LUNG CANCER SCREENING IMPROVING LUNG CANCER SURVIVAL IN THE - - PDF document

8/19/2018 1

LUNG CANCER SCREENING

IMPROVING LUNG CANCER SURVIVAL IN THE COMMUNITY SETTING

Scott Skibo, MD, FCCP Haywood Regional Medical Center Duke LifePoint

8/19/2018 2

PRACTICE LOCATION

159 Bed Hospital

8/19/2018 3 “At present, lung cancer is recognized late. Opportunities to improve survival are through earlier detection, accurate diagnosis, accurate localization, and curative therapy…”

Carbone, PP NIH Conference

Annals of Internal Medicine (1970): 73:1003

8/19/2018 4

• 1. American Cancer Society: Facts and Figures 2013.
• 2. SEER Cancer Statistics Review; 1975-2008; National Cancer Institute, Accessed March 2013.

LUNG CANCER SURVIVAL RATES BY STAGE AT DIAGNOSIS

at 10 years1 at 5 years2

4 |

8/19/2018 5

DIAGNOSING LUNG CANCER EARLY

• f new cases have

late-stage cancer. (Stage III or IV)

• f new cases have

Early-stage cancer. (Stage I or II)

Current State Ideal State

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SCREENING FOR LUNG CANCER: EARLY DETECTION MATTERS

• 70% of patients found to have lung cancer in the LDCT arm of the

National Lung Screening Trial (NLST) were diagnosed in the early stages1

• Only 320 LDCT screenings are needed to prevent one death1
• In the NLST, the mortality for patients at high risk receiving LDCT

screening was reduced by 20% vs. X-ray1

• LDCT screening costs $1631 per person, or $81,0000 per quality-

adjusted year gained in comparison with with no screening2

• 1. N Engl J Med. 2011;365(5):395-409
• 2. N Engl J Med. 2014;371:1793-1802

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SO HAS THIS HAPPENED?

• USPSTF updated guidelines in 2013 recommending yearly

screening for lung cancer using LDCT

• 2015 Medicare/Insurance reimbursed test
• The importance of detecting lung cancer early and

managing incidental pulmonary nodules is well known and accepted.

8/19/2018 8 FEWER THAN 4% OF HIGH RISK PATIENTS GET SCREENED FOR LUNG CANCER- AND NOT CHANGED BY USPSTF GUIDELINES

• 2010 National Health Interview Survey found that only 3.3% of high

risk smokers had been screened by LDCT the previous year

• 2015 National Health Interview Survey found that only 3.9% of high

risk smokers were screened by LDCT

• In 2015, 6.8 million current and former smokers were eligible for CT

screening- only 262,700 were actually screened.

JAMA Oncology 2017;3(9):1278-1281

8/19/2018 9 IN 2016 ONLY 1.9% OF 7.6 MILLION ELIGIBLE PATIENTS UNDERWENT LDCT SCREENING

• Only 1.6% of eligible heavy smokers in the South

underwent LDCT

• Region has the most accredited screening sites

(663/1796)

• Most eligible patients (3,072,095/7,612,975)
• In contrast- 65% of women age 40 or older underwent

mammography for breast cancer screening in 2015

• Pham DC, et al, ASCO 2018, Abstract 6504

8/19/2018 10 WHY IS THE RATE OF SCREENING HIGH RISK PATIENTS SO LOW?

(THIS IS AN EVIDENCE BASED, GUIDELINE RECOMMENDED, AND MEDICARE APPROVED TEST)

WHAT CAN BE DONE TO CHANGE THIS?

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WHY IS THE SCREENING RATE SO LOW?

• Are physicians not referring enough?
• Are eligible patients not wanting screening, even if they

know a test is available?

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WHY IS THE SCREENING RATE SO LOW?

(PROVIDERS)

• Knowledge of, attitudes toward, and use of LDCT for lung cancer

screening among family physicians

• 98% felt LDCT increased odds of detecting cancer at an earlier stage
• 75% felt the benefits outweighed the harms
• 76% discussed risks/benefits of LDCT in some capacity with their

patients

• >50% reported making one or no screening

recommendations in the past year

Cancer 2016;122:2324-31

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WHY IS THE SCREENING RATE SO LOW?

(PROVIDERS)

• LDCT screening practices and attitudes among primary care providers

at an academic medical center

• Few PCPs ordered lung cancer screening
• 21% X-ray, 12% LDCT, 3% sputum cytology
• <50% of PCPs knew three or more of the six guideline components

for screening, and 24% knew zero

• 30% of providers doubted effectiveness of LDCT in improving
• utcomes
• This study was conducted at a medical center that

participated in the NLST

Cancer Epidemiol Biomarkers Prev 2015; 24(4): 664-70

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WHY IS THE SCREENING RATE SO LOW?

(PROVIDERS)

• What are the factors associated with LDCT screening

utilization?

• Lack of knowledge led to a 37% inappropriate referral rate

from 2013 to 20151

• Almost 2/3 of physicians are unsure whether CMS covers the

cost of LDCT2

• 82% of providers are interested in learning more

about lung cancer screening1

1.Prev Med Rep 2017 Jun; 6 :17-22

• 2. Cancer 2016;122:2324-31

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WHAT HAS BEEN LEARNED?

