November 2019 Lung Cancer Screening

PHOTO COURTESY OF BIDMC.be economically viable,” Bankier says. “Butthere’s also a value aspect that you can’t puta dollar amount on, because you’re offeringpreventive care that can improve the healthof your patients and potentially save lives.”The First StepBy addressing the program’s economic potential and patient value, Bankier secured theapproval of the hospital administration, withfull support from the radiology department.The hospital provided funds to hire a programmanager, which was a critical first step in theprogram’s development.“The one thing I learned from witnessingthe final phase of the NLST was that theadministration and patient managementaspects of lung cancer screening are at leastas important as the medical aspect,” saysBankier, noting that BIDMC added a full-timeadministrative position for the duration ofthe NLST. “From the very beginning, I emphasized the need for a dedicated person to runthis program.”In late 2015, Lauren M. Taylor, RN, BSN,joined the team as program manager, and together, she and Bankier began planning howto run a screening program. Administratively,Bankier and Taylor had to plan step-by-stephow to qualify eligible patients for enrollment(See bit.ly/BIDMCLung), order screening exams, discuss shared decision making, designa structured reporting template, organizesubspecialty reads, handle incidental findings,and coordinate annual follow-ups throughongoing patient management.PCPs as PartnersBankier and Taylor quickly learned that implementing a screening program was markedlydifferent than providing diagnostic imaging.“Preventive screening requires a completelydifferent context, because we don’t see patients with symptoms,” Bankier says. “We seeindividuals who are at risk for a disease andwant to stay healthy.”Since ideal candidates for lung cancerscreening typically don’t walk into the hospital seeking a diagnosis, Bankier had to reachhigh-risk participants proactively — throughtheir primary care physicians (PCPs). Early inthe planning process, Bankier and Taylor metThrough its lung cancer screening program, the radiology department at Beth Israel Deaconess Medical Center hasdetected 24 lung cancers in the early stages, when the disease is still treatable.with PCPs to build buy-in while fine-tuningthe details of the program.The goal of these conversations was twofold: first, to educate referring physiciansabout the screening program so they could,in turn, inform their patients; and second, togather PCPs’ feedback and concerns. “A fewof these physicians were enthusiastic aboutthe idea of LDCT lung cancer screening,but there was also a substantial numberof skeptics,” Bankier says. “We learned a lotfrom these conversations, and the inputfrom physicians helped us improve theprogram.”Most of the early concerns echoed thesame risks that were documented in the NLSTfindings and other research — such as overdiagnosis of lung cancer and incidental findingsunrelated to lung cancer. Many PCPs worriedthat the program would add more administrative work and patient management duties totheir workloads, and others feared they’d losecontrol over patients who enrolled.“By knowing the referring physicians’concerns, we were able to tailor the programon the front end to make them more comfortable enrolling patients,” Taylor says. “Werealized how important it was to reduce theiradministrative burden, while keeping themcontinuously in the communication loop sothey didn’t lose contact with their patients.”Collaborative PartnersAfter meeting with referring physicians withinthe hospital, Bankier and Taylor worked theirway outward to reach referrers throughoutBIDMC’s network, which spans 45 affiliatelocations, including primary care practicesand community healthcare centers acrossthe Greater Boston area. “The segment ofour population that qualifies for LDCT lungcancer screening often includes the samepeople who receive care at our communityhealthcare centers,” Bankier says. “A relativelyhigh smoking population exists within thesegroups, so there’s a proportionately highernumber of high-risk patients in these pockets.”Bankier recognized that the communityhealthcare centers in BIDMC’s network wouldbe critical partners for the screening program.“Nancy Kasen, the chief of the communityhealthcare centers, was immediately onboard,because she understood the importance ofscreening these patients,” Bankier says. “Fromday one, the community healthcare centersand the patients they represent were a strongpillar on which our program was built.”Imaging 3.0 in PracticenNovember 20195

