Unique Program Considerations in Lung Cancer Screening, Incidental Programs for Vulnerable Populations
In this video roundtable discussion, Jaspal Singh, MD, MHA, MHS, interviews Jasleen Pannu, MD, Coral Giovacchini, MD, and Leisa Lackey about key issues and solutions in starting a screening and incidental nodule program in vulnerable communities, including leadership lessons learned from experts in the field. This is part three of a three-part series on lung cancer screening.
Additional Resources:
- Tanoue LT, Tanner NT, Gould MK, Silvestri GA. Lung cancer screening. Am J Respir Crit Care Med. 2015;191(1):19-33. doi:10.1164/rccm.201410-1777CI
- Van Haren RM, Delman AM, Turner KM, Waits B, Hemingway M, Shah SA, Starnes SL. Impact of the COVID-19 Pandemic on Lung Cancer Screening Program and Subsequent Lung Cancer. J Am Coll Surg. 2021;232(4):600-605. doi:10.1016/j.jamcollsurg.2020.12.002
- Lake M, Shusted CS, Juon HS, et al. Black patients referred to a lung cancer screening program experience lower rates of screening and longer time to follow-up. BMC Cancer. 2020;20(1):561. doi:10.1186/s12885-020-06923-0
- Meza R, Jeon J, Toumazis I, et al. Evaluation of the benefits and harms of lung cancer screening with low-dose computed tomography: modeling study for the US preventive services task force. JAMA. 2021;325(10):988-997. doi:10.1001/jama.2021.1077
- Haddad DN, Sandler KL, Henderson LM, Rivera MP, Aldrich MC. Disparities in lung cancer screening: a review. Ann Am Thorac Soc. 2020;17(4):399-405. doi:10.1513/AnnalsATS.201907-556CME
TRANSCRIPTION:
Dr Jaspal Singh: Welcome everybody to part 3 of our series on lung cancer screening and incidental lung nodule programs. I'm your host, Dr Jaspal Singh. I’m a pulmonologist at Atrium Health Levine Cancer Institute. I want to talk to you about, part three of our series, which I'm really looking forward to hearing from our experts about unique program considerations in lung cancer screening and in some of our programs with a focus on vulnerable populations. So, with us today, let's start with Coral. Introduce yourself, please.
Dr Coral Giovacchini: Hi, everyone. I'm Coral Giovacchini. I'm an interventional pulmonologist at Duke Health and our director of clinical operations for the interventional pulmonary program. I also co-direct our lung cancer screening and incidental nodule programs across the system.
Singh: Great. Jasleen?
Dr Jasleen Pannu: Hello, everyone. My name is Jasleen Pannu. I'm an interventional pulmonologist at The Ohio State University Medical Center, and I lead our lung nodule program.
Singh: Fantastic. And then Leisa.
Leisa Lackey: Hey there. My name is Leisa Lackey. I oversee the lung screening and incidental lung nodule program at Atrium Health based in Charlotte, North Carolina. Thanks for having me today.
Singh: Thanks all three of you for being here. This is going to be a fun episode. So, just to recap for our audience, on the first episode in this three-part series, we talked about lung cancer screening: (1) important updates in the screening programs; (2) what are some ways to be successful?; (3) What are some considerations?
And part two of the series, we talked about incidental lung nodule programs: (1) finding nodules on routine scans for other reasons, for example; (2) then how do we manage them? And in those programs, we've talked to the importance of the program considerations, some of the software issues, some of the tracking issues, some of the care coordination, the navigation, and it's very programmatic based. But ultimately though, what these programs also have uncovered is the uniqueness of every patient and population, especially the local aspects, and especially the vulnerable populations.
Coral, you and I have talked about this before. Give the audience insight into how to frame these issues. What do you see as the major highlights to consider?
Giovacchini: Yes. Jaspal, we have spoken about this. I think I could take our entire episode about this. But I think there are a few key points to bring out. I would say that when you're doing some of these outreach programs or focusing on more vulnerable or underserved populations, you probably learn just as much, specifically focusing on those populations, as you do when setting up your entire screening and lung nodule program. There are a lot of other special considerations when you're starting these programs.
I think the most important thing is that we know in lung cancer screening, the follow-up is the key. And so ideally, you want to get these patients in for screening, but you also want to start that idea with the fact that you're going to want to continue to care for these patients and allow for follow-up for them. And so, especially in some underserved or underrepresented populations, when you're thinking about bringing them in, you want to be able to think how is that patient going to get there? Are they going to be able to make it to my system? Are they then going to be able to have two visits, the counseling visit for their screening and then their imaging visit? How do you coordinate some of those things? Can one be tied into another? Can you do a counseling visit and then have a CT and a follow-up visit on one day to minimize their transport to the facility? Is there a place where they can get free parking to come and see you? If you have a mobile outreach program, are you going to be able to sustain that program? Are you going to be able to follow up with them? When you screen somebody, do they have a phone to follow up with? How are you going to get back in touch with that patient? And then even approaching them with their understanding. Jasleen spoke a little bit about the stigma of lung cancer. Right?
