[0:01]So I was actually speaking to a primary care audience back a few weeks ago, we were talking about lung cancer screening and they said, you know, our patients, they don't want to do it. And I said, do you remind them that lung cancer is curable?
[0:14]Because everybody thinks it is a death sentence, but when you're talking about screening a patient, I think it's really important to say, listen, if we find this early, you know, stage one to stage two, our chances of curing this and it never coming back again is upwards of 60 to 70%.
[0:30]You are listening to the ONS podcast, where ONS voices talk cancer, a resource from the Oncology Nursing Society.
[0:37]Through conversations with subject matter experts, we examine the important issues in oncology nursing from new treatments to patient-centered research to advancements in clinical practice.
[0:47]Join us as we hear from nurses in all facets of oncology care, from bench to bedside and everywhere in between.
[0:55]Hello and welcome to the ONS podcast. I'm your host Jamie Weimer, Manager of Oncology Nurse Practice at ONS.
[1:02]And today we're talking with Beth Sandy, Thoracic Medical Oncology nurse practitioner at the Abramson Cancer Center at the University of Pennsylvania in Philadelphia, about lung cancer screening and risk assessment.
[1:13]As a reminder, you can earn free NCPD contact hours after listening to this episode and completing the evaluation we've linked in the episode notes.
[1:21]Welcome. Thanks so much for joining us today, Beth. Yeah, thanks for having me, Jamie. So to start off, can you explain the current state of lung cancer screening and how early detection helps and impacts patient outcomes?
[1:33]Unfortunately, the current state of lung cancer screening is pretty low.
[1:37]You know, our rates of uptake in eligible patients is somewhere between 6 and 20%.
[1:43]And you know that falls much further below what we see for screening such as breast cancer screening, prostate cancer screening, and colorectal cancer screening.
[1:51]So certainly we can do better, and how early detection affects outcomes.
[1:54]I mean, certainly, early detection of lung cancer, your chances of cure and survival are much, much higher.
[2:02]And you know, I always remind my patients, you know, lung cancer is a curable disease, and certainly much more commonly curable if you can catch it early.
[2:10]Absolutely. And and relatively speaking, lung cancer screening's kind of the new kid on the block when compared to maybe some of our other screening modalities that we have, but certainly those numbers, we would like to see them much, much higher.
[2:22]So hopefully what we share with our listeners today might help move the needle a little bit on that.
[2:26]Can you discuss a little bit just about the screening methods that we currently use for lung cancer and how those have evolved over the years?
[2:32]You know, the funny thing is, we're not that new of a kid on the block, it's been around for over 10 years.
[2:37]It's just really been quiet, there's not a lot of advocacy for it, so people don't know as much about it.
[2:42]Initially the studies were all about doing chest X-rays, but the problem is is that chest X-rays, it's really hard to see very small things.
[2:51]So when they studied this, you know, years and years ago, back 20, 25 years ago, chest X-rays were not catching lung cancers early enough as a screening method to save lives.
[3:03]And that's the end point you need in the clinical trial is lives saved. So the current way that we screen patients is with a low dose, non-contrast CT of the chest.
[3:11]And that came out of the National Lung Screening Trial and those results have been out for over 10 years, uh, probably 15, 20 years almost at this point.
[3:20]I remember my institution participated in this trial. I remember the clinical trial nurse who I worked with on that study way back 20 years ago, and, you know, I remember patients who are cured as of today because of that screening trial that we did.
[3:34]But it was the results of that national and screening trial that is why now these low dose annual CTs of the chest are approved.
[3:42]Did show that those saved lives by detecting these lung cancers early.
[3:47]And so maybe we could talk a little bit more about sort of that eligibility.
[3:50]Who should be getting screened, who can get screened, and also, are there any patient groups that maybe screening is less definitive, or there are some shortfalls in the screening methods?
[4:00]Well, first of all, who gets screened? So people between the ages of 50 and 80, and I'll start there by saying, the reason for the age is because lung cancer is still a disease of the aging.
[4:10]The median age of patients with lung cancer is somewhere between like 68 and 70.
