Navigation Program Increases Uptake of Lung Cancer Screening and Facilitates Follow-Up

Gean Brown, MSN, RN, OCN

A nurse navigator—led program aimed at improving awareness, access, and uptake of low-dose CT (LDCT) screening for individuals at high risk of lung cancer resulted in improved screening rates with the potential to improve patient outcomes by catching the disease at its earliest stages.

Project leader Gean Brown, MSN, RN, OCN, a clinical manager at Middlesex Hospital Cancer Center in Middletown, Connecticut, explained why oncology nurses are so important to the process during a podium session on oncology navigation April 25 at the 2015 ONS Annual Congress.

Brown said the impetus for her project came from both the prevalence of lung cancer in the United States, accounting for 30% of cancer deaths, plus a very low 15% survival rate—a number that increases to 60%, however, when the disease is diagnosed at stage I.

“I really believe oncology nurses have the power to change that: to make more people stage I and less people stage III and IV … By working with a multidisciplinary team, oncology nurses are uniquely poised to lead the way in implementing [a lung cancer screening program] and its related care pathways, as well as educating the public and getting people to be screened.”

Brown explained that the US Preventive Services Task Force decision to give LDCT a “B” rating was a boost for lung cancer screening advocates, because it meant that as of January 2015, insurers must pay for this screening in individuals who meet the high-risk criteria (asymptomatic adults aged 55-80 years with a 30 pack—year smoking history [equivalent to one pack a day for 30 years or 2 packs a day for 15 years] and who are currently smoking or quit within last 15 years). The Centers for Medicare & Medicaid Services (CMS) has also adopted these criteria, although the CMS cutoff for LDCT coverage is 77 years.

LDCT provides about 25% of the radiation of a normal CT scan. Concurring with recent research indicating that the criteria may not capture all those who need the screening,1 Brown said: “I’m not happy with that. I think people who quit more than 15 years ago are still at risk, and hopefully we can change that.”

When the program started in April 2012 (it was self-pay at that time), the multidisciplinary team involved herself, the head of radiology, a representative from administration, a thoracic surgeon, and a pulmonologist. The Middlesex Hospital Total Lung Care Center (“TLC”) depended on extensive outreach to clinicians, an effort Brown spearheaded.

“We would have thought that when we put [this opportunity out]—$125, self-pay—that people would come flocking to our door,” said Brown, but it “did not happen.”

She said that the navigators needed to get out and educate the physicians. Many of them, she said, “were naysayers, which I couldn’t believe.” Brown added that her team was fortunate that one of the pulmonologists who had been with the hospital for 40 years and retiring, decided to become “our physician champion.”

“We had to answer a lot of questions,” acknowledging that primary care providers are very busy and have a lot on their plate. The nurse can be the point of contact for these practices with questions about which patients should have screening and, in consultation with a radiologist, determine what to do about any suspicious findings using the Lung-RADS system adopted by the American College of Radiology.

She also developed a handout for patients advising them of the risks and benefits of screening, along with a shared decision-making tool clinicians can use with these high-risk patients to help them decide whether to take up the screening.

In addition to the outreach to physicians and the public through health fairs and other community events—which, Brown noted, offers the add-on benefit of answering questions and offering advice about smoking cessation—nurse navigators help to facilitate the screenings and coordinate follow-up for any suspicious findings. She said about 50% of individuals screened through the program will have nodules, and though these will not all be cancerous, they may be precancerous, and these patients will receive additional monitoring.

“We do a lot of support with these patients, so they understand that [at this point] it’s a nodule.” The navigators also make sure high-risk patients understand that patients need to repeat the LDCT annually, even if nothing is found at the first screening, and navigators initiate the patient reminder calls.

“Studies have shown that a lot of these cancers are picked up on the subsequent CT scans, and not the first one,” Brown noted. “It’s important to make sure that patients are getting these.”

Since her lung cancer screening program was launched, Brown reported that a total of 312 scans have been performed, with 5 diagnosed at stage I, a rate that exceeds that of the general population. Within 2 weeks of starting the program, she added, the program identified two patients with early cancer: one stage Ia, and one stage Ib, including an individual whose father and brother had died of lung cancer, but whose regular x-rays did not indicate anything suspicious.

• Wang Y, Midthun DE, Wampfler JA, et al. Trends in the proportion of patients with lung cancer meeting screening criteria. JAMA. 2015;313(8):853-855.

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