Low-Dose Chest CT Reduces Lung Cancer Mortality, but Barriers Remain

Florian Fintelmann, MD

Lung cancer screenings with low-dose chest CT has led to early disease detection and subsequent reduction in mortality, according to Florian Fintelmann, MD; however, despite these benefits, screening barriers remain.

“It’s a fairly new test. The approval came about 5 years ago in terms of coverage decision at the national level, so I think that word is still getting out. I want to help promote awareness,” Fintelmann explained. “Some of the barriers [to screening include] socioeconomic barriers, such as fears that this won’t be covered by insurance. However, it is covered under the Affordable Care Act based on the US Preventive Services Task Force [USPSTF] recommendation.”

Other barriers include a lack of awareness, unfamiliarity with screening guidelines, access challenges, cost concerns, stigma, skepticism regarding evidence supporting its use, the identification of eligible patients, and the management of abnormal results, added Fintelmann.

In an interview with OncLive® during a 2020 Institutional Perspectives in Cancer webinar on lung cancer, Fintelmann discussed lung cancer screening with low-dose chest CT, barriers to testing, and the potential expansion of USPSTF lung cancer screening guidelines. He is a radiologist specializing in thoracic imaging and intervention, head of Thoracic Imaging Percutaneous Thermal Ablation at Massachusetts General Hospital, and an assistant professor at Harvard Medical School.

OncLive^®: Could you start off by speaking to the importance of screening with low-dose chest CT?

Fintelmann: Lung cancer screening with low-dose chest CT has been shown to save lives. It is important that lung cancer screening is viewed not as a [single] test but as a process—[especially since] we have seen a high false- positive rate. We need to [adequately] manage these findings over time. Multiple observations allow us to separate the patients with true cancer [from] those with nodules that are not necessarily harmful.

What are the current recommendations for screening? What does this process look like in practice?

Based on current guidelines, lung cancer screening is indicated for patients aged between 55 and 80 years. When screening has been recommended, it is expected that the patients have at least 30 pack-years of smoking history and are either [currently] smoking or have stopped smoking within the past 15 years. USPSTF is currently reevaluating whether they should extend the screening guidelines to younger patients and those with less smoking history. However, as it stands, this is where patients would start.

Their process would begin with a referring provider; this can be a primary care physician or an oncologist. Patients can expect an informed decision visit or that the process of informed decision-making [will occur as part of] a visit. It is [recommended] that this visit should include a discussion about the risks of the radiation, the need for multiple testing, and the anxiety that can be induced by the potential of false-positive findings. Following that shared decisionmaking discussion with the patients, an order needs to be placed for the patient to be seen in the radiology department for a noncontrast, low-dose chest CT. That only takes seconds to acquire, so the whole visit should not take longer than 15 minutes. After that, the findings will be interpreted by a radiologist, and a Lung–Reporting and Data System [RADS] score will be issued. The Lung-RADS score is used to interpret findings on these screening chest CTs; it is coupled with a management recommendation.

How is the Lung-RADS score used to inform next steps?

There is usually a high incidence of findings that don’t necessarily mean anything for patients in the immediate term. Lung-RADS are issued by the radiologist to the referring provider to provide a sense of what to do next. Usually, most patients will receive a Lung-RADS score of 1 or 2; a score of 1 means that there is no nodule, whereas a score of 2, which is more common, will indicate that there is a nodule, but there’s nothing to do other than follow up in 1 year and continue annual lung cancer screenings with low-dose chest CT.

[However, a score of] 3 is somewhat more concerning; for that, they would say, “OK, repeat the chest CT in 6 months.” Finally, patients who have a score of 4, which is the highest category, should see a subspecialist or have a PET-CT, a contrast-enhanced CT, or a biopsy to really escalate management. Those recommendations are based on the lesion size and attenuation.

Although a couple of trials have demonstrated the benefit of lung cancer screening, screening rates are still not as high as they should be. What are some of the barriers?

[In addition to socioeconomic barriers,] there are sensitivities around lung cancer screening based on smoking history. [We also need to consider] the perception of patients; [some may] feel that they are being stigmatized or singled out. It’s the responsibility of the provider and society as a whole to say, “Look, it’s OK. We’re screening for many other conditions. You’re helping yourself and everyone else by getting this detected early.” Based on the literature, there are also barriers on the side of the referring provider in terms of not explaining well enough that this [screening] is indicated and necessary.

What measures have been implemented at your institution to encourage patients to return for follow-up screening?

As I mentioned, this is a process. The single test may not be that helpful; it’s the series of tests [that matters]. Engagement from the program coordinator or patient navigator has been very important for us at our institution; this is someone who we work with closely. Her role is to keep tabs on all the different patients and ensure that they follow up; she nudges the provider and the patient, especially if the Lung-RADS [score is] 3 or 4. [Those with a score of 4] really need to stay on top [of their screenings]. For those with a Lung-RADS score of 1 or 2, we typically send reminder letters. A third element would probably be an electronic reminder system on the part of the referring providers, such as an electronic medical record system that can give pop-up reminders. Those 3 approaches are a good starting point [for best practices].

What is your advice to those discussing screening with their patients?

[The patient needs to know that it’s their] best shot for dealing with lung cancer. The literature shows that the later we detect the cancer, the worse survival will be, despite advances made with targeted therapy. [With these approaches,] you’re only buying months, maybe years in particular circumstances. The best chance of long-term survival is to detect [the disease] early and deal with it early. [This can be done through] surgery if we are able to or radiation therapy if a patient is not a surgical candidate. For some patients who aren’t eligible for surgery or radiation, we’ll use a percutaneous ablative technique.

As a radiologist, would you say that the risk of radiation exposure is minimal for these patients?

Correct. The CT protocols allow for lower radiation levels, probably akin to background radiation. [Everyone] gets exposed to background radiation every year. Background levels vary depending on where you live and how much radon exposure you have there. Of course, you’re doubling the background level [with this testing], so it’s not negligible, but you’re comparing that with the risk of developing a very deadly disease.

That’s why it’s important to keep in mind that we’re not saying everyone should receive a chest CT every year. The message is specifically for patients who are at high risk for lung cancer. A lot of thinking goes into balancing the pros and cons [of this testing]: The pros include that you can save patients if you detect their lung cancer early, and the cons can include the radiation [itself], the costs, the anxiety, and the effort. However, in summary, if you [weigh] the evidence on both sides of the scale, it [will favor] the side of high-risk patients getting screened.

Do you feel there is enough evidence to warrant the expansion of the USPSTF guidelines?

There is evidence, but whether or not there is enough will depend on what the panel decides. I would welcome the expansion, and it seems that the expansion is going to happen. It’s premature, [though,] for me to say one way or the other. However, from my perspective, it stands to reason that an expansion makes sense. I know that the panel will look at the best evidence they can gather and will have consultants who can inform them [further before they reach a decision].