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. Since 2015, Cleveland Clinic’s lung cancer screening program has performed > 10,000 LDCTs, with > 4,000 in 2019. More than 100 lung cancers have been diagnosed through screening in the past two years.

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 = 8373)

2015-2019

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. At that meeting we either decide to 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)

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)

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.