Lung Cancer Screening Program

Lung Cancer Screening Program

The primary goal of low-dose computed tomography (LDCT) lung cancer screening is to detect lung cancer at curable stages while minimizing harm to those without lung cancer. In the past 6 years, Cleveland Clinic's lung cancer screening program has screened > 2,700 patients, diagnosing 28 lung cancers.

Prior to 2015, the provider ordering LDCT was responsible for managing the screening results. Management of the LDCT screening program was centralized to lung cancer specialists in April 2015. Rather than ordering the screening themselves, providers instead order a consult to the screening program, which then decides whether the patient is eligible.

Lung Cancer Screening Program Volume Growth From Introduction of Best Practice Advisory (N = 4131)

2015-2018

In April of 2015 Cleveland Clinic started a centralized Lung Cancer Screening Program and has since spread to several additional regional sites.

BPA = Best Practice Advisory

ᵃIn April of 2015 the Cleveland Clinic's Lung Cancer Screening Program was centralized.

ᵇIn October 2016 the program opened 5 additional regional sites.

ᶜIn December 2017 a BPA for the program went live resulting in 4 times the number of referrals and was put on hold to strengthen the program infrastructure.

ᵈIn October 2018 the BPA went live again at 11 regional sites resulting in substantial program growth.

Cleveland Clinic's Lung Cancer Screening Program follows the American College of Radiology's Lung-RADS quality assurance tool to standardize lung cancer screening CT reporting and management recommendations, reduce confusion in lung cancer screening CT interpretations, and facilitate outcomes monitoring.¹ Lung-RADS suggests that Category 4A nodules should be monitored with a surveillance CT scan in 3 months and Category 4B nodules should be further evaluated immediately (e.g. PET imaging, non-surgical or surgical biopsy). In our screening program lung nodules that have a Category 4A or Category 4B Lung-RADS score are assessed at a multi-disciplinary Lung Nodule Management Tumor Board meeting. At that meeting we decide to either manage the nodule as per Lung-RADS guidance (“no change”), less aggressively than per Lung-RADS guidance (i.e. for 4A nodules – surveillance at an interval of 6 months or more; for 4B nodules – surveillance instead of immediate evaluation), or more aggressively than per Lung-RADS guidance (i.e. immediate evaluation of a category 4A nodule).

Here we present information about how often we decide to manage Category 4A and 4B nodules different than Lung-RADS guidance. We also present the outcomes of those decisions. Lung-RADS category lowered at the time of follow-up means the nodule is behaving in a benign manner. Lung-RADS category increased at the time of follow-up means a Category 4A became a 4B, 4X, or is proven to be a cancer, or a Category 4B is proven to be a cancer.

Changes in Management and Outcomes in Category 4Aᵃ Lung Nodules After Review at Weekly Lung Nodule Management Tumor Board (N = 64)

2018

Lung-RADS = Lung Imaging Reporting and Data System

ᵃCategory 4A lung nodules are described as suspicious findings for which additional diagnostic testing is recommended.

ᵇChanges in management made after a tumor board discussion about a patient's lung nodule takes place.

ᶜOn follow-up the lung nodule was either labeled a lower category or benign.

ᵈOn follow-up the nodule was either labeled a higher category or cancer.

ᵉOutcome not clear at this time.

Changes in Management and Outcomes in Category 4Bᵃ Lung Nodules After Review at Weekly Lung Nodule Management Tumor Board (N = 35)

2018

ᵃCategory 4B lung nodules are described as very suspicious findings for which additional diagnostic testing and/or tissue sampling is recommended.

ᵇChanges in management made after a tumor board discussion about a patient's lung nodule takes place.

ᶜOn follow-up the lung nodule was either labeled a lower category or benign.

ᵈOn follow-up the nodule was either labeled a higher category or cancer.

ᵉOutcome not clear at this time.

At least 19 of 99 patient cases discussed at tumor boards had less aggressive evaluation and were downgraded, meaning avoidance of costly or invasive procedures. One had more aggressive care leading to earlier cancer diagnosis, and two with less aggressive care were ultimately upgraded.

Rates of Procedures for Benign Lung Nodules

2015-2019

From 2015 to 2019 Cleveland Clinic's Lung Cancer Screening Program has screened 4141 patients and has identified many concerning lung nodules (category 4A or category 4Bᵃ) from 6061 screening scans. Comprehensive managment of lung nodules includes weekly Lung Nodule Management Tumor Boards attended by multi-disciplinary specialists in lung nodule management. There has been a low rate of biopsy procedures performed on patients with nodules confirmed to be benign.

Total Category 4A/B/X (N, % of total) Non-Surgical Biopsy for Benign Nodule (N, %ᵇ, %ᶜ)
**Patients** 4141 485 (11.7%) 12 (0.3%, 2.5%)
**CT Scans** 6061 564 (9.3%) 13 (0.2%, 2.3%)

CT = Computed Tomography

ᵃCategory 4A lung nodules are described as suspicious findings for which additional diagnostic testing is recommended. Category 4B lung nodules are described as very suspicious findings for which additional diagnostic testing and/or tissue sampling is recommended.

ᵇPercentage of total

ᶜPercentage of category 4 findings

Number of surgical biopsies with confirmed benign disease: 1

Number of confirmed lung cancers: 64