Adherence to Radiology Recommendations in a Clinical CT Lung Screening Program

BackgroundAssess patient adherence to radiologist recommendations in a clinical CT lung cancer screening program.MethodsPatients undergoing CT lung cancer screening between January 12, 2012, and June 12, 2013, were included in this institutional review board–approved retrospective review. Patients referred from outside our institution were excluded. All patients met National Comprehensive Cancer Network Guidelines Lung Cancer Screening high-risk criteria. Full-time program navigators used a CT lung screening program management system to schedule patient appointments, generate patient result notification letters detailing the radiologist follow-up recommendation, and track patient and referring physician notification of missed appointments at 30, 60, and 90 days. To be considered adherent, patients could be no more than 90 days past due for their next recommended examination as of September 12, 2014. Patients who died, were diagnosed with cancer, or otherwise became ineligible for screening were considered adherent. Adherence rates were assessed across multiple variables.ResultsDuring the study interval, 1,162 high-risk patients were screened, and 261 of 1,162 (22.5%) outside referrals were excluded. Of the remaining 901 patients, 503 (55.8%) were male, 414 (45.9%) were active smokers, 377 (41.8%) were aged 65 to 73, and >95% were white. Of the 901 patients, 772 (85.7%) were adherent. Most common reasons for nonadherence were patient refusal of follow-up exam (66.7%), inability to successfully contact the patient (20.9%), and inability to obtain the follow-up order from the referring provider (7.8%); 23 of 901 (2.6%) were discharged for other reasons.ConclusionsHigh rates of adherence to radiologist recommendations are achievable for in-network patients enrolled in a clinical CT lung screening program.     

Performance of ACR Lung-RADS in a Clinical CT Lung Screening Program

PurposeThe aim of this study was to assess the effect of applying ACR Lung-RADS in a clinical CT lung screening program on the frequency of positive and false-negative findings.MethodsConsecutive, clinical CT lung screening examinations performed from January 2012 through May 2014 were retroactively reclassified using the new ACR Lung-RADS structured reporting system. All examinations had initially been interpreted by radiologists credentialed in structured CT lung screening reporting following the National Comprehensive Cancer Network’s Clinical Practice Guidelines in Oncology: Lung Cancer Screening (version 1.2012), which incorporated positive thresholds modeled after those in the National Lung Screening Trial. The positive rate, number of false-negative findings, and positive predictive value were recalculated using the ACR Lung-RADS-specific positive solid/part-solid nodule diameter threshold of 6 mm and nonsolid (ground-glass) threshold of 2 cm. False negatives were defined as cases reclassified as benign under ACR Lung-RADS that were diagnosed with malignancies within 12 months of the baseline examination.ResultsA total of 2,180 high-risk patients underwent baseline CT lung screening during the study interval; no clinical follow-up was available in 577 patients (26%). ACR Lung-RADS reduced the overall positive rate from 27.6% to 10.6%. No false negatives were present in the 152 patients with >12-month follow-up reclassified as benign. Applying ACR Lung-RADS increased the positive predictive value for diagnosed malignancy in 1,603 patients with follow-up from 6.9% to 17.3%.ConclusionsThe application of ACR Lung-RADS increased the positive predictive value in our CT lung screening cohort by a factor of 2.5, to 17.3%, without increasing the number of examinations with false-negative results.     

A Coordinated Approach to Implementing Low-Dose CT Lung Cancer Screening in a Rural Community Hospital