PHOTO COURTESY OF BIDMC.Alexander A. Bankier, MD,PhD, professor of radiology atHarvard Medical School andchief of the cardiothoracicimaging section and director offunctional respiratory imagingat Beth Israel Deaconess MedicalCenter, developed an LDCT lungcancer screening program todetect lung nodules as earlyas possible. As LungHealthProgram Manager, Lauren M.Taylor, RN, BSN, handles allpatient management, tracking,and follow-up.Relationship BuildingFor months before the program began in2016, Bankier and Taylor met regularly withreferring physicians throughout the network.Since then, they’ve continued to check inevery few weeks. “In our experience, themost effective way to reach patients hasbeen through regular in-person visits withreferring physicians,” Taylor says. “The referringphysicians are our closest partners in termsof educating patients about the program andgetting them to enroll.”Bankier emphasizes that these visits can’tbe phoned in or delegated, because relationships with referring physicians are criticalto a screening program’s success. “The bestadvice I can give other radiologists is to seekas much personal contact with referring physicians as possible,” Bankier says. “Referringphysicians delegate some of their responsibility to us in terms of patient management,so it’s very important that they know towhom they’re entrusting their patients.”Primary care physicians like Mark D.Aronson, MD, appreciate knowing that theLungHealth team handles patient qualification, education, tracking, and administrationcentrally, so referring doctors don’t have tospend time on those things. “The radiologistsset up a system to track lung cancer screening candidates and take ownership of patientmanagement,” says Aronson, vice chair forquality in the department of medicine atBIDMC and professor of medicine at HarvardMedical School. “Once a patient’s enrolledin the program, I don’t have to worry about6IMAGING 3.0reminding them to get their annual scan.That’s valuable, because it’s very difficultfor doctors to keep track of each individualwhen they have so many patients.”Patient EnrollmentTaylor and Bankier knew they needed tomake it easy for referring physicians to enrollpatients into the program. To that end, theyworked with the hospital’s IT department todevelop an in-house tool that allows referringphysicians to enroll qualified patients —those between the ages of 55 and 77 with asmoking history of at least 30 pack-years, whoeither currently smoke or quit within the last15 years — with just a few clicks.“They developed a tool within ourordering system that calculates a patient’ssmoking history in pack-years,” Aronson says.“So, if a patient smoked half a pack a day for10 years, then a full pack a day for 15 years,and then five cigarettes a day for the last10 years — the calculator determines theaccumulated pack-years. Once they exceed30, they fall into the screening protocol,and the system automatically prompts us torecommend the program.”Referring physicians just click the pop-upnotification, and the system automaticallyissues a screening exam order, auto-populated with the patient’s inclusion criteria. WhenAronson sees the smoking history pop-up,he’ll tell the patient: “You fit into our lungcancer screening protocol. I recommend thatyou get screened, because studies show thatif we screen you regularly, we have a muchbetter chance of picking up lung cancer earlyand treating it. It has saved lives and couldsave your life someday.”Aronson says he’s never had a high-riskpatient decline his screening recommendation. He has enrolled about 20 patients intothe program since it launched.When Marsha DiCesare’s primary care physician told her about the screening programduring her annual physical, it seemed likea “no brainer.“ If you’re a former smoker, it’salways in the back of your mind, because weall know how bad smoking is for your health,”says DiCesare, 59. “Lung cancer doesn’tusually present symptoms until it’s prettyadvanced, so after smoking for many years,screening gives me peace of mind.”Workflow DesignWith the goal of making the programconvenient for both referring physiciansand patients, Bankier and Taylor designeda workflow focused on proactive patientmanagement and thorough follow-up. “Onceenrolled in the screening program, everypatient gets a shared decision-making phonecall from me that explains the benefits, risks,what to expect when they arrive for theirexam, what to expect on their report, andwhat happens if there’s a positive finding,”Taylor says. “We talk through all the steps,and I introduce myself as the central contactperson who will help them through all of it.”BIDMC offers screening exams at three(soon to be four) locations throughout thehospital network, and scans are read centrally by a small group of subspecialty-trainedradiologists. Technically, any CT equipmentcan be programed with the low-dose protocol, allowing for future expansion.When patients arrive for their initial LDCTscreening, they first meet privately with a radiologist to discuss the program. “Having theconversation with the radiologist really putmy mind at ease and made me feel comfortable and well informed,” says DiCesare, whohad her first screening in the spring of 2017.Coordinated Care DecisionsScreening results are sent to patients andtheir referring physicians within a week. Mostscreening results come back negative, Bankier

