Experts Give Advice on How to Plan a Successful Lung Cancer Screening Program

Carey C. Thomson, MD, MPH

Screening high-risk individuals for lung cancer with low-dose computed tomography is an effective and recommended approach for reducing mortality from the condition. That said, planning a lung cancer screening (LCS) program can be challenging, as a successful program requires strategic multidisciplinary collaboration.

Clinicians planning to start a new LCS program would do well to adhere to the new guide developed by the American Thoracic Society and the American Lung Association, particularly to the section on program implementation.¹

The section, Implementation Guide for Lung Cancer Screening, was written by Carey C. Thomson, MD, MPH, director of the Lung Cancer & Lung Nodule Care Program at Mount Auburn Hospital, Cambridge, Massachusetts, and Andrea McKee, MD, cochair of the Lung Cancer Screening Steering Committee at Lahey Hospital & Medical Center, Burlington, Massachusetts, and is available online.²

Establishing Resources and Program Structure

In the “Planning an LCS Program” section of the guide, pulmonary experts from various successful LCS programs across the United States describe the strategies their institutions used to overcome commonly encountered implementation obstacles and ensure the success of an effective program.The first step in starting an LCS program is to secure resources to support a multidepartmental program.

“We engaged hospital leadership to emphasize the importance of developing an LCS program and ensure that the program had the appropriate infrastructure and staffing,” said Katrina Steiling, MD, MSc, cochair of the LCS Program Steering Committee at Boston University School of Medicine in Massachusetts.

Depending on the available resources, the governance structure of each LCS program can vary and is typically categorized as centralized, decentralized, or hybrid. A centralized structure places the majority of LCS responsibilities with the program, whereas a decentralized structure leaves most, aside from the actual exam and interpretation, to the provider. Most programs are governed by a hybrid structure, employing both centralized and decentralized processes.

“This [hybrid structure] means that referrals for LCS exams can be made from a patient’s primary care provider [decentralized referral] or from our Lung Nodule Clinic, where subspecialty providers conduct a shared decision-making visit with patients to review the potential benefits and harms of screening [centralized referral],” Dr. Steiling explained.

“One benefit to a hybrid structure is that patients have more options for discussing LCS with a health care provider and having the test ordered. Some patients may feel more comfortable talking with their primary care provider about their risk factors for lung cancer and whether LCS is right for them, and others might prefer to talk to a specialist,” Dr. Steiling added.

According to Kim L. Sandler, MD, codirector of the Lung Screening Program at Vanderbilt University Medical Center, Nashville, Tennessee, although a centralized structure requires more resources than the other structures, such as staff who can perform the shared decision-making visit, it can significantly decrease the burden on referring providers.

Determining Quality Metrics

“We meet with every patient for 20 to 30 minutes to discuss all components of the shared decision making visit, including providing smoking cessation counseling for our active smokers. This is time that our referrers may not have in their busy practices,” Dr. Sandler said.“Another important component to ensure efficient and effective workflow and communication is regular review of program performance and quality metrics,” Dr. Steiling said.

Building and Implementing a Successful Team

Quality metrics commonly collected and followed in LCS programs include access to the program, smoking habits, radiology results, cancer detection rate, noninvasive procedures, and invasive procedures. Collecting data on these metrics is necessary for both reporting to an approved registry and tracking the quality of the program.Regardless of the type of program structure, most experts agree that a program coordinator is critical for developing a successful program.

“I believe you have to have a program champion, 1 person who is willing to say, ‘This is my responsibility. I will make this happen.’ That doesn’t mean that the person does it alone, but they are accountable for making sure all the pieces are in place to get the program up and running. Then you rely on collaborations with people in other departments for their expertise,” Dr. Sandler explained.

In addition to a program coordinator who provides administrative attention to detail, a multidisciplinary steering committee is essential to guide program development. A steering committee often consists of leaders from diverse departments, including radiology, oncology, pulmonary medicine, thoracic surgery, and primary care.

“We established a multidisciplinary steering committee tasked with the development and implementation of the LCS program,” Dr. Steiling said. “This committee reviews performance data and quality metrics quarterly and discusses any operational opportunities and challenges.”

“High-quality LCS requires attention to details to ensure that only eligible patients are screened, that referred patients get their screening exams, and that abnormal findings are evaluated in a timely manner. An LCS program coordinator and a patient navigator are the important links,” Dr. Steiling concluded.

References

1. Thomson CC, McKee A, Borondy-Kitts A, et al; American Thoracic Society, American Lung Association. Implementation guide for lung cancer screening. lung.org/assets/documents/lung-cancer/implementation-guide-for-lung.pdf. Accessed October 31, 2018.
2. National Lung Screening Trial Research Team, Aderle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. doi: 10.1056/NEJMoa1102873.