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Jefferson Lung Cancer Screening Program

Thomas Jefferson University & Hospital's Pulmonary Division, together with support from related disciplines including radiology, thoracic surgery, and medical/radiation oncology, is leading a novel effort to streamline the initial intake and management of patients with solitary pulmonary lung nodules as well as screening for lung cancer. This is being spearheaded by the establishment of a pulmonary nodule clinic as well as a lung cancer screening program. This effort is one of the first in the Delaware Valley. The service being provided to any referring physician or patient is the one-stop access to: 1. screening of "high risk" individuals (age>55, smoking history); 2. Management of any incidentally-detected pulmonary nodule on any imaging study (plain chest x-ray, CT chest or abdomen, etc); The clinic will be staffed and organized by a nurse coordinator and by physicians with expertise to further evaluate such nodules. The management options for a nodule include observation with serial scans (to document stability), a biopsy by either bronchoscopy or percutaneous needle under CT, or surgical resection. Importantly, the clinic will provide the mechanism for seamless follow-up of patients requiring follow-up studies.

A premium will be placed on timely access and evaluation for patients, coordinated communication for referring physicians, and the involvement of any other services required in the Jefferson health system. It is widely known that lung cancer is a dreaded disease and is causally linked to cigarette smoking, ever since the surgeon general's report in the 1960s. Lung cancer is the most frequent cause of cancer death worldwide and this may be due to the fact that at the usual time of diagnosis the disease is advanced. Solitary pulmonary nodule or a "spot on the lung" is a very common entity that raises concern amongst clinicians and fear in the lay public. There are many causes for pulmonary nodules, but a third of these maybe lung cancers. Interestingly, no specific medical specialty has provided leadership or a specific program to manage solitary pulmonary nodules. So there is a need for such a service here in Philadelphia and at TJU/H.

A solitary pulmonary nodule (SPN) or coin lesion is a mass in the lung smaller than 3 centimeters in diameter. It can be an incidental finding found on a chest X-ray or CT scan. The nodule may represent a benign process such as a granuloma or hamartoma, but in around 20-40% of cases, it represents a malignant cancer, especially in older adults and smokers. Conversely, 10 to 20% of patients with lung cancer are diagnosed in this way. Thus, the possibility of cancer needs to be excluded through further radiological studies and interventions, possibly including surgical resection. The prognosis depends on the underlying condition.

Technology is advancing and the notion of early detection and "screening" for lung cancer has historically been challenging and controversial. However, recent studies and use of "low dose chest CT scan" appears to suggest that screening can improve survival from early detection of lung cancer, by as much as 20%. In addition, other emerging technologies including biomarkers, non-surgical approaches to biopsy, and novel therapies involving radiotherapy is giving hope to patients.

Rationale for lung cancer screening based on a major new research study:

Lung cancer remains the leading cause of death from cancer in the US, and cigarette smoking is the single biggest risk factor. Unfortunately, only 15% of patients with lung cancer are diagnosed with early stage disease when surgical resection offers a 70% 5 year survival rate. Most patients present with symptomatic disease at an advanced stage where the survival is dismal. Prevention by aggressive smoking cessation efforts and early detection by screening would seem to be key approaches to improve outcomes. The optimal approach has been controversial until the results of a massive National Cancer Institute sponsored National Lung Screening Trial (NLST) were recently published (N Engl. J Med 2011). This was a robust trial of over 50,000 high risk subjects (age 55-74, smoking history of 30 pack-years, if ex-smoker then quit <15 years) who were randomized to a low dose CT screening arm vs. a plain chest x-ray screening arm. Patients in each arm underwent an imaging study at baseline (either LDCT or chest x-ray), and if normal, were followed with a follow-up study at 12 and 24 months (total of 3 studies over 2 years). Patients managed by annual CT scans had a better outcome with a 20% improvement in survival.

Following are guidelines for the Jefferson Lung Cancer Screening Program:

Thomas Jefferson University & Hospital has established a new multidisciplinary program for screening for lung cancer in "high risk" patients. The overall goal is to offer a unique service based on the state-of-the-art data. This is a voluntary program, is not a "research study", and does not require a physician referral(although we encourage discussion with your physician); the program is strictly based on the recently published National Lung Cancer Screening Trial and will adhere to guidelines from that study; the costs of the low dose CT of the chest (LDCT) is currently not paid by Medicare or traditional insurance so the patient is responsible for $350 (cost of one scan, physician visit for interpretation and counseling, and simple breathing test); patients who meet inclusion criteria will need to undergo a LDCT along with a same day consultation with a physician provider to discuss the scan findings, follow-up, and discuss smoking cessation strategies; we strongly discourage having a scan without the physician visit; criteria for entry into the screening program at Jefferson: Age 55-74; total smoking history of >= 30 pack years (# years X # packs/d)

If an ex-smoker, cessation must have occurred within 15 years. If a patient meets above criteria and wishes to participate in the screening program: schedule an ambulatory visit for LDCT by protocol at Walnut Towers Jefferson Imaging Center; will need to sign a disclosure and arrange to pay $350 (for the scan and radiology interpretation and patient's visit); immediately following the CT, have appt with Pulmonary on the 6th floor; undergo screening spirometry followed by office visit (total time <60 min); sign an informed consent for de-identified use of data for quality assurance, etc; undergo intense tobacco cessation counseling by NP under physician supervision (time 30 min);

  • If the LDCT is normal (i.e. no identified pulmonary nodule), then patient is scheduled for an annual visit in 12 and 24 months for the same (total of 3 visits and 3 scans);
  • If the LDCT is abnormal (i.e. nodule is detected), then follow-up will be individualized based on pre-established guidelines as per Fleischner criteria (see separate algorithm); In the setting of an abnormal LDCT, subsequent follow-up care will be billed to 3rd party insurance and might include a repeat CT at an interval less than 12 months, needle biopsy or bronchoscopy, or consultation with a thoracic surgeon for curative removal. The particularly unique feature in this program is the immediate availability of all disciplines at one center that includes thoracic surgeons, radiologists, as well as pulmonary medicine and cancer specialists. All possible expertise exists under one roof.
  • If patient meets above criteria but wishes to further discuss, then will arrange an appointment with primary care and/or pulmonologist;
  • If patient does not meet above LCST criteria (age <55, smoking history < 30 pack-yrs), then would offer a separate consultation with a primary care provider and/or pulmonologist for further discussion of risks and benefits and alternative non-protocol approaches;

LDCT protocol to be utilized by the Jefferson Imaging Services:
120 KVP 40 mAs (instead of 250 mAs, which is the standard dose)
Slice thickness = 5 mm
Overall dose = 2 mSv (standard dose for chest CT is 7-8 mSv)
No IV or oral contrast
Protocol can be performed on all CT scanners in the Jefferson system;
In order to access the expertise of the Jefferson Lung Cancer Screening Program or the pulmonary nodule clinic, contact:

Erin Witkowsky, MSN
Nurse practitioner line: 955-2584

Physician Directors:
Michael Unger, MD & Boyd Hehn, MD
955-5161 (6591)
Division of Pulmonary & Critical Care Medicine
Thomas Jefferson University/Hospital
834 Walnut St, suite 650
Philadelphia, PA 19107