The goal of an effective lung cancer screening program is to reduce mortality, and to accomplish that, such a program should be multidisciplinary and must incorporate smoking cessation, said Mollie Meek, MD.
“You also need to be very careful about how you choose to measure your nodules and what risk stratification protocol you're going to use to decide which of your patients should be screened and what the best protocol is for positive-screening patients,” added Meek. “You should be careful about over-biopsying and over-operating, because that's where the harm to the patients is going to come from—the unnecessary procedures and associated complications.”
A critical piece to successfully implementing these multidisciplinary programs is having a nurse coordinator who is knowledgeable about the disease and the screening protocol, Meek adds.
“They are the linchpin of the entire operation [at our practice] for sure,” said Meek, who serves as the director of the Division for Interventional Radiology, and the program director for the Interventional Residency and the Vascular-Interventional Radiology Fellowship, at the University of Arkansas for Medical Sciences.
In an interview with OncLive, a sister publication of Oncology Nursing News, Meek highlighted key lung cancer screening trials, offered insight into how to successfully implement an effective program, and stressed that collaboration is critical in order to provide the best patient care.
OncLive: What is the importance of lung cancer screening programs, and what are the key components necessary to ensure its success?
Meek: The goal of a good screening program is to reduce lung cancer-specific mortality and I use the word "program" intentionally. You really need a multidisciplinary program and you must, must include smoking cessation as part of your program.
It's important to keep your team together when you're working on your program because any change in the way you do things will change your outcomes. For example, if your surgical mortality rate changes, then the benefit from your screening program changes. If the complication rate from your interventional radiologist who does biopsies starts to go up, then your risk-benefit analysis changes.
In the future, be on the lookout for liquid biopsies, new imaging protocols that help us better differentiate malignant from nonmalignant lesions, and better risk stratification for patients who are actually high-risk or patients who are truly too sick from other comorbidities to undergo appropriate screening.
Could you share insight on the lung cancer screening program at your institution and why it is successful?
The most important part of our program is our nurse coordinator. She's an advanced practice nurse; she knows a lot about lung cancer. She sees all of the patients with [resectable] lung cancer. She [oversees] all of our lung cancer screening and smoking cessation efforts for our patients that we screen. Sixteen percent of the patients who get referred to our program are not eligible for lung cancer screening.
Therefore, if we didn't have her, we would over-scan at least 16% of patients. She does a lot of the work in [reporting back to] the referring physicians and educating patients as to why they are not a good candidate [for screening]. She does a good job in keeping track of how many patients she gets to quit smoking, which is way more important than [tracking] the number of cancers that we find or don't find.
What are some key lung cancer screening trials to be aware of?
Definitely read the National Lung Cancer Screening Trial (NLST) publications in the New England Journal of Medicine. When the NELSON data are finally formally published, I believe that will be important, too. Those are the 2 largest studies. The NLST had [at least] 25,000 patients in each of 2 arms for a total of more than 50,000 patients. Then the NELSON trial has, I believe, over 15,000 patients in it. They are good-sized studies.
The NELSON trial showed a lung cancer mortality benefit that was actually better in women than in men, which is an interesting discrepancy. The results of the NELSON trial showed a greater mortality benefit than what was seen in the NLST. The NLST showed a 20% reduction in mortality. In NELSON, [mortality] was [reduced by] 30% in men and then maybe 35% in women.
How do you determine eligibility for lung cancer screening?
A lot of it depends on insurance. The Center for Medicare & Medicaid Services (CMS) will cover a certain age group with a certain pack-year history. Each insurance generally follows CMS, but there may be slight discrepancies with certain insurance policies. If your center decided it was only going to screen higher-risk people, then you would add some sort of risk calculator [to the equation].
Why is lung cancer screening still not as widespread as it should be?
People are scared. We’ve been doing mammograms for a very long time and there are still plenty of patients who don't get mammograms. In a state like Arkansas, what we've learned from our mammography experience is that you have to go to them, and you have to actively recruit them. Many disparities exist in socioeconomic classes as far as who will get screened and who will not get screened.
Some of the concerns with the screening trials is that the people who participate in me are motivated; they're generally more affluent and are more educated. It's a different group of patients than if you just throw it out there to the entire country. Specifically, in the south, I believe it has to do with education, some socioeconomic disparities, and the fact that people are afraid. What happens if they get a positive result? If 20% of the patients are going to get a positive result, what happens next? That's a scary thought for people.
What are some unanswered questions that remain?
There are studies that include sputum [analysis] and there are studies that include [messenger] RNA as circulating tumor markers. Another important thing to realize is that there are a population of patients who get lung cancer who are nonsmokers. Our next puzzle to figure out is how we are going to identify the people who are high risk [for the disease] and how we are going to screen them when they have no smoking history. [The answer to that] may be blood work, some genetic testing, better family history analysis, etc. Researchers are working on this.
What do you hope attendees took away from your presentation?
Cancer care is a team sport. It involves great liaisons between your patients and your referring physicians, surgeons, oncologists, and radiation oncologists. The area I wish we had more inclusion with, although we have certainly gotten better in the last few years, is social work and palliative care. Your team has to include [guidance for those] getting a diagnosis of cancer or for those with a potential cancer diagnosis; it's a big deal. How do the families process that news and how are they going to process the bills that are going to come? When do we say, “Enough is enough?” Those are all things that we should be talking about earlier on.
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