AM: No, our program does not at this time manage incidentally discovered nodules. We are looking into how to best assist primary care, pulmonary medicine and radiology with this functionality. Some centers will refer high risk individuals to their screening program after an incidental nodule is discovered on non-screening CT, to then formally enter these individuals into the screening program.
DTC: An incidental nodule would necessitate a diagnostic CT scan, and is not part of the scope of our lung cancer screening program.
CL: Outside of the screening program the incidental pulmonary nodules are managed based on radiology recommendations and practice patterns of ordering physicians. Primary care or emergency room physicians, where imaging identifies the incidental nodules, will often refer to pulmonary for further evaluation.
CCT: When our program was established, the oversight committee decided to proactively manage and conduct surveillance on all nodules detected regardless of the study detecting the nodule. In this way, nodules found on a diagnostic CT are funneled into the same clinical care pathway as those detected on a lung cancer screening study and the nodule program is notified through the EHR. The nodule is automatically reported to the nodule program for either work-up or surveillance depending on nodule characteristics. Data on clinical evaluation and therapy is collected in the same manner as those detected on LCS studies and cases are discussed in our multi-disciplinary team meetings. Those found on lung cancer screening are reported and tracked according to reporting requirements. This is essential, as is a program that tracks follow-up with the annual screening CT. In recent survey data, there is very poor compliance with annual follow-up and poor mechanisms to track patients following initial enrollment. Creating a parallel program for surveillance of nodules found (both incidental and those on screening), as well as tracking completion of follow-up imaging is an important component of providing safety net systems for imaging. These were included due to the large number of cancers found incidentally and the risk of loss to follow-up.
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.
AM: 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.
JM: 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
SR/BM: Occasionally a pulmonary nodule may appear slightly increased in size to the reading radiologist but does not meet criteria for growth of 1.5mm. In these cases we keep the follow-up interval between the last two exams the same. For example if the prior exam was a LR3 due to the presence of a solid pulmonary nodule between 6 and 8 mm and at the six month follow-up exam the radiologist feels the nodule has increased in size by 1mm the exam will be reported with an overall exam assessment of LR3 with another follow-up in six months recommended.
EMH: Great question. LungRADS tells us to round to the nearest whole number, then makes growth not a whole number. Rounding down, growth becomes 1 mm. Rounding up, growth becomes 2 mm. Other rounding schemes do similar things. We generally do something similar to the above, except we would call it an LR2, then make the return to screening at 12 months (from the initial screen), rather than in 12 months (from the first follow up exam). Functionally it works out the same. An update to Lung-RADS will hopefully improve clarity here.
SR/BJM: 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.
EH: 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.
SR/BM: All solid nodules and micronodules (nodules <4mm) and nodules less than 8mm are under surveillance in a CT lung screening program. Nodules between 6 and 8mm at baseline with no comparison (LR3) require follow-up with low dose non-contrast CT thorax in six months. Nodules less than 6mm including micronodules (nodules less than 4mm) require annual surveillance (LR2) while an individual remains at high-risk and qualified for CT lung screening. Nodules 6-8mm which have been stable for at least three months (LR2) can also be assessed annually. Non-solid nodules of any size (LR2) may be assessed annually as long as they remain non-solid without the suspicion of a developing solid component. Solid nodules greater than 8mm at baseline are suspicious (LR4) and should trigger a formal consultation to determine the next step in evaluation. Nodules greater than 8mm which are stable for at least three months may be assessed annually (LR2).
EMH: We follow LungRADS. The question becomes what to suggest in the 4A and 4B groups—three month follow-up or PET/CT. If PET/CT, there are challenges with what to do for the low-SUV nodule and in deciding when to send the patient directly for biopsy or surgical evaluation. Anything we call 4X we send for diagnostic evaluation, sometimes directed by us, sometimes as a consult to pulmonary or thoracic surgery for management. Difficult 4A and 4B cases get referred to the multidisciplinary conference for a consensus recommendation.
SR/BJM/EH/CT: Patients with LungRADS2 results have two potential indications for their next exam in 12 months: 1) asymptomatic patient meeting high-risk criteria for lung cancer screening, and/or 2) follow-up of benign-appearing nodule(s). Therefore, patients meeting CMS/USPSTF high-risk criteria would have their next exam in 12 months as a screening exam (CPT code G0297). However, patients not meeting CMS/USPSTF high-risk criteria don’t have that first indication, so their scan in 12 months is a diagnostic follow up (CPT code 71250) of the benign-appearing nodule(s).
EH: Great question that I have seen inconsistent information about. Since the follow up exam is a discrete event, if the Lung-RADS 3 nodule was stable at 6 months, it becomes a Lung-RADs 2 (by Lung-RADS definition) and the recommendation becomes a return to screening in 12 months
SR/BJM/CT: LungRADS recommendations are based on each unique exam result. Therefore if the patient has a follow-up exam as a result of a positive baseline scan, and the result of that follow up exam is Lung-RADS™ 1 or 2 with a next recommended date in one year, that would be one year from the follow up exam and it would be considered an annual screening exam.
SR/BJM/CT/EH: We scan the entire chest. If the nodule is stable and there are no new findings in the lungs, the next screening exam can be scheduled one year from that exam. Not scanning the entire lungs means the patient must return in another six months (12 months from the original LungRADS3 exam) to have their entire lungs scanned again, resulting in unnecessary exposure.
EH: Interval scans performed for acute symptoms would not generally be interpreted using Lung-RADS criteria. However, if such as scan serendipitously occurs at the recommended interval as specified in the original LCS report, the result may reclassify the initial Lung-RADS result, which should be included in the final report of the interval scan. An example would be a patient with a Lung-RADS 3 nodule who is involved in a car wreck 6 months later and has a chest CT for trauma, prior to their recommended follow up exam. If the Lung-RADS 3 nodule identified initially is stable, the trauma exam can be used to reclassify the patient into Lung-RADS category 2, with a return to screening in 12 months. This is not an issue as long as we explain it correctly in the report to the referring physician and to the patient.
SR/BM/CCT: We try to catch these ahead of time whenever possible, but in a case where that isn’t possible, the exam is passed along to one of our radiologists credentialed in reading lung screening exams to determine how that interval CT affects the patient’s next CT in the screening program. These interval CTs are not read using LungRADS; however, they can impact when the next screening exam will be.
Our program management system has a patient level score which takes into consideration the most recent information available in the patient’s medical record not simply the result of the last CT lung screening exam. For example, if the patient’s last exam was a LR4 but a biopsy of a suspicious lesion is negative for malignancy the patient level score should be changed from LR4 (the most recent CT lung screening exam score) to LR2 reflecting the fact that the finding which triggered the LR4 score was, in fact, benign. Results of PET/CT exams and CT exams performed for non-lung screening indication. For example a trauma CT of the chest abdomen and pelvis could also result in the patient level score in the program management system deviating from the result of the last CT lung screening exam.
SR/BM/CCT: In cases in which another area was imaged (i.e. cervical spine) that scanned through nodule, the exam is directed to a credentialed lung screening radiologist to determine the impact on the next screening exam.
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.