[4:15]So it's still a disease of the aging, and they capped it at 80 because after 80, your chances of dying from other things, unfortunately, are almost just as good and your ability to receive aggressive treatment is not very good.
[4:30]So that's why the age of 50 to 80, and I always remind people, especially people who are in the position to do screening, is that screening is for healthy, asymptomatic patients.
[4:38]And the reason I say that is if a patient comes in your office and is complaining of cough, shortness of breath, and you get a chest X-ray, it doesn't show anything, you move on to a cat scan, it's not considered a screening cat scan at that point, it's a diagnostic cat scan because you're working up a symptom.
[4:54]So screening is for patients who do not have symptoms of lung cancer and that you feel are healthy.
[5:00]They have to be either currently smoking or quit within the past 15 years.
[5:05]Again, that's because the longer you've quit, your risk significantly reduces.
[5:10]That's kind of a talking point when I talk to patients about quitting smoking.
[5:14]You know, they just say like, oh, I've smoked for so many years, what's the point of quitting now?
[5:17]If you quit more than 15 or 20 years, your risk of developing lung cancer at that point is significantly lower.
[5:24]And so that's why once patients have quit more than 15 years, they're actually not eligible for screening anymore, because their risk of developing lung cancer is dramatically reduced.
[5:51]And then the other part of screening is, how many years have they smoked?
[5:54]We say 20 pack years. So remember, 20 pack years means one pack a day for 20 years, a half a pack a day for 40 years, or two packs a day for 10 years.
[6:05]So you do the math, and they have to have smoked at least 20 pack years to be eligible for screening.
[6:10]So for example, if you have a patient who is 65 years old and they quit smoking 10 years ago at age 55, but they had smoked a pack a day between the ages of 25 and 55, so they smoked 30 pack years, that would be a patient who would be eligible for screening.
[6:26]Now, I think the other part of your question is what are the risks of screening, like what patients sometimes does this cause issues for it?
[6:36]And I'll say probably one of the biggest things is false positives.
[6:40]So, for those of you, anyone that works in pulmonary or lung cancer like I do, we get cat scans of the chest and we can see things in the chest that are not cancer, but we can't tell necessarily from the cat scan.
[6:54]You know, sometimes the radiologist can tell, but sometimes it looks like, you know, they'll call it ground glass opacity.
[6:58]It's like, okay, is that not solid enough that it's cancer, or could it be cancer, we can get calcifications.
[7:05]Those usually show up really bright white on the cat scan, so usually radiologists can say, I don't think that's cancer, but it really causes a lot of anxiety in patients when you get a cat scan, and it's like, oh, there's something there, we're not sure what it is.
[7:19]We don't think it's cancer. Right? But you want to hear that in the doctor's office.
[7:25]So sometimes there ends up being unnecessary procedures that we do to try to chase after that because we're not sure what it is.
[7:34]Sometimes there's overdiagnosis. So, for example, and again, I go back to this ground glass opacity.
[7:38]They'll, if you put a piece of glass in a mortar and pestle set and you ground it up.
[7:44]Think of what that would look like, that's kind of what it looks like on the cat scans, and sometimes that's what we call an adeno carcinoma in situ, meaning that that is a cancer, but probably something that won't really turn malignant or spread for maybe 10 or more years.
[7:57]And so, it's like, well, then we've diagnosed it, but now we're going to do this big surgery on you for probably something that wasn't going to affect you maybe ever in your life.
[8:07]The other thing that people think about is, you know, if you're doing a cat scan every year for, you know, let's say 20 years, you know, you're getting exposure to radiation.
[8:16]Now, it's only annual cat scans, so it's not a ton and it's low dose, but it's just something to think about for sure.
[8:23]So I think those are kind of the areas where screening methods sometimes can be less definitive, you know, and not able to tell us exactly what's going on.
[8:33]You know, as I'm listening to you, it's those of us that have had worked in oncology and are just very sort of familiar and find some comfort in this space.
[8:40]You know, we do see a lot of scans, we do see a lot of sort of those nebulous results and when we see it, we're like, ah, we'll just keep watching it and it just feels very like just routine, you know, if that is the pathway of of oversight, but I, you know, we know for patients who don't live in this world, anything that suggests or might be or could possibly be like that, that creates a very different feeling and reality for our patients.
