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Transcript of Www.Lahey.org/LungScreening 1-855-CT-CHEST Andrea McKee, M.D. Chairman Department Radiation Oncology...
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www.Lahey.org/LungScreening1-855-CT-CHEST
Andrea McKee, M.D.Chairman Department Radiation Oncology
Sophia Gordon Cancer CenterLahey Clinic
May 15, 2012
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Disclosures
• None
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Outline
• Lung Cancer Background• Incidence/Mortality• National Lung Screening Trial (NLST)• National Comprehensive Cancer Network (NCCN)
• Lung Cancer Screening at Lahey Clinic• Program Structure• Structured Reporting
– LUNG-RADS Classification System• Challenges
• Rescue Lung, Rescue Life
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Lung CancerIncidence/Mortality: US
• Number one cause of cancer-related death in the US and World
• Kills more women than Breast, Ovarian, and Uterus Cancer Combined
200K new cases/yr 160K deaths/yr
![Page 5: Www.Lahey.org/LungScreening 1-855-CT-CHEST Andrea McKee, M.D. Chairman Department Radiation Oncology Sophia Gordon Cancer Center Lahey Clinic May 15, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551a0a7f55034619378b4c28/html5/thumbnails/5.jpg)
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Risk Factors?
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Tobacco Trends
• History of tobacco use– <20% in 2006– 42% in 1965– Demonization campaign
• Higher prevalence– Military (1 in 3) vs (1 in 5)
– Less educated
• Higher risk– Rescue workers– Occupational exposure
![Page 7: Www.Lahey.org/LungScreening 1-855-CT-CHEST Andrea McKee, M.D. Chairman Department Radiation Oncology Sophia Gordon Cancer Center Lahey Clinic May 15, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551a0a7f55034619378b4c28/html5/thumbnails/7.jpg)
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Tobacco Trends
Competition has been tough - tobacco industry, Hollywood, press
Guard against withholding of health care services or advocacy based on social history – slippery slope
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Lung CancerIncidence/Mortality: US
Primary Prevention (Smoking Cessation) Success Decreased number of overall lung cancer deaths in US Despite success 160K still die every year from lung cancer Most people who die from lung cancer now are FORMER SMOKERS
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Lung CancerIncidence/Mortality: US
Primary Prevention (Smoking Cessation) Success Decreased number of overall lung cancer deaths in US Despite success 160K still die every year from lung cancer Most people who die from lung cancer now are FORMER SMOKERS
35% of Lung Cancer Diagnosis Current Smokers 50% of Lung Cancer Diagnosis Former Smokers 15% of Lung Cancer Diagnosis Never Smokers
Lung Cancer 5-Year Overall Survival Remains Unchanged 1975 12%, Current 15%
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Lung CancerIncidence/Mortality: US
Primary Prevention (Smoking Cessation) Success Decreased number of overall lung cancer deaths in US Despite success 160K still die every year from lung cancer Most people who die from lung cancer now are FORMER SMOKERS
Lung Cancer 5-Year Overall Survival 1975 12%, Current 15%
Stagnant survival result of absent Secondary Prevention FORMER SMOKERS cannot benefit from PRIMARY PREVENTION Secondary Prevention = LUNG SCREENING LUNG SCREENING Find disease at early more treatable stage LUNG SCREENING GOAL Decrease Mortality not Incidence
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Lung Cancer ScreeningData to support screening been around awhile
• NEJM October 2006– 31,567 patients baseline screened with low dose
CT from 1993-2005– 484 lung cancers detected (85% clinical stage I)– 10 year survival 92% for those having surgery– 8 patients refusing therapy died within 5 years of
diagnosis
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Lung Cancer TreatmentNSCLC: Unscreened Population
NSCLC• Stage I, II, IIIA
– Potential Cure• Surgical resection• Radiotherapy• Chemotherapy
• Stage IIIB/IV – Palliative
Goldstraw P, Crowley J, Chansky K, et al. (2007) The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours. J Thorac Oncol 2:706–714.