PurposeThe authors describe a rural community hospital’s approach to lung cancer screening using low-dose CT (LDCT) to address the high incidence of lung cancer mortality.MethodsAn implementation project was conducted, documenting planning, education, and restructuring processes to implement a lung cancer screening program using LDCT in a rural community hospital (population 64,917, Rural-Urban Continuum Code 5) located in a region with the highest lung cancer mortality in Oregon. The hospital and community partners organized the implementation project around five recommendations for an efficient and effective lung cancer screening program that accurately identifies high-risk patients, facilitates timely access to screening, provides appropriate follow-up care, and offers smoking cessation support.ResultsOver a 3-year period (2018-2020), 567 LDCT scans were performed among a high-risk population. The result was a 4.8-fold increase in the number of LDCT scans from 2018 to 2019 and 54% growth from 2019 to 2020. The annual adherence rate increased from 51% in 2019 to 59.6% in 2020. Cancer was detected in 2.11% of persons scanned. Among the patients in whom lung cancer was detected, the majority of cancers (66.6%) were categorized as stage I or II.ConclusionsThis rural community hospital’s approach involved uniting primary care, specialty care, and community stakeholders around a single goal of improving lung cancer outcomes through early detection. The implementation strategy was intentionally organized around five recommendations for an effective and efficient lung cancer screening program and involved planning, education, and restructuring processes. Significant stakeholder involvement on three separate committees ensured that the program’s design was relevant to local community contexts and patient centered. As a result, the screening program’s reach and adherence increased each year of the 3-year pilot program.     

Leveraging Emergency Department Encounters to Improve Cancer Screening Adherence

ObjectiveWe aimed to estimate the proportion of patients visiting the emergency department (ED) who were not up to date with cancer screening guidelines to assess the scope of need and potential impact of ED-based cancer screening interventions.MethodsAdult participants from the 2015 National Health Interview Survey were included. Among patients nonadherent to national breast, colorectal, or lung cancer screening guidelines, the proportion of patients reporting an ED visit within the last year was estimated, accounting for complex survey sampling design features. Multiple variable logistic regression analyses were then conducted to evaluate the association between sociodemographic characteristics and screening adherence.ResultsOf screening eligible respondents, 17.2% of women nonadherent to mammography screening, 16.9% of patients nonadherent to colorectal cancer screening, and 25.0% of patients nonadherent to lung cancer screening reported at least one ED visit in the preceding year. Patients visiting the ED with postsecondary school education were more likely to be up to date with mammography screening than those without advanced education (odds ratio [OR] 1.45; 95% confidence interval [CI]: 1.21-1.74; P = .01). Patients without insurance were less likely than those with insurance to report being up to date with both mammography screening (OR 0.31; 95% CI: 0.21-0.48; P = .01) and colorectal cancer screening (OR 0.56; 95% CI: 0.34-0.93; P = .03).DiscussionOpportunities to improve cancer screening adherence exist through ED-based preventative care interventions, which leverage multidisciplinary partnerships, including radiologists, to reach large volumes of patients who are not engaged in cancer screening.     

Implementation and Uptake of Rural Lung Cancer Screening

ObjectiveGiven the higher rates of tobacco use along with increased mortality specific to lung cancer in rural settings, low-dose CT (LDCT)-based lung cancer screening could be particularly beneficial to such populations. However, limited radiology facilities and increased geographical distance, combined with lower income and education along with reduced patient engagement, present heightened barriers to screening initiation and adherence.MethodsIn collaboration with community leaders and stakeholders, we developed and implemented a community-based lung cancer screening program, including telephone-based navigation and tobacco cessation counseling support, serving 18 North Texas counties. Funding was available to support clinical services costs where needed. We collected data on LDCT referrals, orders, and completion.ResultsTo raise awareness for lung cancer screening, we leveraged our established collaborative network of more than 700 community partners. In the first year of operation, 107 medical providers referred 570 patients for lung cancer screening, of whom 488 (86%) were eligible for LDCT. The most common reasons for ineligibility were age (43%) and insufficient tobacco history (20%). Of 381 ordered LDCTs, 334 (88%) were completed. Among screened patients, 61% were current smokers and 36% had insurance coverage for the procedure. The program cost per patient was $430.DiscussionImplementation, uptake, and completion of LDCT-based lung cancer screening is feasible in rural settings. Community outreach, health promotion, and algorithm-based navigation may support such efforts. Given low lung cancer screening rates nationally and heightened lung cancer risk in rural populations, similar programs in other regions may be particularly impactful.     

