In 2013 we spoke to Lahey Hospitals and Medical Center’s Dr. Andrea McKee about establishing a high-performing lung cancer screening program. Part one of our Q&A focuses on making the case for a lung cancer screening program, while part two describes Lahey’s challenges establishing their program, including engaging physicians and marketing to patients.
We recently had an opportunity to catch up with Dr. McKee, the Director of Rescue Lung, Rescue Life program—a pioneer in lung cancer screening—to learn about how Lahey’s program has advanced over the past few years.
Q: Lahey was an early adopter of lung cancer screening, offering services even before payers were providing reimbursement. Can you tell us about how the program has evolved and the impact the program has had on your patient population?
Dr. McKee: A fundamental goal of lung cancer screening programs is to diagnose patients at easier stages of cancer when the disease is more treatable. Not only does early diagnosis lead to improved outcomes, but it also lowers cost of treatment. And we’ve seen significant improvement in early detection. Currently, the percentage of cancers diagnosed at stage 1 are 69% for our program, compared to the national average of 25%.We’ve also been able to significantly reduce the percentage of screening patients that are diagnosed at stage IV, down from 35% to less than 10%. This shift from late to early stages has tremendous implications for survival rate and patient care overall.
Lung Cancer Stage at Diagnosis
Before and After Screening Program Implementation at Lahey
All patients, before screening program established
Screening program patients
Q: Lung cancer screening programs are a multidisciplinary effort. Collaboration enables an organization to increase service offerings and provide more coordinated, high quality care to patients. Can you describe what your program looks like after that initial CT scan?
Dr. McKee: Our program relies on the clinical collaboration of physicians from radiology, oncology, pulmonology, and internal medicine. But it doesn’t just end with the clinical team. We also included administrators, marketers, and representatives from the finance, business development, philanthropy, and legal departments.
The Rescue Lung, Rescue Life program includes what we call a “prehab” program for patients diagnosed with lung cancer. The program allows us to prepare patients for treatment with the ultimate goal of impacting outcomes. There are four major components of the prehab program:
- Smoking cessation: To help patients quit smoking before treatment, which increases the potential for improved treatment outcomes.
- Nutrition assessment and intervention: To improve protein intake prior to surgery, which is also linked to more positive outcomes.
- Physical therapy and intervention: To help patients improve physical mobility prior to surgery. Many lung cancer patients are elderly and have limited mobility. We help optimize patients’ physical condition prior to surgery to improve recovery.
- Psychosocial assessment and intervention: To help improve patients’ coping skills throughout treatment.
Our prehab program allows us to manage patients throughout lung cancer treatment and help patients achieve the best possible outcomes.
Q: If other organizations are interested in starting a more holistic lung cancer screening program similar to the Rescue Lung, Rescue Life Screening Program where would you advise they begin?
Dr. McKee: Smoking cessation—because smoking cessation programs have benefits for patients both with and without lung cancer and help organizations achieve broader population health goals. First, smoking cessation lowers patients’ overall risk, reducing the likelihood of developing certain diseases and conditions. Compared to current smokers, past smokers also have a lower risk of complications and shorter average length of stay for procedures. Second, smoking cessation programs also help us collect data on these high-risk patients. We can use this data over time to better understand how tobacco use and quitting impacts patient health.
Our program has been able to improve smoking cessation rates, with a quitting rate three times that in the general population. We take advantage of having high-risk patients’ attention by continuously educating our patients about the benefits of quitting smoking. Results of the low-dose CT screening can be highly motivating for patients, even those that do not have lung cancer, to quit smoking. For example, the exam can illustrate changes tobacco use has on patients’ health, such as coronary calcifications.
Quitting smoking has such significant implications for patients overall health—reduced risk of cancer, heart disease, stroke, peripheral vascular disease, reduced risk for infertility, reduced readmission rates—so we try and support them with various tools, including online resources and meetings.
Q: What are the biggest challenges that even a mature program like yours faces?
Dr. McKee: Our biggest challenge is improving patient compliance rate, particularly getting new patients that are high risk for lung cancer involved our program. While we have had our program in place for several years, the public has only recently become aware of this service. The additional challenge is getting the message about the benefits of low dost CT lung cancer screening to high-risk patients.
Based on data from the National Lung Screening Trials, the expected volumes of a lung cancer screening program should be about 1/6th of a mammography program. So while the days of a handful of screening patients a month are behind us, we still have a long road ahead of us to ensure that we are maximizing the benefit of low-dose CT scans.
Lung screening programs must overcome several challenges with patient compliance that other screening programs like breast, prostate, or colon, do not. Likely the most prominent of these challenges is the stigma associated with smoking. Many patients feel that since smoking is a choice, others will blame them for having lung cancer. There is also a misperception about outcomes for lung cancer; due to the traditional late stage diagnoses, many patients are unaware of the improved survival rates when the cancer is diagnosed earlier. Additionally, many patients are concerned about quitting smoking and feel they will have to confront this overwhelming challenge face on after a screening.
Referring providers are vital in overcoming these patient perception challenges. The shared decision making conversation between primary care physicians and high risk patients is an essential component of the lung cancer screening process. In addition to our shared decision making guides, we are investigating ways to use physicians’ EMRs to help identify high-risk patients and document those shared decision making conversations.
Q: You have certainly been among the leaders in lung cancer screening, so are there any other opportunities you see for improving the scope of your program?
Dr. Mckee: As I mentioned above, smoking cessation is a vital component of an effective lung cancer screening program. One area we are actively interested in is the possibility of providing counseling for smoking cessation virtually. We aren’t yet at the point to share the results, but we are very excited about what we are seeing. This is a great way to ensure that you’re getting the full value from your program, and it also helps to identify high-risk patients that would benefit from lung cancer screening.
We are also assessing the practicality of offering oral cancer screening at the same time of the CT lung screening exam since this population is high risk for both. This would allow patients to be screened for multiple tobacco-related diseases during one visit.
We are always looking for ways to improve the safety of lung screening for patients. Currently we are evaluating the effectiveness of certain clinical protocols to reduce the number of interventions on false positive cases by utilizing biomarkers.
And finally, we are evaluating the benefits of expanding screening exams to group 2 patients. As you know, Medicare only approved low dose CT screening for group 1 patients—adults 55-74 who have a 30 pack-year smoking history and are either current smokers or quit in the past 15 years. But data suggestions that group 2 patients—adults 50 or older who have a 20 pack-year smoking history—also benefit from low dose CT lung cancer screening. We are interested in speaking with other organizations screening both high-risk groups.
Tumor Site Strategy,
Screening and Prevention,