Every different population has a different idea about what screening means. What does their health mean within the system? Do they want to be approached about this? I am an advocate for maybe changing some of the language about this. Lung cancer screening is the only one that we focus on the actual cancer word in the screening. People get their screening mammograms and they're screening colonoscopies, but they get their lung cancer screening. And so changing some of the terminology around that and how we speak about it can be a little bit destigmatizing.
And then, we also broached the lung cancer screening module, and a little bit about the changing algorithm around who are we screening. Are we screening the right folks? Smoking is a major risk factor for lung cancer, but there are also changing risk factors. I think there was just an AJRMCSC article that came out about fine, particulate matter and air pollution in Southern California and changing risks for adenocarcinoma in nonsmokers. And so making sure that we are approaching what might be vulnerable, underrepresented, patient populations in our lung cancer screening population and a focus on who those patients are is going to be important in the future.
Singh: Holy cow. It's a lot to unpack. All right. I'm just going to give some of the highlights. But basically, I think what you're saying is every part of the program, you're learning a lot about. I mean, these programs, to be honest, are fairly new. Right? But we're learning a lot. I think you said very nicely that we're learning a lot about how we deliver healthcare in these programs as we scale them, like software's great, hardware's great, all these things that we've put together. Though the human element of trying to uncover important aspects of how we coordinate their care, who’s helping them?
Who's walking them through that? I mean, for those of us taking care of family members and others who navigate a system, it's a very hard system to navigate. Let's add to what Coral discussed. Jasleen, I get the sense that a lot of people are in an era of mistrust of healthcare, especially in certain populations, how do you manage that as we scale these programs? How do you factor that in? Walk us through your thoughts here.
Pannu: So, that's important here. This is something that we need to address because even though dealing with this issue with vulnerable populations is difficult one to deal with, it's important to deal with because we know now that in these populations, the incidence of lung cancer, as well as the outcomes may be worse than what we know from other studies. So, I think one thing or a couple of things I may want to add is we found it was super useful to include leaders from the specific populations, the community itself, to be involved in the voice towards lung cancer screening, like involving pastors and churches, where you're not asking the community to come to you but go to the community to speak to them in their voice. Addressing the suspicions at a very local level and in a very casual sort of informal way.
So those three things help to break a barrier. And so to provide very clear, direct upfront solutions because most of the concern would be around "Am I going to have to pay for this?" And to have some sort of resource available up front, which can tell them point blank "Okay. This for you is going to mean it's free for this." "For you, it may mean that there may be a co-pay because of the amount of insurance that you have or do not have or how much social support can be offered." So, I think that people sometimes even hesitate to ask because there's a shame about it or we may not be able to afford this. So, having those sorts of facilities available is something that we found is very applicable to breaking those barriers. Recently, we have had more and more social events where we are talking about lung cancer in ads in a very casual way. It becomes almost like something that is a sinister problem that people walk away from. Sometimes we have a desk displaying stuff about lung lung cancer and people walk just past it and distance themselves.
So, talk about it in a way where it's not a dreaded disease, but more like a hopeful disease. It's not a problem, but an opportunity. To flip the narrative in a more positive sense, I think, is helpful in these communities.
Singh: That's great. I think the idea of flipping the narrative is important, and almost, let's say not even lung cancer. I think back to what Cora was saying and relabel it. Right?
And what you're talking about is normalizing lung screening. Right? This is part of what attention to health is. And I like what you said about financial concerns being a huge thing. But you also said something really important with the idea of going local, finding who they trust, who they connect to, who can help them navigate, who can promote this aspect of your program, and give the human touch to all this, because I think we're learning a lot about that aspect.
Is that about right?
Pannu: Yes.
Singh: Yeah. Leisa, what what else would you add? I know you help run a big program. And what have you and your navigator teams learned along these lines?
Lackey: Yeah, so to echo a few things of what Coral and Jasleen have mentioned, we have tried to do some outreach, and I think meeting folks in the space that they're in. So, we've connected with our faith-based nursing team to educate them and offer that we can come speak to their congregations. I think that's an important thing, doing the outreach where it's more informative but where they're not feeling pressured to sign up for screening or otherwise. The other thing, I think, that has been an adjustment that we've had to make is we've now identified a pulmonary nodule and a patient needs follow-up care, we have eleven pulmonary offices in our Charlotte region. That seems like a lot, and it is. But sometimes access is a problem in some of those locations, so we can't get the patient in within a week or two weeks as we had hoped. We're booked out for 60 days. So, a couple of things that we tried to do was how can we increase? So, we look at schedules and try to make sure that we can add some appointments.
