Extending Lung Cancer Screening to Primary Care
This grant proposes to extend a newly developed Lung Cancer Screening-Shared Decision Making (LCS-SDM) program, previously funded by Maine Cancer Foundation in 2013-14, to the primary care setting. The current LCS-SDM program is specialty-based, utilizing pulmonary medicine physicians to assess patient eligibility for Low Dose CT (LDCT) screening, provide in-depth counseling to ensure shared decision making (SDM) about screening, to provide close follow-up of normal and abnormal findings for all patients, to refer patients for smoking cessation counseling services, and to track patient outcomes. The current program focused on establishing reliable processes and procedures for all of these services, and was successful in providing screening services for 25 patients that were studied during the pilot period. The program's eligibility screening process resulted in 13 referred patients being deemed ineligible for screening due to not meeting established criteria.
All of the first 25 eligible patients elected to proceed with LDCT screening after receiving SDM counseling, and scores on a validated survey showed that counseling increased their knowledge and preparedness for undergoing screening. The pilot cohort had an average age of 65.4 years and included 14 men and 11 women. In this cohort, 13 were current and 12 were former smokers, with an average smoking history of 58.7 pack-years. Of these patients, 8 were found to have lung nodules by LDCT, and will receive further follow up imaging studies over the next year; none have been diagnosed with cancer.
The program continues to accept referrals for lung cancer screening service according to the same general model developed during the pilot, with some minor readjustments to improve coordination of services and the overall patient experience. However, the current specialty-based model of LDCT screening is not scalable and feasible for widespread implementation. Now that LDCT screening for lung cancer has been recommended as a covered preventive service by the Centers for Medicare and Medicaid Services (CMS), there is a need to expand LDCT screening to the primary care setting. A delivery model extending LDCT screening to the primary care setting, with primary care physician (PCP) involvement, is the next logical step, and many PCPs in our community have asked for such a model. The current project will respond to this need.
Lung cancer is the #1 killer within the United States, with only 15% of lung cancers cases found in the early stages, where the survival rate is 53.5%. Most cancers are not diagnosed until later stages, when the survival rate is only 3.9%. Within Maine, the Annual Report (2014) from the Maine CDC Registry reports that an average of 1,282 people were diagnosed per year between 2009-2011. The Maine Comprehensive Cancer Control Plan (2011-2015) identified lung cancer as, by far, the cancer with the highest age-adjusted mortality rate in 2006 for both men and women. Early detection and reducing modifiable risk factors, such as smoking, are major goals embedded in the Maine Cancer Plan, both of which are supported by this project.
The current project addresses the need to establish a reliable and effective process for implementing LDCT screening for lung cancer in the primary care setting. This is a need that numerous practices throughout the country are beginning to address, in response to the recent Centers for Medicare and Medicaid Services (CMS) decision to provide coverage for this service. However, we currently lack evidence regarding the optimal approaches to providing LDCT screening in the primary care setting. The current project will produce preliminary evidence on the feasibility, acceptability, and effectiveness of one approach that builds on our initial experience, and promising evidence, with providing LDCT screening in the specialty care setting.
- Patients, who are at risk for lung cancer and eligible for LDCT screening, will have the opportunity to engage in the only evidence-based early detection intervention that can lower mortality from lung cancer.
- Primary care physicians, will gain knowledge and experience in implementing LDCT screening.
- Clinical practices and health care systems, will gain insight on procedures and best practices in implementing LDCT screening in the primary care setting.