Impact of a Hybrid Lung Cancer Screening Model on Patient Outcomes and Provider Behavior

Digital Interventions to Support Lung Cancer Screening: A Systematic Review

INTRODUCTION

Lung cancer remains a leading cause of cancer-related deaths globally. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) can reduce lung cancer mortality, but its adoption in the U.S. has been limited. Digital interventions have the potential to improve uptake of LCS. This systematic review aims to summarize the evidence for the effectiveness of digital interventions in promoting LCS.

METHODS

A systematic search of three electronic databases (PubMed, Embase, and Medline) was conducted to identify studies published between January 2014 and May 2023. Studies were reviewed and abstracted between February 2023 and July 2023. Outcomes related to knowledge, decision-making and screening were measured. Study quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools.

RESULTS

Of 1,979 screened articles, 30 studies were included in this review. Digital interventions evaluated included decision aids (n=20), electronic health record (EHR)-based interventions (n=7), social media campaigns and mobile applications (n=3). Decision aids were the most commonly studied digital interventions, with most studies showing improved knowledge (13/13) and reduced decisional conflict (7/9) but most did not show a substantial change in screening use. Fewer studies tested clinician-facing or multi-level interventions.

DISCUSSION

Digital interventions, particularly decision aids, have shown promise in improving knowledge and the quality of decision-making around LCS. However, few interventions have been shown to substantially alter screening behavior and few clinician-facing or multi-level interventions have been rigorously tested. Further research is needed to develop effective tools for engaging patients in LCS, to compare the efficacy of different interventions, and evaluate implementation strategies in diverse healthcare settings.

Results of a pilot risk-based lung cancer screening study: outcomes and comparisons to a Medicare eligible cohort

PURPOSE

Risk-based lung cancer screening holds potential to detect more cancers and avert more cancer deaths than screening based on age and smoking history alone, but has not been widely assessed or implemented in the United States. The purpose of this study was to prospectively identify patients for lung cancer screening based on lung cancer risk using the PLCOm2012 model and to compare characteristics, risk profiles, and screening outcomes to a traditionally eligible screening cohort.

METHODS

Participants who had a 6 year lung cancer risk score ≥ 1.5% calculated by the PLCOm2012 model and were ineligible for screening under 2015 Medicare guidelines were recruited from a lung cancer screening clinic. After informed consent, participants completed shared decision-making counseling and underwent a low-dose CT (LDCT). Characteristics and screening outcomes of the study population were compared to the traditionally eligible Medicare cohort with Fisher's Exact, t-tests, or Brown Mood tests, as appropriate.

RESULTS

From August 2016 to July 2019, the study completed 48 baseline LDCTs. 10% of LDCTs recommended further pulmonary nodule evaluation (Lung-RADs 3 or 4) with two early-stage lung cancers diagnosed in individuals that had quit smoking > 15 years prior. The study population was approximately 5 years older (p = 0.001) and had lower pack years (p = 0.002) than the Medicare cohort.

CONCLUSION

Prospective application of risk-based screening identifies screening candidates who are similar to a traditionally eligible Medicare cohort and future research should focus on the impact of risk calculators on lung cancer outcomes and optimal usability in clinical environments. This study was retrospectively registered on clinicaltrials.gov (NCT03683940) on 09/25/2018.