[9:00]And so I I appreciate you bringing up the notion of false positives or these sort of undefined results and kind of what feelings and what that can cause for patients, you know, the stress and the concern that comes with that.
[9:12]Certainly, not something we should dismiss, but it has to be weighed and balanced with the potential benefits of screening and finding those things early.
[10:54]So certainly, and I think you know, you mentioned earlier about just the notion of, you don't want to wait until they're symptoms.
[10:58]Because then it's no longer screening, right? Then it's diagnostic, but exactly.
[11:02]It's the same for really any screening, you know, you think of women and mammograms and we hope to find nothing and if we do find something very small, like that's the ideal scenario and that the whole point of why we do it.
[11:11]And so same for lung cancer, you know, hopefully there won't be symptoms when it's very early stage and so it is, it is sort of hard maybe to convert some of our patients into that sort of kind of thought process, but we're glad you feel great.
[11:22]We hope there's nothing, but if we're going to find it, we want to find it now while you do feel great and it is so small and and so difficult to detect that you're not experiencing any problems from it yet.
[11:33]So those are certainly some powerful statistics and just impacts on survival and prognosis that should hopefully inspire our patients to want to get their screening completed.
[11:42]What do you see in terms of like disparities that exists for our patients in getting access to lung cancer screening and who do you see most affected by this or where do you see the gaps in the access to screening most commonly?
[11:54]Well, I think there's kind of two main things.
[11:57]One of them is people who live in rural areas, I mean, it's just hard.
[12:00]You know, a lot of lung cancer screening programs are run out of larger institutions, versus if you're in a more rural area, it's up to your primary care doctor to just say, you know, go get this cat scan done, whereas screening centers, they'll bring patients kind of in and bulk on a certain day, do all the screening test and have the patients stay there and give them the results and do their screening visit there.
[12:23]So, I think just living in rural areas, but I think that that applies to really all health care in general and not just screening.
[12:30]Probably the number one barrier, I would say, to screening at this point is the lack of knowledge about it.
[12:35]Like everybody knows about mammograms, everybody knows about mammograms, PSAs.
[12:40]I mean, come on. Like everybody knows, like, oh, okay, my PSA checked.
[12:44]And if I see another cologuard commercial on television, honestly.
[12:47]I mean, we all know about colonoscopies, and people love to joke about colonoscopies about how horrible the procedure is and whatever, but people can do it, you know, but it's like no one knows that lung cancer screening is an issue or is something that can be done and saves lives.
[13:01]And I'll tell you there's a couple strategies that I've seen that I really love. One of the strategies is I, you know, live in the Philadelphia area.
[13:07]And a lot of times you think about what audience do I want to reach?
[13:11]I mean, typically, we want to reach people who are smokers or who may have smoked in their life.
[13:17]So one of the strategies that they've used to get the word out is I watch a lot of baseball, I love the Philadelphia Phillies.
[13:23]Watch Phillies games. And so at least once a year, maybe even twice a year, they will take an inning of the baseball broadcast on TV and on the radio separately, and they will bring on either an oncologist or pulmonologist from one of the local cancer centers in our area, and the whole inning, between batters of course, they will talk about lung cancer screening.
[13:46]And why it's beneficial, kind of what we're talking about right now.
[13:49]And I'm so proud of it when I'm listening to the game because I'm like, yes, this is how we have to get the word out, you know, talked about it between innings at a baseball game where a maybe older men are listening, you know, they're target audience.
[14:02]Another one that I saw that was really good, and it was a pharma company, I'm only the company, I'm not sure I know what company it was, but this was at a NASCAR racing event.
[14:11]So where they expect, you know, lots and lots, you know, thousands, tens of thousands of people to be there, and they had inflatable lungs.
[14:19]And so you could go to this, I don't know what to call it, booth, but like, I mean, they were like huge inflatable lungs, so people were like, what the heck is that?
[14:26]And they walk over to it, and you could like walk inside of the lungs and kind of look around.
[14:30]And then they had information there about lung cancer screening.
[14:33]I was like, brilliant. You're reaching a target audience, there's a large number of people here, you have this interactive display.
