By Dara O’Brien

LDCT makes inroads as screening tool for patients at high risk of lung cancer.

Lung cancer is the leading cause of cancer-related deaths in the United States, and the most common cancer worldwide. With symptoms that typically manifest only in the later stages of the disease, individual diagnosis frequently comes too late to stop its progression. Early detection is critical to effective treatment.

Studies based on the 2010 National Lung Screening Trial (NLST) concluded that low-dose computed tomography (LDCT) imaging of high-risk individuals can detect lung cancer at its earliest stages; analysis showed a 20% reduction in deaths from the disease among those who were screened.1

In addition, further analysis of the data presented at a meeting of the National Cancer Institute in June of this year examined efficacy of screening in terms of quality-adjusted life year (QALY) scores. When compared to chest x-ray or no scan at all, LDCT produced the highest number of QALYs, with an incremental cost-effectiveness ratio well below the acceptable range. “This evidence demonstrates that not only is LDCT valuable in reducing mortality associated with lung cancer in high-risk patients, but it is also cost effective,” said Gail Rodriguez, executive director, Medical Imaging & Technology Association (MITA).2

In light of the data, the US Preventive Services Task Force has issued a draft recommendation for LDCT for individuals at high risk of developing lung cancer. While a final recommendation, along with Medicare reimbursement, is still to come, some private payors now include the scans as a covered benefit, and the Departments of Defense, Veterans Affairs, and Energy have begun phased implementation. LDCT for high-risk individuals has been endorsed by the National Comprehensive Cancer Network, the American Association for Thoracic Surgery, the American Society of Clinical Oncology, the American Cancer Society, and the American College of Clinical Pharmacy.2

Implementing a Program

Some pioneering private healthcare facilities have responded to the data by implementing LDCT lung cancer screening programs for high-risk patients. Among them is Orange Coast Memorial Medical Center (OCMMC) in Fountain Valley, Calif.

“We had been following the data in regard to lung cancer screenings,” said Jack Jacoub, MD, OCMMC’s medical director of thoracic oncology. “We thought the most recent NLST data were mature enough, so we moved forward with a formal CT screening program.”

Proper targeting is key to program implementation. Jacoub pointed out that the test is not a diagnostic tool to be used for patients who are already evidencing symptoms. “You’re looking for entirely asymptomatic patients who have an increased risk for lung cancer,” he said.

Orange Coast’s program has been up and running for 2 years, and employs a nurse navigator to oversee its implementation. “She is integral in making sure that nothing falls through the cracks,” said Jacoub. “The last thing you want to do is to have an abnormality that is not followed up. You need to have that infrastructure in place.”

The Center was concerned about the high risk of false positives that could result from lung cancer screenings. “There is always a potential harm when you are subjecting patients to various modalities, especially in an area like the lung,” said Jacoub. “There are going to be nodules, and the majority of them are going to be benign. But they’re going to get biopsied, and that’s going to create some anxiety among the patients.” He stressed the importance of having a system like Orange Coast Memorial’s in place in order to do structured follow-up.

OCMMC’s program has screened about 100 patients so far. “We’ve already detected an early stage lung cancer, and the rest of the patients are being followed by our nodule clinic and/or the nurse navigator,” said Jacoub. He observed that while the program is still in its infancy, it is slowly gaining momentum. “It’s nowhere near the numbers for mammography or other established screening studies, but it may very well be there in a few years.”

With the issue of reimbursement still pending, OCMMC charges $125 for each scan, billable to the patient. Jacoub noted that while out-of-pocket cost might be a barrier for low-income individuals, it has not proved a significant impediment to the more affluent population Orange Coast Memorial serves. He acknowledged that Medicare approval is a factor many centers will weigh as they consider implementing their own lung cancer screening program. 

Most of Orange Coast Memorial’s lung cancer screenings to date have been initiated by the patients themselves, who learned of the program through the lay press or from the hospital. However, Jacoub has seen a growing interest in CT screening for lung cancer within the medical community. “Physicians are now starting to look at the data, talking about it with their colleagues,” he said. Orange Coast Memorial has undertaken one-on-one outreach to local physicians to help them better understand the program, its impact, and the Center’s commitment to follow up with every patient.

Jacoub noted the caution with which facilities must approach an LDCT screening program for lung cancer. “You have to know exactly what you are dealing with, what the implications are,” he said. ”You know there are going to be false positives, but you also understand that there are going to be those individuals who have lung cancer, and you’ve caught it early.”

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REFERENCES:

1-National Cancer Institute

2-Medical Imaging & Technology Association