Low-Dose CT Cancer Screening Program 1
History of Low-Dose CT Screening In 2011, the National Lung Screening Trial (NLST) was the first trial that provided evidence based support that Low-Dose CT (LDCT) reduced lung cancer deaths. The study, which utilized 53,454 high risk subjects in 33 U.S. medical centers, concluded that LDCT saved 3 lives per 1000 people screened as compared to those screened with general chest x-rays (Lung Cancer Screening With Low-Dose CT, 2016). The United States Preventative Services Task Force (USPSTF), a team of unpaid experts in preventative medicine, utilized this research and other current data to make recommendations on screening and prevention programs. They supported LDCT screening in conjunction with specific criteria such as age, smoking history, and symptoms (Is Lung Cancer Screening Right for Me?, 2017). LDCT screening programs began initial development following those recommendations. Since 2015, all insurance companies cover LDCT as a screening test which has further evolved to become part of a larger comprehensive cancer program initiative to not only be a screening tool, but also to help educate providers and patients on prevention and assist current smokers in getting the means to quit (e.g. smoking cessation programs). Why is lung cancer awareness important? Lung cancer remains the leading cause of cancer related deaths in the U.S. In 2016, there was an estimated 224,000 new cases with 158,000 lung cancer associated deaths. Worldwide, there were about 1.8 million new cases and 1.6 million deaths in 2012. In that same year in the U.S., about 27% of all cancer-related deaths were attributed to lung cancer with the median age at diagnosis at 70 years. Smoking is the leading risk factor for developing cancer causing about 85% of the lung cancer cases. Men who smoke are 23 times more likely to develop lung cancer whereas women are 13 times more likely compared to non-smokers. Other risk factors are exposure to second-hand smoke and other carcinogens such as radon gas, asbestos, and arsenic (AHRQ, 2017). What are the screening criteria? Eastern Connecticut Health Network s (ECHN) program has adopted the USPSTF and the Center for Medicare and Medicaid Services (CMS) recommendations, which are outlined below. Our dedicated team of imaging specialists utilizes these criteria when obtaining authorizations from providers and insurances. Adhering to these guidelines also helps ensure that patients receive full coverage of their insurance screening benefits. 2
ECHN s Program In 2014, ECHN began its initial efforts of offering LDCT while adhering to the newly developed American College of Radiology (ACR) guidelines which specified strict criteria on CT dose usage, dose reporting, and result interpretations. In 2015, ECHN achieved ACR designation as a Lung Cancer Screening Center at both Rockville General Hospital and Manchester Memorial Hospital. As the initiative evolved, it was clear that a more comprehensive program needed to be developed for the community beyond the technical aspect of actually providing the CT screening. ECHN elected to partner with the Lung Cancer Alliance (LCA) and adhere to their guidelines and algorithms which are outlined below: Provide clear information on the risks and benefits of CT screening through a shared decision-making process Comply with standards based on best published practices for controlling screening quality, radiation dose and diagnostic procedures Work with a lung cancer multi-disciplinary clinical team to carry out a coordinated process for screening, follow up and treatment when appropriate Include a comprehensive cessation program for those still smoking or refer to comprehensive cessation programs 3
Report results to those screened and their primary care doctors and transmit requested copies in a timely manner Have received or intend to receive designation as a lung cancer screening program through the American College of Radiology In 2016, the LCA designated Rockville General Hospital and Manchester Memorial Hospital as Screening Centers of Excellence Offering Responsible Screening & Care (Lung Cancer Alliance, 2017). Success of Program The initial screening LDCT was a fee-for-service offering in 2014. 2015 showed 44% growth while 2016 and 2017 showed an incredible growth rate of 66% and 64% respectively. During this time, the ECHN Cancer Program also began a campaign that involved adolescent education in community schools, prevention programs and education in the community, creation of smoking prevention classes (Freedom From Smoking), pulmonary nodule tracking, physician outreach, and navigator intervention algorithms. In 2017, well over 30 different providers referred patients into the program. Over 230 students were educated on prevention screening in the Manchester and Vernon school systems. In partnership with the American Lung Association (ALA), ECHN held formal smoking cessation classes following the structure of the quit program called Freedom From Smoking. Finally, a physician education Continuing Medical Education lecture was held at the ECHN Cancer Center presented by 6 physicians outlining the history of LDCT, screening criteria, and ECHN s successful program. The volume statistics of ECHN s program are displayed in the graph below: Year # of Patients Screened % Increase 2017 283 64% 2016 173 66% 2015 104 44% 2014 72 4