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National Lung Screening TrialResults: Stage Shift
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Stage IV NSCLC
<1% = 5 year OS
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Incidental Finding on CXR
58% 5-year Overall Survival
Stage T1BN0
Goldstraw P, Crowley J, Chansky K, et al. (2007) The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours. J Thorac Oncol 2:706–714.
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Annals of Internal MedicineOctober 2011
• 62 year-old female with a history of well-controlled hypertension presents for routine follow-up. She is asymptomatic and feels well. She has jogged 3 miles 3 times weekly for years with no recent change in exercise tolerance. She has a 30 pack-year history of tobacco use but quit 10 years ago. Normal physical exam. She read a recent study that found a benefit to screening with LDCT and inquires if this is appropriate for her?
• What should you recommend?
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Secondary PreventionPreclinical Diagnosis: Screening Awareness
What is this patient’s 5-year overall survival?
5mm nodule
6 month fu diagnostic CT recommended
7mm NSCLC treated with lobectomy and nodal evaluation
T1aN0 (screened)
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Secondary PreventionPreclinical Diagnosis: Screening Awareness
92% = 5 year OS
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Secondary PreventionPreclinical Diagnosis: Screening Awareness
Asymptomatic
Screening
Stage I92% 10-year OS
85% of patients in screened population have stage I lung cancer
58% 5-year OS
Stage IV1% 5-year OS
Symptomatic
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US Cancer Mortality RatesSecondary Prevention
U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2007 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2010. Available at: www.cdc.gov/uscs.
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US Cancer Mortality RatesSecondary Prevention
PSA
Mammography
Colonoscopy
U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2007 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2010. Available at: www.cdc.gov/uscs.
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National Lung Screening Trial(NLST): 6/29/2011
National Lung Screening Trial Research Team (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365(5):395–409.
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National Lung Screening TrialDesign Overview
• Multicenter Randomized Controlled Trial– Sponsor: NCI Division of Cancer Treatment and Diagnosis– 33 US Screening Centers
• NCI Division of Cancer Prevention (LSS)• American College of Radiology Imaging Network (ACRIN)
• $300,000,000 +
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National Lung Screening TrialDesign Overview
• 53,456 participants
• Enrolled 2002 – 2004
• Ages 55-74
• Greater than 30 pack-year smoking history
• Active or quit < 15 years
Exclusions Metallic implants chest or back Treatment or evidence of cancer in previous 5
years History of lung cancer Prior lung resection except needle biopsy Home O2 requirement Symptoms: Hemoptysis, weight loss, treated
respiratory infection within past 12 weeks Chest CT within previous 18 months Participation in other cancer screening/prevention
trial Unable to lie on back with arms above head
National Lung Screening Trial Research Team (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365(5):395–409.
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National Lung Screening TrialDesign Overview
• Treatment Arms: – Low Dose Chest CT (1.5 mSv)– PA Chest Radiograph (0.02 mSv)
• Screening Intervals: – T0: Baseline prevalence screen – T1: Year 1 incidence screen– T2: Year 2 incidence screen
• Positive Test– Non-calcified nodule greater than 4mm in mean diameter– Other findings suspicious for lung cancer (adenopathy, effusion…)– Workup of positives determined by PCPs not NLST
• NLST reading radiologist recommendation available
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National Lung Screening TrialResults: Mortality
• Lung cancer specific mortality– 20% reduction in lung cancer specific mortality– LDCT = 356 deaths, CXR = 443 deaths– Median follow-up 6.5 years
• Overall mortality– 6.6% reduction in overall mortality– LDCT = 1877 deaths, CXR = 2000 deaths– Not statistically significant when lung cancer deaths
excluded National Lung Screening Trial Research Team (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365(5):395–409.
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National Lung Screening TrialResults: Other
• Lung cancer prevalence: 1%– 1 in 100 at risk patients have cancer
• Lung cancer annual incidence: 0.5 – 0.8%– Decrease in # of late stage cancers in CT group vs CXR– Real stage shift not just overdiagnosis
• Small cell lung cancer– Not detected at earlier stage– Overrepresented as interval cancers
• Number Needed to Screen (NNS) is 320
National Lung Screening Trial Research Team (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365(5):395–409.
