Letters RESEARCH LETTER
Table 1. Site Listings
Computed Tomographic Screening for Lung Cancer Trends at Leading Academic Medical Centers From 2013 to 2015 In 2013, we1 surveyed leading US academic medical centers (AMCs) and found variability in lung cancer screening (LCS) practices. Since then, favorable policy and payment decisions have been announced by the US Preventive Services Task Force (USPSTF)2 and Centers for Medicare and Medicaid Services (CMS),3 and radiology-specific nodule guidelines have been established by the American College of Radiology (ACR).4 We resurveyed these same leading AMCs in 2014 and 2015 to reassess their practices and hypothesized that there would be greater conformity of practice patterns and increased patient volumes in response to these developments. Methods | Surveys were emailed in March of 2013, 2014, and 2015 to thoracic radiology division chiefs at leading US AMCs, identified from the 2012-2013 US News & World Report overall ranking of best hospitals (n = 17), top 10 cancer centers, and top 10 pulmonology centers.5 From the 37 listings, 21 unique sites were identified (Table 1). Thirteen sites (67%) participated in prior multicenter LCS trials. Each survey (Table 2) inquired whether the site currently offered lung cancer screening. Additional questions related to screening practices, with selected questions repeated annually. Institutional review board approval and informed consent were waived by Beth Israel Deaconess Medical Center. Results | Response Rates and Prevalence of Screening Programs. Of 21 sites, 19 (91%) responded in 2013, 20 (95%) in 2014, and 18 (86%) in 2015. The percentage of sites with a LCS program increased from 79% (15 of 19) in 2013 to 95% (19 of 20) in 2014 and 94% (17 of 18) in 2015. Patient Selection Criteria. Whereas 11 (73%) of 15 LCS sites used National Lung Screening Trial (NLST) entry criteria in 2013, only 6 of 17 sites (35%) used them in 2015, because several sites adopted CMS (n = 4) and USPSTF criteria (n = 4). Fee/Payment Model. While an exclusive self-pay model was the norm in 2013, the percentage of sites using this model decreased to 47% in 2014 (9 of 19) and 6% in 2015 (1 of 17). Number Scanned. The most common response was 1 to 5 patients scanned per week each survey year, although the percentage of sites in this category decreased steadily from 87% (13 of 15) in 2013 to 74% (14 of 19) in 2014 and 53% (9 of 17) in 2015. Only 1 site reported scanning more than 20 patients per week in each survey year. jamaoncology.com
Site
Location
Barnes-Jewish Hospital, Washington Universitya
St Louis, Missouri
Brigham and Women’s Hospitala
Boston, Massachusetts
Cleveland Clinic
Cleveland, Ohio
Duke University Medical Center
Durham, North Carolina
Hospital of the University of Pennsylvaniaa
Philadelphia
Indiana University Health
Indianapolis
Johns Hopkins Hospital
Baltimore, Maryland
Massachusetts General Hospital
Boston
Mayo Clinic
Rochester, Minnesota
Memorial Sloan-Kettering Cancer Center
New York, New York
Mount Sinai Medical Centerb
New York, New York
National Jewish Health, University of Coloradoa
Denver, Colorado
New York-Presbyterian University Hospital of Columbia and Cornellb
New York
New York University Langone Medical Centerb
New York
Northwestern Memorial Hospitala
Chicago, Illinois
Ronald Reagan University of California, Los Angeles, Medical Centera
Los Angeles
University of California, San Francisco
San Francisco
University of Michigan Hospitals and Health Centersa
Ann Arbor
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
University of Texas MD Anderson Cancer Centera
Houston
Vanderbilt University Medical Centera
Nashville, Tennessee
a
National Lung Screening Trial site.
b
International Early Lung Cancer Action Program site.
