Feature | Lung Imaging | September 16, 2022 | By Christine Book

Special Report on Lung Cancer and Screening Initiatives

A look inside the imaging industry’s efforts to enhance lung cancer screenings

“Lung cancer is the deadliest cancer in men and in women, and it all boils down to how it is detected and when it is diagnosed,” said Michael Wert, MD, director of The James Lung Cancer Screening Clinic at The Ohio State University Wexner Medical Center. Referencing screening programs, like the one he leads, he emphasized, “It’s low risk, high reward.”

Lung cancer kills more people each year than breast, colorectal and prostate cancer combined, according to the American College of Radiology (ACR), in a Feb. 2022 statement in response to CMS updates on lung cancer screenings.

This is not a contest pitting one cancer against another. To be sure, it’s a dubious achievement. Yet the fact remains: lung cancer is a leading cause of cancer mortality in the United States and has one of the lowest 5-year survival rates because of the high proportion of late-stage diagnoses.

The bottom line: expansion of screening programs can save lives by detecting cancers earlier and by reaching a larger population. The good news, from a comprehensive review of many programs and initiatives across the country, is there seems a stronger than ever consensus that the tide is turning toward more scans and, as such, more lives saved. Here then, the first in a series of articles on this important work. We’ll first review key findings from a comprehensive nationwide review of screening availability, offer updates on a range of related programs being implemented by ACR and through the Biden Administration, and share the latest guidelines from the U.S. Preventive Services Task Force (USPSTF).

Report Looks at Screening Demographics

Significant work and findings were reported in the journal Cancer (Feb. 2022, “Geographic access to lung cancer screening among eligible adults living in rural and urban environments in the United States” authored by Liora Sahar, PhD et al).

In comprehensive research that serves as a clarion call for action, the authors focused on higher lung cancer incidence and mortality rates in rural areas, noting this is likely due to higher smoking rates and possibly more limited access to care. The primary author of the landmark research paper is Liora Sahar, PhD, GISP, Principal, Sr. Consultant at G.R.A.C.E. GIS, who has served as a Director of Evaluation Informatics at the American Cancer Society. A summary from the report follows.

This study complements a previous nationwide assessment of access to lung cancer screening within 40 miles by evaluating differences in accessibility across rural and urban settings for the population aged 50 to 80 years and a subset eligible population based on the 2021 US Preventive Services Task Force LDCT lung screening recommendations.

Distances from population centers to screening facilities (American College of Radiology Lung Cancer Screening Registry) were calculated, and the number of individuals who had access within graduating distances were estimated.

The article also noted that because CMS required facilities to submit their data to a CMS-approved registry as a facility requirement for payment, the American College of Radiology (ACR) followed by creating the Lung Cancer Screening Registry (LCSR), the only CMS-approved registry. In March 2021, the USPSTF released an update of its recommendations for lung cancer screening (LCS). By both lowering the age at which screening begins to 50 years and reducing the pack-year history criterion to 20, it nearly doubled the population now eligible for LCS.

Sahar and her co-authors offered the following lay summary of their findings:

"As annual lung cancer screening rates remain low, this study examines access to lung cancer screening nationwide and across rural and urban settings. A geographic information system network analysis of census tract-level populations is used to estimate access at different distances, including 10, 20, 40, 50, and 100 miles, and the results are aggregated to counties. Approximately 5% of the eligible population does not have access to screening facilities within 40 miles; however, different patterns of accessibility are observed at different distances, between regions, and across rural-urban environments. Across all distances and geographies, there is a larger percentage of the population in rural geographies with no access.”

ACR and Partners Respond to New CMS Recommendations

The ACR issued a statement in Feb. 2022 urging providers to pursue quality assurance as screening proliferates. The statement, titled “New Medicare Lung Cancer Screening Guidelines a Huge Step Forward — More Lives to be Saved” conveys the collective reassurance and enthusiasm the radiology community shares on this vital issue, gaining an increasingly brighter spotlight on the national stage. The statement noted:

“New Centers for Medicare and Medicaid Services (CMS) recommendations to lower lung cancer screening initial age and smoking history requirements can make these exams the most effective cancer screening tests in history. The American College of Radiology, the GO2 Foundation for Lung Cancer and the Society of Thoracic Surgeons (STS) will work with CMS, medical providers and those seeking care to implement and update screening recommendations.

“Lung cancer kills more people each year than breast, colorectal and prostate cancer combined. Annual lung cancer screening with low dose computed tomography (LDCT) in high-risk patients significantly reduces lung cancer deaths. Yet, less than 15% of Americans who met previous criteria are tested. The American Cancer Society predicts 131,180 lung cancer deaths in 2022. More-widespread screening could save 30,000–60,000 lives in the United States each year.”

“I am enthusiastic about this Medicare expansion of eligibility for lung cancer screening,” said Douglas E. Wood, MD, a Past President of the Society of Thoracic Surgeons and Chair of the National Comprehensive Cancer Network Lung Cancer Screening Panel. “The U.S. has set records for falling rates of cancer mortality in the last few years, and this is largely driven by lower rates of lung cancer mortality since screening was approved by Medicare in 2015. Early detection of lung cancer allows more effective treatment and a chance to turn more cancer victims into cancer survivors.”

In addition to lowering the initial screening age from 55 to 50, and smoking history requirements from 30 pack years to 20 pack years, CMS expanded coverage to thousands of independent diagnostic testing facilities nationwide and retained a requirement that providers use Lung-RADS structured reporting.