Initial Outcomes of a Lung Cancer Screening Program in an Integrated Community Health System

PurposeLung cancer screening with low-dose CT (LDCT) demonstrated reduced mortality in the National Lung Screening Trial, yet there is debate as to whether the reported efficacy can translate into comparable effectiveness with community-based screening. The authors’ purpose is to report the baseline patient characteristics and malignancy rate in the first 18 months after implementing a lung cancer screening program in an integrated community health system.MethodsPatients were screened at 1 of 10 participating community-based centers within a 22-hospital system from 2013 to 2015. LDCT examinations were interpreted by 1 of 20 radiologists using structured reporting and an internally developed tracking system. Manual chart review was performed to ascertain the malignancy detection rate.ResultsA total of 357 patients were screened with LDCT. Of these, 80 patients were ineligible and 3 declined enrollment. The remaining 274 patients satisfied accepted screening criteria and were enrolled in the program. Malignancy was detected in a total of 11 enrollees (4.0%), 8 with lung cancer and 3 with extrapulmonary primary malignancies. Three patients (1.1%) were diagnosed with early-stage lung cancer and received definitive therapy.ConclusionsEarly-stage lung cancer was detected with LDCT screening in an integrated community health system at a rate similar to other trials.     

Development and Cost Analysis of a Lung Nodule Management Strategy Combining Artificial Intelligence and Lung-RADS for Baseline Lung Cancer Screening

ObjectivesTo develop a lung nodule management strategy combining the Lung CT Screening Reporting and Data System (Lung-RADS) with an artificial intelligence (AI) malignancy risk score and determine its impact on follow-up investigations and associated costs in a baseline lung cancer screening population.Materials and MethodsSecondary analysis was undertaken of a data set consisting of AI malignancy risk scores and Lung-RADS classifications from six radiologists for 192 baseline low-dose CT studies. Low-dose CT studies were weighted to model a representative cohort of 3,197 baseline screening patients. An AI risk score threshold was defined to match average sensitivity of six radiologists applying Lung-RADS. Cases initially Lung-RADS category 1 or 2 with a high AI risk score were upgraded to category 3, and cases initially category 3 or higher with a low AI risk score were downgraded to category 2. Follow-up investigations resulting from Lung-RADS and the AI-informed management strategy were determined. Investigation costs were based on the 2019 US Medicare Physician Fee Schedule.ResultsThe AI-informed management strategy achieved sensitivity and specificity of 91% and 96%, respectively. Average sensitivity and specificity of six radiologists using Lung-RADS only was 91% and 66%, respectively. Using the AI-informed management strategy, 41 (0.2%) category 1 or 2 classifications were upgraded to category 3, and 5,750 (30%) category 3 or higher classifications were downgraded to category 2. Minimum net cost savings using the AI-informed management strategy was estimated to be $72 per patient screened.ConclusionUsing an AI risk score combined with Lung-RADS at baseline lung cancer screening may result in fewer follow-up investigations and substantial cost savings.     

Stereotactic Breast Biopsy With Benign Results Does Not Negatively Affect Future Screening Adherence

