My name is Stella Ogake, I'm an assistant professor at the Ohio State University Wexner Medical Center. I'm going to let my colleagues introduce themselves. Hey everybody, thanks for joining us. My name is Matty Triplett, I'm an associate professor at the University of Washington and then within the Cancer Prevention Program at the Fred Hutch Cancer Center. Good morning everyone, my name is Francesca Duncan, I am an assistant professor at Indiana University School of Medicine, and there I work with our Lung Cancer Screening Program primarily at our community-based hospital, and thank you all for joining today. So we want this session to be as interactive as possible, so feel free if you have any questions, raise your hand and then walk up to the mic, or if you have anything you'd like to contribute, please feel free to raise up your hand and walk up to the mic. So disclosures today, Matt has a disclosure, gets consultation free from GoToLungCancer. And then for the session outline today, we want to discuss gaps in lung cancer screening and examine the evidence for alternative individual-based screening approaches to achieve lung cancer screening equity and reduce barriers to screening. We also want to identify barriers to accessing lung cancer screening among underserved communities and individuals at the highest risk for lung cancer development. And then we'll discuss some intervention strategies to improve lung cancer screening uptake, shared decision-making, and shared decision-making among high-risk individuals. And then finally, we'll define disparities in post-lung cancer screening care, including tobacco cessation strategies to mitigate disparities along the lung cancer screening pipeline. So to start off, I wanted to show this because lung cancer is actually the most effective cancer screening exam that we have. So when you look at all the different screenings that we do, like colonoscopy, pap smear, HPV testing, checking PSA for prostate cancer, you look at mammogram, this is the number needed to screen for them. So say, for example, mammogram, number needed to screen is 377, colonoscopy, 871. Pap smear and HPV screening, number needed to screen is up there, 1,400, 2,100. Below the CT screening for lung cancer screening, the number needed to screen is 320, which is like one of the lowest numbers needed to screen to prevent cancer mortality. But having said that, only 5% of people who are eligible for lung cancer screening get screened. So when we look at lung cancer screening uptake, on the y-axis there, we have a percentage of people who are eligible for lung cancer screening. And down here is like you look at the number of years since lung cancer screening started. And you can see the uptake for cervical cancer screening is close to 90%. When lung cancer screening is actually the data from this year, it's like 5.8% of people who are eligible for lung cancer screening get screened for lung cancer, even though we know that it's a really effective way of screening for lung cancer and preventing mortality for lung cancer. And additionally, people who are racial and ethnic minorities, those people get screened even less. So there is this data from Taylor and his colleagues. They did a study on how utilization of lung cancer screening in the Medicare free-for-service population. And they found that for people who are black and Hispanic, for people who are eligible for screening in those communities, only 2% of black people who are eligible for screening get screened. Only 0.7% of Hispanic people who are eligible for screening get screened. And even though the white population, they're getting more screening, still it's only 5.4% of people who are eligible for screening get screened. So I want us to discuss a little bit, what do you guys think are some barriers? Like, why are people not getting screened? What are some thoughts that you guys have? Well, thank you for that engaging discussion. So this is actually what everything that we talked about. This is actually a figure that was published by Waite and his colleagues. And they were pretty much like writing a paper on how to implement lung cancer screening in Europe. And they were thinking about barriers to lung cancer screening uptake. Because the behavior that you want to achieve is uptake of lung cancer screening. And so classify barriers to opportunity, motivation, and capability. So when you're talking about motivation, which is forgetting appointments, distrust of health care, which we talked about, stigma around smoking, and then just like denial of fatalistic beliefs about lung cancer. And then when you're thinking about opportunity, they don't have money, finding time around work, they don't have a health care provider to refer them, and then capability is just what Dr. Aldenabi said, low awareness of screening, and then just having sudden beliefs related to screening and the harms associated with screening, and then issues with transportation. And so when we are thinking about interventions to try and increase lung cancer screening uptake, there are some that are put up there. So like, if you want to improve capability, explaining benefits in an appropriate way that patients can understand, using decision aids, initiatives to improve awareness about lung cancer, and then just like trying to make sure lung cancer screening is available in the communities. People don't have to travel long distance to get to a big center to get lung cancer screening. Engaging communities, engaging primary care physicians, sending texts, reminders, and stuff like that. But having said all of that, all these strategies to improve lung cancer screening uptake, they remain unproven. So we don't have evidence that if you do all these things that it's going to work, but we just have to keep trying. So I wanted to show what the lung cancer screening eligibility is now. So obviously, between 2013 to 2021, we're using the National Lung Cancer Screening, the NLST criteria, which is what was taken by the USPSTF and put up as their criteria for guidelines for lung cancer screening. So 55 to 80, 30 or more