Centralized lung cancer screening program aims to reduce mortality, late-stage disease

For pulmonologist Nichole Tanner, M.D., increasing uptake of lung cancer screening goes far beyond a simple research interest — it’s a passion driven by the patients sitting in front of her at MUSC Hollings Cancer Center.

“I’ve diagnosed people with stage 3 and 4 lung cancer who would have been eligible for screening but simply didn’t know about it. While we have new and cutting-edge precision oncology treatments that were not available just a few years ago for stage 4 lung cancer, we still cannot say that we can cure it,” said Tanner.

“Instead of consoling patients and their family members as I point to all of the places on the scans where their cancer has spread, I would much rather be able to tell them that we found it early and that a cure is very possible. I’m excited to come into work every day to advance early detection efforts and to figure out how we can reach those at risk for lung cancer.”

Lung cancer screening for those who are eligible has been a covered service by the Centers for Medicare and Medicaid Services and most private insurers for nearly six years, but it’s estimated that only about 4% of those who are eligible have been screened. According to Hollings researchers, health disparities, unequal access to screening, stigma surrounding smoking and lack of education about the benefits of screening are all barriers that prevent people from being screened.

To increase screening uptake and awareness, staff at Hollings have built a centralized program that merges screening services with a robust tobacco treatment program, allowing providers an opportunity to have a balanced conversation with patients who are at high risk for lung cancer about the benefits of screening for early detection and options for tobacco treatment for those who currently smoke.

Started in 2015 and co-directed by Tanner and tobacco treatment specialist Benjamin Toll, Ph.D., the comprehensive lung cancer screening program is supported by the multidisciplinary thoracic oncology program at Hollings. Suspicious screening scans are reviewed by a Virtual Thoracic Tumor Board that brings together a group of specialists who represent more than 200 years of medical knowledge to review the case and discuss the next best steps.

 

Lung cancer screening at MUSC Health has a hybrid design that enables primary care providers either to screen eligible patients in their own practice or to refer their patients to the centralized Hollings Lung Cancer Screening Program. While providers often don’t have much time to discuss preventive care during a patient visit where chronic disease management is often the focus, specialists at Hollings have the luxury of being able to solely focus on lung cancer screening as a preventive service. They can assess and discuss patients’ personal risk and whether screening may be right for them.

“Lung cancer screening is the first time that a screening test has required a shared decision-making visit beforehand. While the actual scan itself is easy enough, there are risks to undergoing lung screening, including the detection of pulmonary nodules that can cause alarm in patients and lead to unnecessary procedures,” said Tanner.

“We want to have that conversation with patients ahead of time so that they know the risks and benefits of the screening in a way that’s individualized to them. A real shared decision-making discussion like that takes longer than a minute, which unfortunately research has shown is about the amount of time primary care providers have to conduct those types of discussions.”

Following a referral to the Hollings program, patients will have an in-person or virtual visit with the program’s dedicated nurse practitioner, Cassie Frazier, who will provide information about the benefits and risks of lung cancer screening. She will also inform patients of their personal risk for developing lung cancer within the next few years.

Patients are given the opportunity to ask questions and share how screening fits into their values and beliefs and are encouraged to make their own informed decision about whether they’d like to be screened. Patients who smoke are provided an opportunity to meet with tobacco treatment specialists on the same day.

When patients are referred to Hollings, the program handles insurance authorization and follow-up care. Patients are tracked in a dedicated database to ensure no one falls through the cracks. While getting patients in for their first screening is the initial goal, making sure they come back annually based on current screening guidelines can be a challenge, and the centralized program works to promote adherence.

A large part of the program’s effort also involves trying to reach people of diverse backgrounds who live in medically underserved parts of the state. Rates of smoking are higher among certain racial and ethnic groups, rural populations and those who fall into lower socioeconomic levels, putting them at higher risk for developing lung cancer. People within these populations are also less likely to have a primary care provider and often seek medical care only when symptoms arise, making them more vulnerable to late-stage disease.

“We can’t just do lung cancer screening one way in the academic ivory tower in Charleston. We have to make sure that the best practices are replicated in rural and community settings so that all patients in our state receive the same high-quality care.”
— Dr. Nichole Tanner

Tanner said she benefits from working with experts in Hollings’ Cancer Control Research Program, including Marvella Ford, Ph.D., who is associate director of Population Sciences and Cancer Disparities at Hollings and specializes in research related to cancer health disparities. Ford and Tanner recently contributed to a new set of statements released by the American Thoracic Society that helped call attention to disparities that exist in access to lung cancer screening among diverse populations.

Ford said, “We’re talking about people whose lives are highly stressful and who are using tobacco as a coping mechanism. Right now we’re in a pandemic, but imagine your life feeling this chaotic every single day outside of a pandemic. When people experience continued job and food insecurity, they may turn to tobacco to help with these stressors. Tobacco products are also heavily marketed in communities of color. We want to find ways to reach smokers before a cancer develops.”

Current research at Hollings focuses on strategies for increasing surgery rates among Black people with lung cancer, incorporating tobacco treatment into lung cancer screening and looking at whether blood tests could help determine whether a pulmonary nodule found on a scan is likely to be cancerous.

The program is also working within MUSC Health’s network of regional hospitals in Lancaster and Chester counties to expand access to screening across the state, with a goal of increasing services across the MUSC Health system.

Tanner said the goal is to make access to screening easy.

“We can’t just do lung cancer screening one way in the academic ivory tower in Charleston. We have to make sure that the best practices are replicated in rural and community settings so that all patients in our state receive the same high-quality care,” said Tanner.

“Any system or practice with a CT scanner can technically do lung cancer screening, but it is much more than that. People who are eligible must be provided with balanced information they need to make a decision that’s in line with their own values and beliefs. I think providing that balanced information, coupled with our comprehensive and multidisciplinary approach to screening, is what makes our program unique.”

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