PurposeTo evaluate whether false-positive stereotactic vacuum-assisted breast biopsy (SVAB) affects subsequent mammographic screening adherence.Materials and MethodsThis Institutional Review Board–approved, HIPAA-compliant retrospective review of women with SVAB was performed between 2012 and 2014. Patient age, clinical history, biopsy pathology, and first postbiopsy screening mammogram were reviewed. Statistical analyses were performed using Fisher’s exact, Mann-Whitney, and χ² tests.ResultsThere were 913 SVABs performed in 2012 to 2014 for imaging detected lesions; of these, malignant or high-risk lesions or biopsies resulting in a recommendation of surgical excision were excluded, leaving 395 SVABs yielding benign pathology in 395 women. Findings were matched with a control population consisting of 45,126 women who had a BI-RADS 1 or 2 screening mammogram and did not undergo breast biopsy. In all, 191 of 395 (48.4%) women with a biopsy with benign results and 22,668 of 45,126 (50.2%) women without biopsy returned for annual follow-up >9 months and ≤18 months after the index examination (P = .479). In addition, 57 of 395 (14.4%) women with a biopsy with benign results and 3,336 of 45,126 (7.4%) women without biopsy returned for annual follow-up >18 months after the index examination (P < .001). Older women, women with personal history of breast cancer, and women with postbiopsy complication after benign SVAB were more likely to return for screening (P = .026, P = .028, and P = .026, respectively).ConclusionThe findings in our study suggest that SVABs with benign results do not negatively impact screening mammography adherence. The previously described “harms” of false-positive mammography and biopsy may be exaggerated.     

Impact of Telephone Communication on Patient Adherence With Follow-Up Recommendations After an Abnormal Screening Mammogram

ObjectiveThe Mammography Quality Standards Act requires written communication to every patient after an abnormal screening mammogram. Starting in 2013, our institution began telephoning all patients with a Breast Imaging Reporting and Data System (BI-RADS) assessment 0 on the next business day to schedule their diagnostic follow-up. Our aim is to analyze the changes in adherence and time to follow-up of patients recalled from screening mammography after the implementation of telephone communication.MethodsThis retrospective study reviewed data from screening mammograms at our institution with a BI-RADS 0 assessment excluding technical recalls between January 1, and December 31, 2011 (pre-intervention group), 2014 (early post-intervention group), and 2018 (later post-intervention group). We compared patient adherence with timely follow-up diagnostic mammography (within 60 days) in these three groups using univariate and multivariate logistic regression. Cox proportional hazards regression analysis was done to evaluate the impact of telephone communication on time to follow-up.ResultsThis study included 1899 women in 2011, 2829 women in 2014, and 1999 women in 2018. We found that 73.1% patients in 2011 returned for their diagnostic follow-up within 60 days compared to 87.6% in 2014 and 90.0% in 2018, P < 0.001. Median time to follow-up in 2011 was 28 days (IQR 17-76 days) compared to 15 days (IQR 9-28 days) in 2014 and 9 days (IQR 5-18) in 2018, P < 0.001.ConclusionA higher percentage of women were adherent with a timely diagnostic follow-up examination after an abnormal screening mammogram with the addition of telephone communication.     

Education Level Predicts Appropriate Follow-Up of Incidental Findings From Lung Cancer Screening

PurposeThe aim of this study was to identify predictors of appropriate follow-up for clinically significant incidental findings (IFs) detected with low-dose CT during lung cancer screening.MethodsCharts of 1,458 prospectively enrolled lung screening patients from January 1, 2015, to October 31, 2018, were reviewed. IFs, other than coronary artery calcification and emphysema, were identified. ACR practice guidelines defined appropriate patient follow-up. Patient demographic and social characteristics were obtained from the initial shared decision-making visit and the electronic medical record. Factors of interest included age, gender, race, education level, and insurance status. Education level was reported as high school graduate or less or education past high school. A multivariate logistic regression was estimated to assess patient factors associated with appropriate follow-up.ResultsOne hundred thirty-eight participants (9%) with 141 actionable IFs were identified. The overall appropriate follow-up rate was 82%. The most common IFs were renal lesions (16%), dilated thoracic aorta (10%), and pulmonary fibrosis (10%). Univariate analysis of appropriate patient follow-up revealed a significant difference for education level (P = .02). A greater than high school education remained strongly associated with appropriate follow-up after controlling for other demographic factors.ConclusionsAppropriate patient follow-up of clinically significant IFs from lung cancer screening is a well-recognized avenue to improve population health. Education level is a significant independent predictor of appropriate follow-up of IFs, whether as a surrogate for low socioeconomic status or as an indication of health literacy. To address these realities, lung screening shared decision making should adapt to consider health care access and health literacy.     