years of smoking. And then if you're a current smoker or you quit within the last 15 years, but that has changed since 2022. So now we are screening people between age 50 to 80 who have 20 or more past years of smoking history if they're currently smoking or quit within the last 15 years. So there is definitely some, I mean, these guidelines are not foolproof. We know that there's a lot of people, if we stick strictly to this criteria, there's a lot of people who we miss who have a high risk of lung cancer. So in the NLST, the participants were younger, they were less racially and ethnically diverse, and they had fewer comorbidities. And we know that black people and Hispanic people develop cancer at younger ages than people. And even with like a lower smoking history, there's still a risk of getting cancer. So we're hoping that with a new updated eligibility, you know, that we're going to capture like more of the people who are left outside of them, like who are not getting captured in the initial criteria. So hopefully the number of people who are eligible will double, and then there's going to be a larger proportion of eligible black and Hispanic individuals who get captured with a new criteria. So having said that, I was curious, do you guys know of any models that we can use for lung cancer screening? So like, you know, the way we have models for atherosclerotic cardiovascular disease, you put numbers in a calculator, and it tells you this is your risk for ASCVD, or this is your risk. Like you can use the Gale model for breast cancer. Have you guys heard of any models that we can use for lung cancer screening? All right, so there's actually numerous studies that have found that if you have like the right risk prediction model, it works even better than the, like your SPSTF guidelines or the NLST criteria that we use. So the one that I was thinking about is what you brought up, the PLCOM 2012. It's a validated logistic regression lung cancer risk prediction model, and it's based on data that was collected over the control arm of the prostate, lung, colorectal, and ovarian cancer screening trial. And pretty much that trial was done like to study screening and to reduce lung cancer mortality. So the studies have found that like if you use this model, like in the right population, it will identify individuals who develop lung cancer at a significantly higher sensitivity. It averts more lung cancer deaths. It has a smaller number needed to screen to avert one lung cancer death, and it's actually more cost effective than categorical approaches. So the PLCOM 2012, it predicts incident of lung cancers within six years of screening using 11 predictors. So those are age, race, ethnicity, BMI, COPD, smoking status. So smoking status is whether you're smoking or you quit smoking, and then intensity is how much you smoked in terms of like pack years, and then duration, and how long has it been since you quit. And then it also takes into consideration personal and family history of lung cancer. And this model has actually been validated in multiple countries, including the United States of America, even though we don't use it. It's been validated in Canada, in Australia, in Brazil, and in some European countries as well. And this is a Venn diagram from an article that was published, just comparing like how did this model do. And pretty much when you look at the Venn diagram there, so comparing the NLST, like USPSTF criteria, and the Venn diagram, there were 36 small lung cancers that were like you know detected by this model compared to the USPSTF criteria, right there. And then like he correctly said, this has actually been studied against the USPSTF criteria, and it captures more people who are at a higher risk of like you know getting lung cancer in all populations, but also like more in people who are ethnic minorities. So you can see there. So for example, like for African American, when you compared USPSTF and the PLCOM 2012, and like if your threshold for like lung cancer was like 1.51%, there was like 74% people who were captured compared to African Americans, which was like 50%, I mean 50% for that same demographic. And with that, I'm going to let Matt come and take over. Thanks. So disclaimer for me is that these slides were actually made by my good friend and colleague Eduardo Nunez. So I'm taking over, pinch hitting at the last minute, but this is a topic that I'm really passionate about. So I'm excited to be able to join you all today. And when I looked at Eddie's portion, I said, oh no, I've got a bit of a challenge here because we're talking all about the patient experience and uptake. And as Stella mentioned, we're really in a data-free zone for lung cancer screening at this point in how to really improve that uptake number from that, you know, five to maybe optimistically 15% and do it with attention to equity because just bringing that number up will exaggerate disparities in care. So I'm excited that you all are a very engaged audience, so you're going to pull me through these slides that I didn't create, but there's a lot of great opportunity for discussion, so I'm excited about that. So Eddie gave me these two quotes, which are very reflective of things I've heard in my own qualitative studies with underserved groups. And it already harkens back to a lot of the things I've heard in this room. So the first is, what scared me was when they said the word lung cancer. Just like you'd say pap smear or mammogram, we know it's for cancer. To come right out and say lung cancer screening, because when she said that to me, I was like, do you see something? Do I have cancer already? So there is this idea that, you know, there might be some differential fear around lung cancer screening versus other types of cancer screening. And then obviously we have these terms that don't have the word cancer in them for the other cancer screening. So even just knowing that our patients, this population who has smoked who probably does have fear and fatalism around their smoking behavior, may have a reaction to using lung cancer and that word, kind of moving