Getting lung cancer screening right in the community setting

When Methodist Health System, a community hospital in Omaha, Neb., first launched lung cancer screening in November 2000, the Midwest provider was finding significantly more nodules in its patients than other screening sites reported. “Academic centers on the coast had a nodule detection rate of 15 to 20 percent; ours was 70 percent,” recalled Richard Kutilek, MD. The difference, however, reflected disparate patient populations not clinical expertise.

Providers on the East and West coasts dominated early adoption of lung cancer screening. The highly agricultural Midwest, particularly communities near major rivers, is characterized by a different patient demographic than coastal providers. Histoplasmosis is prevalent, translating into an unusually high nodule detection rate.

The challenge of the Methodist’s unique patient demographics was exacerbated by early algorithms. Follow-up algorithms, which were developing in the first half of the decade, called for fairly rigorous follow-up of nodules.

At the time, which pre-dated the advent of low-dose CT, the algorithm recommended follow-up CT scans at 3, 6, 12, 18 and 24 months for patients with nodules. Methodist ceased promoting its program until November 2007, when it joined the International Early Lung Cancer Action Project (I-ELCAP). The more mature I-ELCAP algorithm advised annual scanning for the small nodules like those found in the program’s patients.

“Then we saw we could offer screening without the downside of overradiating the patient,” said Kutilek, medical director of imaging at Methodist Estabrook Cancer Center.

Kutilek credits the program’s success to its partnership with I-ELCAP and its staffing infrastructure. One of the largest challenges in lung cancer screening, he noted, is decision-making on nodules in the intermediate range and deciding when to follow a nodule more aggressively and when to watch it. “It’s helpful to have a resource such as I-ELCAP. We can share scans with them and get recommendations.”

In terms of infrastructure, most current-generation CT systems and radiology departments can handle the basics of a 2-3 minute screening CT. Staffing is a key differentiator of an effective lung cancer screening program.

Lung cancer screening is analogous to breast cancer screening in many ways, said Kutilek. Methodist employs a screening coordinator to manage patient care, which includes not only tracking patients and ensuring that they adhere to follow-up imaging but also educating them prior to the scan.

“She prepares patients for the likelihood of finding a nodule and sensitizes them to the fact that there may be a finding,” explained Kutilek.

Another key resource is the physician champion. A sustainable lung cancer screening program requires clinical teamwork and financial resources. A physician champion can promote the program to primary care providers, engage the essential multidisciplinary team to review and follow abnormal findings and, equally important, lobby for funding.

“Lung cancer screening won’t be a big moneymaker. Our hospital agreed to charge $250 a scan, and we secured a foundation grant to subsidize the cost at $175 on the condition that screening is free to patients who can’t afford it,” Kutilek explained.    

Currently, Methodist Health System screens nearly 600 patients, and has found 18 cancers, primarily stage 1, in its cohort. While its patient demographics may differ from the majority of its screening colleagues, the goals—early diagnosis and cancer-free survival—are universal.