the shared decision-making work. We don't have to refer them to a third party to do that shared decision making work, so I think that's really helped our program, too. But the culture around tobacco and the habits that are involved with smoking are very hard to break. As a rule, we're not dealing with our most compliant patients, and patients that smoke tend not to be the most health-conscious patients that we run across. That tends to create a barrier and itself, and we want to try to help these patients quit smoking, of course, too. And then the stigma around tobacco-related disease and smoking and lung cancer, that's a it's a big problem. Patients feel that they brought it upon themselves, they're embarrassed to say they smoke, they're embarrassed to say they have this habit and they're not able to quit. And when you hear somebody has lung cancer, the first thing that enters most people's minds is "Well, you smoked right? How much did you smoke?" It's not like, "Oh, gosh, I'm so sorry to hear that." Immediately, your mind goes to well, "You did it to yourself." And nicotine is such a highly addictive substance. And it was very glamorous and popular to smoke 20 or 30 years ago. It's gotten a little bit better over the last couple decades or so, but a lot of these patients started smoking in a very early age and got addicted in a very early age. And the other problem that we really contend with is what we refer to as nihilism. Historically, lung cancer has been a death sentence. I've been in practice for 36 years, and still when I hear a patient has lung cancer, I get this visceral feeling in my gut. It's a bad feeling—you know this patient is probably not going to live very much longer. But we know now that that's different. We're finding lung cancer early, for one thing—we're going after it, we're catching the early stages. And even now we find lung cancer and stage III or stage IV, the late stages of lung cancer. These patients now or sometimes live in 15 to 20 years or more—with no evidence of disease—that had late-stage lung cancer. We're finding targetable mutations, we're using precision medicine, we're using immunotherapy, and advanced surgical techniques. A lot of the treatments now we have for lung cancer are making a tremendous difference, so it's so important to get that message out there.

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