[14:41]So I think those are the types of things, if we can think about better marketing strategies to get the knowledge out there that lung cancer screening is a thing.
[14:50]And that's besides the point of then getting to the topic of it's it can save your life, but even just getting the word out that this is actually something.
[14:57]Absolutely. I think those are all great points of trying to reach the target audience and certainly we can do that at the local level in our own communities on an individual basis, but those opportunities to do that widespread, reaching a large audience across the entire nation, potentially the world, depending on who's tuning in, just how much power is behind those types of tactics.
[15:17]So certainly, and I agree with you, I think it has been around for a while, but in terms of people's awareness and and familiarity with it, it seems to be new for a lot of people when they first hear about it.
[15:26]So I appreciate you bringing up those opportunities for us to really get that message out at whatever kind of our platform is, if there's a way to share that knowledge, the more we can do that, the better.
[15:36]Let's talk a little bit about insurance coverage, how patients can not only get the screening but get it covered through their medical benefits.
[15:43]Can you elaborate a little bit on the role of insurance coverage in lung cancer screening, especially for our Medicaid population and other public health insurance programs?
[15:52]We'll start with Medicaid. So it is generally covered by Medicaid. Now, I don't know all 50 states, and as most of the listeners likely know, you guys know that Medicaid is state by state coverage.
[16:04]So you would have to really look at your state coverage guidelines, but it is generally a covered service by Medicaid.
[16:11]And I think anyone that would be lobbying for their state to include lung cancer screening is that it is way cheaper to pay for a non-contrast annual lung CT scan than it is for someone to develop stage four lung cancer and have very expensive treatments over years and years, as opposed to someone finding an early stage one lung cancer, having a quick surgery, and they're good to go.
[16:38]A lot of them don't even need adjuvant therapy if they catch it at a stage one A.
[16:42]So, you know, I think there's definitely a cost benefit ratio to it, but most Medicaid's are covering it.
[16:48]Again, I don't know every single state.
[16:51]I think we have to talk about Medicare and, you know, Medicare always has its idiosyncrasies.
[16:56]So, Medicare, you know, I went over the rules with you, so the age, the smoking, they follow all of it, except they have a slight difference in age.
[17:06]So they cover it for age 50 to 77 as opposed to 80.
[17:11]Sure, I mean, it's like, whatever. I was talking to a friend of mine who runs a lung cancer screening clinic and I said, if they have Medicare, do you really not screen them at 78?
[17:19]She's, I don't. She's like, if they get audited, it won't be covered.
[17:23]The institution won't get paid. So I'm like, oh geez. The other thing with Medicare is documentation.
[17:30]Medicare requires not only that the patient meets all of those criteria, but that also you document the following things.
[17:39]Number one, it's a shared decision-making discussion and it has to be done with either an APP or an MD, and the documentation has to cover these different bullet points.
[17:48]Number one that you've discussed the risks or harms of the screening.
[17:53]And that's kind of what I went over earlier, like there could be false positives, which could lead to tests that may not be necessary, the importance of adhering to annual scans.
[18:00]So it's not just the one and done, you know, you have to continue to do this annually for us to possibly catch this early.
[18:07]They have to have discussed smoking cessation.
[18:11]Even if the patient has quit smoking 10 years ago, you have to document that you've discussed smoking cessation.
[18:17]And that's again, that's just part of Medicare's rule and it, these are all not documented in that shared decision-making visit, Medicare can turn around and deny the service.
[18:27]Then you have to provide the order, the prescription for the low dose CT, and the last thing is you have to be sure that you document that the patient is asymptomatic.
[18:36]That must be documented, or else it's not considered a screening test.
[18:39]So Medicare has its own kind of separate rules of documentation that must be documented prior to the patient getting that cat scan.
[18:48]So that is a barrier to me as an insurance goes because, you know, for mammograms, it's like, you can just get a script, your doctor can call it in, they don't have to see you.
[18:56]Exactly. You know, a PSA is just a lab order that gets put in.
[19:01]But for cat scan screening, all of these bullets have to be documented in a actual visit, office visit, prior to the patient getting screened.
[19:10]So that can be a barrier, unfortunately.
