Planning and Implementation of Low-dose Computed Tomography Lung Cancer Screening Programs in the United States

Rebecca Qiu, BSN, RN; Amy Copeland, MPH; Erica Sercy, MSPH; Nancy R. Porter, MS; Karen Kane McDonnell, PhD, RN, OCN; Jan Marie Eberth, PhD


Clin J Oncol Nurs. 2016;20(1):52-58. 

In This Article


Quantitative Findings

Sixty-five centers (72% response rate) completed the electronic survey. One-third (n = 21) were standalone hospitals not affiliated with a university. Nearly half (n = 30) reported one to four years of screening since inception of their program (see Table 1). Many screening centers (n = 28) reported screening 50 or fewer patients since program initiation. More than one-third of the institutions (n = 23) reported involvement in NLST or the International Early Lung Cancer Action Project (I-ELCAP). More than 70% (n = 47) reported adoption of National Comprehensive Cancer Network (NCCN) or NLST screening eligibility criteria.

Challenges faced included attracting patients (n = 38) and participation issues with clinicians and staff (n = 21). One statement echoed through many open-ended survey responses indicated that primary care providers "are not convinced of the validity of screening for lung cancer." Many participants reported "the lack of education that the surrounding community has regarding the risk of smoking and its correlation with lung cancer" as a challenge. Eight institutions offered free screening, and the average screening cost across 18 of the other centers was $100–$199 (n = 18). Some participants expressed distress regarding reimbursement, with one participant stating that "the largest obstacle has been developing a plan to ensure financial viability." However, a majority of institutions said that resources such as new equipment and additional staff were unnecessary (see Table 2).

Qualitative Findings

Ten themes were identified from the interview transcripts, reflecting common characteristics of LDCT lung cancer screening centers, barriers during and after implementation, and the influence of research programs such as I-ELCAP and NLST. Many interviewees reported that multidisciplinary teams—groups of medical specialists from different fields—were the foundation for establishing and developing screening centers.

We launched it through the multidisciplinary care team, which is a meeting of our pulmonologists, radiologists, radiation oncologists, pathologists, and the whole cancer team specifically for lung cancer, and we were able to develop through that.

Lung cancer nurse navigators were involved in the development, implementation, and surveillance of many programs.

Right now, I'm really doing it [follow-up] myself. I call everybody who is screened, and once you do this, you need to have a consistent person to develop the process that is reliable so that people aren't screened and no one follows up with them.

Another participant said,

I had gone to a nurse navigator meeting, and I had heard about lung screening there…. We were just in the middle of developing what we call a total lung care center…. We had two meetings, and then I brought the idea to them. So we decided to do it.

Screening guidelines varied across institutions. The majority of screening centers interviewed reported adoption of NCCN or NLST screening eligibility criteria (n = 11), with a couple starting to use the most recent USPSTF recommendations (see Table 3). Regardless of the criteria used, each institution demonstrated a wide spectrum of adherence to the guidelines. As can be seen from the following participant's quote, one institution did originally allow for self-paying patients to be screened regardless of whether they met the eligibility criteria but then later became more restrictive in its approach.

We did [screen] initially because they were self-paying, and some of them really wanted to have it done…. So we agreed in certain circumstances, but then we realized that that was not right. We decided that we should really only screen folks that are within the criteria because that's where the research has [been] done … and we don't know truthfully those that are outside the criteria, if the benefits outweigh the risks, so we stopped screening everybody else outside the criteria.

Some institutions remained strictly within their set guidelines: "We actually had people who have been nonsmokers or never smokers that wanted to be screened, so obviously we do go by the [NCCN] guidelines for that."

Other institutions were lenient regarding screening guidelines, explaining that certain cases require personal judgment and reevaluation, and they would simply make sure that the patient was informed about the reasons for the defined eligibility criteria.

I tell them if they want to be screened once for their own peace of mind, that's fine. They're paying for the test; there is no issue with insurance eligibility … but I am very open with people about what their risk is and whether or not they qualify.

Another interviewee narrated the reasoning behind leniency.

I have to use my discretion…. I have a patient who is 57, and she's never smoked, but her sister was just diagnosed with lung cancer who has also never smoked, so we are opening that [screening] to her if she wants it. But I try to explain the reasoning behind why we don't want to do it.

According to the study participants, the objective of a hospital should be to educate and serve its community. Consequently, they considered the establishment of a lung cancer screening center to be a critical part of this goal.

It's absolutely a part of our mission…. It's to try and get the word out about screening and to try to save lives—ultimately, to try and catch it early, and that's what really motivated our physicians.