High risk lung nodule: A multidisciplinary approach to diagnosis and management

Pulmonary nodules are often discovered incidentally during CT scans performed for other reasons. While the vast majority of nodules are benign, a small percentage may represent early-stage lung cancer with the potential for curative treatments. With the growing use of CT for both clinical purposes and lung cancer screening, the number of pulmonary nodules detected is expected to increase substantially. Despite well-established guidelines, many nodules do not receive proper evaluation due to a variety of factors, including inadequate coordination of care and financial and social barriers. To address this quality gap, novel approaches such as multidisciplinary nodule clinics and multidisciplinary boards may be necessary. As pulmonary nodules may indicate early-stage lung cancer, it is crucial to adopt a risk-stratified approach to identify potential lung cancers at an early stage, while minimizing the risk of harm and expense associated with over investigation of low-risk nodules. This article, authored by multiple specialists involved in nodule management, delves into the diagnostic approach to lung nodules. It covers the process of determining whether a patient requires tissue sampling or continued surveillance. Additionally, the article provides an in-depth examination of the various biopsy and therapeutic options available for malignant lung nodules. The article also emphasizes the significance of early detection in reducing lung cancer mortality, especially among high-risk populations. Furthermore, it addresses the creation of a comprehensive lung nodule program, which involves smoking cessation, lung cancer screening, and systematic evaluation and follow-up of both incidental and screen-detected nodules.

An Evaluation of Annual Adherence to Lung Cancer Screening in a Large National Cohort

INTRODUCTION

Lung cancer screening reduces mortality in large RCTs where adherence is high. Unfortunately, recently published adherence rates do not replicate those seen in trials. Previous publications support a centralized approach to ensure patient eligibility and improve adherence.

METHODS

Investigators reviewed a large, geographically diverse cohort of patients from 14 health systems, with 73 centers across the U.S. Lung cancer screening patients were screened from 2015 to 2019 and tracked utilizing a commercial system. Data were analyzed in 2019-2021. Demographics, eligibility, imaging results, and cancer diagnosis were collected. Overall return was calculated for 2 years (Time 0-Time 1 and Time 1-Time 2) on the basis of follow-up through March 31, 2020. Only U.S. Preventive Services Task Force-eligible patients with a normal or benign result (Lung-Reporting and Data System 1 or 2) at baseline (Time 0) were included in annual adherence calculations.

RESULTS

A total of 30,166 patients were screened; 50% were male, with a mean age of 65 years. Most individuals currently smoked (58.3%), with an average of 48.3 pack years. A total of 58% were White, 6% were Black, and 34% had race information unavailable. U.S. Preventive Services Task Force eligibility criteria were not met by 10.6%. Of the 26,958 patients eligible at baseline, 76% were Lung-Reporting and Data System 1 or 2. Annual adherence at Year 1 (Time 0-Time 1) was 48.4%. Adherence at Year 2 (Time 1-Time 2) was 44.4%. A total of 93 U.S. Preventive Services Task Force‒eligible patients were diagnosed with lung cancers, mostly during the first annual follow-up.

CONCLUSIONS

In this large cohort screened and managed primarily using a commercial tracking platform, most patients were U.S. Preventive Services Task Force eligible. However, annual adherence was poor despite this resource, suggesting that additional interventions are needed to recognize the full mortality benefit from screening programs.

Challenges in initiating a lung cancer screening program: Experiences from two VA medical centers

Establishing a lung cancer screening (LCS) program is an important endeavor that delivers life-saving healthcare to an at-risk population. However, developing a comprehensive LCS program requires critical elements including obtaining institutional level buy-in, hiring necessary personnel, developing appropriate infrastructure and actively engaging primary care providers, subspecialty services, and radiology. The process required to connect such services to deliver an organized LCS program that reaches all eligible candidates must be individualized to each institution's needs and infrastructure. Here we provide detailed experiences from two successful LCS programs, one using a primary care provider-based service and the other using a consult-based service. In each case, we provide the pros and cons of each system. We propose that the decision to setup an ideal LCS program could include a hybrid design that combines aspects of each system.

