Navigating the Non-small Cell Lung Cancer Patient: CT Lung Cancer Screening Development

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Early detection is an important factor in lowering lung cancer mortality.
Early detection is an important factor in lowering lung cancer mortality.
The following article features coverage from the 2017 ONA Navigation Summit in Austin, Texas. Click here to read more of Oncology Nurse Advisor's conference coverage. 

Lung cancer is one of the most deadly cancers. The death rate of patients with lung cancer per year is greater than colon, prostate, and breast cancers combined. Aging (after the age of 60) and the long-term use of cigarettes are the usual causative factors of lung cancer.

According to the American Cancer Society, 5-year survival for those who have lung cancer is 15%-18%. Such low rates of survival can be attributed to several factors: 

Lung cancer is often asymptomatic in the early stages, until progression.  Symptoms that may be associated with the disease may often be overlooked and considered something other than cancer (a cold, the flu, or pneumonia).

The stigma that is associated with smoking followed by self-blame of “I did this to myself” may often deter someone from seeking medical attention for increasing symptoms.

If caught in the early stages, lung cancer survival rates improve dramatically. Unfortunately, the majority of patients diagnosed with the disease are in the later stages.

The key to improving the statistics is early detection, as with most cancers. In 2010, the National Lung Screening Trial was completed, concluding that high-risk patients (based on age and smoking history) who have a low-dose CT lung screening decrease their mortality rate by 20% .1 The U. S. Preventative Services Task Force (USPSTF) issued recommendations in favor of annual low-dose CT lung screening for high-risk persons. In February 2015, Medicare approved coverage of those persons at risk. Many commercial insurers have followed Medicare's lead by agreeing to pay for low-dose CT lung screenings as well.

The CT Lung Program at CHI Memorial in Chattanooga, TN, started initially in 2014. However, in 2015 a steering committee, consisting of physician champions, other stake holding physicians, administration, and the thoracic oncology nurse navigator, was assembled to establish a viable Thoracic Oncology Lung Center of Excellence including a CT lung screening program.

A scheduling and billing process was implemented to reflect the Medicare guidelines. A provider ordering form was developed, which included the high-risk guidelines and documentation of other necessary requirements.  

Provider education through newsletters and calling on the providers and their office staff began and is ongoing. Community marketing through TV, radio, and newspaper advertisements occurs frequently. In addition, smoking cessation classes are held in multiple locations throughout Chattanooga.

One of the first challenges to occur was how to gather the required data (28 points in all) to send to a national registry, the American College of Radiologist (ACR), to satisfy Medicare billing requirements. A data manager was hired to monitor every scheduled CT lung screening patient, extracting the required information from each patient's record, and then submitting the information to the registry, registry “gatekeeper.”

Another challenge was inappropriate, non-high risk patients being scheduled for CT lung screenings.  Because each patient had to be scheduled through the hospital scheduling department, a hard stop would appear in the scheduler's screen, requiring the high risk guidelines to appear.  If the patient was not appropriate, the screening cannot be scheduled, the scheduling “gatekeeper.”

Key factors in developing a CT Lung Screening Program:

  • Physician champion
  • Administration buy in
  • Identifying the “gatekeepers” to keep the program on track
  • Marketing to community and providers
  • Education, education, education
  • Keep it simple

A frequent concern and ongoing challenge is patients who do not return for their annual screening and are lost to follow up. Patients do not return for many reasons. Many patient's insurance coverage waxes and wanes because of employment situations; therefore, patients who do not have health insurance are unwilling to access the health care system for any reason. 

An actual patient case study is used to illustrate the navigation clinical concepts of a patient who is lost to follow up and his disease progression. The patient lost his job and had no insurance coverage. He continued to smoke. He re-entered the health care system because of increasing symptoms associated with lung cancer progression. 

Navigating this patient who was homeless and unemployed was a social and financial challenge because of many community resources were used and exhausted. Finding stable housing and transportation were the greatest barriers to overcome.  

Having a rich network of community resources is key to navigating such a patient. Access to county, state, and federal resources as well as civic and church programs allows for shouldering the burdens by many, not just a few programs.

Read more of Oncology Nurse Advisor's coverage of the 2017 ONA Navigation Summit by visiting the conference page.

Reference

1. Wender R, Fontham ET, Barrera E Jr, et al. American Cancer Society lung cancer screening guidelines. CA Cancer J Clin. 2013;63(2):107-17. doi: 10.3322/caac.21172

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