Lung Cancer Screening. Eric S. Papierniak, DO NF/SG VHA UF Health

Transcription

1 Lung Cancer Screening Eric S. Papierniak, DO NF/SG VHA UF Health

2 Overview Background Supporting evidence Guidelines Practical considerations Patient selection What to do with abnormal results Billing/coding

3 Background Lung cancer is the third most common cancer in the US, behind breast and prostate

4

5 Background Lung cancer is the third most common cancer in the US, behind breast and prostate It is the leading cause of cancerrelated death, however

6

7 Background Lung cancer is the third most common cancer in the US, behind breast and prostate It is the leading cause of cancerrelated death, however Responsible for more deaths than the next 3 deadliest cancers combined

8

9 Background This trend holds for both men and women

10

11 Background Early detection could result in a substantial survival benefit as most patients are diagnosed with metastatic disease

12

13 Does screening work? Screening for lung cancer by plain chest radiographs (CXR) has been shown to be ineffective in multiple RCTs dating back to the 1970s but interest (and use) continued for many years

14 Does screening work? Starting in 2001, a number of trials were published evaluating screening with low dose CT (LDCT) Screening via any method was not recommended by any major society/group until recently

15 National Lung Screening Trial (NLST) The NLST randomized 53,454 highrisk patients to either plain CXR or LDCT Imaging was performed at enrollment and annually for 2 years (3 total) N Engl J Med 2011; 365:

16 NLST 1060 patients in LDCT group and 941 patients in CXR group were diagnosed with lung cancer Most of the cancers in the LDCT group were found via screening Most cancers in the CXR group were not N Engl J Med 2011; 365:

17 Cumulative Numbers of Lung Cancers and of Deaths from Lung Cancer. The National Lung Screening Trial Research Team. N Engl J Med 2011;365:

18 NLST More cancers were found in the LDCT group but there were fewer deaths N Engl J Med 2011; 365:

19 NLST 354 deaths in LDCT group 442 in CXR group 20% relative risk reduction Number needed to screen: 320 N Engl J Med 2011; 365:

20 Review of Guidelines USPSTF: Ann Intern Med. 2014;160: ACCP: Chest 2018; 153(4):

21 Who to screen? Age (80) Smoking history of 30 pack-years or more Still smoking or quit less than 15 years ago

22 Who to screen? Note: The USPSTF actually recommends screening up to age 80 but the ACCP guidelines (and Medicare reimbursement) only go up to age 77 as that was the cutoff in the NLST

23 Who not to screen? Because of the tenuous balance of benefit and harms, routinely screening other patients based on risk calculators or other estimates of high risk is not recommended Shared decision-making is also universally recommended before formal referral for screening

24 Shared decision making Numerous studies have shown that patients drastically over-estimate the benefit and under-estimate the risk of harm from cancer screening

25 Shared decision making If you are fortunate enough to be part of a healthcare system with a comprehensive program there will be coordinators to handle a lot of the pre-screening education and counseling

26 Benefits of screening Lower chance of dying from lung cancer Not a lower risk of getting lung cancer

27 Harms of screening Radiation exposure False positive results Overdiagnosis Smoking cessation

28 Harms of screening Radiation exposure Risk depends on a number of factors including baseline cancer risk Higher in women (breast cancer) USPSTF guideline cites an estimated 4/10,000 people that would die from cancer related to the excess radiation from screening J Med Screen 2008; 15(3):

29 Harms of screening False positive results: 96% of abnormal findings in the NLST were false positives Extra scans Unnecessary invasive procedures

30 Harms of screening Overdiagnosis No hard data but it has been estimated that ~10% of cancers found by screening would not have been detected otherwise (patient would have died with it, not from it) Ann Intern Med. 2014;160:

31 Smoking cessation All patients who smoke and are referred for screening should also have smoking cessation counseling In one VA study, while virtually all PCP s assessed smoking histories, only 23% referred active smokers for smoking cessation services Ann Am Thoracic Soc 2016 Nov;13(11):

32 Smoking cessation Unfortunately, another VA study demonstrated that half (49%) of the patients seemed to be less motivated to stop smoking after enrolling in screening JAMA Intern Med. 2015;175(9):

33 When to stop screening When a patient no longer meets criteria: greater than 80 years of age or 15 years of abstinence from smoking Patient is no longer healthy enough to benefit from screening

34 Who not to screen? Routinely screening patients (especially younger ones) that do not fall into the listed criteria but are deemed high risk is not recommended

35 Who not to screen? USPSTF estimates that if you started screening before the age of 40 it would be mathematically impossible to justify the radiation exposure (would need a 125% reduction in mortality) J Med Screen 2008; 15(3):

36 Who not to screen? Arguably the most frequent cause of inappropriate screening, however, is to refer patients who would not benefit from early detection

37 Who not to screen? Typically these would be patients who: Have a limited life expectancy due to other end stage disease(s) Are not candidates for curative surgery (98% of stage I patients in NLST underwent surgery) Would not tolerate chemo/radiation due to poor functional status

38 Components of a good screening program Having a high quality screening program is essential to achieve the maximum patient benefit The cost/benefit ratio, in particular, can change substantially with relatively small changes in implementation N Engl J Med 2014;371:

39 Components of a good screening program Has mechanisms in place to ensure patients meet appropriate criteria and are counseled prior to screening as already discussed (shared decision making, smoking cessation, etc)

40 Components of a good screening program Multidisciplinary involvement by radiologists, pulmonologists, thoracic surgeons, and oncologists with algorithms in place to guide management of any positive findings (including the avoidance of overtreatment and unnecessary invasive procedures)

41 Components of a good screening program Scans should be read by experienced thoracic radiologists with standardized definitions of what constitutes a positive test and report the results in a structured format (e.g., LungRADS)

42 LungRADS Similar to Bi-RADS used for mammography Allows for standardization and reporting of findings into a database for further study (also recommended by the guidelines)

43

44 Components of a good screening program Strategies should be in place to ensure compliance with follow up (both annual and any short-interval scans that may be needed)

45 Other challenges Outside of a research setting it may be difficult to achieve the same results Worth noting that the surgical mortality in the NLST was only 1%, much lower than the national average

46 Other challenges The sheer volume of patients who qualify preclude many health systems from creating centralized screening programs

47 Other challenges The VA has estimated that there are approximately 900,000 eligible veterans and a feasibility study suggested it will be very difficult to administer a comprehensive program with the available resources

48 Incidentalomas Most abnormal findings will not be lung nodules Many will be new/incidental and may require follow up (detailed guidelines are in process)

49 Billing/Coding Lack of time is the most commonly cited reason for not counseling patients prior to screening Can t do much about time but medicare does cover a visit for LDCT counseling and shared decision making Chest 2017; 152(1):

50 Billing/Coding G0296 Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan (service is for eligibility determination and shared decision making) Need to document the eligibility criteria and the LDCT order Chest 2017; 152(1):

51 Billing/Coding G0297 Low dose CT scan (LDCT) for lung cancer screening ICD-10 Codes Z Chest 2017; 152(1):

52 Take home points LDCT screening for lung cancer carries a favorable but tenuous balance of benefit and harms. (ACCP) Appropriate patient selection and counseling are crucial (smoking cessation!)

53 Take home points Referral to an experienced program is also recommended in order to realize the full benefit while minimizing harms

54 Questions? My thanks to the FSACOFP for inviting me to speak and to you for listening