[19:14]It definitely seems like some unequal hoops for certain screenings to jump through versus others that are like you said, you can just call up the mammogram suite or wherever they're performed and you can schedule it on your own in certain places, like it doesn't require any of that.
[19:27]Certainly there is still documentation that comes along with that, but it's not quite as detailed or prescriptive, and maybe that will change with time, maybe or with increased uptake, but it is, I agree with you, it does seem like trying to find opportunities to make it more challenging, perhaps the underlying rationale for all of those documentation points are certainly good intended, but just seems like one, one other way to make it just difficult enough that it might sway patients to avoid it.
[19:53]When if they could just go and get it done without having to have a separate physician visit or provider visit and all of those things, like, how much easier would that make it?
[20:00]All questions, maybe we don't have answers to yet, but hopefully we'll see that those rules change as we continue to offer this service.
[20:08]What do you see as some of the challenges that individuals maybe in underserved communities face when it comes to getting screened and how do you think we can help them to overcome these?
[20:17]I mean, a lot of these we already talked about.
[20:20]The education about lung cancer screening, do you even know it exists?
[20:24]Things like getting to and from the screening.
[20:28]You know, screening as a rule of thumb, whether it's lung cancer, breast cancer screening, whatever it is, insurance is usually have a mandate that they cannot charge a copay because it's considered screening.
[20:39]And so, the financial aspect, you have to have insurance, so if you don't have insurance, that's barrier number one.
[20:45]But even if you do have insurance, they should not be allowed to charge you a copay for a screening test for cancer.
[20:54]So that's something that we have to make sure that insurance are abiding by that rule.
[20:59]I don't know if they always do, because I don't typically perform screening.
[21:02]And I think just the other thing that people don't think about is that to go get a medical test done, no matter what test it is, typically people have to take time off of work, and it can be really hard to do that when you are relying on your job, maybe you don't have vacation time, maybe you have children at home that you need to get home to.
[21:20]You know, when people are weighing the risk benefit and thinking, I'd love to get screened for lung cancer, but I just can't find time to fit it into my schedule and my job won't let me take off.
[21:32]These are all things that we don't always think about if you have the luxury of just taking the day off.
[21:38]So I think that's another thing that how we overcome it, I'm not really sure.
[21:42]I think just trying to make maybe the screening test, which is of course done in radiology because it's a cat scan, available after hours times, even considering grants for transportation to get people to and from the doctor visit and the screening test, things like that.
[21:59]Absolutely. And I think I've even seen some institutions doing like screening events, screening drives, and as you said, in the afternoon or in late afternoon, in the evening so that it can accommodate work hours and be open later so that people can do it after their normal day-to-day.
[22:12]I think those are all important things to think about.
[22:15]What do you see as nurses' role, not only in screening itself, not only in getting patients to screening, but what happens after the screening results come back?
[22:23]How do you see nurses as being involved in that process?
[22:27]I think it all depends on where you work. Now, in being that this is an ONS podcast, a lot of us are on the other side of it, unfortunately.
[22:34]A lot of us are on the other side of patients already been diagnosed with lung cancer.
[22:38]One thing that and I've talked to my pulmonary colleagues often about this is that if you have, let's say a patient with lung cancer and their spouse is there, and their spouse is asking about, oh, I hope I don't get lung cancer or something like that.
[22:52]You say, well, do you meet the screening criteria?
[22:55]And that's how a lot of them in thoracic surgery and pulmonary actually get their screening patients is actually family members or spouses of individuals who already are being screened or already have been diagnosed and say, well, if you're at risk, you know, we can screen you.
[23:10]So I think that's one way that us as nurses, because we get to know the patients' families.
[23:15]We get to talk to them. If you get to talking to them and they have questions about it, you can say, like, yeah, you know, I can hook you up with someone and it's good to know in your institution, who does the screening.
[23:25]Like, in my institution where I work, it's run out of pulmonary.
[23:30]So like, we have an MP and a PA in our pulmonary department and thoracic surgery.
[23:36]So they kind of team up, and they'll do it like one day every other week, and they'll have their screening clinic.