“ We can make a multidisciplinary management decision based onour discus sion, and then immediately organize the next steps.”—Alexander A. Bankier, MD, PhDsays, so the typical recommendation is for patients to return in a year for annual screening.Some findings may require patients to returnin three to six months for a re-scan. More suspect findings, however, require a collaborativemultidisciplinary discussion.Every suspicious case (with nodulesclassified as 4B or 4X, according to ACR’sstandardized LUNG-RADS assessment categories bit.ly/ACR LungRADS) is discussedat a weekly thoracic oncology conference.During each conference, multiple disciplinesrelated to thoracic disease come together,including radiology, thoracic surgery, thoracic pathology, interventional pulmonology,respiratory medicine, nuclear medicine,oncology, and radiation therapy. Bankier alsoinvites referring physicians whose patientsare being discussed.At the conference, the reading radiologisttakes the lead — sharing the clinical findingsof each case and then moderating thediscussion as various subspecialties chimein about the upsides and downsides of potential next steps, including biopsy, surgery,or simply waiting three to six months for afollow-up scan. “The advantage of this setting is that we can make a multidisciplinarymanagement decision based on our discussion, and then immediately organize thenext steps,” Bankier says. “We can refer thepatient to the thoracic surgeon, the referringphysician, or the specialist, all of whom areusually at the conference and already knowthe patient’s history. That’s a huge advantagefor patient management.”If primary care physicians are unable toattend these conferences, Taylor takes notesand reports back to keep them informed.She also schedules any follow-up exams orappointments — whether it’s surgery, a routine screening, or a re-scan in several months— while maintaining ongoing contact withreferring physicians. “We try to be cognizantof the referring physician’s time, but alsokeep them totally apprised of their patients,”she says. “Sometimes I’ll just send an email,and then if it’s acute, I also call them. Butwe track it and order it all centrally, so we’retaking that administrative burden off of thereferring physicians.”Growth OpportunityIn addition to detecting lung cancer as earlyas possible, the screening program is catching other abnormalities, including cardiacdisease and abdominal issues. (Read the“Standardized Findings” case study at bit.ly/StandardizedFindings to learn more.)Perhaps more importantly, patientsenrolled in the program are more likely to reduce their smoking habits or stop altogether.Smoking cessation information and supportare offered through the program, and Tayloreven became a certified smoking cessationcounselor to help patients stop smoking. “Ifwe’re telling you that you’re at high risk forlung cancer because of smoking, it’s a big incentive to quit smoking,” says Aronson, who’snoticed that all of his patients have stoppedsmoking since enrolling.To build on these positive results, Bankierhas a vision to continue growing thescreening program: expanding into newaffiliate healthcare sites, increasing patientenrollment, and ultimately broadening theprogram’s overall reach. “The program isnamed LungHealth — not specific to cancerbut really about overall lung health,” Bankiersays. “In the future, we might be able to usethe information we acquire, not only forpreventing cancer but also to look at otherrespiratory diseases where early detectionmay benefit the patient. We want to be ascomprehensive as we can to save as manylives as possible.”By Brooke BilyThe screening program has been well-received byreferring physicians like Mark D. Aronson, MD, vice chairfor quality in the department of medicine at Beth IsraelDeaconess Medical Center and professor of medicine atHarvard Medical School.ENDNOTES:1. Knight SB, Crosbie PA, et al. Progress and prospects of earlydetection in lung cancer. Open Biol. 2017 Sep; 7(9): 170070.doi: 10.1098/rsob.170070. Published online 2017 Sep 6.2. Seigel RL, Miller KD, et al. Cancer facts & figures 2018. CA: ACancer J Clin. 2018; 68:7-30. doi.org/10.3322/caac.214423. National Lung Screening Trial Research Team. Reducedlung-cancer mortality with low-dose computedtomographic screening. N Engl J Med. 2011 Aug 4;365(5):395-409. doi: 10.1056/NEJMoa1102873. Publishedonline 2011 Jun 29.Next Steps Meet personally with referringphysicians to share ideas about implementing a lung cancer screeningprogram that makes practical sense foreveryone involved. Encourage radiologists to take a moreproactive role in patient care by meeting with participants before screeningexams to discuss the process and alleviate concerns. Build a multidisciplinary team to regularly discuss complex cases and improvepatient care through collaboration.Imaging 3.0 in PracticenNovember 20197