Comparison Data As part of the Accreditation with the ACR for LDCT, ECHN is required to upload statistical data to the ACR National Radiology Data Registry for all Medicare patients. ECHN has elected to upload all of its data in an effort to more accurately compare the entirety of its program with that of other testing facilities. The ACR, in turn, provides ECHN with quarterly reports comparing its screening program with community like-size facilities, all New England facilities, and all U.S. facilities reporting data. ECHN routinely reviews and analyzes four important benchmarks utilized in the comparison data: 1. Smoking Cessation: Number of current smoking patients that were offered smoking cessation programs or educated on the benefits of smoking cessation. This is a measure of how well our cancer program educates the community physicians on smoking prevention and how often they pass that knowledge onto their patients. ECHN realized an 8% increase in the number of referring physicians in the community that educated patients on smoking cessation or provided information on the means to quit. While an impressive increase, it remains slightly below the community, New England and national averages. 2. Abnormal Interpretation: Review of abnormal interpretations utilizing ACR s Lung Screening Reporting and Data System program (LUNG-RADS). This is a quality assurance tool that helps ensure the standardization of LDCT results and management, eliminate confusion, and facilitate outcome monitoring (ACR, 2017). Comparison of data with community, New England, and national averages shows that ECHN is consistent with the rest of the programs being offered across the country. ECHN realized an 18% abnormal interpretation rate in 2017 compared to a 19% rate in 2016. Both were within the appropriate ranges as reported by other facilities across the nation. 3. Radiation Exposure: Overall radiation exposure utilizing a factor called the CT Dose Index demonstrates whether or not a facility is utilizing the proper technique/exposure based on patient s weight/age while also adhering to ACR s imaging guidelines. In 2016, ECHN saw an increased average of its overall CT Dose Index as compared to the rest of the LDCT facilities. However, 2017 saw a 43% improvement in this measure and was markedly better in overall dose than all other comparison facilities. This was 5
achieved through more effective staff education, adherence to protocols, and better awareness. 4. Appropriateness of screening criteria: Measures the facilities ability to routinely and accurately screen patients prior to their exam utilizing the USPSTF criteria. This helps ensure they meet the insurance requirements for a screening and reduce potential billing concerns of non-payment or charge to the patient. In 2016, ECHN s percentage rate for appropriateness criteria was below expectations in this measure as well as below U.S. averages. However, in 2017 there was a large improvement of 11% in the rate of appropriateness of care. ECHN s average on this measure also outperformed all other programs in the U.S. The below graph displays the statistics comparing 2016 to 2017: 2017 Smoking Cessation Offered Amongst Current Smokers Abnormal Interpretation (LUNG RAD 3, 4a, 4b, 4x) Radiation Exposure (CT Dose Index Overall) Appropriateness of Lung Screening Criteria ECHN ALL LDCT Community Like-size New England 84% 86% 86% 89% 18% 17% 18% 16% 2.7 3.28 3.3 3.09 93% 90% 91% 92% 2016 Smoking Cessation Offered Amongst Current Smokers Abnormal Interpretation (LUNG RAD 3, 4a, 4b, 4x) Radiation Exposure (CT Dose Index Overall) Appropriateness of Lung Screening Criteria ECHN ALL LDCT Community Like-size New England 78% 84% 83% 90% 19% 19% 20% 17% 4.73 3.17 3.10 2.99 82% 88% 89% 90% 6
Summary The National Lung Screening Trial paved the way for cancer programs across the nation to initiate and evolve lung screening and prevention programs. ECHN s program has developed from simply another imaging exam to become part of a more important and comprehensive program on a patient s continuum of care. ECHN s LDCT program will continue to adapt to the community needs and strive for better early detection of lung cancer. 7
References AHRQ: Is Lung Cancer Screening Right for Me? (March 2016). AHRQ. Publication No. 16- EHC007-12-A AHRQ: Lung Cancer Screening With Low-Dose Computed Tomography. (March 2016). AHRQ. Publication No. 16-EHC007-10 American College of Radiology. (2017). Lung CT Screening Reporting and Data System (Lung-RADS). Retrieved from: https://www.acr.org/quality- Safety/Resources/LungRADS Lung Cancer Alliance. (2017). Treatment Options. Retrieved from: https://lungcanceralliance.org/ American Lung Association. (2017). Lung Cancer Fact Sheet. Retrieved from: http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/lungcancer/resource-library/lung-cancer-fact-sheet.html 8