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National Lung Screening TrialResults: Rate of Positive ScreeningsAq
• CT (24.2%) > 3x more sensitive than CXR (6.9%) – T0 & T1 Rate: 27-28%– T2 Rate: 16.8%
• 2 year stability benign (Fleischner Guidelines)• Expected rate for ongoing LDCT screening
• At least one positive result (3 screens): 39.1%• Significant incidental finding:
7.5%
• Not screening everyone – highly selected group (3%)
National Lung Screening Trial Research Team (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365(5):395–409.
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National Lung Screening TrialResults: Positive Workup/Adverse Events
• False Positives– Most have noninvasive imaging follow-up
• CXR: 14.4%• Chest CT: 49.8%• PET/CT: 8.3%
– Invasive diagnostic procedures: 2.6 %– Complication rate: 1.4%– Major complication rate: 0.06%
• True Positives– Invasive procedure major complication: 11.2%– Surgical resection mortality: 1%
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NLSTResults: False Positive Workup/Adverse Events
• False Positive Rate:– 20-25%: Chance you will end up with a false positive– ~10-12% for Mammography (“Call back”)
• False Discovery Rate (1-PPV): – 96%: Chance if you are positive you do not have cancer– Same as mammography
• False Positive Biopsy Rate– 0.4-2.4%: Chance if screened you will have an unnecessary invasive
procedure (LDCT)– 7-15%: Chance if you end up having a biopsy it will be negative
(mammography).
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NLST NEJM 6/29/2011 NCCN 10/26/2011
NLST Summary
• 20% lung cancer mortality benefit• 7% overall mortality benefit• 1 in 100 has lung cancer• NNT = 320• Opportunity to save 30,000 lives/yr
NCCN Considerations
• Prolonged debate• Cost to Society• Patient anxiety• Radiation exposure• False positives/informed consent• Operational concerns
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National Comprehensive Cancer Network (NCCN): 10/26/2011
NCCN Guidelines® for Lung Cancer Screening (V.1.2012) www.nccn.org
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NCCN RecommendationCategories
NCCN Guidelines® for Lung Cancer Screening (V.1.2012) www.nccn.org
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NCCN RecommendationCategories
NCCN Guidelines® for Lung Cancer Screening (V.1.2012) www.nccn.org
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NCCNHigh-Risk Groups
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NCCN High-Risk Group 2Risk Factors
• Personal Cancer History– Lung, lymphoma, smoking related cancers
• Family History Lung Cancer in 1st Degree Relative
• Chronic Lung Disease– Emphysema– Pulmonary Fibrosis
• Carcinogen Exposure– Arsenic, asbestos, cadmium, chromium, diesel fumes, nickel,
radon, silica
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NCCN GuidelinesSolid or Part Solid Nodules Follow-up
NCCN Guidelines® for Lung Cancer Screening (V.1.2012) www.nccn.org
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Lung Cancer ScreeningRisks and Benefits (NCCN)
NCCN Guidelines® for Lung Cancer Screening (V.1.2012) www.nccn.org
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Overdiagnosis, Survival, Mortality
Diagnosis Death
Survival
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Diagnosis Death
Survival
Mortality
Overdiagnosis, Survival, Mortality
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Diagnosis Death
Survival
Mortality
Death due to lung cancer = 20%
Lung Cancer Mortality
365
443
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Diagnosis Death
Survival
Mortality
Death due to any cause across entire group= 6.6%
Overall Mortality
1877
2000
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Overall Survival Benefit 7%Adjuvant Therapy Reduces Risk
• Breast cancer• ACT chemotherapy• 5 years anti-estrogen therapy• Post-mastectomy RT
• Prostate Cancer• Post prostatectomy RT
• Head and Neck cancer• Post-operative chemoRT
• Cervix Cancer• Post-operative chemoRT
• Medical-legal consequences
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Diagnosis Death
Mortality
OverdiagnosisDetermine time and cause of death in those patients diagnosed and treated for lung cancer
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CT Lung Cancer ScreeningMorbidity
• Radiation exposure– MDCT resolution allows for dose reduction– LDCT <1mSv, Mammography 0.7mSv
1 mSv 10 mSv
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Radiation Exposure LDCT <1 mSv Years of annual
lung screening
Mammogram .7 mSv
Lumbar Spine Films 2 mSv 2
Diagnostic Chest CT 10 mSv 10
Triphasic CT AB/P 25 mSv 25
Background Exposure Colorado
3 mSv/year4.5 mSv/year
34.5
Occupational Exposure 50 mSv/year 50
Transatlantic Flight .1 mSv 7 flights = 1 LDCT
10 -30 year latency period to develop secondary malignancies from RT exposure
Average age of patients in screening trials is 62
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LUNG-RADSOverview
• Purpose: Establish a standardized quality assurance tool to mirror the tool widely utilized in Mammography (BI-RADS).