Lung cancer screening at the VA: Past, present and future

Lung cancer is responsible for more deaths annually in the United States than breast, prostate and colon cancers combined. Lung cancer screening with annual low-dose computed tomography reduces lung cancer mortality in high-risk patients through early detection. The incidence of lung cancer is higher in the veteran population compared to the general population due, in part, to the prevalence of tobacco use. Early detection of lung cancer is therefore an important goal of the Veterans Health Administration (VHA), the largest integrated health care system in the United States. The following will review previous and current initiatives undertaken by the VHA to implement and expand access to lung cancer screening and will highlight target areas of interest to improve uptake and quality of lung cancer screening. Through these initiatives and programs, the VHA aims to provide high quality and equitable access to lung cancer screening for all Veterans that incorporates research that will improve outcomes and potentially inform and optimize the practice of Lung cancer screening across the United States.

Referring high-risk individuals for lung cancer screening: A systematic review of interventions with healthcare professionals

OBJECTIVE

This systematic review described the effect of interventions aimed at helping Healthcare Professionals refer high-risk individuals for lung cancer screening. Primary outcomes included: patient outcomes such as lung cancer detection, screening for lung cancer, lung cancer treatments received and lung cancer mortality. Healthcare professionals' knowledge and awareness of lung cancer screening served as secondary outcomes.

METHODS

Experimental studies published between January 2016 and 2021 were included. The search was conducted in MEDLINE, CINAHL, ERIC, PsycARTICLES, PsycInfo and Psychology and Behavioral Sciences Collection. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool and the level of evidence was assessed using the Scottish Intercollegiate Guidelines Network grading system.

RESULTS

Nine studies were included. Nurse navigation, electronic prompts for lung cancer screening and shared decision-making helped improve patient outcomes. Specialist screenings yielded more significant incidental findings and a higher percentage of Lung-RADS 1 results (i.e. no nodules/definitely benign nodules), while Primary Care Physician screenings were associated with higher numbers of Lung-RADS 2 results (i.e. benign nodules with a very low likelihood to becoming malignant). An increase in Healthcare Professionals' knowledge and awareness of lung cancer screening was achieved using group-based learning compared to lecture-based education delivery.

CONCLUSIONS

The effectiveness of Nurse navigation is evident, as are the benefits of adequate training, shared decision-making, as well as a structured, clear and well-understood referral processes supported by the use of electronic system-incorporated prompts.

Guideline-Recommended Lung Cancer Screening Adherence Is Superior With a Centralized Approach

BACKGROUND

To recognize fully the benefit of lung cancer screening (LCS), annual adherence must approach the high levels seen in the National Lung Screening Trial. Emerging data suggest that annual adherence is poor and that a centralized approach to screening improves adherence.

RESEARCH QUESTIONS

Do differences in adherence exist between a centralized and decentralized approach to LCS within a hybrid program and what are predictors of adherence?

STUDY DESIGN

A retrospective evaluation of a single-center hybrid LCS program was conducted to compare outcomes including patient eligibility and adherence between the centralized and decentralized approaches.

METHODS

Patient demographics and outcomes were compared between those screened with a centralized and decentralized approach and between adherent and nonadherent patients using two-sample t tests, χ ² tests, or analyses of variance, as appropriate. Annual adherence analysis was conducted using data from patients who remained eligible for screening with a baseline Lung CT Screening Reporting and Data System (Lung-RADS) score of 1 or 2. Logistic regression was used to estimate the association between adherence and the primary exposure, adjusting for potential confounders.

RESULTS

A cohort of 1,117 patients underwent baseline low-dose CT imaging. Two hundred eleven patients (19%) were ineligible by United States Preventative Services Task Force criteria and most (90%) were screened with the decentralized approach. After exclusions, 765 patients with Lung-RADS score of 1 or 2 remained eligible for annual screening. Overall adherence was 56%; however, adherence in the centralized program was 70%, compared with 41% with the decentralized approach (P < .001). Individuals screened in a decentralized approach were 73% less likely to be adherent (OR, 0.27; 95% CI, 0.19-0.37). A greater proportion of patients with three or more comorbidities were screened outside the centralized program.

INTERPRETATION

Those screened using a centralized approach were more likely to meet eligibility criteria for LCS and more likely to return for annual screening than those screened using a decentralized approach.