VA Lung Cancer Screening Pilot Was Valuable but ’Challenging and Complex’

While the benefits of lung cancer screening are undeniable for some former smokers—especially those whose lives were saved because of it—the VA recently learned some important lessons on how to use the technology most efficiently. The key? Regular screening of those veterans who fall into the highest risk categories.

By Annette M. Boyle

DURHAM, NC—The U.S. Preventive Services Task Force recommends annual lung cancer screening for heavy smokers between the ages of 55 and 80.

With a much-higher proportion of smokers than the general population and a sophisticated electronic medical record, the VA appears to be the perfect place to test such a program. A three-year demonstration project that included eight VAMCs provided valuable insights into the best way to conduct a comprehensive lung cancer screening program and the resources required for success.

In a review of the program published in JAMA Internal Medicine, VA researchers led by Linda S. Kinsinger, MD, MPH, who at the time was the VHA chief consultant for Preventive Medicine and is now retired, characterized the demonstration project as “challenging and complex, requiring new tools and patient care processes for staff as well as dedicated patient coordination.”1

“We recognized that we needed to test it out first before rolling a screening program out across the VA,” Kinsinger told U.S. Medicine. The researchers noted that as many as 900,000 veterans in VA care likely meet the criteria for lung cancer screening, and many of those could remain in that category for 25 years or more.

“It’s not a one-time screening, but a huge annual effort,” she noted.

The project team chose eight geographically dispersed VAMCs and put into place the steps and resources to help implement the program—tools, reporting templates, patient education materials, education for site directors and coordinators—and funding for a full-time cancer screening coordinator at each site. All sites had the CT equipment required for the screening itself. The participating VAMCs included those in Ann Arbor, MI; Charleston, SC; Cincinnati, OH; Durham, NC; Minneapolis; Portland, OR; San Francisco and New York Harbor Healthcare System.

The researchers stayed in close contact with the sites for two years, responded to problems experienced by the sites and evaluated patient records. They also activated clinical reminders in the EHR. Still, “we found it to be quite complex, even with all that support and all the resources we were able to bring to bear,” Kinsinger recounted.

Even so, she urged a clear-eyed approach to demands of a comprehensive screening program. At the VA, some surprising challenges arose from the start. While identifying veterans in the age range was simple and eliminating those who “immediately fall out of the screening group because they are extremely sick” was no problem, “figuring out what their smoking history is turned out to be quite complicated,” she said.

The recommendation calls for screening those who have a 30 pack-year history of smoking and are either still smoking or have quit within the past 15 years. Because people often do not smoke consistently, it can be hard to determine how many packs a day they have smoked over what period of time. In addition, many who had quit could not remember exactly when they last smoked, Kinsinger explained.

Communication proved to be a critical challenge as well, she added. Facilitating communication between team members, including primary care providers, radiologists, pulmonologist and the subspecialists who treated patients was more difficult than expected. The dedicated lung cancer screening coordinators provided a crucial service in managing communication in a comprehensive, multidisciplinary program.

Christopher Slatore, MD, MS, and Mark Deffebach, MD, of the Portland, OR, VAMC, stand next to a CT scanner, like those used for a pilot program of lung cancer screening there and at facilities in Ann Arbor, MI; Charleston, SC; Cincinnati, OH; Durham, NC; Minneapolis, MN;; San Francisco and New York Harbor Healthcare System. VA photo

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