IMPLEMENTATION OF
Lung Cancer Screening

Proceedings of a Workshop

Erin Balogh, Margie Patlak, and Sharyl J. Nass, Rapporteurs

National Cancer Policy Forum

Board on Health Care Services

Health and Medicine Division

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This project was supported by Contract No. 200-2011-38807 (Task Order No. 0051) and Contract No. HHSN263201200074I (Task Order No. HHSN26300052) with the Centers for Disease Control and Prevention and the National Cancer Institute/ National Institutes of Health, respectively, and by the American Association for Cancer Research, American Cancer Society, American College of Radiology, American Society for Radiation Oncology, American Society of Clinical Oncology, American Society of Hematology, Association of American Cancer Institutes, AstraZeneca, Bristol-Myers Squibb, Cancer Support Community, CEO Roundtable on Cancer, Helsinn Healthcare SA, LIVESTRONG Foundation, National Comprehensive Cancer Network, Novartis Oncology, Oncology Nursing Society, and Pfizer Inc. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-45132-1
International Standard Book Number-10: 0-309-45132-9
Digital Object Identifier https://doi.org/10.172216/23680

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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2017. Implementation of lung cancer screening: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/10.172216/23680.

WORKSHOP PLANNING COMMITTEE¹

GRETA MASSETTI (Chair), Associate Director for Science, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention

LORI HOFFMAN HŌGG, Veterans Health Administration National Oncology Clinical Advisor and Program Manager, Prevention Policy, Department of Veterans Affairs

SAMIR N. KHLEIF, Professor of Medicine, Biochemistry, Molecular Biology, and Graduate Studies, Augusta University

BARNETT KRAMER, Director, Division of Cancer Prevention, National Cancer Institute

LEE M. KRUG, Disease Area Head, Lung and Head & Neck Cancer, Immuno-Oncology, Bristol-Myers Squibb

CHRISTOPHER S. LATHAN, Assistant Professor of Medicine, Harvard Medical School; Director, Cancer Care Equity, Dana-Farber Cancer Institute

JENNIFER A. PIETENPOL, Director, Vanderbilt-Ingraham Cancer Center; Executive Vice President for Research, Vanderbilt University Medical Center; and Benjamin F. Byrd, Jr. Professor of Oncology, Vanderbilt University

YA-CHEN TINA SHIH, Professor of Health Economics, Chief, Section of Cancer Economics and Policy, Department of Health Services Research, University of Texas MD Anderson Cancer Center

ROBERT SMITH, Vice President, Cancer Screening, American Cancer Society

JAMIE L. STUDTS, Associate Professor, Department of Behavioral Science, University of Kentucky College of Medicine; Director, Behavioral & Community-Based Research Shared Resource Facility, Markey Cancer Center

DANIEL SULLIVAN, Professor Emeritus, Department of Radiology, Duke University School of Medicine

___________________

¹ The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.

ROBERT J. VOLK, Professor, Department of Health Services Research, Division of Cancer Prevention and Population Sciences, University of Texas MD Anderson Cancer Center

Project Staff

SHARYL J. NASS, Director, National Cancer Policy Forum

ERIN BALOGH, Senior Program Officer

CYNDI TRANG, Research Assistant

PATRICK ROSS, Research Assistant (until July 2016)

NATIONAL CANCER POLICY FORUM¹

MICHAEL CALIGIURI (Chair), Chief Executive Officer, James Cancer Hospital and Solove Research Institute; Director, The Ohio State University Comprehensive Cancer Center

PATRICIA A. GANZ (Vice Chair), Distinguished Professor, University of California, Los Angeles, Fielding School of Public Health; Director, Cancer Prevention and Control Research, Jonsson Comprehensive Cancer Center

AMY P. ABERNETHY, Chief Medical Officer and Senior Vice President for Oncology, Flatiron Health

LUCILE ADAMS-CAMPBELL, Professor of Oncology, Associate Director for Minority Health and Health Disparities Research, Georgetown University Lombardi Cancer Center

KENNETH ANDERSON, Kraft Family Professor of Medicine, American Cancer Society Clinical Research Director, Jerome Lipper Multiple Myeloma Center, Harvard Medical School, Dana-Farber Cancer Institute

MONICA M. BERTAGNOLLI, Richard E. Wilson Professor of Surgery, Harvard Medical School; Chief, Division of Surgical Oncology, Dana-Farber/Brigham and Women’s Cancer Center; Group Chair, Alliance for Clinical Trials in Oncology

OTIS W. BRAWLEY, Chief Medical Officer, American Cancer Society

ROBERT W. CARLSON, Chief Executive Officer, National Comprehensive Cancer Network

GREGORY CURT, Executive Director, External Scientific and Clinical Relations, U.S. Medical Affairs, AstraZeneca

WENDY DEMARK-WAHNEFRIED, Professor and Webb Endowed Chair of Nutrition Sciences, Associate Director for Cancer Prevention and Control, University of Alabama at Birmingham Comprehensive Cancer Center

___________________

¹ The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.

