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.
In addition, the team needed to understand patients’ concerns and figure out what they needed to know and how to tell them. “Do you send a letter saying there’s something on the CT scan that we want to follow up, but don’t worry? Is that a sufficient way of communicating?” Kinsinger asked.
The team had to overcome other hurdles as well. Even with a well-developed EHR, the team needed to create special fields to track results and train staff to record the information correctly. Patient education materials turned out to be remarkably complicated in reviewing the advantages and disadvantages of screening. Scheduling, tracking patients to follow up in a year and standardizing radiology notes also proved more challenging than expected.
The demonstration project evaluated 93,033 primary care patients for screening appropriateness and found 4,246 who met the criteria and 2,452 (58%) agreed to screening. About half (2,106) received lung cancer screening with low-dose computed tomography (CT) from July 2013 to June 2015. Of those screened, nearly 60% (1257) had nodules, and 56.2% (1184) required tracking. Only 42 (2%) needed additional evaluation but did not have cancer, and 31 (1.5%) veterans were discovered to have lung cancer.
Other incidental findings were identified in 41% of those screened. These results included diagnoses of pulmonary abnormalities, coronary artery calcification and emphysema.
“It took a lot of effort to find 31 cancers, with many patients told of findings that turned out not to be important. There is certainly a harm to patients to be told there may be something that turns out not to be significant. Patients become very anxious,” Kinsinger said.
“The downsides of screenings and procedures are often underrepresented and underplayed,” she said. “There’s interest around the world about medicine’s tendency to favor benefit and ignore harm. Harms are real. They are immediate and can occur for anyone, where benefits only accrue to those who would have developed cancer.”
Yet, Kinsinger argued that the undeniable benefit to the individuals who had cancers that were detected by the screening must be weighed.
In light of the experience with the demonstration project, Kinsinger suggested that narrowing the criteria for screening could make the program more manageable. When other researchers divided into quintiles the participants in the National Lung Screening Trial, which provided the basis of the USPSTF recommendation, they found that those in the lowest category of high risk had little benefit from screening, while those in upper categories received a mortality benefit, she pointed out.
“In this country, we tend to think if a little is good, a lot must be better. That may not be true for screening,” suggested Kinsinger. “If we screened for a set period of time or for those who were 40 pack-year smokers, maybe we would find fewer cancers but also many fewer incidental findings and false results. It might make the process more manageable, and at least we could screen those veterans who are highest of the high risk and most likely to benefit.”
- Kinsinger LS, Anderson C, Kim J, Larson M, Chan SH, King HA, Rice KL, Slatore CG, Tanner NT, Pittman K, Monte RJ, McNeil RB, Grubber JM, Kelley MJ, Provenzale D, Datta SK, Sperber NS, Barnes LK, Abbott DH, Sims KJ, Whitley RL, Wu RR, Jackson GL. Implementation of Lung Cancer Screening in the Veterans Health Administration. JAMA Intern Med. 2017 Mar 1;177(3):399-406. doi: 10.1001/jamainternmed.2016.9022.
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