Another participant said,

Truthfully, in order to be a respected cancer center … we have to have it [a lung cancer screening center]. If you look who participates, it's the most respected cancer centers in the country.

Many participants thought the results of research programs, particularly NLST, were instrumental in the expansion of screening centers.

I think the trial [NLST] is what prompted it [development of lung cancer screening program] … so the best way to start that would be early diagnosis … to increase cure rate, and … that trial had a huge impact on it.

For those already interested in reducing lung cancer–related deaths, the results cemented the need for a screening program.

I followed the NLST results … and had an interest because we have a large lung cancer population and a lot of mortality from lung cancer, so we had an interest in some way participating in lung cancer screening.

Three institutions reported involvement with NLST or I-ELCAP before initiating their own LDCT program and acknowledged the benefits of firsthand experience from their association with these studies.

We are one of the NLST sites…. It was a gateway for all of this. So once NLST were [sic] reported and showed that CT had mortality benefit, we started planning, introducing clinical screening.

Comparatively, an I-ELCAP participant said, "We were actually a part of I-ELCAP … and so we did have some background and some protocols … and we sort of developed from there."

Lack of insurance reimbursement was a considerable barrier within screening centers, as has been previously reported in other studies (Eberth, Qiu, Linder, Gallant, & Munden, 2014). Multiple interviewees said that this factor has hindered participation rates, referrals, and public interest.

They [physicians] aren't going to recommend things that aren't going to be covered by insurance because … you're going to have an upset patient that [says], "Oh, you're telling me I need this lung screening, but insurance/Medicare doesn't cover it. What am I going to do?"

Nevertheless, some institutions were not deterred from continuing their program.

Even though it's not yet covered by insurance, it eventually would be, and it would be good to offer reduced costs to the community; we would have the program in place when insurance—Medicare and private insurance—started to pay for it.

Although certain insurance payers offer reimbursement, other limitations may hinder the patient or institution from receiving prompt or correct reimbursement.

Even insurance companies are challenged a bit when you send through a screening CT, and you have to tell whoever you're talking with at [insurer A], "Let me email you [insurer B's] medical coverage policy … so getting the message to people who work at the insurance companies on the front line [that] doesn't know there has been a change [is a barrier].

The expense to the patient and centers was a major issue. Centers have attempted to address this financial hurdle with varying rates of success: "We were charging $300 … and we dropped the price to $99, and that seemed to make a big difference."

Monetary problems also narrowed screening effectiveness in other ways. Physicians, already uneasy about ordering LDCT scans because of limitations (e.g., false positives), were further strained by burdening patients with screening costs: "Physicians feel a little uncomfortable…. They're used to recommending things but not things a patient is going to write a check for."

A lack of patient referrals plagued lung cancer screening programs. Many factors have contributed to this shortage, including physician reluctance. "I think the barriers were the physicians … not referring … patients may have found out about it, and they were requesting it more than the physicians were referring."

This reluctance was not without reason; participants reported the absence of professional organization endorsement and insurance coverage as reasons for their low numbers of referrals.

The primary care physicians … were reluctant to send referrals, because it was still unproven and without the USPSTF recommendations. The questions about reimbursement, and not wanting patients to incur out-of-pocket costs—they were reluctant to send orders over.

With the introduction of the USPSTF screening recommendations, institutions found that public interest and physician referrals increased. However, the number of physician referrals still remained below expectations.

Not many cases were referred to us until [the] U.S. Preventive Services Task Force introduced the recommendations. So at that time, there were [sic] more interest and more pick up, so now we have been doing more … but still it is slow.

Lack of awareness and knowledge about LDCT screening among the public and physicians is another limitation. This issue is concerning, particularly because physicians are the gatekeepers to screening: "I would ask people about primary care physicians—what they know about the guidelines for lung cancer screening [and] most of them don't know about it."

Some participants spoke of the need for physician education. "I think primary care doctors are aware of the studies but are not sure…. They're concerned about false positives, the side effects of the false positives, and so one [barrier] was educating primary care physicians."

Participants discussed the importance of patient follow-up with a healthcare professional after screening results have been processed. Despite this necessity, methods for systematic follow-up remained underdeveloped in certain facilities.

Physicians may suggest to patients to get screened, but they don't necessarily order them through an electronic record. So I think there is a little bit of confusion as far as whose responsibility it is to follow up.

Nevertheless, some institutions have implemented a working follow-up method: "It's really important that you're just not saying, 'Oh, on this one, we're going to recommend this and on this.' … We're following a very formal follow-up algorithm."