GEORGE D. DEMETRI, Professor of Medicine, Harvard Medical School; Director, Ludwig Center; Senior Vice President for Experimental Therapeutics, Dana-Farber Cancer Institute; Associate Director for Clinical Sciences, Dana-Farber/Harvard Cancer Center

JAMES H. DOROSHOW, Deputy Director for Clinical and Translational Research, National Cancer Institute

JOHN FRIEND II, Senior Vice President, Helsinn Therapeutics

LORI HOFFMAN HŌGG, Veterans Health Administration National Oncology Clinical Advisor and Program Manager, Prevention Policy, Department of Veterans Affairs

LINDA HOUSE, President, Cancer Support Community

HEDVIG HRICAK, Chair, Department of Radiology, Memorial Sloan Kettering Cancer Center

LISA KENNEDY SHELDON, Chief Clinical Officer, Oncology Nursing Society; Editor, Clinical Journal of Oncology Nursing

SAMIR N. KHLEIF, Professor of Medicine, Biochemistry, Molecular Biology, and Graduate Studies, Augusta University

RONALD M. KLINE, Medical Officer, Patient Care Models Group, Center for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services

LEE M. KRUG, Disease Area Head, Lung and Head & Neck Cancer, Immuno-Oncology, Bristol-Myers Squibb

RICHARD A. LARSON, Professor of Medicine and Director, Hematologic Malignancies Clinical Research Program, The University of Chicago Comprehensive Cancer Center

MICHELLE M. LE BEAU, Arthur and Marian Edelstein Professor of Medicine and Director, The University of Chicago Comprehensive Cancer Center

GRETA MASSETTI, Associate Director for Science, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention

DANIEL R. MASYS, Affiliate Professor, Biomedical and Health Informatics, University of Washington School of Medicine

MARTIN J. MURPHY, Chief Executive Officer, CEO Roundtable on Cancer

LOYCE PACE, Executive Director, Global Health Council (LIVESTRONG Representative)

RICHARD PAZDUR, Director, Oncology Center of Excellence; Acting Director, Office of Hematology and Oncology Products, Food and Drug Administration

STEVEN PIANTADOSI, Phase One Foundation Endowed Chair and Director, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center

JENNIFER A. PIETENPOL, Director, Vanderbilt-Ingraham Cancer Center; Executive Vice President for Research, Vanderbilt University Medical Center; and Benjamin F. Byrd, Jr. Professor of Oncology, Vanderbilt University

MACE L. ROTHENBERG, Chief Development Officer, Oncology, Pfizer Global Product Development, Pfizer Inc.

RICHARD L. SCHILSKY, Senior Vice President and Chief Medical Officer, American Society of Clinical Oncology

DEBORAH SCHRAG, Chief, Division of Population Sciences, Professor of Medicine, Department of Medical Oncology, Harvard Medical School, Dana-Farber Cancer Institute

YA-CHEN TINA SHIH, Professor of Health Economics, Chief, Section of Cancer Economics and Policy, Department of Health Services Research, University of Texas MD Anderson Cancer Center

ELLEN V. SIGAL, Chair and Founder, Friends of Cancer Research

RALPH WEICHSELBAUM, Daniel K. Ludwig Professor and Chair, Department of Radiation; Oncology and Cellular Director, Ludwig Center for Metastasis Research, The University of Chicago Medical Center

GEORGE J. WEINER, President, Association of American Cancer Institutes; C.E. Block Chair of Cancer Research, Professor of Internal Medicine, and Director, Holden Comprehensive Cancer Center, University of Iowa

RICHARD WOODMAN, Senior Vice President and Head, North America Oncology Clinical Development & Medical Affairs, Novartis Pharmaceuticals Corporation

WENDY WOODWARD, Associate Professor and Section Chief of Clinical Breast Radiation, Department of Radiation Oncology, University of Texas MD Anderson Cancer Center

National Cancer Policy Forum Staff

SHARYL J. NASS, Forum Director and Director, Board on Health Care Services

ERIN BALOGH, Senior Program Officer

SYLARA MARIE CRUZ, Senior Program Assistant

MATINA KAKALIS, Summer Intern (May-July 2016)

KIMBERLY MAXFIELD, Mirzayan Science and Technology Policy Fellow (January-May 2016)

PATRICK ROSS, Research Assistant (until July 2016)

CYNDI TRANG, Research Assistant

PATRICK BURKE, Financial Officer

Reviewers

This Proceedings of a Workshop has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published Proceedings of a Workshop as sound as possible and to ensure that the Proceedings of a Workshop meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this Proceedings of a Workshop:

MICHAEL K. GOULD, Kaiser Permanente

ELLA KAZEROONI, University of Michigan

MICHAEL L. LEFEVRE, University of Missouri

PETER MAZZONE, Cleveland Clinic

IDE MILLS, Patient Advocate

Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the Proceedings of a Workshop before its release. The review of this Proceedings of a Workshop was overseen by SUSAN J. CURRY, University of Iowa. She

was responsible for making certain that an independent examination of this Proceedings of a Workshop was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this Proceedings of a Workshop rests entirely with the rapporteurs and the institution.