• Objectives: – Standardize terminology– Organized reporting and assessment structure– Data collection tool to facilitate outcome monitoring
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LUNG RADSLung Number Category
• Category 1: Negative (12mo)• Category 2: Negative with
benign pulmonary findings (12mo)
• Category 3: Positive/likely benign (follow-up per NCCN guidelines)
• Category 4: Positive/suspicious for malignancy
• Category 5: Known cancer
“S” Category
• Positive for extra-pulmonary finding not suspicious for lung cancer but requiring clinical follow-up– Thyroid mass– Aneurysm– Kidney Mass
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LUNG RADSLung Number Category
• Category 1: Negative (12mo)• Category 2: Negative with
benign pulmonary findings (12mo)
• Category 3: Positive/likely benign (FU per NCCN guidelines)
• Category 4: Positive/suspicious for malignancy
• Category 5: Known cancer
“S” Category• Positive for extra-pulmonary
finding not suspicious for lung cancer but requiring clinical follow-up– Thyroid mass– Aneurysm– Kidney Mass– Fracture
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An Actuarial Analysis Shows That Offering Lung Cancer Screening As An Insurance Benefit Would Save Lives At Relatively Low Cost
• Cost per life-year saved would be below $19,000
Pyenson et al, Health Affairs 31, No.4 770-779: April 2012
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Cost-Effectiveness
Private Insurance Coverage• 11/2011 Anthem California• 12/2011 Wellpoint
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Productivity Loss due to Cancer
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Who Is Screening?• MDACC• Brigham and Women’s Hospital• Georgetown University• Thomas Jefferson University
Hospital• UCSF• Cedars-Sinai Medical Center• Yale University Cancer Center• Mayo Clinic• John Hopkins Medical Center• Memorial Sloan Kettering Cancer
Center• Lahey Clinic• Self pay rate $170 to $1000
(Average $230)
• Oncology Round Table Survey 3/2012– 32% Currently screening (n=104) – 77% Starting screening program
(n=77)– Most CT lung screening programs
have been launched in the past 9 months
– Mean # of patient’s screened in 2011 = 70
– 88% of patients pay out of pocket
The Advisory Board Company 3/12
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The Advisory Board Company 3/12
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www.Lahey.org/LungScreening1-855-CT-CHEST
Barriers to Screening
• Applicability to patients outside study group?
• Duration of screening?
• Education/awareness/endorsement
• Access to care in the absence of established reimbursement – Rescue Lung, Rescue Life
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www.Lahey.org/LungScreening1-855-CT-CHEST
Lung Cancer Screening Practices of Primary Care Physicians: Results From a National Survey
• 962 family physicians, general practitioners and general internists surveyed in 2006-2007– 38% no test– 55% CXR– 22% LDCT– <5% sputum cytology
• Multivariate modeling: – Lung cancer screening endorsed by expert groups– Screening shown to be effective– Patients ask about screening
Klabunde, PhD et al: Annals of Family Medicine Vol. 10, No.2 March/April 2012
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Lung Cancer Screening Practices of Primary Care Physicians: Results From a National Survey
• “To date, because of a lack of evidence from rigorous studies, major expert groups have not recommended screening asymptomatic individuals, even those with heavy or long-term smoking histories, for lung cancer”– US Preventative Services Task Force– American Cancer Society 2009 guidelines– American College of Chest Physicians
Klabunde, PhD et al: Annals of Family Medicine Vol. 10, No.2 March/April 2012
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Screening Endorsements• NCCN – Category I recommendation to screen
high-risk patients October 2011• American Lung Association – April 2012
– Best way to prevent lung cancer is to never smoke or quit– LDCT for NLST group (does not give parameters on frequency)– Do not screen with CXR– LDCT not for everyone– ALA to develop public health materials to educate patients– Call to action to hospitals and screening centers to screen responsibly
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• James Mulshine, MD, associate provost and vice president for research at Rush University Medical Center
• "With this positive trial result, we have the opportunity to realize the greatest single reduction of cancer mortality in the history of the war on cancer.”