“Expanded lung cancer screening access can help doctors hit back against the nation’s leading cancer killer and ease lung cancer outcomes disparities — particularly among women, black men, and those in rural areas,” said Debra Dyer, MD, FACR, chair of the ACR Lung Cancer Screening Steering Committee. She added, “Screening providers, particularly those starting new programs, should seek accreditation, use Lung-RADS, take part in the Lung Cancer Screening Registry, and leverage educational offerings to maximize screening’s lifesaving benefit. Providers must act on this opportunity.”

To continue to broaden access to LCS for those who need it and optimize the lifesaving ability of these exams, CMS, payers and providers must continue to work together to:

• Simplify and streamline patient workflow.

• Reduce documentation burden on the provider.

• Reduce the administrative burden on providers and institutions.

To make LCS more accessible and save even more lives, CMS should consider the following steps moving forward:

• Continue Medicare coverage for older current and former smokers past age 78.

• Continue coverage for beneficiaries who stopped smoking more than 15 years prior.

• Inform future screening improvements by reinstating registry participation requirements.

• Drop the requirement for a shared decision-making session prior to the first screening (a current barrier to care).

“This is a major step forward in lung cancer screening coverage for the millions at risk for the disease,” said Laurie Fenton Ambrose, Co-Founder, President and CEO of GO2 Foundation for Lung Cancer. “We know we can save more lives and will continue to work with CMS to remove barriers and improve access to screening for the people this preventive service is intended to help, particularly the underserved. Our work to achieve equitable access of this lifesaving preventive service
will not wane.”

Lung CT Screening Reporting and Data System, Lung-RADS, is a quality assurance tool designed to standardize lung cancer screening CT reporting and management recommendations, reduce confusion in lung cancer screening CT interpretations, and facilitate outcome monitoring.

The ACR Lung Cancer Screening Registry (LCSR) helps clinicians monitor and demonstrate the quality of CT lung cancer screenings in their practice through periodic feedback reports that include peer and registry benchmarks. Because screening is performed on an asymptomatic population, there is an added responsibility for the medical community to ensure that risks and benefits are adequately measured and monitored. Contributing data to the LCSR not only helps clinicians improve their own quality of care, but also helps improve and refine lung cancer screening care for everyone at the national level. LCSR participation is certified as Practice Quality Improvement (PQI) projects toward American Board of Radiology Part IV Maintenance of Certification (MOC) credit.

President’s Cancer Panel Zeroes in on Screening

Information from the White House was provided in conjunction with a Feb. 2, 2022, briefing on President Biden’s Cancer Moonshot Program. Highlights are summarized below.

As Vice President, in 2016, Joe Biden launched the Cancer Moonshot with the mission to accelerate the rate of progress against cancer. The cancer and patient community and medical researchers responded with tremendous energy and ingenuity.

President Biden announced at the briefing that he is reigniting the Cancer Moonshot with renewed White House leadership of this effort. Because of recent progress in cancer therapeutics, diagnostics and patient-driven care, as well as the scientific advances and public health lessons of the COVID-19 pandemic, it’s now possible to set ambitious goals: to reduce the death rate from cancer by at least
50 percent over the next 25 years, and improve the experience of people and their families living with and surviving cancer — and, by doing this and more, end cancer as we know it today.

An executive summary released after that briefing, noted, in part:

In 2020–2021, the President’s Cancer Panel held a series of meetings on cancer screening, with a focus on breast, cervical, colorectal and lung cancers. The Panel concluded that more effective and equitable implementation of cancer screening represents a significant opportunity for the National Cancer Program, with potential to accelerate the decline in cancer deaths and, in some cases, prevent cancer through detection and removal of precancerous lesions. While continued research undoubtedly will lead to improvements in cancer screening in the coming years, meaningful gains can be made through better application of existing evidence-based modalities and guidelines.

A Lung Cancer Companion Brief was also issued by the President’s Cancer Panel. The document, “Closing Gaps in Cancer Screening: Connecting People, Communities, and Systems to Improve Equity and Access,” outlined program goals, offered here, with excerpts from the brief.

Goal #1: Improve and align cancer screening communication

•Communications campaigns for lung cancer screening are needed.

•Support for the National Lung Cancer Roundtable (NLCRT) should be increased so it can continue its work and expand its reach to communities with low rates of screening and follow-up care.

Goal #2: Facilitate equitable access to cancer screening

•Community-oriented outreach and support services are needed to promote appropriate screening and follow-up care.

Goal #3: Strengthen workforce collaborations to support cancer screening and risk assessment

•Systems and processes that support team-based care should be established.

• Additional members of physician-led healthcare teams should be allowed to conduct shared decision-making for lung cancer screening.

Goal #4: Create health information technology that promotes appropriate cancer risk assessment and screening

• Computable guidelines for lung cancer screening should be created.

• Effective clinical decision support (CDS) for lung cancer screening and follow-up care should be created and deployed.

Editor’s note: Part 2 in this series will be published in the November/December issue. Up next, we will provide a snapshot summary of global and national initiatives, share highlights of the American Lung Association’s “State of Lung Cancer” Report expected out in November, during Lung Cancer Awareness Month, and share insights from imaging leaders eager to expand lung screening programs. Meanwhile, if you are part of an ongoing lung screening program, make sure to update us by contacting ITN Managing Editor, Christine Book at [email protected].