Experience With a CT Screening Program for Individuals at High Risk for Developing Lung Cancer

PurposeThe aim of this study was to compare results of National Comprehensive Cancer Network (NCCN) high-risk group 2 with those of NCCN high-risk group 1 in a clinical CT lung screening program.MethodsThe results of consecutive clinical CT lung screening examinations performed from January 2012 through December 2013 were retrospectively reviewed. All examinations were interpreted by radiologists credentialed in structured CT lung screening reporting, following the NCCN Clinical Practice Guidelines in Oncology: Lung Cancer Screening (version 1.2012). Positive results required a solid nodule ≥4 mm, a ground-glass nodule ≥5 mm, or a mediastinal or hilar lymph node >1 cm, not stable for >2 years. Significant incidental findings and findings suspicious for pulmonary infection were also recorded.ResultsA total of 1,760 examinations were performed (464 in group 2, 1,296 in group 1); no clinical follow-up was available in 432 patients (28%). Positive results, clinically significant incidental findings, and suspected pulmonary infection were present in 25%, 6%, and 6% in group 2 and 28.2%, 6.2%, and 6.6% in group 1, respectively. Twenty-three cases of lung cancer were diagnosed (6 in group 2, 17 in group 1), for annualized rates of malignancy of 1.8% in group 2 and 1.6% in group 1.ConclusionNCCN group 2 results were substantively similar to those for group 1 and closely resemble those reported in the National Lung Screening Trial. Similar rates of positivity and lung cancer diagnosis in both groups suggest that thousands of additional lives may be saved each year if screening eligibility is expanded to include this particular high-risk group.     

Management of Lung Nodules and Lung Cancer Screening During the COVID-19 Pandemic: CHEST Expert Panel Report

BackgroundThe risks from potential exposure to coronavirus disease 2019 (COVID-19), and resource reallocation that has occurred to combat the pandemic, have altered the balance of benefits and harms that informed current (pre-COVID-19) guideline recommendations for lung cancer screening and lung nodule evaluation. Consensus statements were developed to guide clinicians managing lung cancer screening programs and patients with lung nodules during the COVID-19 pandemic.MethodsAn expert panel of 24 members, including pulmonologists (n = 17), thoracic radiologists (n = 5), and thoracic surgeons (n = 2), was formed. The panel was provided with an overview of current evidence, summarized by recent guidelines related to lung cancer screening and lung nodule evaluation. The panel was convened by video teleconference to discuss and then vote on statements related to 12 common clinical scenarios. A predefined threshold of 70% of panel members voting agree or strongly agree was used to determine if there was a consensus for each statement. Items that may influence decisions were listed as notes to be considered for each scenario.ResultsTwelve statements related to baseline and annual lung cancer screening (n = 2), surveillance of a previously detected lung nodule (n = 5), evaluation of intermediate and high-risk lung nodules (n = 4), and management of clinical stage I non–small-cell lung cancer (n = 1) were developed and modified. All 12 statements were confirmed as consensus statements according to the voting results. The consensus statements provide guidance about situations in which it was believed to be appropriate to delay screening, defer surveillance imaging of lung nodules, and minimize nonurgent interventions during the evaluation of lung nodules and stage I non–small-cell lung cancer.ConclusionsThere was consensus that during the COVID-19 pandemic, it is appropriate to defer enrollment in lung cancer screening and modify the evaluation of lung nodules due to the added risks from potential exposure and the need for resource reallocation. There are multiple local, regional, and patient-related factors that should be considered when applying these statements to individual patient care.     

