A Collaborative Solution to Lung Nodule Management

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances. A Cleveland Clinic podcast for medical professionals. Exploring the latest innovative research in clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase I and Sarcoma Programs. Today I'm happy to be joined again by Dr. Peter Mazzone, Director of the Lung Cancer Program and the Lung Cancer Screening Program for the Respiratory Institute. He's here today to talk to us about the Lung Nodule Management Program. So welcome Peter.

Peter Mazzone, MD: Thanks, Dale. Thanks for having me.

Dale Shepard, MD, PhD: Absolutely. So maybe to start, you can tell us a little bit about your role here at Cleveland Clinic.

Peter Mazzone, MD: Sure. I'm a pulmonary and critical care physician. I've been here on staff for about 20 years or more. And as you mentioned, I'm Director of the Lung Cancer Program, and that includes all things pulmonologist do for cancer from smoking cessation to screening and diagnosis and staging and preoperative testing and survivorship care, and fortunate to have a great, great team involved in all of the programs that we run.

Dale Shepard, MD, PhD: Excellent. So we're going to focus on lung nodules today, and I guess sort of as background, we certainly commonly find these as incidental findings on radiology reports and what we do about them, and that is a common concern. So tell us a little bit about the origins of the program to manage lung nodules, how it developed and kind of where we are today.

Peter Mazzone, MD: For sure, yeah. You highlighted, I think, the most important nidus of the program. It was that, there's a lot of imaging done and incidentally a lung nodule might be detected. Someone might have gone to the emergency department for chest pain or a totally unrelated issue, had a scan done of their chest and a small nodule was found. And it struck us seeing a lot of these patients in clinic that sometimes, because it wasn't the focus of their visit, that they were never told about the nodule or the nodule didn't receive timely follow up. And so we wanted to develop a program so that these nodules didn't go missing. In particular, some of them, very few but enough to worry about, represent early stage lung cancers. And so we want to identify those early stage lung cancers when they're quite curable instead of later in their course.

So for a couple of years, we struggled to put the program together because there wasn't a way to systematically identify who was found to have a lung nodule. In parallel to our program growth, a broader actionable findings program was being developed in the Cleveland Clinic, led by our radiology groups. And so in partnering with them for the last couple of years, they now electronically flag every report that has a lung nodule found. So now we can track all of these patients who have lung nodules found. The numbers are quite large and so we partnered with our Heart, Vascular & Thoracic Institute to pilot a program where we in pulmonary medicine would own the management of all of the patients who their providers ordered a scan on, were found to have a lung nodule. This could be a belly scan, a neck scan, a chest scan, a heart scan, whatever it may be.

And we learned quite a bit. We learned this as a ... these nodules and we found anywhere in our health system many different types of scans can identify them. And often enough they don't know about them, that we had to put together a process for communicating with the patient, letting them know about the finding, arranging for appropriate follow up. Follow up of small low risk nodules being different than a large worrisome looking nodule. We develop care pathways. We have a group of provider champions, physicians and advanced practice providers throughout our health system who follow those care paths when we shunt patients their way. It's been very, very rewarding. We're expanded the program to try and address all nodules across the health system. That's about 10 to 15 in times the number as with the HVTI. So we're now growing our programs, providers and systems so that we can adequately accommodate all of the patients that have lung nodules.

Dale Shepard, MD, PhD: When we talk about lung nodules, and you said the volume is high, and I can only imagine given the number of scans that we do. How many nodules are we talking about on average per year?

Peter Mazzone, MD: It's a good 200 a week. So you're talking about 10,000 in a year in our health system.

Dale Shepard, MD, PhD: That's a daunting number.

Peter Mazzone, MD: Absolutely.

Dale Shepard, MD, PhD: And certainly we don't want to miss an early stage lung cancer, which you mentioned. What percentage, on average, end up being identified as a lung cancer?

Peter Mazzone, MD: I think it's a great point too. It's just a few percent, 2% to 3% of those that have entered our program. And that highlights the other value of having care provided by this group with an interest in lung nodule management. The other end of it is, we don't want to over test individuals that have benign nodules. Scan them too often, or do a procedure with a potential complication only to find out it was a benign lung nodule. And so we have those dual goals, identifying lung cancer as soon as we can, but minimizing testing for individuals who have benign nodules.

Dale Shepard, MD, PhD: You may or may not have any information that you've collected on this, but what about from the patient perspective? Just the psychological benefit of knowing that someone's actually identified it and sort of guiding them along what to do because, it seems as though people see a nodule and they automatically think cancer whereas most of them, as you mentioned, are not. Is this something that we're getting good feedback from patients in terms of sort of an appreciation that they can have some peace of mind?

