LUNG CANCER SCREENING IMPROVING LUNG CANCER SURVIVAL IN THE - PDF document

8/19/2018 LUNG CANCER SCREENING IMPROVING LUNG CANCER SURVIVAL IN THE COMMUNITY SETTING Scott Skibo, MD, FCCP Haywood Regional Medical Center Duke LifePoint 1

8/19/2018 PRACTICE LOCATION 159 Bed Hospital 2

8/19/2018 “ At present, lung cancer is recognized late. Opportunities to improve survival are through earlier detection, accurate diagnosis, accurate localization, and curative therapy…” Carbone, PP NIH Conference Annals of Internal Medicine (1970): 73:1003 3

8/19/2018 LUNG CANCER SURVIVAL RATES BY STAGE at 10 years 1 AT DIAGNOSIS at 5 years 2 1. American Cancer Society: Facts and Figures 2013. 2. SEER Cancer Statistics Review; 1975-2008; National Cancer Institute, Accessed March 2013 . 4 | 4

8/19/2018 DIAGNOSING LUNG CANCER EARLY Current State Ideal State of new cases have of new cases have late-stage cancer. Early-stage cancer. (Stage III or IV) (Stage I or II) 5

8/19/2018 SCREENING FOR LUNG CANCER: EARLY DETECTION MATTERS • 70% of patients found to have lung cancer in the LDCT arm of the National Lung Screening Trial (NLST) were diagnosed in the early stages 1 • Only 320 LDCT screenings are needed to prevent one death 1 • In the NLST, the mortality for patients at high risk receiving LDCT screening was reduced by 20% vs. X-ray 1 • LDCT screening costs $1631 per person, or $81,0000 per quality- adjusted year gained in comparison with with no screening 2 1. N Engl J Med. 2011;365(5):395-409 2. N Engl J Med. 2014;371:1793-1802 6

8/19/2018 SO HAS THIS HAPPENED? • USPSTF updated guidelines in 2013 recommending yearly screening for lung cancer using LDCT • 2015 Medicare/Insurance reimbursed test • The importance of detecting lung cancer early and managing incidental pulmonary nodules is well known and accepted. 7

8/19/2018 FEWER THAN 4% OF HIGH RISK PATIENTS GET SCREENED FOR LUNG CANCER- AND NOT CHANGED BY USPSTF GUIDELINES • 2010 National Health Interview Survey found that only 3.3% of high risk smokers had been screened by LDCT the previous year • 2015 National Health Interview Survey found that only 3.9% of high risk smokers were screened by LDCT • In 2015, 6.8 million current and former smokers were eligible for CT screening- only 262,700 were actually screened. JAMA Oncology 2017;3(9):1278-1281 8

8/19/2018 IN 2016 ONLY 1.9% OF 7.6 MILLION ELIGIBLE PATIENTS UNDERWENT LDCT SCREENING • Only 1.6% of eligible heavy smokers in the South underwent LDCT • Region has the most accredited screening sites (663/1796) • Most eligible patients (3,072,095/7,612,975) • In contrast- 65% of women age 40 or older underwent mammography for breast cancer screening in 2015 • Pham DC, et al, ASCO 2018, Abstract 6504 9

8/19/2018 WHY IS THE RATE OF SCREENING HIGH RISK PATIENTS SO LOW? (THIS IS AN EVIDENCE BASED, GUIDELINE RECOMMENDED, AND MEDICARE APPROVED TEST) WHAT CAN BE DONE TO CHANGE THIS? 10

8/19/2018 WHY IS THE SCREENING RATE SO LOW? • Are physicians not referring enough? • Are eligible patients not wanting screening, even if they know a test is available? 11

8/19/2018 WHY IS THE SCREENING RATE SO LOW? (PROVIDERS) • Knowledge of, attitudes toward, and use of LDCT for lung cancer screening among family physicians • 98% felt LDCT increased odds of detecting cancer at an earlier stage • 75% felt the benefits outweighed the harms • 76% discussed risks/benefits of LDCT in some capacity with their patients • >50% reported making one or no screening recommendations in the past year Cancer 2016;122:2324-31 12

8/19/2018 WHY IS THE SCREENING RATE SO LOW? (PROVIDERS) • LDCT screening practices and attitudes among primary care providers at an academic medical center • Few PCPs ordered lung cancer screening • 21% X-ray, 12% LDCT, 3% sputum cytology • <50% of PCPs knew three or more of the six guideline components for screening, and 24% knew zero • 30% of providers doubted effectiveness of LDCT in improving outcomes • This study was conducted at a medical center that participated in the NLST Cancer Epidemiol Biomarkers Prev 2015; 24(4): 664-70 13

8/19/2018 WHY IS THE SCREENING RATE SO LOW? (PROVIDERS) • What are the factors associated with LDCT screening utilization? • Lack of knowledge led to a 37% inappropriate referral rate from 2013 to 2015 1 • Almost 2/3 of physicians are unsure whether CMS covers the cost of LDCT 2 • 82% of providers are interested in learning more about lung cancer screening 1 1.Prev Med Rep 2017 Jun; 6 :17-22 2. Cancer 2016;122:2324-31 14

