Lessons from real-world implementation of lung cancer screening

1. In this clinical demonstration project of implementing lung cancer screening for smokers in selected Veterans Health Administration hospitals, there were challenges in project implementation and patient selection. There was significant variability in local implementation and radiographic detection of nodules.

2. Increasing the scale of lung cancer screening to the entire VHA is estimated to include around 900,000 patients, which may lead to significant incidental findings. In this population, there was an increased incidence of nodule identification than in prior trials

Evidence Rating Level: 2 (Good)       

Study Rundown: The National Lung Screening Trial (NLST) demonstrated reduction in lung cancer mortality when screening for lung cancer in high-risk individuals with low-dose computed tomography scans. There has been hesitancy with widespread implementation of this program because of resources needed, risk of increased interventions for non-malignant legions, and appropriate patient selection. The current report details the experiences of implementing lung cancer screening (LCS) in 8 VHA hospitals.

At the eight sites, there were significant variations in identifying and enrolling patients. Of note, despite the relatively robust electronic medical records system shared amongst the sites, accurate smoking history was unavailable for a large number of individuals (~40%). Close to two-thirds of eligible patients agreed to go forward with screening, of whom more than half had nodules identified that required tracking with subsequent scans, which was substantially more than in the original NLST. There was variation in the rate of nodule identification based on site of evaluation. A small number (3.5%) underwent diagnostic evaluation and lung cancer was confirmed in 1.5% of patients screened. Incidental conditions such as emphysema, pulmonary abnormalities, and coronary artery calcification were identified in 40% of patients screened. Based on the incidence of patients identified for LCS, implementation across all VHA hospitals is estimated to encompass close to 900,000 patients for screening. Implementation would require substantial clinical and administrative effort to manage the burden of increased number of scans and diagnostic interventions. The study had key limitations including the lack of current data on mortality outcomes, and the predominantly older, male population with high rate of smoking use leading to potentially more common positive findings than the general population.

Click to read the study, published today in JAMA Internal Medicine

Relevant Reading: Screening for Lung Cancer: U.S. Preventive Services Task Force Recommendation Statement

In-Depth [prospective cohort]: This study included 8 VHA hospitals chosen based on facilities and staff required to implement a LCS program. Enrolment was in two steps, with initial selection for those aged 55 to 80 years, without prior diagnosis of cancer, with an expected life expectancy of greater than 6 months, and who had known 30-pack-years or greater smoking history. Patients were excluded if they had CT chest within 12 months, or if primary care physicians felt there was significant comorbidity limiting life expectancy to less than 5 years.

Of the 93,033 patients who met initial inclusion, 39.3% had no smoking history available. After all exclusion criteria were applied 4,246 patients were offered screening with 57.7% agreeing to the program. The population that received screening was therefore 2,028 people (96.3% male; 52.5% over the age of 65). A total of 59.7% had a positive screening result, with the majority identifying nodules that would need further tracking. Across the eight sites there was significant variation in nodule detection (from 30.7% to 85.0% of patients screened). A small proportion (3.5%) underwent diagnostic evaluation for lung cancer, and 1.5% of the total screened population had a lung neoplasm. Twenty of the 31 cancers were stage 1.

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