Nodule Management Guidelines. From 2013 to 2015, there was an evolution from using a variety of nodule management guidelines toward using ACR Lung Imaging Reporting and Data System (Lung-RADS) at most sites (13 of 17 [75%]) in 2015. Concurrently, there was greater uniformity among sites regarding the size threshold of a solid nodule for a positive screening result, with most (12 of 17 [70%]) using a criterion of 6 mm in 2015. Discussion | Our survey demonstrates several trends in LCS from 2013 to 2015, including broad adoption of ACR Lung-RADS, with associated greater conformity regarding threshold nodule size criteria for a positive screen. These findings suggest that radiology-specific guidelines have contributed to greater uniformity in LCS practices. Despite favorable public policy decisions in support of LCS between 2013 and 2015, we observed only a modest increase in patient volume. We emphasize, however, that the timing of (Reprinted) JAMA Oncology Published online February 11, 2016
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://oncology.jamanetwork.com/ by a New York University User on 02/14/2016
E1
Letters
Table 2. 2015 Survey Questions Question
Answer Choices
1. Is your department or practice currently offering low-dose CT screening for patients at risk of lung cancer outside of a research study?
A. Yes B. No, we do not have a program and we are not planning a program at this time. C. No, but we are in the process of planning or setting up a program.
2. What criteria are you using to select patients for low-dose CT screening for lung cancer? Check all that apply:
A. Age 55-74 y, ≥30 pack-years smoking history, former smokers must have quit within past 15 y (NLST entry criteria; ACCP/ASCO, ACS, and NCCN screening criteria) B. Age 55-80 y, ≥30 pack-year smoking history, former smokers must have quit within past 15 y (USPSTF screening criteria) C. Age 55-77 y, ≥30 pack-year smoking history, former smokers must have quit within past 15 y (CMS screening criteria) D. Age 55-79 y old, ≥30 pack-year smoking history, no time limit of duration for former smokers (AATS screening criteria) E. Age ≥50 y, ≥20 pack-year, plus ≥1 additional lung cancer risk factor (AATS and NCCN screening expanded screening criteria) F. Other (please specify):
3. Approximately what proportion of your CT screening studies is self-paid by the patients (ie, the percentage of examinations that are not covered by insurance or other payer)?
A. 100% (all examinations are self-pay) B. 75%-99% of examinations are self-pay C. 50%-74% of examinations are self-pay D. 20
5. How does the current number of patients screened each week in your department compare to the number of patients you were screening each week 3-6 mo ago?
A. Similar (±20% of previous number) B. ≥20% fewer patients now C. ≥20% more patients now D. Not applicable (we did not offer screening 6 mo ago) E. Other (please specify)
6. Has your site been designated as an ACR Lung Cancer Screening Center?
A. Yes B. No, we are not planning to seek this designation C. No, but we plan to apply for this designation
7. What threshold size for solid nodules are you using to define a positive screening result?
A. No size threshold B. ≥4 mm C. ≥5 mm D. ≥6 mm E. Other (please specify): _____
8. Are you using any of the following methods routinely in your screening practice? (Check all that apply.)
A. Volumetric nodule measurement software B. CAD software C. Data management software to facilitate tracking patient enrollment, communication and follow-up D. Local training and/or credentialing requirements for radiologists interpreting screening CT scans
9. Are you using Lung-RADS for reporting and guiding management of screen-detected lung nodules?
A. Yes (if you answer yes, please submit your survey by clicking the “done” button at the bottom of the page) B. No (if you answer no, please answer the final question below before clicking the “done” button at the bottom of the page)
10. Which of the following factors has contributed to your decision not to use Lung-RADS? (Check all that apply.)
A. Prefer to use a different set of guidelines (please list): _____ B. Not familiar with Lung-RADS C. Waiting for further validation of Lung-RADS D. Other: please list:
Abbreviations: AATS, American Association for Thoracic Surgery; ACCP/ASCO, American College of Chest Physicians and American Society of Clinical Oncology; ACR, American College of Radiology ; ACS, American Cancer Society; CAD, computer-aided detection; CMS, Centers for Medicare and
Medicaid Services; CT, computed tomography; Lung-RADS, Lung Imaging Reporting and Data System; NCCN, National Comprehensive Cancer Network; NLST, National Lung Screening Trial; USPSTF, US Preventive Services Task Force.
the survey occurred too early to determine the impact of CMS coverage on patient volumes. By design, we targeted a focused population of leading AMCs to determine whether there is a consensus of “best practices.” We acknowledge that our results may not be representative of all AMCs or of other practice types offering screening in the community setting. In summary, the development of radiology-specific guidelines has likely contributed to reduced variability in LCS practices at leading AMCs. We plan to continue our longitudinal survey of these sites to determine the impact of CMS coverage on patient screening volumes.