![Page 60: Www.Lahey.org/LungScreening 1-855-CT-CHEST Andrea McKee, M.D. Chairman Department Radiation Oncology Sophia Gordon Cancer Center Lahey Clinic May 15, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551a0a7f55034619378b4c28/html5/thumbnails/60.jpg)
www.Lahey.org/LungScreening1-855-CT-CHEST
Why Free?• Ethical
– Make lung screening available for all socioeconomic groups until CMS reimburses
• Power of Free– Human Motivation– Few people screened when charge– Helping to Raise Awareness
• Multidisciplinary centers may not need to charge (TBD)
• Seize Opportunities to fulfill Hospital Mission• Save Lives, Growth, • Innovation, Sustainability, Teamwork
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www.Lahey.org/LungScreening1-855-CT-CHEST
How Free?• Existing Infrastructure
– Pilot – Use existing time in CT schedule (30 slots on PET/CT per
week)– 1-855-CTCHEST
– Use downtime on installed CT Scanners• M – F: 6PM-9PM (12 scans per shift)• Additional capacity exists at LCN and Burlington• Sat/Sun: 12Hrs x 2
– IT - build/manage database of findings
– January 9th started free lung screening
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www.Lahey.org/LungScreening1-855-CT-CHEST
LDCT Lung ScreeningPatient Flow
Intake StaffEvaluate Eligibility
FAQ Given
PCP Order
Patient Calls(855-CT-CHEST)
![Page 63: Www.Lahey.org/LungScreening 1-855-CT-CHEST Andrea McKee, M.D. Chairman Department Radiation Oncology Sophia Gordon Cancer Center Lahey Clinic May 15, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551a0a7f55034619378b4c28/html5/thumbnails/63.jpg)
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LDCT Lung ScreeningPatient Flow
Group 3(Refer to PCP)
Intake StaffEvaluate Eligibility
FAQ Given
PCP Order
Patient Calls(855-CT-CHEST)
Don’t Qualify
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LDCT Lung ScreeningPatient Flow
Group 3(Refer to PCP)
Intake StaffEvaluate Eligibility
FAQ Given
PCP Order
Patient Calls(855-CT-CHEST)
Call Back(Cancer History, Risk Factors)
Don’t Qualify
May Qualify
Don’t Qualify
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www.Lahey.org/LungScreening1-855-CT-CHEST
LDCT Lung ScreeningPatient Flow
Group 3(Refer to PCP)
Intake StaffEvaluate Eligibility
FAQ given
PCP Order
Patient Calls(855-CT-CHEST)
Call Back(Cancer History, Risk Factors)
Don’t Qualify
May Qualify
Don’t Qualify
Group 1 & Group 21. Record PCP2. Assign Lahey PCP if no PCP3. Schedule Appointment4. Asymptomatic Disclosure
Do Qualify
Do Qualify
![Page 66: Www.Lahey.org/LungScreening 1-855-CT-CHEST Andrea McKee, M.D. Chairman Department Radiation Oncology Sophia Gordon Cancer Center Lahey Clinic May 15, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551a0a7f55034619378b4c28/html5/thumbnails/66.jpg)
www.Lahey.org/LungScreening1-855-CT-CHEST
LDCT Lung ScreeningPatient Flow
Group 3(Refer to PCP)
Intake StaffEvaluate Eligibility
FAQ Given
Screen Patient1. No IV2. No changing3. Scan < 10 sec
PCP Order
Patient Calls(855-CT-CHEST)
Call Back(Cancer History, Risk Factors)
Don’t Qualify
May Qualify
Don’t Qualify
Group 1 & Group 21. Record PCP2. Assign Lahey PCP if no PCP3. Schedule Appointment4. Asymptomatic Disclosure
Do Qualify
Do Qualify
Obtain PCP Order
Appt Reminder Call(48 hrs before exam)