Lung cancer screening with low-dose computed tomography at a tertiary hospital in Anhui,China and secondary analysis of trial data

Objective:Lung cancer screening with low-dose computed tomography (LDCT) partly reduces cancer-specific mortality. However, few data have described this specific population for screening in mainland China. Here, we conducted a population-based screening program in Anhui, China.Methods:9084 individuals were participating in the screening program for lung cancer in Anhui province from 1 June 2014 to 31 May 2017. LDCT was offered to all participants who joined the program.Results:Of 9084 individuals undergoing LDCT, we detected 54 lung cancers (0.594%). The age with the highest rate was 61–65 years (up to 1.016%), followed by 56–60 (0.784%). Most patients (98.1%, 53/54) were in stage I–II (early stage), and only one was in stage III (advanced stage). Adenocarcinoma, squamous cell carcinoma and small cell lung cancer accounted for 57.4% (31/54), 37% (20/54) and 5.6% (3/54) of the individuals, respectively. Notably, There were 4,102 never smokers in our study. The median age was 63 years. Males and females accounted for 53.4 and 46.6%, respectively. Among the 4102 never smokers, 96 participants had a positive family cancer history. Additionally, we detected 20 lung cancers (0.488%), slightly lower than the whole rate 0.594%. Finally, our data showed that age, smoking, family cancer history and features of nodules were risk factors for lung cancer.Conclusion:Our study qualified the efficiency of LDCT to detect early-stage lung cancers in Anhui, China. Further establishment of appropriate lung cancer screening methods specifically for individuals in China is warranted.Advances in knowledge:We evaluated the performance of lung cancer screening for asymptomatic populations using LDCT in Anhui, an eastern inland province of China. Our study qualified the efficiency of LDCT to detect early-stage lung cancers in Anhui, China.     

Application of Lung-Screening Reporting and Data System Versus Pan-Canadian Early Detection of Lung Cancer Nodule Risk Calculation in the Alberta Lung Cancer Screening Study

BackgroundFalse-positive scans and resultant needless early recalls can increase harms and reduce cost-effectiveness of low-dose CT (LDCT) lung cancer screening. How LDCT scans are interpreted and classified may impact these metrics.MethodsThe Pan-Canadian Early Detection of Lung Cancer risk calculator was used to determine nodule risk of malignancy on baseline screening LDCTs in the Alberta Lung Cancer Screening Study, which were then classified according to Nodule Risk Classification (NRC) categories and ACR Lung Screening Reporting and Data System (Lung-RADS). Test performance characteristics and early recall rates were compared for each approach.ResultsIn all, 775 baseline screens were analyzed. After a mean of 763 days (±203) of follow-up, lung cancer was detected in 22 participants (2.8%). No statistically significant differences in sensitivity, specificity, or area under the receiver operator characteristic curve occurred between the NRC and Lung-RADS nodule management approaches. Early recall rates were 9.2% and 9.3% for NRC and Lung-RADS, with the NRC unnecessarily recalling some ground glass nodules, and the Lung-RADS recalling many smaller solid nodules with low risk of malignancy.ConclusionPerformances of both the NRC and Lung-RADS in this cohort were very good with a trend to higher sensitivity for the NRC. Early recall rates were less than 10% with each approach, significantly lower than rates using the National Lung Screening Trial cutoffs. Further reductions in early recall rates without compromising sensitivity could be achieved by increasing the NRC threshold to 20% for ground glass nodules or by applying the nodule risk calculator with a 5% threshold to 6- to 10-mm solid nodules under Lung-RADS.     

Evaluation of Alternative Diagnostic Follow-up Intervals for Lung Reporting and Data System Criteria on the Effectiveness of Lung Cancer Screening

