Initial Experience Following Implementation of Lung Cancer Screening at an Urban Safety Net Hospital
Katrina A Steiling1, Juan A Munoz-Largacha2, Nirupama Vellanki3, Marjory Charlot4, Carmel Fitzgerald1, Hasmeena Kathuria1, Kei Suzuki2, Virginia R Litle2
1Boston University School of Medicine, Department of Medicine, Division of Pulmonary, Allergy, Sleep and Critical Care Medicine, Boston, MA;2Boston University School of Medicine, Department of Surgery, Division of Thoracic Surgery, Boston, MA;3Boston University School of Medicine, Boston, MA;4Boston University School of Medicine, Department of Medicine, Division of Hematology and Medical Oncology, Boston, MA
OBJECTIVE: Lung cancer screening with low-dose computed tomography (LDCT) reduced lung cancer mortality within a high risk population of smokers in the National Lung Screening Trial. The adoption of a standardized Lung-Reporting and Data System (Lung-RADS) and the use of a multidisciplinary team (MDT) have shown to be essential for a successful screening program. Safety net hospitals provide most of their care to low-income, uninsured and vulnerable populations who have high rates of smoking and in whom delays in cancer screening are established barriers. We hypothesized that socioeconomic barriers might pose important challenges to the success of a lung cancer screening program at a safety net hospital. We aimed to determine LDCT follow-up compliance in Lung-RADS 4 patients, the rate of diagnostic and treatment procedures and the cancer diagnosis rate.
METHODS: A retrospective review of all the patients enrolled in our Lung Cancer Screening Program was conducted. From March 2015 - July 2016, 554 patients were evaluated in our MDT screening program. Demographics, smoking status, Lung-RADS score, and number of diagnostic and therapeutic interventions and cancer diagnoses were captured.
RESULTS: Mean age was 63 years (range 47-85) with 95% between 55-80 years. Sixty percent were male, 48% white non-Hispanic, 31% African-American, 10% Hispanic, 5% Asian, 5% declined this information or was not documented. Sixty-four percent had Medicare/Medicaid and 36 % had a private/other insurance. All patients had a history of smoking with a mean number of pack-years of 42.2. Screening referral came from primary care physicians and pulmonary/medicine services in 82% and from other services in the remaining 18% of the cases. Ninety-two percent (512/554) of the patients were categorized into Lung-RADS 1-3 and 8% (42/554) into Lung-RADS 4. Of the Lung-RADS 4, 98% (41/42) completed their recommended follow-up and 1 patient died from unrelated cause before diagnostic intervention. Twenty-nine percent (12/42) of the Lung-RADS 4 underwent a diagnostic procedure, for a 2% (12/554) overall diagnostic intervention rate (Table 1). Of these 12, 92% had cancer and 1 patient had sarcoidosis. The overall rate of surgical resections was 0.9% (5/554) and the diagnostic intervention for non-cancer diagnosis was 0.1% (1/554).
CONCLUSIONS: Implementing a MDT lung cancer screening program at a safety net hospital is feasible. Ninety-eight percent of our Lung-RADS 4 patients completed recommended follow-up despite social barriers. The number of Lung-RADS 4 patients identified in our study was higher than reported in other studies and the compliance with interventional recommendations was high in this socially challenged population.
|Lund-RADS 4 patients - Diagnostic and Surgical Procedures|
|Patient #||Lung-RADS Category||Diagnostic Procedure||Histologic Diagnosis||Treatment||Stage|
|1||4A||CT-guided biopsy||Adenocarcinoma||VATS resection||IA|
|2||4X||CT-guided biopsy||Adenocarcinoma||Definitive chemo-radiotherapy||IIIB|
|3||4B||US-guided biopsy||Small Cell Carcinoma||Chemotherapy||Stage IV|
|4||4B||ENB and Mediastinoscopy||Squamous Cell Carcinoma||VATS resection (LUL segmentectomy)||IA|
|5||4X||Bronchoscopy and Mediastinoscopy||Small Cell Carcinoma||Chemotherapy||Limited Stage|
|7||4A||Diagnostic VATS wedge resection||Adenocarcinoma||VATS lobectomy||IIA|
|8||4B||Bronchoscopy and Mediastinoscopy||Sarcoidosis clinic||Followed in Sarcoidosis||Benign|
|9||4B||Diagnostic VATS resection (LLL segmentectomy)||Adenocarcinoma||Chemotherapy||IB|
|10||4B||Bronchoscopy||Squamous Cell Carcinoma||Definitive chemo radio therapy||IIIA|
|11||4B||Diagnostic VATS wedge resection||Adenocarcinoma||VATS |
|12||4X||Bronchoscopy and Mediastinoscopy||Adenocarcinoma||Palliative Chemotherapy||IV|
|*ENB: Electromagnetic Navigational Bronchoscopy, VATS: Video-Assisted Thoracoscopic Surgery, SBRT: Stereotactic Body Radiation Therapy. LLL: Left Lower Lobe, LUL: Left Upper Lobe, RLL: Right Lower Lobe.|
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