One of the things we've even tried is a virtual video visit. Right? Getting the patient in just for the very first time. There are sometimes barriers to technology. They may not have internet. They may not have a smartphone. We've happened to work through some of those barriers in our rural areas concerning access or technology. Those have been things we've had to kind of struggle with and say, how can we make things better for those patients? They don't want to drive to a larger city or 20 miles down the road to go to a different clinic. They want to stay in their region, so we've tried to figure out ways where people can access rural clinics. Just because they're used to going in person for a visit, they don't want to do a video visit. And certainly, we don't always want to do a video visit either, but sometimes that is the best option. One of the things we recently did was there was limited access in one of our clinics, so we tried telehealth visits. So pulmonary office to pulmonary office, instead of a specialist in primary care, we decided to just make the telehealth visit between two pulmonary offices so that the patient would arrive in person at our rural location, but they were having a visit with a pulmonary specialist who was in another location. That was a good effort to try to create access. There were some technology issues because now we're having a virtual visit between two practices, and so making sure that the technology was there between our practices was one of the barriers we had to overcome. I think that trying to think about those vulnerable communities, and I mentioned at some point, sometimes patients don't have a family member. They don't have transportation. We have to think outside the box. Sometimes our team has to be more intentional and more involved in making sure that patient gets what they need. If they need transportation or food or all the things. We're always thinking about how can we make things better for the patient.
Singh: You said a lot there. I'm just trying to process all three of your comments. You said so much here. But I like what you're getting at is the idea that you're willing to try different things than the traditional model. You're trying to look at health care delivery with a different lens, knowing that this population might benefit even more than our usual population from these programs.
Right? There's some evidence that suggests that they might have a higher risk and are more likely to benefit from some of the programs that we've instituted, Yet they're the ones that potentially might be a little more challenged to receive the benefit out here. Right? And so as we try to target interventions, it sounds like you're trying different avenues using technology, using other relationships, using newer methods of and you know different alliances than traditionally you might have done, for other diseases and other practices, but we're learning along the way. Is that pretty accurate? And more to come.
Lackey: Right.
Singh: Any other concluding thoughts on this segment? This is very enlightening and very interesting for me.
Pannu: I think, starting off the mobile screening options, including mobile CT scans, that can reach the community and maybe bypass all the barriers that line between, appear the most exciting and the most promising to me of all the options we have. And I think that can be applied more and more, and lung cancer screening is one of the only ones that probably can be accessible to do because it does not require a procedure to undergo this. So this is exciting and something that can be looked into with more and more institutions.
Singh: So mobile screening buses and stuff like that, that's what you're talking about. Absolutely. Very interesting. Coral, any other last-minute thoughts?
Giovacchini: I guess I would say, you know, I think some of this can be overwhelming and I think some people can then have the perspective of well, if they can't follow up, should we be screening these populations? And I would say absolutely. As you mentioned, they probably need it even more. And so just because it's a barrier, doesn't mean shouldn't work on it. One other thing that we have done is try to add on like Jasleen was mentioning, maybe you can't get your colonoscopy, but perhaps you can actually get your mammogram and so tagging with screening and imaging systems, if you're going to come in and get your annual mammogram and your lung screening CT, just being able to do that in one visit and then having kind of separate sites, where if you can, somewhere imaging-based that they could do that has something like free parking or easier access rather than coming into the main hospital, is going to be really beneficial.
Singh: I like that. I almost imagine, some of us driving a bus in the future that just does pan imaging and all kinds of interesting models with a telehealth option and whatever else might be there. But, this is fascinating. I think this is an important aspect to think about.
When we think about vulnerable populations who might benefit a lot from these programs, but they offer unique insight and opportunities to potentially readdress, and we're going to keep trying, and we're gonna keep trying to understand this and do this better. And, I want to thank you all for your leadership in that space.
Thank you. Thank you.
Singh: Well, this concludes part three of our series. I hope you all enjoyed our webinar series here on lung cancer screening and lung nodule programs. On behalf of Consultant360, I'm your host Dr Jaspal Singh. I wanted to thank our esteemed guests today, Dr Coral Giovacchini, Dr Jasleen Pannu, and Leisa Lackey, on behalf of all of us, thank you so much, and thank you for everything you do every day.
All: Thank you.