away from that. The other quote, the medical world and advertising point the finger at smokers and say they're bad, they're going to die, and that's it. I didn't smoke because I was a bad person. It's a bad habit that I enjoy. So again, I do think in my encounters that if we are going to engage people who have smoked cigarettes, we do have to approach it in a way where, you know, for lack of a better term, that our patients understand that this is a safe kind of judgment-free space that obviously we're going to talk about smoking. We want to engage people in longitudinal conversations around smoking, but we may need to change our language a little bit so that we're not driving patients away. So with that in mind, I wanted to kind of open it up to the room a little bit. There's no right answer here, but even thinking about that first part of the patient experience, how are you going to interact with your patient and introduce screening to them, what are some considerations in just that framing if you take a health equity lens? So the first, you know, potential strategy, there's a new screening test called lung cancer screening. The test is an annual low-dose chest CT and would be a CT every year, potentially until the age of 80. The second, similar to getting a mammogram for breast cancer screening, there's a test to get your lungs checked if you have a smoking history. It is done with a CT chest every year, potentially until the age of 80. Because you are a smoker, you are eligible for lung cancer screening. There's evidence that shows that a yearly low-dose CT of the chest can detect cancer at an early and treatable stage and can reduce mortality from lung cancer by 20%. So to me, I think there's good elements in all these, but there is some language that may either bring a patient into the fold of lung cancer screening or potentially drive them away. So I'm wondering from you all, what are some strategies that you've used just to talk about this with your patients that you think help? Yeah. Great. I love that. And we heard that earlier, right, that this, there's two issues. One that smoking is going to be concentrated in populations that face health disparities, have lower socioeconomic status, so maybe less health literacy. And also, this is a new test. Like to us, it's not new. To us, it's 10 years old, but this is a new concept and relating it back to mammograms. Yeah. Yeah. And that's so interesting, right? It's like, how do you have this conversation that includes smoking? Because we want this to, I mean, we can talk about the scale trial results, but we want this to be potentially a teachable moment, so we can't ignore smoking, but how do we introduce it in this way that's very acceptable, appropriate to the patients that you are? So I love that, too, because I think we're very primed in the shared decision-making discussion, and we're going to hit this in the next slide to talk about the risk, but we don't talk about the benefits in a tangible way. So to Gerard's point, number three is a more intangible population-level benefit of lung cancer screening, and Gerard's talking about how to bring, potentially, the benefit to the patient that, you know, if you have lung cancer, we can detect it when it's small. I like that. Yeah, I just want to add, on three, this idea of reduced mortality by 20% of the test. Yeah. Yeah, I totally agree with that. Yeah, and I think what I'm seeing, I don't know what you all's experience is, that we're obviously changing it quite a bit in written language now, which is good, but I think it's still part of our common parlance in conversations and definitely is such at this meeting. Right, right, well, we love smaller, the smallest word possible, and you know, that's what we call it, so that's just a short word we can use, but you're right, it has implications for people. So that's a great discussion. So I'm going to talk a little bit about shared decision making, because I think everybody in this room has been a part of that conversation with their patients, and whether you have programmatic control over a lung cancer screening program, you can definitely change the way you frame things in these individual conversations with patients. Now I bet a lot of people in this room, and I know a lot of people in this room, have programmatic control, so we will talk about like tools you can use on a larger level. But first, talking about the individual discussion, I'm interested in how people do this, so these are now not the benefits, but the risk of screening, and I will tell you my own bent is that I see a lot of discussion of radiation, because we know what the lung cancer screening test is, it is a CT, so we tend to hear all this discussion around radiation, because that's the immediate risk, but to me that is the least important of these particular potential risks. One thing I brought up there that we're going to talk a little bit more about, because I think it's important from a health equity lens, is this idea of a health care burden, that there's a risk of finding an abnormality that may require a series of tests and referrals to specialists, and can be a source of a health care burden, and that's very differentially felt, I think we heard that in the room, right, around rurality, around getting off of work, around lower socioeconomic, how that plays into a health care burden, so that's something that I talk about. But I'm wondering of these risks, which ones have you all tried to highlight with patients both before or after their screening exam, and how is that different when you're taking kind of a health equity lens, or working with a population that faces disparities? Well I think the challenge, right, and so the subsequent slides are going to quantify all these things, but to Gerard's point, I'm not sure patients can perceive the quantifications around these things. Let's forget patients for a second, I'm telling you that I think half the physicians out there don't know what a diagnosis is. Exactly, yeah. So like I never bring that up with patients, even though I am fascinated by the whole field, right? I