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LDCT Lung ScreeningPatient Flow
Group 3(Refer to PCP)
Intake StaffEvaluate Eligibility
FAQ Given
Screen Patient1. No IV2. No changing3. Scan < 10 sec
PCP Order
Credentialed RadiologistInterpretation
Patient Calls(855-CT-CHEST)
Call Back(Cancer History, Risk Factors)
Don’t Qualify
May Qualify
Don’t Qualify
Group 1 & Group 21. Record PCP2. Assign Lahey PCP if no PCP3. Schedule Appointment4. Asymptomatic Disclosure
Do Qualify
Do Qualify
Obtain PCP Order
Appt Reminder Call(48 hrs before exam)
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LDCT Lung ScreeningPatient Flow
Group 3(Refer to PCP)
Intake StaffEvaluate Eligibility
FAQ Given
Screen Patient1. No IV2. No changing3. Scan < 10 sec
PCP Order
(2/3 Screenings)
Schedule Rescreen (<74y)
Credentialed RadiologistInterpretation
Patient Calls(855-CT-CHEST)
Call Back(Cancer History, Risk Factors)
Don’t Qualify
May Qualify
Don’t Qualify
Group 1 & Group 21. Record PCP2. Assign Lahey PCP if no PCP3. Schedule Appointment4. Asymptomatic Disclosure
Do Qualify
Do Qualify
Obtain PCP Order
Appt Reminder Call(48 hrs before exam)
S Negative &Lung-Rads 1, 2
![Page 69: Www.Lahey.org/LungScreening 1-855-CT-CHEST Andrea McKee, M.D. Chairman Department Radiation Oncology Sophia Gordon Cancer Center Lahey Clinic May 15, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551a0a7f55034619378b4c28/html5/thumbnails/69.jpg)
www.Lahey.org/LungScreening1-855-CT-CHEST
LDCT Lung ScreeningPatient Flow
Group 3(Refer to PCP)
Intake StaffEvaluate Eligibility
FAQ Given
Screen Patient1. No IV2. No changing3. Scan < 10 sec
PCP Order
(2/3 Screenings)
(1/3 Screenings)
Schedule Rescreen (<74y)
Follow NCCN Guidelines
Credentialed RadiologistInterpretation
Patient Calls(855-CT-CHEST)
Call Back(Cancer History, Risk Factors)
Don’t Qualify
May Qualify
Don’t Qualify
Group 1 & Group 21. Record PCP2. Assign Lahey PCP if no PCP3. Schedule Appointment4. Asymptomatic Disclosure
Do Qualify
Do Qualify
Obtain PCP Order
Appt Reminder Call(48 hrs before exam)
S Negative &Lung-Rads 1, 2
S Positive or Lung Rads 3, 4, 5
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CT Lung Screen Pilot Statistics
• As of the week of 2/24/12– Patients verbally screened 209– Patients scheduled
179 85%– Patients scanned* 105
59%– Lahey patients*
156 87%– Non Lahey Patients* 23
13%
* percentage of Patients Scheduled
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Patient Survey
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Statistical Correlation to the NLST StudyLahey Pilot NLST study• Finalized cases 101
– Negative (cat 1,2) 70
– Positive (cat 3,4,) 31– Incidentals (S pos) 3
– Lahey PCP assigned 1
• Total Screened26,000• Negative 72.7%• Positive
27.3%• Incidentals 7.5%• Cancers found 1%
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www.Lahey.org/LungScreening1-855-CT-CHEST
How did you start?• Multidisciplinary
coordinated effort • Steering Committee• Evidence based• Business plan• Legal• Compliance• Education and CME
• Concerns– Informed consent – Involvement of PCP– Education regarding screening
as process– Enticement or hidden cost– Uninsured– Volume overload of radiology,
PCPs, and specialists– Perception of outside hospitals
and clinicians– How long before
reimbursement is established?
