As appeared in the Spring 2022 issue of Scripts.
The care for lung cancer and cancers of the chest, like other cancers, is a multispecialty affair. Some patients with chest tumors will see their primary care provider, a pulmonologist, a thoracic surgeon, an oncologist, and a radiation oncologist. Their tumors will also be evaluated by a pathologist, and they may need to see a geneticist for genetic counselling and a nutritionist as well. The first step in cancer care is determining if someone has a cancer. Lung cancer screening and lung nodule clinic (LNC) are integral in finding, diagnosing and treating cancers of the chest quickly and efficiently.
The first part of lung cancer screening is to effectively screen the patients to a high risk group. In 2011, the National Lung Cancer Screening Trial showed that early detection is possible with low-dose chest CT (LDCT) in appropriately chosen patients. In this study, 53,454 patients, age 55-74 with a minimum 30-pack-year history of smoking, were enrolled starting in 2002 at 33 centers across the U.S. and followed for five years. A 20% reduction in lung cancer specific mortality was observed compared with chest X-ray alone in this trial. The reason for this significant improvement in survival is that screening with LDCT shifts the stage of diagnosis from late (stage III/IV) and poor prognosis to early (stage I/II) with good prognosis. Earlier in 2022, CMS expanded the criteria for lung cancer screening to pts age 50 from 55 and with a 20-pack-year history of smoking, down from 30. If an abnormality is found, the next course of action should be to refer the patient to an LNC to both expedite care and to minimize interventions.
Lung cancer screening is not just getting a chest CT and seeing if there are any abnormalities. If that were the case, many people would be found to have some abnormality and many unnecessary interventions would be requested. Having lung lesions are, for most people, just a matter of time on Earth. The longer we are here, the more likely we are to have them. Not to mention, there are many abnormalities that can be found on chest CTs that are not lung cancer, like lung metastases, thymomas, esophageal cancers and mediastinal masses. In order to differentiate between benign and malignant findings, it is best to employ a team of specialists along with the radiologists who initially read the images.
The LNC is a multispecialty clinic that is attended by pulmonologists, a thoracic surgeon, medical and radiation oncologists, and a nurse navigator. Within this group of physicians, LDCT are reviewed, along with pertinent patient history, so that a further course of action can be undertaken. Not all abnormalities found on a LDCT need to be evaluated. Some abnormalities can be followed up with a new LDCT in a few months; some can be ignored and some may require further interventions (biopsy, bronchoscopy or surgery) to evaluate. All of these can be discussed and evaluated by the physicians themselves, so that any further work up can be done in a timely manner.
In a traditional treatment setting, a patient may be required to go to multiple specialists’ offices multiple times, and usually over a few months, before treatment or treatments can be started. The goal of the LNC is to shorten the time from diagnosis to treatment by significantly reducing the number of clinic appointments and to minimize the number of interventions. The LNC has all the specialists available at a single clinic to see a patient if necessary. Not every patient in the LNC gets seen by every specialty, but every patient’s LDCT/cancer is reviewed by all specialties in a tumor board type setting, and their workup and treatment is agreed to by everyone. Once a treatment or work up plan is determined, the nurse navigator makes and facilitates any further appointments and makes sure the patient knows where and when to go. Once a diagnosis is made, we aim to get the patient’s treatment (surgery, chemotherapy or radiation) started in no more than 14 days.