September Spotlight – Radiology: Lung Cancer Screening – Radiology’s Role

 

Submitted by William M. Merenich, MD, Radiology Campus Chief, Riddle Hospital

 

Lung Cancer screening, using low dose CT, has been demonstrated to reduce lung cancer mortality by 20% and all cause mortality by 6.7% (1).

 

Implementation of a lung screening program requires many elements to be successful including: institutional support, integrated multidisciplinary team, lung screening navigators, and prompt appropriate care if a suspicious nodule is detected. The MLH System Lung Cancer Committee is coordinating the implementation of the Lung Screening program.

 

Currently, several recommendations are available which differ slightly as to whom should be screened for lung cancer; U.S. Preventative Services Task force (2013): CMS (Feb 2015), NCCN. CMS has added the requirement for a shared decision making counseling, smoking cessation counseling and submission of data to a qualified CMS approved Qualified Clinical Data Registry (QCDR).

 

MLH has developed a program to help clinicians through the lung screening and reporting process.  Each hospital has a nurse navigator to help clinicians and patients through the process. The purpose of this article is to discuss Radiology’s role in the program.

 

Physician Order

Since the publication of the National Screening Lung Trial (NSLT) findings, CT low dose lung screening has been endorsed by both the USPSTF and CMS. Numerous agencies have put forward recommendations on which patient populations should be screened.

 

The Affordable Care Act mandates that private insurers cover low-dose lung cancer screening based on the USPSTF recommendations:  LDCT screening in individuals between 55-79 years of age who have a 30-pack-year history of smoking or have quit in the past 15 years.

 

In February 2015, a national coverage determination (NCD) of CMS, whose beneficiaries are typically 65 years or older, recommended CT screening for adults between 55-77 years of age who have a 30-pack-year history of smoking and who are current smokers or have quit smoking in the past 15 years.  The lung screening coordinators at each MLH campus are available to help determine screening eligibility.

 

CPT codes appropriate for Screening are:

Code S8032 (Low dose Computed Tomography for Lund Screening)*Preferred*

CT Thorax 71250 (CT Thorax without contrast material)

ISDN 9 Codes:

If selection criteria met

305.1 Nondependent tobacco disorder (current or former smoker aged 55-80)

V15.82 Personal history of tobacco use

ISDN 10 Codes:

Z72.0 Tobacco Use (current or former smoker)

Z87.891 Personal History of Tobacco Dependence

 

It is important to note, a patient does NOT qualify for screening if there are symptoms or signs of lung malignancy. These patients should undergo a routine CT Thorax preferably with IV contrast. If an order for a screening CT is received and the patient does not meet criteria, the CT technologist and/or Radiologist will attempt to contact the ordering clinician to change the order and discuss. If not available, a routine dose non-contrast CT will be performed. It is important to remember Screening Lung nodule CT is tailored to detect and follow-up lung nodules and may not detect significant pathology in the mediastinum or surrounding tissues.

Lung screening CT Study

 

Standardized ACR CT protocols for performing and interpreting lung screening CT include: All scans are performed with a spiral CT, with a radiation dose level less than 3 mSV  (conventional CT 7-10 mSV) and with interpretation by Radiologists who have read over 300 chest CT exams over the preceding year.

 

CT Interpretation:

Lung nodules detected are classified as ground glass (a), mixed (b), and solid (c).

lungcancer

 

Classification is significant because each nodule type has different risks of malignancy, different growth rates and different requirements for follow-up. In general, non-solid nodules have the highest risk of malignancy (63%) compared to solid nodules (18%) (4). Ground Glass nodules could represent inflammation, pre-cancerous lesion (Atypical adenomatous hyperplasia [AAH]), or carcinoma (adenocarcinoma in situ [AIS] and minimally invasive adenocarcinoma [MIA]). The main reason for a 3-month follow-up is to evaluate for resolution of inflammatory lesions.

 

Recommendations for follow-up

In order to standardize lung cancer screening reporting and management recommendations; the MLH Lung Cancer Committee adopted the ACR Lung-RADS (Version 1) as our standard reporting method.

lungcancertable

From ACR

 

1.Reduced Lung-Cancer Mortality with Low-Dose Tomographic Screening, NLST N Eng J Med 2011;365: 395-409: August 4, 2011

2.Cost –Effeectiveness of CT Screening int  he National Lung Screening Trial William C. Black,M.D. Ilana F Gareeen, Ph.D., Samir S. Soneji, etc N Engl J Med 2014; 371:1793-1802;November 6, 2014

3.Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Archives of Internal Medicine 2009; 169(22):2078–2086.

  1. Henschke CI, Yankelevitz DF, Mirtcheva R, et al. CT screening for lung cancer: frequency and significance of part-solid and nonsolid nodules. AJR Am J Roentgenol. 2002;178:1053–1057. PMid:11959700. Henschke CI, Yankelevitz DF, Mirtcheva R, et al. CT screening for lung cancer: frequency and significance of part-solid and nonsolid nodules. AJR Am J Roentgenol. 2002;178:1053–1057. PMid:11959700.
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