PurposeThe ACR developed the Lung CT Screening Reporting and Data System (Lung-RADS) to standardize the diagnostic follow-up of suspicious screening findings. A retrospective analysis showed that Lung-RADS would have reduced the false-positive rate in the National Lung Screening Trial, but the optimal timing of follow-up examinations has not been established. In this study, we assess the effectiveness of alternative diagnostic follow-up intervals on lung cancer screening.MethodsWe used the Lung Cancer Outcome Simulator to estimate population-level outcomes of alternative diagnostic follow-up intervals for Lung-RADS categories 3 and 4A. The Lung Cancer Outcome Simulator is a microsimulation model developed within the Cancer Intervention and Surveillance Modeling Network Consortium to evaluate outcomes of national screening guidelines. Here, among the evaluated outcomes are percentage of mortality reduction, screens performed, lung cancer deaths averted, screen-detected cases, and average number of screens and follow-ups per death averted.ResultsThe recommended 3-month follow-up interval for Lung-RADS category 4A is optimal. However, for Lung-RADS category 3, a 5-month, instead of the recommended 6-month, follow-up interval yielded a higher mortality reduction (0.08% for men versus 0.05% for women), and a higher number of deaths averted (36 versus 27), a higher number of screen-detected cases (13 versus 7), and a lower number of combined low-dose CTs and diagnostic follow-ups per death avoided (8 versus 5), per one million general population. Sensitivity analysis of nodule progression threshold verifies a higher mortality reduction with a 1-month earlier follow-up for Lung-RADS 3.ConclusionsOne-month earlier diagnostic follow-ups for individuals with Lung-RADS category 3 nodules may result in a higher mortality reduction and warrants further investigation.     

Repeat Annual Lung Cancer Screening After Baseline Screening Among Screen-Negative Individuals: No-Cost Coverage Is Not Enough

PurposeAdherence to lung cancer screening (LCS) is central to effective screening. The authors evaluated the likelihood of repeat annual LCS in a national commercially insured population and associations with individual characteristics, insurance characteristics, and annual out-of-pocket cost (OOPC) burden.MethodsUsing claims data from an employer-insured population (Clinformatics), individuals 55 to 80 years of age undergoing LCS between January 1, 2015, to September 30, 2019, with “negative” LCS were included. Repeat LCS was defined as low-dose chest CT occurring 10 to 15 months after the preceding LCS. Analysis was conducted over a 6-year period. Multivariable logistic regression was used to evaluate associations between repeat LCS and individual characteristics, insurance characteristics, and total OOPC incurred by the individual in the year of the index LCS, even if unrelated to LCS.ResultsOf 14,943 individuals with negative LCS, 4,561 (30.5%) underwent repeat LCS. Likelihood of repeat LCS was decreased for men (adjusted odds ratio [aOR], 0.91; 95% confidence interval [CI], 0.86-0.97), Hispanic ethnicity (aOR, 0.82; 95% CI, 0.69-0.97), and indemnity insurance plans (aOR, 0.36; 95% CI, 0.25-0.53). Relative to New England, individuals in nearly all US geographic regions were less likely to undergo repeat LCS. Finally, individuals with total OOPC in the highest two quartiles were less likely to undergo repeat LCS (aOR, 0.85 [95% CI, 0.77-0.92] for OOPC >$1,069.02-$2,475.09 vs $0-$351.82; aOR, 0.75 [95% CI, 0.68-0.82] for OOPC >$2,475.09 vs $0-$351.82).ConclusionsAlthough federal policies facilitate LCS without cost sharing, individuals incurring high OOPC, even when unrelated to LCS, are less likely to undergo repeat LCS. Future policy design should consider the permeative burden of OOPC across the health continuum on preventive services use.     

Disparities Associated With Patient Adherence of Post-Breast-Conserving Surgery Surveillance Imaging Protocols