don't bring up radiation, because I tell them it's really low dose, and you know, the two that I think are important are complications of procedures, and that actually varies with each patient, right? If you have a 78-year-old who's got bad COPD, getting a needle biopsy might be important, so that frames your conversation. Yeah. and the false positives. Yeah. Absolutely. Yeah. And I think that's probably the most important one for an underserved population. Well, and I think we're seeing the results, right? If we're seeing this high rate of missed initial appointments, low uptake, and then the adherence to follow-up data that Gerard published looks relatively abysmal, right, on the first million screens, that has to reflect, in some way, the kind of healthcare burden that we're putting on the patients. So I'm going to walk through these, but I open to more conversation. So false positives. I think we all know about 24% of the exams in the NLST had false positive findings using a really strict threshold. It is nice that we are near universally on this new system, Lung RADS, and you can say what you want about Lung RADS, but there is something really nice about the universality of it, and then the fact that we have reduced the number of false positives with kind of standards. So this is what you're going to expect, right, in terms of potentially a breakdown of the prevalence of the different Lung RADS categories, that a lot of patients are going to have nodules, right? Anybody above Lung RADS 2 is going to have a quote-unquote nodule, but that only Lung RADS 3 or higher are going to be actionable, and then the reality is that the majority of these are not lung cancer, right, which we need to reassure the patient. So how does the patient perceive these? I don't think we have a ton of data on this. My own studies would suggest that overall, the stress of people undergoing screening is low, but in this veterans population, which is not this exact same setting, which Chris Latour's group looked at, in incidental pulmonary nodules, about half of patients had some distress around a nodule with a, you know, a small fraction, but a, you know, a decent fraction having distress at two years, and this I have seen replicated a number of times, and I wonder if resonates with you all, this idea that if you bring any positive finding that the patient perceives that that risk of malignancy associated with it is higher than it actually is. So in this case, about half estimated a risk of malignancy of 30% when in reality the average risk was 10%, and we are in that space with lung cancer screening, right, we're going to see a lot of positive findings, and those of us who are in this world say, okay, well, you got a Lung RADS 3, get your CT in six months, I'm not really worried about it. Patient may be worried about it, right? And so high-level communication at least is associated with less distress. In terms of over-diagnosis, I agree with Gerard in that it's one of the more complicated to understand, and so besides running a screening program, I run the Lung Nodule Referral Center, so I have a lot of these conversations around this may be adenocarcinoma in situ, the best and safest and most aggressive thing we can do is just follow it now. So there's that level of over-diagnosis. What I would, when you put your health equity hat on, the side of over-diagnosis I would think about is that if you're trying to reach patients with lower socioeconomic status, that may go along with higher burden of comorbid illness. So that level of over-diagnosis we don't think of. A patient population who has less than five years life expectancy is likely to have the highest risk of lung cancer, the highest quintile of risk, but the lowest benefit, right, because they're not going to survive long enough to benefit. So that is a level of over-diagnosis that at least we need to consider when doing any kind of personalized shared decision making with a patient. The radiation, I was feeling out the room, Eddie put this up here, I love not talking about radiation very much, right, and part of that is because this is a nice comparator to what the average background radiation is for a patient every year. In terms of complications, I think very important that we are kind of tracking these in real time because we know, as Stella said, the NLST population is a different population. So on the right side of that you can see the CT arm of the NLST population, and on the left side you can see a collection of veterans within the demonstration projects that underwent lung cancer screening. And what is nice about comparing these numbers is that actually the overall percentage who underwent an invasive procedure following lung cancer screening was lower in this more diverse real world setting than it was in this kind of healthier NLST setting, and that's guided by probably a lot more experience and comfort around how to follow these things with the old time biopsy, which I like. But what is going to be a challenge if we have this attention on screening a more diverse health equity population is that the overall rate of complications ends up being the same despite lower number of procedures because within each invasive procedure probably a real world population may face more challenges. And to what Gerard said, that's going to vary a lot on the individual level. I am a big fan of personalizing shared decision making, so we all know that there are certain patients that are just going to be more likely to have complications, some of which are related to underlying smoking-related lung disease. So in terms of healthcare burden, I really like this quote, I hate to get in that wheel. You go see one clinician and then they start passing you around, it's like a hamster in a wheel, it just keeps going. Every time you go to see a specialist they send you to another one for another opinion and pick on something else and then three, four times and then you wind up back where you start. So we're in this interesting place with lung cancer screening where the only data we have is largely in the adherence setting