By Nathaniel Marchetti, DO
Professor, Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University
With expanded 2021 guidelines from the U.S. Preventive Services Task Force for lung cancer screening of current and former smokers, many health care organizations are ramping up their screening efforts. Yet such widespread use of LDCT can—and should—be harnessed to provide other diagnostic benefits and follow-up services as well.
The Temple Healthy Chest Initiative (THCI) is one example of how a health system is leveraging lung cancer screening to diagnose a host of conditions detectable using a chest CT—from emphysema to osteoporosis to diseases of the esophagus and upper abdomen—to make sure patients get the treatment they need.
Lung cancer is the third most commonly detected cancer in the United States, and causes the most deaths (more than 142,000 in 2018)[i] . The disease has a relatively low five-year survival rate (21.7%, based on 2011-2017 data)[ii], as it tends to be detected at a late stage: only 24% of lung cancer cases are diagnosed when the tumor is confined to its primary site, which have higher survival rates. The USPSTF guidelines recommend low-dose CT (LDCT) screening for all adults ages 50–80 with at least a 20 pack/year smoking history who have smoked within the past 15 years. The American College of Radiology estimates that this expansion could save 30,000-60,000 lives through earlier diagnosis of lung cancer.[iii]
Increased outreach, integrated follow-up
Ramping up screening efforts can be resource-intensive. A program like the Temple Healthy Chest Initiative maximizes the impact of those investments by providing comprehensive follow-up on all medically relevant findings, allowing earlier treatment for multiple conditions with the hope of better outcomes.
The new USPSTF guidelines increase screening eligibility among many at-risk populations. It is up to providers to fulfill this potential through efforts to increase actual screening referrals and access among under-served communities.[iv] This includes Black, Latinx, Asian/Pacific Islander, and Indigenous Americans, who are all more than 15% less likely to have their lung cancer diagnosed at an early stage compared with white Americans. Black Americans with lung cancer are 18% less likely to be diagnosed early, and have a 21% worse five-year survival rate compared to white Americans (18% vs. 22% five-year survival).[v] A key goal of Temple’s coordinated push for more accessible lung cancer screening is to reach patient communities in underserved neighborhoods who have higher lung cancer mortality rates and less access to routine care and screenings.
How THCI works
The Temple Lung Center, Fox Chase Cancer Center, and all Temple’s clinical locations are working together to extend lung cancer screening to all patients who meet eligibility criteria, employing a multifaceted patient navigation model to follow up on any indications of suspicious pulmonary nodules AND on any comorbidities detectable through the LDCT screening. The first step is outreach to Temple-affiliated providers, encouraging them to refer patients who meet the guidelines even if they’re not currently being treated for lung disease. Those referred to the program receive LDCT screening at the Temple location most convenient to them. A Temple radiologist reads the CT scan and generates a report, and a nurse navigator ensures that every report is reviewed and submitted to the patient and the referring physician.
The nurse navigator meets with the patient to explain the CT scan results, go over next steps, and answer questions. If there are findings that require medical follow-up, the patient is referred to the appropriate physician. For example, a patient with pulmonary nodules, mild emphysema, and coronary artery calcification would be referred to a pulmonologist as well as a cardiologist. The screening program can also be point of entry for clinical trials.
The nurse navigator is key to THCI, serving as a touchpoint for patients to ask questions, helping arrange additional appointments, ensuring that results are documented and that patients get appropriate follow-up care, and maintaining the cohesiveness of the care team by keeping appropriate treating professionals aware of important developments.
In addition to clinical follow-up, the Initiative provides access to smoking cessation and other support. Even if screening does not find suspicious pulmonary nodules, other noteworthy conditions are often found. Early experiences with THCI indicate that patients who see the radiographic impacts of smoking may have additional impetus to participate in smoking cessation efforts.
Some conditions detectable through chest LDCT
- Lung nodules/lung cancer
- Coronary artery calcification
- Aortic aneurysm
- Pulmonary fibrosis
- Hiatal hernia
- Masses, cysts and other abnormalities of the thyroid, kidney, liver, pancreas, breast, lymph nodes, spine, kidney, etc.
- Adipose tissue/obesity (risk factors for diabetes)
- Other thyroid and esophageal abnormalities
Better-informed lung cancer diagnosis and treatment
The same smoking history that increases a patient’s risk for lung cancer can also increase the risk of comorbid conditions including COPD, osteoporosis, and cardiovascular diseases. LDCT can detect both certain cardiovascular comorbidities and COPD, which can be associated with a significantly higher death rate among patients with lung cancer.[vi] Catching comorbidities in their earlier stages provides the best chance of minimizing their impact both on a patient’s quality of life and on their cancer diagnosis and treatment.
Participating in a comprehensive lung cancer-plus screening program could bring myriad potential benefits to both patients and providers, and Temple is currently investigating these impacts through clinical research. To learn more about the Temple Healthy Chest Initiative/refer a patient for lung cancer screening, call 800-TEMPLE MED.
[i] U.S. Cancer Statistics Working Group. 2021. U.S. Cancer Statistics Data Visualizations Tool, based on 2020 submission data (1999-2018): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; www.cdc.gov/cancer/dataviz, released in June 2021.
[ii] SEER Cancer Stat Facts: Lung and Bronchus Cancer. National Cancer Institute. Bethesda, MD, https://seer.cancer.gov/statfacts/html/lungb.html (accessed April 2022)
[iii] American College of Radiology. “Statement from the American College of Radiology: Updated USPSTF Lung Cancer Screening Guidelines Would Help Save Lives.” July 7, 2020. https://www.acr.org/Media-Center/ACR-News-Releases/2020/Updated-USPSTF-Lung-Cancer-Screening-Guidelines-Would-Help-Save-Lives
[iv] Ritzwoller, D.P., et al. 2021. Evaluation of Population-Level Changes Associated With the 2021 US Preventive Services Task Force Lung Cancer Screening Recommendations in Community-Based Health Care Systems. JAMA Netw Open 4(10): e2128176. doi: 10.1001.jamanetworkopen.2021.28176
[v] American Lung Association. State of Lung Cancer 2021 Report. November 16, 2021.