ObjectiveCurrently, national and international breast imaging practices utilize variable postsurgical surveillance protocols without uniform recommendations. Because of the innate differences between screening versus diagnostic mammography from scheduling flexibility to out-of-pocket costs, this creates the opportunity for lapses in patient adherence, which has the potential to impact clinical outcomes. The purpose of this study is to evaluate the relationship between sociodemographic factors and postsurgical surveillance imaging protocols on patient adherence rates.MethodsThis retrospective study reviewed 3 years of surveillance imaging for all patients having breast-conserving surgery at our institution from January 2011 to December 2016. Follow-up adherence was defined as returning for all of the first 3 years of annual follow-up after breast-conserving surgery (institutional surveillance protocol). Associations between adherence to surveillance imaging and patient sociodemographic characteristics were evaluated using univariate and multivariate logistic regression.ResultsThe study included 1,082 patients after breast surgery, 715 of whom adhered completely to the first 3 years of annual follow-up (66.1%). Black women were 1.36 times less likely to follow up annually compared with White women (95% confidence interval 1.02-1.80). Similarly, patients with Medicare were 1.84 times less likely to follow up annually compared with patients with private insurance (95% confidence interval 1.34-2.51). Women with benign breast disease after breast-conserving surgery were significantly less likely to adhere to annual surveillance than women with breast cancer.ConclusionSociodemographic disparities exist as barriers for annual mammography surveillance in patients after breast-conserving surgery.     

Leveraging the Mammography Setting to Raise Awareness and Facilitate Referral to Lung Cancer Screening: A Qualitative Analysis

PurposeDespite compelling support for the benefits of low-dose CT (LDCT) screening for lung cancer among high-risk individuals, awareness of LDCT screening and uptake remain low. The aim of this project was to explore the perspectives of ACR mammography screening program directors (MPDs) regarding efforts to raise LDCT screening awareness and appropriate referrals by identifying high-risk individuals participating in routine mammography.MethodsMPDs were recruited from ACR-accredited mammography facilities to participate in semistructured interviews after the completion of an online survey. Interviews were conducted over the telephone, recorded, transcribed, and subsequently reviewed for accuracy. Twenty MPDs were interviewed, and 18 interviews were transcribed and included in the thematic analysis. A theme codebook was developed, and all interviews were coded using NVivo by two trained reviewers.ResultsKey themes were organized into four broad domains: (1) general attitudes toward the integration of LDCT screening, (2) identifying mammography patients at high risk for lung cancer, (3) counseling about LDCT screening, and (4) strategies to identify high-risk women and increase awareness and knowledge of LDCT screening. Overall, MPDs recognized the benefits of integrating mammography and LDCT screening and were receptive to educating and referring women for LDCT screening. However, training and workflow changes are needed to ensure successful implementation.ConclusionsQualitative data suggest that MPDs are amenable to leveraging the mammography setting to engage women about LDCT screening; however, additional tools, training, and/or staffing may be necessary to leverage the full potential of reaching women at high risk for lung cancer within the context of mammographic screening.     

Clinical Impact and Generalizability of a Computer-Assisted Diagnostic Tool to Risk-Stratify Lung Nodules With CT

ObjectiveTo evaluate whether an imaging classifier for radiology practice can improve lung nodule classification and follow-up.MethodsA machine learning classifier was developed and trained using imaging data from the National Lung Screening Trial (NSLT) to produce a malignancy risk score (malignancy Similarity Index [mSI]) for individual lung nodules. In addition to NLST cohorts, external cohorts were developed from a tertiary referral lung cancer screening program data set and an external nonscreening data set of all nodules detected on CT. Performance of the mSI combined with Lung-RADS was compared with Lung-RADS alone and the Mayo and Brock risk calculators.ResultsWe analyzed 963 subjects and 1,331 nodules across these cohorts. The mSI was comparable in accuracy (area under the curve = 0.89) to existing clinical risk models (area under the curve = 0.86-0.88) and independently predictive in the NLST cohort of 704 nodules. When compared with Lung-RADS, the mSI significantly increased sensitivity across all cohorts (25%-117%), with significant increases in specificity in the screening cohorts (17%-33%). When used in conjunction with Lung-RADS, use of mSI would result in earlier diagnoses and reduced follow-up across cohorts, including the potential for early diagnosis in 42% of malignant NLST nodules from prior-year CT scans.ConclusionA computer-assisted diagnosis software improved risk classification from chest CTs of screening and incidentally detected lung nodules compared with Lung-RADS. mSI added predictive value independent of existing radiological and clinical variables. These results suggest the generalizability and potential clinical impact of a tool that is straightforward to implement in practice.