RSNA: Lung cancer screening—where hope and fear converge

CHICAGO—My biggest hope was that the National Lung Screening Trial (NLST) would work, Reginald Munden, MD, MBA, of MD Anderson Cancer Center in Houston, told an audience Nov. 26 at the annual meeting of the Radiological Society of North America (RSNA). Munden also shared his biggest fear—that  NLST would work.

Lung cancer screening differs from other organized screening initiatives, Munden said, because findings have to be managed differently. Hence, learning from the experiences (and mis-steps) of early adopters is essential.

“I can’t emphasize enough the need for a multidisciplinary team,” Munden said. This team should include a radiologist, primary care physician, surgeon, pulmonologist, prevention physician, oncologist and radiation oncologist. Other key players include a physicist to answer questions about radiation; a coordinator to serve as the face of the screening program, meet patients and answer their questions; a marketing representative; and a patient advocate.

One of the first steps to establishing a screening program is to establish guidelines regarding who will be screened and how often. MD Anderson initially used guidelines a bit broader than NLST, but reverted to NLST recommendations as the data apply to those criteria.

Other decisions can be more challenging.

For example, there are pros and cons to physician ordering and patient self-referral of studies. Self-referral is standard in mammography but an anomaly in lung cancer screening, said Munden. On the plus side, a physician order requires the patient to visit a physician, who can provide counseling about smoking and the risks of screening. However, this approach requires two visits for the patient, which might deter some patients.

Providers also need to decide on a payment model: self-pay or no fee. Lung cancer screening costs range from free to $400-$500, according to Munden, and two third-party payers, WellPoint and Blue Cross/Blue Shield, cover the exam.

Munden anticipates wider coverage in the future, and cautioned that practices may run into issues if they offer free screening now and then start charging when insurers start covering can the exam. On the flip side, providers may be able to cost-justify free screening with downstream revenues.

Screening is limited to the healthy wealthy in practices that use the self-pay model, said Munden. However, they minimize the equity issue if they tap into philanthropic funding to cover costs for other patients.

“Marketing can make or break the program,” Munden said. He noted the initial deluge of hundreds of calls when MD Anderson announced its screening program slowed to a trickle within weeks. “Patient interest dies over time. You need to keep numbers to sustain program,” he explained.

Another lesson learned came on the implementation side. Munden admitted he underestimated its import. “Have a phone hotline system for the screening program. It’s an emotional decision. If there is a delay, people can convince themselves self not to screen.” MD Anderson uses an 800 phone number and trained operators to use a decision tree analysis to answer patient questions.

Another operational issue is scheduling. MD Anderson initially blocked off Friday afternoon, a typically slow time, for lung cancer screening. The plan failed. Referring physicians wanted immediate access for patients who requested screening, and with 12 scanners at his disposal Munden can fit in most patients immediately.

Munden also recommended standardized reporting. If radiologists begin inundating physicians with a variety of non-standard reports, screening could fail, he said. MD Anderson also sends patients a copy of their report to ensure that results are communicated.

Finally, he recommended that healthcare facilities develop and maintain a good database to lay the groundwork for future research to improve lung cancer screening in practice.