IN MEMORIAM

This Proceedings of a Workshop is dedicated to Dr. Gregory Curt, an accomplished physician and scientist, a valued member of the National Cancer Policy Forum, and an irreplaceable colleague and friend.

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Acknowledgments

Support from the many annual sponsors of the National Academies of Sciences, Engineering, and Medicine’s National Cancer Policy Forum is crucial to the work of the Forum. Federal sponsors include the Centers for Disease Control and Prevention and the National Cancer Institute/National Institutes of Health. Non-federal sponsors include the American Association for Cancer Research, American Cancer Society, American College of Radiology, American Society for Radiation Oncology, American Society of Clinical Oncology, American Society of Hematology, Association of American Cancer Institutes, AstraZeneca, Bristol-Myers Squibb, Cancer Support Community, CEO Roundtable on Cancer, Helsinn Healthcare SA, LIVESTRONG Foundation, National Comprehensive Cancer Network, Novartis Oncology, Oncology Nursing Society, and Pfizer Inc.

The Forum wishes to express its gratitude to the expert speakers whose presentations helped examine the policy and implementation issues in lung cancer screening. The Forum also wishes to thank the members of the planning committee for their work in developing an excellent workshop agenda.

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Contents

ACRONYMS AND ABBREVATIONS

INTRODUCTION

EVIDENCE BASE FOR LUNG CANCER SCREENING

ELIGIBILITY, CLINICAL PRACTICE GUIDELINES, AND MODELING

Representativeness of the NLST Population

Adherence to Clinical Practice Guidelines

INSURANCE COVERAGE OF LUNG CANCER SCREENING

CMS National Coverage Decision on Lung Cancer Screening

SHARED DECISION MAKING

Patient Decision Aids

CHALLENGES TO IMPLEMENTATION OF LUNG CANCER SCREENING PROGRAMS

Clinician Awareness and Concerns About Lung Cancer Screening

Incorporation of Lung Cancer Screening in Clinical Practice

Patient Access to Screening and Health Disparities

OVERCOMING IMPLEMENTATION CHALLENGES

Clinician and Practice Strategies

Patient Outreach and Information Needs

Patient Access to Lung Cancer Screening

SCREENING PROGRAM CAPACITY

STRUCTURING LUNG CANCER SCREENING PROGRAMS

Program Set-Up

Lessons Learned

ENSURING THE QUALITY OF LUNG CANCER SCREENING

Confirming Eligibility for Lung Cancer Screening

Maintenance of Annual Lung Cancer Screening

Ensuring Access to Smoking Cessation Services

High-Quality Image Interpretation and Management of Findings

Monitoring Results

SMOKING CESSATION AND LUNG CANCER SCREENING

Challenges in Implementation

Results of Cessation Efforts Linked to Screening Programs

Risk Perception

Impact of Screen Results on Willingness to Quit

The Importance of Empathy

Intensity of Smoking Cessation Programs and Quitting Success

VALUE AND EFFICIENCY IN LUNG CANCER SCREENING

SUGGESTED AREAS OF RESEARCH

WORKSHOP WRAP-UP

REFERENCES

APPENDIX A: Statement of Task

APPENDIX B: Workshop Agenda

APPENDIX C: Glossary

Boxes, Figures, and Tables

BOXES

1 Suggestions Made by Individual Workshop Participants to Improve Implementation of Lung Cancer Screening

2 Risk Modeling for Assessing Lung Cancer Risk and Selecting Screening Participants

3 Resources and Tools to Facilitate Implementation of Lung Cancer Screening

4 Department of Veterans Affairs Lung Cancer Screening Pilot

5 Cleveland Clinic’s Lung Cancer Screening Program

FIGURES

1 Age and smoking pack-year history eligibility criteria for lung cancer screening from different organizations

2 Variability in lung cancer screening among different institutions

3 Aetna LDCT screening utilization

4 Percent change in LDCT scans performed by health service area

5 CT scanner capacity and geographic disparities in the United States by health service area

TABLES

1 Overview of the Current Eligibility Criteria for LDCT Lung Cancer Screening

2 Projected Likelihood Over 6 Years of Lung Cancer Death with or Without Screening per 1,000 Persons Screened

3 The Effect of Patient Decision Aids Compared to Usual Care

4 Quality Dimensions for Decision Aids Defined by the International Patient Decision Aids Standards Collaboration

5 American College of Radiology Lung-RADS Structured Reporting and Management

6 Incremental Costs According to Subgroups in Examining the Cost-Effectiveness of Screening with Low-Dose Computed Tomography in the National Lung Screening Trial

Acronyms and Abbreviations