(PROVIDERS)

• There is a well documented disconnect in moving clinical research

findings into clinical practice (1981 Beta-Blocker Heart attack Trial, etc)1 -This is a evidence based, guideline recommended, Medicare covered test.

• Physician knowledge is not optimal
• Physician belief that LDCT is valuable for early detection, but a

lower proportion believe that LDCT reduces lung cancer mortality2

• Physicians believe lung cancer screening to be less efficacious than
• ther cancer screenings2
• 1. N Engl J Med. 2003;349:868-874
• 2. Cancer Epidemiol Biomarkers Prev. 2015;24:664-670

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WHY IS THE SCREENING RATE SO LOW?

(PATIENTS)

• 60% of patients that qualify for LDCT screening adhered to

recommendation

• Younger, white, and female patients show a trend towards better

adherence1

• No difference for cancer history, residential area, level of education, type
• f insurance, occupation, or provider location1
• 79% of the patients that did not go through with their prescribed LDCT

wanted to do one in the future1

• Fatalistic beliefs, fear of radiation exposure, and anxiety related to CT

scans2

• Those who quit smoking or smoke less are more likely to be adherent1
• (smokers are less likely to seek out care for lung cancer)3
• 1. Prev Med Rep. 2017 Jun;6:17-22
• 2. Lung Cancer. 2012;77(3):526-531
• 3. Thorax. 2016 (PubMed PMID: 26911574)

8/19/2018 17

WHY IS THE SCREENING RATE SO LOW

(PATIENTS)

Those who quit smoking or smoke less are more likely to be adherent1

• (smokers are less likely to seek out care for lung cancer)3
• Patients may perceive screening-detected lung cancer as confirmation
• f a poor lifestyle choice2
• 1. Prev Med Rep. 2017 Jun;6:17-22
• 2. Pham DC et al. ASCO 2018, Abstract 6504
• 3. Thorax. 2016 (PubMed PMID: 26911574)

8/19/2018 18

WHAT CAN BE DONE TO IMPROVE SCREENING RATE?

• Provider Education
• Most (82%) were interested in learning more about LDCT1
• 59% stated an on-line lecture was the preferred method1
• Focus on mortality reduction, CMS coverage
• In office decision aides
• Patient Education
• Decision aids reduce the proportion of undecided participants and

appeared to have a positive effect on patient-clinician communication2

• Community outreach
• 1. Prev Med Rep. 2017;6:17-22
• 2. Cochrane Database Syst Rev. 2014;1:CD001431

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SHARED DECISION AIDS IMPROVE ADHERENCE TO LDCT SCREENING

Providers who discussed the benefits of LDCT screening with the use of shared decision aids increased screening participation from 10% to 95%1

• 1. Asian Pac. J. Cancer Prev. 2015;16(15):6293-6298

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SHARED DECISION MAKING MATERIALS

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PHYSICIAN OUTREACH/EDUCATION

= Individual practices visited

8/19/2018 22 COMMUNITY OUTREACH/EDUCATION NEWSPAPERS

8/19/2018 23

COMMUNITY OUTREACH/EDUCATION LOCAL TV

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COMMUNITY OUTREACH/EDUCATION COMMUNITY EVENTS

8/19/2018 25

LUNG CANCER SCREENING OUTCOMES

• 2016
• 96 total screens
• LR-3 10
• LR-4 6
• Diagnosed Cancer 2
• 2017
• 269 total screens
• LR-3 22
• LR-4 18
• Diagnosed Cancer 3

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5 10 15 20 25 30 35 40

2016 & 2017 LDCT Screenings

2016 2017 January December

8/19/2018 27

2018 – THROUGH JULY WE HAVE SCREENED 277 PATIENTS 96 269 474

8/19/2018 28 LUNG CANCER DIAGNOSED BEFORE AND AFTER PROGRAM DEVELOPMENT (SYSTEM WIDE)

• 2014 (Pre- ENB)
• 2015 (Post-ENB)

10% 10% 32% 48%

N= 31 (20% Stage 1 and 2)

Stage 1 Stage 2 Stage 3 Stage 4

29% 27% 18% 26%

N=92 (56% Stage 1 and 2)

Stage 1 Stage 2 Stage 3 Stage 4

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54% OF OUR PATIENTS DIAGNOSED

WITH NSCLC IN 2017 EITHER UNDERWENT SURGICAL RESECTION OR STEREOTACTIC RADIOSURGERY (SBRT)

8/19/2018 30

NEXT STEPS

• Improve adherence to LDCT
• QI program launched to improve efficiency of scheduling

process (automation)

• Piloting a program for same day screening.
• Revisiting primary care programs/improved shared

decision making materials

• Expand availability of LDCT screening exams beyond our

immediate market

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DIAGNOSING LUNG CANCER EARLY

56%

• f new cases have

early-stage cancer. (Stage I or II)

85%

• f new cases have

Early-stage cancer. (Stage I or II)

Current State Ideal State

8/19/2018 32

POLICY CHANGE IS NEEDED TO IMPROVE ADHERENCE NATIONALLY

• Make lung cancer screening a national quality health

measure for healthcare systems by CMS to optimize reimbursement

• In 2008 CMS made mammograms for breast cancer and

colonoscopies for colorectal cancer national areas of improvement

8/19/2018 33

QUESTIONS?