8/19/2018 WHAT HAS BEEN LEARNED? (PROVIDERS) • There is a well documented disconnect in moving clinical research findings into clinical practice (1981 Beta-Blocker Heart attack Trial, etc) 1 -This is a evidence based, guideline recommended, Medicare covered test. • Physician knowledge is not optimal • Physician belief that LDCT is valuable for early detection, but a lower proportion believe that LDCT reduces lung cancer mortality 2 • Physicians believe lung cancer screening to be less efficacious than other cancer screenings 2 1. N Engl J Med. 2003;349:868-874 2. Cancer Epidemiol Biomarkers Prev. 2015;24:664-670 15

8/19/2018 WHY IS THE SCREENING RATE SO LOW? (PATIENTS) • 60% of patients that qualify for LDCT screening adhered to recommendation • Younger, white, and female patients show a trend towards better adherence 1 • No difference for cancer history, residential area, level of education, type of insurance, occupation, or provider location 1 • 79% of the patients that did not go through with their prescribed LDCT wanted to do one in the future 1 • Fatalistic beliefs, fear of radiation exposure, and anxiety related to CT scans 2 • Those who quit smoking or smoke less are more likely to be adherent 1 • (smokers are less likely to seek out care for lung cancer) 3 1. Prev Med Rep. 2017 Jun;6:17-22 2. Lung Cancer. 2012;77(3):526-531 3. Thorax. 2016 (PubMed PMID: 26911574) 16

8/19/2018 WHY IS THE SCREENING RATE SO LOW (PATIENTS) Those who quit smoking or smoke less are more likely to be adherent 1 • (smokers are less likely to seek out care for lung cancer) 3 • Patients may perceive screening-detected lung cancer as confirmation of a poor lifestyle choice 2 1. Prev Med Rep. 2017 Jun;6:17-22 2. Pham DC et al. ASCO 2018, Abstract 6504 3. Thorax. 2016 (PubMed PMID: 26911574) 17

8/19/2018 WHAT CAN BE DONE TO IMPROVE SCREENING RATE? • Provider Education • Most (82%) were interested in learning more about LDCT 1 • 59% stated an on-line lecture was the preferred method 1 • Focus on mortality reduction, CMS coverage • In office decision aides • Patient Education • Decision aids reduce the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication 2 • Community outreach 1. Prev Med Rep. 2017;6:17-22 2. Cochrane Database Syst Rev. 2014;1:CD001431 18

8/19/2018 SHARED DECISION AIDS IMPROVE ADHERENCE TO LDCT SCREENING Providers who discussed the benefits of LDCT screening with the use of shared decision aids increased screening participation from 10% to 95% 1 • 1. Asian Pac. J. Cancer Prev. 2015;16(15):6293-6298 19

8/19/2018 SHARED DECISION MAKING MATERIALS 20

8/19/2018 PHYSICIAN OUTREACH/EDUCATION = Individual practices visited 21

8/19/2018 COMMUNITY OUTREACH/EDUCATION NEWSPAPERS 22

8/19/2018 COMMUNITY OUTREACH/EDUCATION LOCAL TV 23

8/19/2018 COMMUNITY OUTREACH/EDUCATION COMMUNITY EVENTS 24

8/19/2018 LUNG CANCER SCREENING OUTCOMES • 2016 • 2017 • 96 total screens • 269 total screens • LR-3 10 • LR-3 22 • LR-4 6 • LR-4 18 • Diagnosed Cancer 2 • Diagnosed Cancer 3 25

8/19/2018 2016 & 2017 LDCT Screenings 2016 2017 40 35 30 25 20 15 10 5 0 January December 26

8/19/2018 2018 – THROUGH JULY WE HAVE SCREENED 277 PATIENTS 96 269 474 27

8/19/2018 LUNG CANCER DIAGNOSED BEFORE AND AFTER PROGRAM DEVELOPMENT (SYSTEM WIDE) N= 31 (20% Stage 1 and 2) N=92 (56% Stage 1 and 2) • 2014 (Pre- ENB) • 2015 (Post-ENB) 10% 26% 10% Stage 1 Stage 1 29% Stage 2 Stage 2 48% Stage 3 Stage 3 32% 18% Stage 4 Stage 4 27% 28

8/19/2018 54% OF OUR PATIENTS DIAGNOSED WITH NSCLC IN 2017 EITHER UNDERWENT SURGICAL RESECTION OR STEREOTACTIC RADIOSURGERY (SBRT) 29

8/19/2018 NEXT STEPS • Improve adherence to LDCT • QI program launched to improve efficiency of scheduling process (automation) • Piloting a program for same day screening. • Revisiting primary care programs/improved shared decision making materials • Expand availability of LDCT screening exams beyond our immediate market 30

8/19/2018 DIAGNOSING LUNG CANCER EARLY Current State Ideal State 56% 85% of new cases have of new cases have early-stage cancer. Early-stage cancer. (Stage I or II) (Stage I or II) 31

8/19/2018 POLICY CHANGE IS NEEDED TO IMPROVE ADHERENCE NATIONALLY • Make lung cancer screening a national quality health measure for healthcare systems by CMS to optimize reimbursement • In 2008 CMS made mammograms for breast cancer and colonoscopies for colorectal cancer national areas of improvement 32

8/19/2018 QUESTIONS? 33