Author Affiliations: Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts (Boiselle); Department of Radiology, Wake Forest University, Winston-Salem, North Carolina (Chiles); Department of Radiology, The Medical University of South Carolina, Charleston (Ravenel); Department of Radiology, The University of Maryland School of Medicine, Baltimore (White).
Phillip M. Boiselle, MD Caroline Chiles, MD James G. Ravenel, MD Charles S. White, MD E2
Corresponding Author: Phillip M. Boiselle, MD, Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, TCC-4, Boston, MA 02215 ([email protected]). Published Online: February 11, 2016. doi:10.1001/jamaoncol.2015.6419. Author Contributions: Dr Boiselle had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Boiselle, Ravenel. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Boiselle. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Boiselle. Administrative, technical, or material support: Boiselle, Ravenel, White. Conflict of Interest Disclosures: None reported.
JAMA Oncology Published online February 11, 2016 (Reprinted)
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://oncology.jamanetwork.com/ by a New York University User on 02/14/2016
jamaoncology.com
Letters
1. Boiselle PM, White CS, Ravenel JG. Computed tomographic screening for lung cancer: current practice patterns at leading academic medical centers. JAMA Intern Med. 2014;174(2):286-287. 2. Moyer VA; US Preventive Services Task Force. Screening for lung cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(5):330-338. 3. Centers for Medicare & Medicaid Services. Decision memo for screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439N).
jamaoncology.com
https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo .aspx?NCAId=274. Accessed November 11, 2015. 4. American College of Radiology. Lung CT screening reporting and data system (Lung-RADS). http://www.acr.org/Quality-Safety/Resources/LungRADS. Accessed November 11, 2015. 5. US News & World Report. Best Hospitals 2012-2013. http://health.usnews .com/best-hospitals. Accessed March 20, 2013.
(Reprinted) JAMA Oncology Published online February 11, 2016
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://oncology.jamanetwork.com/ by a New York University User on 02/14/2016
E3
Table 1. Site Listings
Computed Tomographic Screening for Lung Cancer Trends at Leading Academic Medical Centers From 2013 to 2015 In 2013, we1 surveyed leading US academic medical centers (AMCs) and found variability in lung cancer screening (LCS) practices. Since then, favorable policy and payment decisions have been announced by the US Preventive Services Task Force (USPSTF)2 and Centers for Medicare and Medicaid Services (CMS),3 and radiology-specific nodule guidelines have been established by the American College of Radiology (ACR).4 We resurveyed these same leading AMCs in 2014 and 2015 to reassess their practices and hypothesized that there would be greater conformity of practice patterns and increased patient volumes in response to these developments. Methods | Surveys were emailed in March of 2013, 2014, and 2015 to thoracic radiology division chiefs at leading US AMCs, identified from the 2012-2013 US News & World Report overall ranking of best hospitals (n = 17), top 10 cancer centers, and top 10 pulmonology centers.5 From the 37 listings, 21 unique sites were identified (Table 1). Thirteen sites (67%) participated in prior multicenter LCS trials. Each survey (Table 2) inquired whether the site currently offered lung cancer screening. Additional questions related to screening practices, with selected questions repeated annually. Institutional review board approval and informed consent were waived by Beth Israel Deaconess Medical Center. Results | Response Rates and Prevalence of Screening Programs. Of 21 sites, 19 (91%) responded in 2013, 20 (95%) in 2014, and 18 (86%) in 2015. The percentage of sites with a LCS program increased from 79% (15 of 19) in 2013 to 95% (19 of 20) in 2014 and 94% (17 of 18) in 2015. Patient Selection Criteria. Whereas 11 (73%) of 15 LCS sites used National Lung Screening Trial (NLST) entry criteria in 2013, only 6 of 17 sites (35%) used them in 2015, because several sites adopted CMS (n = 4) and USPSTF criteria (n = 4). Fee/Payment Model. While an exclusive self-pay model was the norm in 2013, the percentage of sites using this model decreased to 47% in 2014 (9 of 19) and 6% in 2015 (1 of 17). Number Scanned. The most common response was 1 to 5 patients scanned per week each survey year, although the percentage of sites in this category decreased steadily from 87% (13 of 15) in 2013 to 74% (14 of 19) in 2014 and 53% (9 of 17) in 2015. Only 1 site reported scanning more than 20 patients per week in each survey year. jamaoncology.com
