By Sarah Jersild
CT screening for lung cancer has gotten a thumbs-up from medical organizations, is starting to gain traction with insurers, and is certainly piquing interest among patients. But is it right for your practice? To find out, you may have to adjust your expectations. This is not an arena where you can go it alone.
Assemble your team
“Screening for lung cancer is not an event; it’s not a test. It’s a process,” said Eric Hart, MD, director of thoracic imaging at Northwestern Memorial Hospital in Chicago. “That process has a lot of different stakeholders ranging from the potential person to be screened, their loved ones, their primary care providers, to radiologists, thoracic surgeons, oncologists, and pulmonologists.”
Just what makes the perfect team is up for debate. At Northwestern, the lung cancer screening program is a collaboration between radiology, thoracic surgery and pulmonary medicine. The practice at Smilow Cancer Hospital at Yale-New Haven and Yale Cancer Center adds a smoking cessation counselor into the mix.
“It doesn’t make a lot of sense to me to say ‘We’re going to screen people for lung cancer but we’re going to pat them on the back and say you go on smoking, don’t worry about it,'” said Frank Detterbeck, MD, Chief of Thoracic Surgery at the Yale Medical Group. “If we’re really serious about decreasing the chance of dying from lung cancer, we ought to get people to stop smoking. In some ways it is a teachable moment; it’s an opportunity to get people to think about that.”
Most important: Your patients need to be able to get the care they need quickly if their screen does detect a problem. If you’re not part of a larger institution or in a densely populated area, that may be difficult. But Hart said that shouldn’t necessarily stop you. “It’s more viable in a larger area, but radiologists in smaller areas should look at it as an opportunity to partner with bigger institutions who have the downstream help available.”
Pick your patients
The criteria developed from the National Lung Screening Trial (NLST) recommend that current and former smokers aged 55 to 74 who have smoked for 30 pack years or more should be offered low-dose CT screening. Some organizations argue those criteria are too strict. Whether you choose to stick with these guidelines or not, you will have to set some limits on who you screen.
“It’s critical that you have people in your scheduling section that are familiar with inclusion and exclusion criteria, because you will just get flooded with patients,” said Les Ciancibello, radiology manager at University Hospitals Case Medical Center Seidman Cancer Center in Shaker Heights, Ohio. “You have to have someone right at the front gate that can control access.”
But if you get it right, the pre-screening may be the most time-intensive part of the process.
“We’ve tracked this — the time it takes for a patient to come in, have their scan, and get out the door, is about two to five minutes,” said Robert Gilkeson, MD, vice chairman of research and chief of thoracic imaging at University Hospitals Case Medical Center. “It doesn’t need contrast, it doesn’t need an IV, it’s a single breath hold. It’s not that hard to do this. You just need to do this very efficiently.”
That means adding lung cancer screening won’t disrupt your normal workflow, Northwestern’s Hart said. “The beauty of it from a workflow perspective is this is not coming from your ED and has to be answered in the next 10 minutes. This is something that is being done electively, and while you want to have appropriately rapid turnaround, 10 minutes isn’t it. If this gets turned around in 24 hours, that’s appropriate service.”
Know your market
NLST data showed that almost 25 percent of findings with this type of screening were false positives. But that rate may be higher depending on where you practice. The prevalence of cases of endemic histoplasmosis in the Midwest and coccidioidomycosis in the Southwest means you’ll find many more people with lung nodules in those areas. You need to be sure your patents are aware that these initial findings aren’t necessarily a reason to panic — or to get a potentially unnecessary surgery, experts said.
With a few exceptions, this will be an out-of-pocket expense for your patients. How much you decide to charge will depend on your market your patient base. Both Yale and Northwestern charge $300 for a scan. Detterbeck called that the break-even cost. At Case Medical Center, they’ve chosen to keep the price as low as $100 per scan to make it available to wider population.
But all three doctors cautioned against looking at lung cancer screening as a loss leader to get people in the door.
“There are certainly people who look at it from a financial standpoint, if we do a lot of procedures, we start making money,” Detterbeck said. “I am very nervous about that angle. We should do the procedures that are appropriate, and if we structure screening programs so there’s a lot of pressure to do procedures in order to make the program solvent, we’ve created a dangerous structure.”