Lung cancer is the leading cause of death in the U.S. and highly treatable when caught early. But less than 15% of people at high risk for lung cancer receive potentially life-saving screening.
If you’ve been considering setting up a lung cancer screening program in your office, new screening recommendations, better shared decision-making approaches, and stronger follow-up guidelines make getting started easier than ever.
Matthew Triplette, MD, MPH, is a pulmonologist, lung cancer screening expert and medical director of the Seattle Cancer Care Alliance (SCCA) and University of Washington Medicine (UW) Lung Cancer Screening Program. SCCA was among the first programs in the U.S. to receive the designation as a Screening Center of Excellence by the Lung Cancer Alliance. At SCCA, Dr. Triplette studies how to tailor lung cancer screening to save the most lives and make this an effective service for eligible patients.
Dr. Triplette sheds light on the fundamentals of lung cancer screening, including:
Lung cancer screening is a quick, simple scan that uses low-dose CT. Two landmark trials established that low-dose CT is an effective tool to reduce lung cancer mortality in high-risk patients. They are:
Recently, national lung cancer screening guidelines have been updated to reflect advances in clinical trial research and the epidemiology of lung cancer. This change impacts who should be screened and expands insurance coverage for screening tests.
In a 2021 update to their national guidelines, the USPSTF recommended annual lung cancer screening using low-dose CT for patients who:
Providers should not offer screening if patients have not smoked for 15 years, have a life-limiting health problem or are unable or unwilling to have curative lung surgery. The strength of this USPSTF recommendation is grade B, which means there is moderate certainty the benefit is moderate to substantial.
This update expands the number of people who may be eligible for screening from the 2013 guidelines by lowering the minimum screening age to 50 from 55 years old and pack year smoking history to 20 from 30 pack years. “These changes are especially important for improving early detection among Black men who are at higher risk of lung cancer despite lower smoking histories,” says Dr. Triplette.
In February 2022, CMS updated their lung cancer screening eligibility criteria to align more closely with the USPSTF recommendations. However, the CMS guidelines recommend an age range of 50 to 77 years old, compared to 50 to 80 years old.
CMS also requires a visit prior to the first lung cancer screening that documents shared decision-making between the patient and provider.
Expanded USPSTF and CMS eligibility criteria translate to insurance benefits for more patients, says Dr. Triplette.
The Affordable Care Act requires private insurances to cover USPSTF-recommended screening modalities with a grade A or B at no cost sharing to the patient. Patients who are eligible for lung cancer screening and are covered by Medicare, Washington State Medicaid or private insurance can access lung cancer screening with no cost sharing.
When establishing a lung cancer screening program, it’s essential to consider clinician behavior and system-wide processes. Four key considerations include:
Identifying patients who are eligible for lung cancer screening can be challenging. This is because providers do not always record smoking history.
Dr. Triplette recommends documenting smoking history as you would a vital sign. This will provide updated data on smoking status, quit dates and pack years so providers can recommend lung cancer screening, as appropriate.
CMS requires a counseling and shared decision-making visit prior to lung cancer screening. This visit should include determination of eligibility. It's also required to use a decision aid, such as Should I Screen, and provide counseling on the following topics:
Some EMR systems have built-in decision aids to guide and document the visit.
“Once you determine a patient is eligible for screening, counseling them can be tricky,” says Dr. Triplette. “It’s important to clearly explain the benefits and risks of screening.”
Lung cancer screening benefits include:
The risks of lung cancer screening include:
Smoking cessation counseling is an important component of lung cancer screening. But not all providers feel comfortable having these conversations with patients. Strategies Dr. Triplette recommends for smoking cessation counseling include:
Manage follow-up using the latest tools
The ACR Lung Reporting and Data System (Lung-RADS) provides a useful tool for managing lung nodules found during lung cancer screening, especially in the lower categories. For higher grade findings, Dr. Triplette recommends referral to a pulmonologist or multidisciplinary clinic for management.
Follow-up also includes putting systems into place to remind patients of their annual screening. Dr. Triplette recommends using the ACR registry, which is compatible with many EHR systems and can assist with patient tracking and reminders.
SCCA is accredited by the American College of Radiology. Together, Seattle Cancer Care Alliance (SCCA) and UW Medicine offer screening for people at high risk for lung cancer at six locations through Puget Sound.