Peter Mazzone, MD: Yeah. I think it's another value of the program. High quality communication allows our patients to be managed in a way that doesn't have as much psychological impact on them. And it's challenging. Sometimes the patients don't know that their scan showed a nodule at all. Again, it really wasn't the reason they were hospitalized or had the test done to begin with. So this kind of cold call from our team has to be quite delicate. Other times they know, and they are already following with another provider at a distance in another house system. And oftentimes they just at least appreciate that we were paying close attention in not letting anything escape. Once they come to clinic and we learn from the literature about what sort of communication is most helpful in allaying their fears when it's benign and how to make sure they're comfortable and follow up appropriately when we're more worried about the nodule.

Dale Shepard, MD, PhD: So when we think about the nodules, I guess you have to identify them. And I guess it raises a point that I end up seeing in clinic often and that's, you mentioned patient awareness and whether they know there are nodules, and I know that in the institution there's some efforts to standardize the reads on films. Some radiologists are a little more descriptive than others. Is this program to look at lung nodules, is that sort of been a piece of that in terms of, there are patients that want to know absolutely everything and there's others that only want to know if it's important or we think it's important. And so it irritates patients when they say, "Previously seen lung nodule is stable." And like, "What lung nodule?" Are you working with radiology to try to work on that standardization of reports?

Peter Mazzone, MD: Yeah, the radiologists have been great partners in this, and the broader actual findings program. They have a large group of diverse radiologist to work with and make sure they all try to report things in a relatively standard way, in at minimum are flagging the reports when there is an actionable finding. That's been an evolution and it's getting better and more accurate all the time. Our chest radiology group themselves, they don't read all of the scans of the chest, but they have a very standard approach and very standard way to format their radiology report, which can be very helpful.

The second point you mentioned is, we do, as an institution, release these results through the electronic health record, to MyChart and patients may, for the first time, see that their report suggested they have a nodule in that way. And we want to be sure that that doesn't happen frequently. We don't want people to be nervous about something they don't need to be. At the same time we also want anyone who does see the report in that way to have access to a program that can help them understand what that finding means to them.

Dale Shepard, MD, PhD: So you've certainly gone through lots of nodules at this point with the volume we're seeing. Is this going into a registry? Do you have outcomes data from looking either at the initial HVI collaboration or the bigger picture overview of this program?

Peter Mazzone, MD: Yeah, absolutely. A part of the program was developing a dashboard or health management system within Epic, where we can track who's enrolled and who's not, requires a little bit of work from our providers to complete documentation and templated notes so that the data's extractable. Allows us to say why patients choose not to come, why they do come, what types of nodules we're seeing and what the downstream testing is from that. How often are we diagnosing cancer, ordering pet scans, doing biopsies. The information that we looked at from the pilot program helped us justify the need to grow in the number of providers, recognizing the revenue from seeing patients and from the downstream testing and treatment for those who have disease. So without good data collection, our program wouldn't be as high quality and we probably wouldn't have been allowed to grow as much as we have.

Dale Shepard, MD, PhD: How large is it at this point? What's the size of the team do you expect?

Peter Mazzone, MD: So this team overlaps with our lung cancer screening team, and our lung cancer team, as a whole, is growing in other ways. In the near future we'll be up to 11 advanced practice providers, and they'll be located across the region. The physicians with an interest in the pulmonary department, in lung nodule management, blanket the region and we're up to about 22 physician providers who we count as valuable parts of our team. So far, we've contacted about 2,500 or so patients through the HVTI program, and that's rapidly expanding as we expand the program across the health system.

Dale Shepard, MD, PhD: So it seems like a great framework. Is there discussion about moving this into other areas like pancreatic masses or liver nodules, or other sorts of things that are kind of incidental thyroid nodules, things that are incidental findings on imaging?

Peter Mazzone, MD: Absolutely. The imaging team who we're working in parallel, and now in partnership with us, have an actionable findings program. And so on the imaging reports they're now flagging any actionable finding that could be those you mentioned. Thyroid nodule or adrenal nodule, it could be brain aneurysm. And through our partnership, they developed other partnerships with institutes that might help guide the management of those patients. And so programs are being developed across the health system to make sure patients get appropriate care, regardless of what the incidental findings are. The primary care community has been a big part of these discussions and knowing which patients they should continue to follow, because they know them well and are vested in their care. And when it's appropriate to have those patients go to a specialty provider has been ongoing discussion and part of the program.

Dale Shepard, MD, PhD: What do you think has been the greatest challenge, and what do you think is the biggest success?

Peter Mazzone, MD: I think the greatest challenge is really the volume. The numbers are large and like most programs, you have to do it a little while and show some success to justify the number of people you need to manage that volume of patients. And so that's taken time and has been the biggest challenge. I think the biggest success is maybe where we're at in now. We've seen a lot of good feedback, both from patients but from leadership and a recognition of the importance of these programs and the support that's required to make them work well.

Dale Shepard, MD, PhD: Certainly you've set up a great program that can only help patients that are worried about these nodules and providers that aren't quite sure what to do with them. And so I appreciate your insights on the program today.

Peter Mazzone, MD: Thanks so much.

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