Q&A For Referring Physicians
ABM: Our program appealed to desire for organizational leadership as a result of involvement in this clinically impactful multidisciplinary program, and appeal to desire for professional advancement through content expertise in this emerging new field within pulmonary medicine.
MD: Most pulmonary specialists have experience with advanced lung cancer diagnosis and its complications, and would welcome the opportunity to participate in early detection. One of the most important skills pulmonary can bring to lung cancer screening is in the management of pulmonary nodules. However, very few nodules will require a procedure, such as bronchoscopy. Lung cancer screening is neither an opportunity to greatly expand procedures, or an activity that will overwhelm a practice with invasive procedures. Most nodules detected through screening can be determined as benign or likely malignant with serial imaging alone. Patients will appreciate the support and patience that can lead to successful treatment of an early stage lung cancer detected through screening, or the determination that a suspicious nodule is actually benign, and associate those outcomes with the pulmonary providers.
CRL: Pulmonologists have significant experience in diagnosing, staging and managing lung cancer. There is also significant experience in the assessment of the pulmonary nodule. The risk stratification that occurs in lung screening, as well as the standardization of Lung-RADS reporting, is to the pulmonologists’ benefit. It also provides the pulmonologist opportunity to have important teachable opportunities in smoking cessation counseling, as well assessing and establishing the COPD diagnosis. It also provides opportunity to develop centers of excellence and enhance the role of an interventional pulmonary program and subspecialty research. The well-rounded focus on lung health for patients is valued by patients
CCT: Pulmonary is central to this program as they are the “first line” in diagnosing, staging, and deciding on the next step for the patient with a pulmonary nodule. Many patients prefer to see a pulmonologist even if their nodule could be managed with serial follow-up. This is to speak with a knowledgable specialist regarding lung nodules, to review their imaging, and to understand the likelihood that the nodule(s) could be a worrisome process.
CF: Pulmonary developed and runs the program.
CCHS: Our program was initiated by the pulmonary department.
SR/BJM: Coronary artery calcifications and emphysema of varying degrees are expected in this patient population. We qualitatively reporting of the presence and extent of both findings using a four-point scale: none, mild, moderate, marked.
ABK/CT: AHRQ’s SHARE Approach is a five-step process for shared decision making that includes exploring and comparing the benefits, harms, and risks of each option through meaningful dialogue about what matters most to the patient.
- Seek your patients’ participation
- Help your patient explore and compare treatment options
- Assess your patients’ values and preferences
- Reach a decision with your patient
- Evaluate your patients’ decision
ABM: It was helpful to demonstrate radiology downstream financial events, appeal to desire for organizational leadership as a result of involvement in this clinically impactful multidisciplinary program, and appeal to desire for professional advancement through content expertise in this emerging new field within radiology.
MD: There is evidence that lung cancer screening is effective at preventing deaths from lung cancer, something all medical providers can support, and radiology practices are often committed to other forms of cancer screening, such as mammography. Using the number needed to screen to prevent a cancer death, lung cancer screening may be the most effective form of cancer screening, more effective than mammography. Every major organization involved in lung cancer recommends lung cancer screening. Many programs allow the screening LDCT studies to be “batched” and read outside of the flow of clinically indicated studies by a subset of radiologists committed to lung cancer screening, significantly reducing the burden of screening on the overall practice. From a strictly business standpoint, many screening studies lead to additional clinically indicated studies, nodule follow-up for example, and it has been shown that these downstream studies can support many components of a lung cancer screening program.
JLM: The emerging evidence is that community hospital systems are implementing lung cancer screening with results as least as good as the NLST results and people are going to be expecting to have access to such high quality services this service is rolling out.
CCT: Radiology was on board as it is a revenue generator for them with screening, PET scans, interventional procedures. The issue related to who is responsible to collect data required for reporting, required eligibility data, and surveillance was discussed and these areas of responsibility were assigned across the program.
CCHS: Pulmonary department encouraged our radiologists to become certified to read low dose studies
CF: This has been difficult because of their perceived loss of revenue. It remains a work in progress but has come a long way since we started. We now consistently get reports per Lung RADS protocol.
ABK: The summary table in the resource section describes several lung cancer screening decision aids including key features, strengths and weaknesses and links to the decision aid. None of the decision aids met all of the International Patients Decision Aid Standards Collaboration (IDPAS) criteria, however, most of the decision aids met the majority of the criteria.
ABK/CCT: We have found physician recommendation to screen to be important in the screening decision. Others have described demographics: insurance status, education, age, smoking status, family history of lung cancer, psychological – perceived smoking related stigma, cancer fatalism, medical mistrust, lung cancer worry, lung cancer fear, knowledge lung cancer and lung cancer screening, social influences and media exposure
EJ/CCT: Our experience has shown a patient’s knowledge and awareness of lung cancer screening is the most important factor for successful screening. This knowledge is most easily gained through physician and patient interaction. Among patients who have an established primary care provider physician influence is also an important factor. Among patients who do not receive annual routine medical care or do not have an established primary care provider screening is much more challenging. These patients often are not screened for the following reasons.
- Concern over the complexity and cost of screening
- Refuse screening because they have no symptoms
- Are fearful of the results
- Misperceptions of treatment options, thinking all cancer is a death sentence
- Mistrust of healthcare providers
SR/BM: We assign these patients an overall exam assessment of 2i with a follow-up recommendation to consider antibiotics and repeat lung screening exam in three to six months depending on the nature of the finding. These findings are present in 7-8% of baseline “prevalence” scans and 6-7% of annual “incidence” scans despite multistep formal process to remind patients and ordering physicians to delay screening exam for 12 weeks following an acute respiratory illness.
EMH: In general we use the “S” modifier in Lung-RADS to cover what are identified as potentially significant non-malignant findings. We then issue an appropriate follow up recommendation for that finding, as well as for the screen as a whole.