Case Study Published November 2018Breathe EasierIndiana radiologists work alongside care partners to create a successful lung cancerscreening program that addresses a population health need.KEY TAKEAWAYS: Radiologists at Elkhart General Hospital(EGH) collaborated with referringclinicians and administrative staff toorganize, market, and manage a lungcancer screening program. Since founding the program in 2012,the EGH team has diagnosed 29 lungcancers, more than 50% of which wereStage 1. Now, EGH is working with sister hospitals within Beacon Health System todevelop similar lung cancer screeningprograms at those institutions.8IMAGING 3.0According to the Centers for Disease Controland Prevention, 25.6% of Indiana residents smoked in 2011, and the state rankedfifth in the nation for number of smokers. Inthe northern Indiana city of Elkhart alone,smoking was so prevalent that many residentsidentified it as a top concern in a 2011-2012community health assessment. These findingsprompted radiologists and other providersat Elkhart General Hospital (EGH) to considerthe dangerous effects of smoking on theircommunity and act to address them.One of the most obvious impacts of smoking is a high mortality rate. Lung cancer is aleading cause of cancer deaths in the U.S.1,and research indicates that identifying highrisk patients and screening them for cancerwith low-dose computed tomography(LDCT) can reduce lung cancer mortality byup to 20% among smokers.2Unfortunately, though, most at-riskpatients do not undergo regular screening,and many patients go undiagnosed untilsymptoms arise in the later stages of the disease. By that point, the chances of effectivelytreating the disease are low. The five-yearsurvival rate for patients with early-stagelung cancer can be as high as 90%, while thelate-stage survival rate is only 5%. Hoping togive its patients a better chance of survival,EGH partnered with its existing smokingcessation group to establish a lung cancerscreening program six years ago.Since then, the program has undergonemany changes, but most importantly, itis getting results: EGH radiologists havediagnosed more patients with early-stagelung cancer than they did before implementing the program. Of those diagnosedthrough the program, more than 50% hadStage 1 lung cancer. “It is critical to detectlung cancer early, before patients becomesymptomatic,” says Allison M. Lamont, MD,chair of radiology at EGH. “If patients becomesymptomatic, it is often too late. This is alife-saving program.”Allison M. Lamont, MD, chair of radiology at ElkhartGeneral Hospital, says that “old-fashioned dialogue” wascritical to educating referring physicians about the benefitsof lung cancer screening.Getting StartedEGH’s lung cancer screening program begantaking shape in 2012, after the hospitalsecured a CT scanner for the program. Anoncology nurse proposed establishingthe screening program during a quarterlymeeting of the hospital’s cancer committee,which includes representatives from thedepartments involved in oncology care. Theradiologists, cardiologists, and pulmonologists in attendance immediately supportedthe idea — recognizing that it would addressan urgent population health need.“As a radiology department, we arecommitted to offering new services thatwill improve patient health,” explains AlbertW. Cho, MD, vice chair of radiology at EGH.“We had been interested in developing alung cancer screening program for a while toaddress this public health crisis. Once we hadthe scanner available and buy-in from otherdepartments, we saw an opportunity to helpdrive the implementation.”To start, the radiologists met with specialty

partners, administrative staff, and care coordinators to construct a framework for theprogram. “One of the most exciting aspects ofthis program has been working with the otherspecialties and with hospital administrators,”Cho says. “There is often a view that specialties, particularly radiology, are independentand operate on their own, but workingtogether has so many benefits, such as increased camaraderie throughout the hospitaland enhanced dialogue among specialties tobetter serve patients. It’s very rewarding.”Building a Business CaseOne of the first things the team had to defi

Sep 06, 2017 · MD, MBA, FACR Marc H. Willis, DO, MMM Sabiha Raoof, MD, FACR Imaging 3.0 Staff G. Rebecca Haines VP, ACR Press Chris Hobson Imaging 3.0 Senior Communications Manager Jenny Jones Imaging 3.0 Managing Editor Linda Sowers Consulting Editor ACR Press Staff Lyndsee Cordes Director of Periodicals Lisa Pampillonia Art Director Nicole Racadag ACR .