[23:40]But a lot of places do it out of primary care. I mean, sometimes it's just your primary care doctor or nurse practitioner or PA who would be seeing you for an annual visit and say, okay, you're due for this screening, this screening, this screening.
[23:53]So just know who runs the clinic, how does it work in your institution?
[23:57]You know, those can be ways, but just really talking to our patients and their families is probably the biggest thing.
[24:02]Absolutely. And I think, as you mentioned, oncology nurses, we're kind of on the other side, but sometimes they're on the other side of a different cancer diagnosis, and so reminding our patients that you may have cervical cancer or some, you know, you might have something very different, but that doesn't absolve you from potential risks of other cancers.
[24:19]And this is again, one of those screenings that can be done and should be done, but I think your idea about, you know, connecting with those family members when you see them, you get to know them, making sure that they are staying up to date on all of their screenings, especially if they do have a loved one with lung cancer, it's probably, certainly more top of mind for them.
[24:34]And so just using any of those opportunities to share that information, spread the awareness and so that people can know better and do better by taking care of themselves.
[24:41]Well, Beth, thank you so much for sharing this information today about lung cancer screening.
[24:44]This is just the first in in a few different episodes we'll have specifically focused on lung cancer, so definitely a great start to that series.
[24:51]As we get to the end of our podcast, we do like to always wrap up with just a few quick fire questions that help us summarize some of the bigger talking points that we covered today.
[25:00]So to start things off, how do you think healthcare professionals should evaluate maybe their own hidden or their implicit bias about lung cancer screening?
[25:06]You don't have to focus it on, well, you smoked, so you should get this done.
[25:12]It should be more of a, we have a tool to help detect this disease early, and by doing that, we can make this a curable illness.
[25:20]So, I think that's probably the biggest one. What do you think are some common misconceptions about lung cancer screening? That it's a death sentence, so why would I do it?
[25:28]And you know, I also thought about this question too.
[25:31]I was thinking, we have to make sure that when people get screened, and the screening comes back and shows that there's no lung cancer, that's great.
[25:37]Patients will sometimes say, great, I can continue to smoke.
[25:40]Well, no, that's not the point.
[25:44]We remind them that continuing that reminder of smoking cessation.
[25:48]We're going to do it again next year, so every year we're going to look for this, but we need you to quit smoking.
[25:52]This is not like something that's supposed to be a reassurance that you you can continue detrimental behavior.
[25:57]What's something about this topic that's not often discussed, but you wish people knew more about?
[26:01]I really think just what I already said, it's not often discussed that it's a screening tool.
[26:06]This is something that saves lives. So it should be done just like we do mammograms and other things.
[26:12]What additional training or education do oncology nurses need to stay current on this topic?
[26:16]You know, I think just following the recommendations.
[26:20]So the recommendations that I just gave you, like age 50 to 80 and currently quit within 15 years, they just changed three years ago, or two years ago maybe.
[26:28]It used to be currently smoking or quit within 20 years.
[26:31]Now they've actually lowered that to 15 years.
[26:34]So it does change a little bit here and there, so just keeping up to date on what the exact guidelines are.
[26:40]And what are some additional resources that you'd recommend for maybe patients or other providers who want to learn more?
[26:44]Probably the best one is the American Lung Association.
[26:49]You know, I know that we are all so oncology focused and like American Cancer Society and things like that, which are great, but the American Lung Association really has some of the best stuff on their website about screening and it's really focused for patients.
[27:03]Outstanding. Well, Beth, thank you again so much for sharing your time with us today and and giving us some of this great information about lung cancer screening that we can hopefully share not only with our patients, but with their families and caregivers, um, so that we can spread the word.
[27:15]Do you have any final comments to share with our guests today? That's it. Thank you for having me and just definitely get the word out about lung cancer screening.
[27:21]It saves lives. Outstanding. Thanks so much, Beth. Thank you. Thank you for listening to the ONS podcast.
[27:28]Tell us about your favorite part in this episode by leaving a review wherever you download your podcast.
[27:33]For more resources and information about oncology nursing, visit us at ONS.org and ONS.org/voice.
[27:40]The ideas and opinions shared in this episode represent those of the guest and not necessarily ONS.