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Rescue Lung, Rescue Life MovementSteering Committee:
• Radiology– Brady McKee, MD– Sebastian Flacke, MD– Robert French, MD– Christoph Wald, MD
• Oncology– Andrea McKee, MD– Paul Hesketh, MD
• GIM– Guy Napolitana, MD– Brendan Connell, MD
• Pulmonary– Andrew Villanueva,MD– Anthony Campagna, MD– Jeffrey Klenz, MD– Carla Lamb, MD
• Administration– Richard Guarino– Jeffery O’Brien– Samuel Skura– Patricia Grady– Patricia Doyle– Angela Tambini
• Marketing– Erika Clapp
• Finance– Kevin Bennett
• Business Development– Robert Toporoff
• Philanthropy– Elizabeth Garvin
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Volume ReassuranceMammography LDCT Screen
US Population 60,000,000 9,000,000 (high-risk)
Lahey 30,000 4500
100 screenings per week
![Page 76: Www.Lahey.org/LungScreening 1-855-CT-CHEST Andrea McKee, M.D. Chairman Department Radiation Oncology Sophia Gordon Cancer Center Lahey Clinic May 15, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551a0a7f55034619378b4c28/html5/thumbnails/76.jpg)
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Volume ReassuranceMammography LDCT Screen
US Population 60,000,000 9,000,000 (high-risk)
Lahey 30,000 4500
100 screenings per week
1 cancer per week
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Volume ReassuranceMammography LDCT Screen
US Population 60,000,000 9,000,000 (high-risk)
Lahey 30,000 4500
100 screenings per week
1 cancer per week
27 positives
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Volume ReassuranceMammography LDCT Screen
US Population 60,000,000 9,000,000 (high-risk)
Lahey 30,000 4500
100 screenings per week
1 cancer per week
27 positives
7 potentially significant findings
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www.Lahey.org/LungScreening1-855-CT-CHEST
Volume ReassuranceMammography LDCT Screen
US Population 60,000,000 9,000,000 (high-risk)
Lahey 30,000 4500
100 screenings per week
1 cancer per week
27 positives
7 potentially significant findings
After 2 years we will save 1 life every 3 weeks
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Volume Reassurance
100 screenings per week
1 cancer per week
27 positives
7 potentially significant findings
After 2 years we will save 1 life every 3 weeks
~75 patients: Qualify for lung screening (NCCN high-risk)~20 patients: Positive for a lung nodule ~5 patients: Potentially significant incidental findings
Clinic
Example Individual PCP: 2500 Patient Panel
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When Will CMS Reimburse?Lung vs Breast Screening
Lung Cancer Breast Cancer
5 Yr Overall Survival 1975 12% 75%
5 Yr Overall Survival 2007 15% 89%
Screening Modality LDCT Mammogram
Screening Frequency Annual Annual/Biannual
Patient Population 30PY, 55-74y Females 40-80y
Patient Number Estimates 9,000,000 60,000,000
Cost of Exam $300 $100
Per Year Cost of 1 Screen $2.1 B $6 B
Radiation Exposure 0.5-1.7 mSv 0.7 mSv
Mortality Reduction 20% 10-35%
NNS 320 1250 (40-49y)
Overdiagnosis < 17% vs CXR* 5-50%
False Positive Rate ~35%/ 3 years 30-35%/10 years (annual)
Cost/QALY < $50,000 $38K - 58K (40-80y)
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Risks of Free Screening
• States where health insurance is not required by law– Massachusetts >98% insured– US Population statistics – ~ <4% of high-risk patients will not have
insurance
• Operational endeavor – Instructional CD
• Potential for patient harm - Lung Cancer Alliance National Framework For Excellence
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Rescue Lung, Rescue Life MovementMission:
Save lives through the early detection of lung cancer with responsible CT lung screening
Encourage the government to establish reimbursement for CT lung screening
Encourage other centers of excellence in the treatment of lung cancer to offer FREE CT lung screening until CMS establishes reimbursement
Break down barriers and prejudice faced by those at risk for lung cancer
Raise public awareness of the power of CT lung screening to save lives
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Thank You