Site
Location
Barnes-Jewish Hospital, Washington Universitya
St Louis, Missouri
Brigham and Women’s Hospitala
Boston, Massachusetts
Cleveland Clinic
Cleveland, Ohio
Duke University Medical Center
Durham, North Carolina
Hospital of the University of Pennsylvaniaa
Philadelphia
Indiana University Health
Indianapolis
Johns Hopkins Hospital
Baltimore, Maryland
Massachusetts General Hospital
Boston
Mayo Clinic
Rochester, Minnesota
Memorial Sloan-Kettering Cancer Center
New York, New York
Mount Sinai Medical Centerb
New York, New York
National Jewish Health, University of Coloradoa
Denver, Colorado
New York-Presbyterian University Hospital of Columbia and Cornellb
New York
New York University Langone Medical Centerb
New York
Northwestern Memorial Hospitala
Chicago, Illinois
Ronald Reagan University of California, Los Angeles, Medical Centera
Los Angeles
University of California, San Francisco
San Francisco
University of Michigan Hospitals and Health Centersa
Ann Arbor
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
University of Texas MD Anderson Cancer Centera
Houston
Vanderbilt University Medical Centera
Nashville, Tennessee
a
National Lung Screening Trial site.
b
International Early Lung Cancer Action Program site.
Nodule Management Guidelines. From 2013 to 2015, there was an evolution from using a variety of nodule management guidelines toward using ACR Lung Imaging Reporting and Data System (Lung-RADS) at most sites (13 of 17 [75%]) in 2015. Concurrently, there was greater uniformity among sites regarding the size threshold of a solid nodule for a positive screening result, with most (12 of 17 [70%]) using a criterion of 6 mm in 2015. Discussion | Our survey demonstrates several trends in LCS from 2013 to 2015, including broad adoption of ACR Lung-RADS, with associated greater conformity regarding threshold nodule size criteria for a positive screen. These findings suggest that radiology-specific guidelines have contributed to greater uniformity in LCS practices. Despite favorable public policy decisions in support of LCS between 2013 and 2015, we observed only a modest increase in patient volume. We emphasize, however, that the timing of (Reprinted) JAMA Oncology Published online February 11, 2016
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://oncology.jamanetwork.com/ by a New York University User on 02/14/2016
E1
Letters
Table 2. 2015 Survey Questions Question
Answer Choices
1. Is your department or practice currently offering low-dose CT screening for patients at risk of lung cancer outside of a research study?
A. Yes B. No, we do not have a program and we are not planning a program at this time. C. No, but we are in the process of planning or setting up a program.
2. What criteria are you using to select patients for low-dose CT screening for lung cancer? Check all that apply:
A. Age 55-74 y, ≥30 pack-years smoking history, former smokers must have quit within past 15 y (NLST entry criteria; ACCP/ASCO, ACS, and NCCN screening criteria) B. Age 55-80 y, ≥30 pack-year smoking history, former smokers must have quit within past 15 y (USPSTF screening criteria) C. Age 55-77 y, ≥30 pack-year smoking history, former smokers must have quit within past 15 y (CMS screening criteria) D. Age 55-79 y old, ≥30 pack-year smoking history, no time limit of duration for former smokers (AATS screening criteria) E. Age ≥50 y, ≥20 pack-year, plus ≥1 additional lung cancer risk factor (AATS and NCCN screening expanded screening criteria) F. Other (please specify):
3. Approximately what proportion of your CT screening studies is self-paid by the patients (ie, the percentage of examinations that are not covered by insurance or other payer)?
A. 100% (all examinations are self-pay) B. 75%-99% of examinations are self-pay C. 50%-74% of examinations are self-pay D. 20
5. How does the current number of patients screened each week in your department compare to the number of patients you were screening each week 3-6 mo ago?
