Lung Cancer Screening – Not Just a Primary Care Responsibility

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There is a major statewide push to encourage primary care providers (PCPs) to refer eligible patients to low-dose computed tomography (LDCT) lung cancer screening. However, a pulmonologist in Lexington wants specialists to know that they, too, can refer eligible patients to this potentially life-saving screening.

Mahmoud Moammar, MD, of KentuckyOne Health Pulmonology Associates, said his practice sees many patients with chronic obstructive pulmonary disease (COPD), a disease most frequently caused by cigarette smoking. Many of them meet all of the lung cancer screening criteria, he said, adding, “They deserve the screening.”

LDCT screening for lung cancer was recommended by the U.S. Preventive Services Task Force in December 2013, following the National Lung Screening Trial (NLST). The National Cancer Institute-sponsored study proved that new technology could detect small tumors early enough to remove them by surgery.

Moammar said he has been referring patients to LDCT screening since 2015 when the Centers for Medicare & Medicaid Services (CMS) added it as a preventive service benefit under the Medicare program. “We do it every day,” Moammar said. “I believe in it.” Moammar said he has had several patients whose lung cancer was caught at an early stage. “They got a cure for lung cancer; not palliative care,” he added. “It was surgery with intent to cure.”

CMS covers screening as a preventive services benefit for beneficiaries who are:

Current smokers, or those who have quit within the last 15 years, age 55–77.
Individuals that have a tobacco smoking history of at least 30 pack-years; a pack year equals one pack per day for a year.
Asymptomatic, with no signs or symptoms of lung cancer.

Anthony Weaver, MD, of the University of Kentucky College of Medicine, is also a major proponent of lung cancer screening. He wants healthcare providers to view LDCT lung screening like mammography and other recommended tests ordered “as a matter of general health.” He said that Kentucky, with the nation’s highest lung cancer incidence and mortality, has a responsibility to show that LDCT screening can lower lung cancer death rates. “It is up to us,” Weaver said.

Angela Criswell of Lung Cancer Alliance, a national nonprofit advocacy group, said some specialists hesitate to refer patients because of the “asymptomatic” requirement of CMS. She said that criterion is to ensure that patients with true symptoms, such as coughing up blood and weight loss, receive diagnostic tests rather than screening. A “persistent cough” does not make a patient ineligible for screening, she said.

Criswell pointed out that many patients with chronic conditions see specialists much more frequently than PCPs. “The specialists have strong relationships with their patients, many of whom meet high-risk criteria for lung cancer screening, and they see these patients regularly for evaluation and management of their health concerns – so they are a major referral pathway,” Criswell said.

Moammar said specialists might hesitate to refer patients to screening because they do not want to be burdened if lung cancer screening requires follow-up attention. He pointed out that most screening facilities, particularly within large health systems, have staff dedicated to ensuring follow-up of abnormal findings. “That takes the burden off their shoulders,” Moammar said.

Since early 2016, Kentucky LEADS Collaborative team at the University of Louisville has been promoting LDCT screening to PCPs through several continuing medical education offerings, including visits to providers, presentations to medical groups, and a free interactive online course “Lung Cancer in Kentucky: Improving Patient Outcomes,” at www.LungCancerinKentucky.org. The online course familiarizes providers with screening eligibility and how to conduct CMS-required shared decision making with patients, and it features resources for tobacco treatment and cancer survivorship.

Jesse Adams III, MD, a cardiologist with Baptist Health in Louisville, recently took the online course and called it a “succinct means of getting up to date on this important topic.” Adams, immediate past-Governor of the Kentucky Chapter of the American College of Cardiology, said he does not yet refer patients to LDCT screening. “The course prepared me to appropriately refer patients when I choose to do so, and to provide guidance to patients who are eligible,” he said.

The free interactive course is available at www.LungCancerinKentucky.org. For more information about Kentucky LEADS Collaborative, see www.KentuckyLEADS.org

Ruth Mattingly, MPA, is co-investigator, Kentucky LEADS, and assistant director for special initiatives, Kentucky Cancer Program at University of Louisville, 501 E. Broadway, Ste. 160 Louisville, KY 40202. She can be reached at (502) 852-4065.