A. Similar (±20% of previous number) B. ≥20% fewer patients now C. ≥20% more patients now D. Not applicable (we did not offer screening 6 mo ago) E. Other (please specify)
6. Has your site been designated as an ACR Lung Cancer Screening Center?
A. Yes B. No, we are not planning to seek this designation C. No, but we plan to apply for this designation
7. What threshold size for solid nodules are you using to define a positive screening result?
A. No size threshold B. ≥4 mm C. ≥5 mm D. ≥6 mm E. Other (please specify): _____
8. Are you using any of the following methods routinely in your screening practice? (Check all that apply.)
A. Volumetric nodule measurement software B. CAD software C. Data management software to facilitate tracking patient enrollment, communication and follow-up D. Local training and/or credentialing requirements for radiologists interpreting screening CT scans
9. Are you using Lung-RADS for reporting and guiding management of screen-detected lung nodules?
A. Yes (if you answer yes, please submit your survey by clicking the “done” button at the bottom of the page) B. No (if you answer no, please answer the final question below before clicking the “done” button at the bottom of the page)
10. Which of the following factors has contributed to your decision not to use Lung-RADS? (Check all that apply.)
A. Prefer to use a different set of guidelines (please list): _____ B. Not familiar with Lung-RADS C. Waiting for further validation of Lung-RADS D. Other: please list:
Abbreviations: AATS, American Association for Thoracic Surgery; ACCP/ASCO, American College of Chest Physicians and American Society of Clinical Oncology; ACR, American College of Radiology ; ACS, American Cancer Society; CAD, computer-aided detection; CMS, Centers for Medicare and
Medicaid Services; CT, computed tomography; Lung-RADS, Lung Imaging Reporting and Data System; NCCN, National Comprehensive Cancer Network; NLST, National Lung Screening Trial; USPSTF, US Preventive Services Task Force.
the survey occurred too early to determine the impact of CMS coverage on patient volumes. By design, we targeted a focused population of leading AMCs to determine whether there is a consensus of “best practices.” We acknowledge that our results may not be representative of all AMCs or of other practice types offering screening in the community setting. In summary, the development of radiology-specific guidelines has likely contributed to reduced variability in LCS practices at leading AMCs. We plan to continue our longitudinal survey of these sites to determine the impact of CMS coverage on patient screening volumes.
Author Affiliations: Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts (Boiselle); Department of Radiology, Wake Forest University, Winston-Salem, North Carolina (Chiles); Department of Radiology, The Medical University of South Carolina, Charleston (Ravenel); Department of Radiology, The University of Maryland School of Medicine, Baltimore (White).
Phillip M. Boiselle, MD Caroline Chiles, MD James G. Ravenel, MD Charles S. White, MD E2
Corresponding Author: Phillip M. Boiselle, MD, Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, TCC-4, Boston, MA 02215 ([email protected]). Published Online: February 11, 2016. doi:10.1001/jamaoncol.2015.6419. Author Contributions: Dr Boiselle had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Boiselle, Ravenel. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Boiselle. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Boiselle. Administrative, technical, or material support: Boiselle, Ravenel, White. Conflict of Interest Disclosures: None reported.
JAMA Oncology Published online February 11, 2016 (Reprinted)
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://oncology.jamanetwork.com/ by a New York University User on 02/14/2016
jamaoncology.com
Letters
1. Boiselle PM, White CS, Ravenel JG. Computed tomographic screening for lung cancer: current practice patterns at leading academic medical centers. JAMA Intern Med. 2014;174(2):286-287. 2. Moyer VA; US Preventive Services Task Force. Screening for lung cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(5):330-338. 3. Centers for Medicare & Medicaid Services. Decision memo for screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439N).
jamaoncology.com
https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo .aspx?NCAId=274. Accessed November 11, 2015. 4. American College of Radiology. Lung CT screening reporting and data system (Lung-RADS). http://www.acr.org/Quality-Safety/Resources/LungRADS. Accessed November 11, 2015. 5. US News & World Report. Best Hospitals 2012-2013. http://health.usnews .com/best-hospitals. Accessed March 20, 2013.
(Reprinted) JAMA Oncology Published online February 11, 2016
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://oncology.jamanetwork.com/ by a New York University User on 02/14/2016
E3