to improve interventions and so we say, hey centralized programs will increase adherence, you will reduce disparities, nice paper by Roger Kim from the Prosper Group. But the reality is that's just another specialist for these patients, that's just another center that people need to go to. And it really is an underappreciated source of misdeployment, so again the comorbidity burden comes in, I think we don't appreciate that, we have patients that are already spending two hours a day potentially on healthcare-related activities and now we're asking them to add something to it. And there's a big difference between asking someone to get screened for a condition that they do not have than treating their medical illness which they do have, and I think we sometimes forget that when we're asking patients to go through the rigor, the rigmarole, the one hour drive, everything else, it's a screening exam, right, it is not usually something that the patient has a highest priority. So this is where I really want to see some awesome discussion because when I think, when I put my program director hat on, I'm like I'll take all of these, right, but we don't have infinite resources. So if you're going to think about tools from a program level of how to get people into that initial LCS, which would you highlight, which would you, if you had an infinite amount of money, focus your attention on, and then how might that change or how might any of these tools be adapted if you are applying a health equity lens? That is crucial information. Yeah, I love that. And so the first one is one of the few things we have evidence for in the lung cancer screening space. Again, kind of Roger Kim's study, looking at the centralized and decentralized sites within the PROSPER cohort, the coordinator was the thing that was centralization. And it certainly helped with follow-up once you were in the care continuum. But my challenge with the coordinator is you gotta get your way into that care continuum. So I'm not sure it's gonna improve uptake, but it certainly holds onto patients. And the navigator, I think Gerard mentioned this as well, seems to be effective at reducing disparities in the mammogram colorectal cancer space. We've got some single arm studies within the lung cancer screening space. I'm excited to see a higher level of evidence and really understand what the intensity is. These things are expensive. They can be time intensive. So do we need lower level intensity navigation? Is there some low amount that can be spread among patients and then stepped up when patients need it? Or do we need really intensive interventions to really help with this health equity challenge? Anybody else? I'm not sure if it's that lucky. Yeah, and that's part of the reason why we're trying to define the intensity, is just this financial piece that it really is not a reimbursable activity in two levels. One, usually their services are not directly reimbursable. And two, to Gerard's point, it's going to change the payer mix in a way that you're not going to hear this directly, but it's not going to be favorable to your center necessarily. Anybody else have any thoughts? Yeah, and I think that's great. That's been a challenge in convincing our program because all the things that I showed you before about the care continuum, it's hard to convince people it's a one-time event, right? That sometimes you are setting up people to have all this follow-up testing and other things, and the program may pay for that one-time CT or bring the mobile CT out and have free lung cancer screening day, but what happens with the findings? So you do need to think about the whole care continuum when you're thinking through things. Well, I'm going to turn it over to Francesca, but the other things I would say are all valuable, but if you're using that health equity lens, also think about how to tailor them. For example, the electronic tools. Sure, you can identify eligible individuals, but is that going to be differential and bring in a disparities population? Can you use that tool to then do prospective outreach to people that you identify as eligible? So that's something that we're doing. It's kind of universally calling patients, collecting the smoking history, doing that soft handoff and information about lung cancer screening, and handing back to the PCP. So just thinking about tailoring any approach that really, if you just increase your uptake, you're going to magnify the disparities. So every approach you add, really apply that equity lens. All right, thanks everybody. All righty, last but not least. So I'm Francesca, and kind of wanted to piggyback that. We've listed several different tools or things that we know are very important in terms of lung cancer screening, but don't get boggled down in thinking that in order to create an ideal program, you have to tackle all of these before you're able to do something. I think a lot of us within this space are trying to pick one or two of these, and trying to see if we can improve lung cancer screening uptake, decrease disparities by trying to tackle one or two of these. And I think the reason that that is important is because as mentioned today, a lot of this has not been implemented into practice right now. And so I think if we can all kind of pick one or two of these and try to study that, at least that's what our group is doing, I think that might help us out in the long run. So I'm going to kind of talk about disparities and the post-lung cancer screening care, and I just wanted to kind of take you through the walk of our patients. Those patients that are more likely to be the recipient of disparities in lung cancer care have gone through disparities across the entire continuum, and now I'm going to focus on post-lung cancer screening care and including follow-up as well. So our follow-up can kind of be broken up into three large categories. So one is lung cancer treatment and management of next steps for suspicious findings. The second is tobacco cessation, which should be a huge part of our lung cancer screening focus and programs. And lastly, annual follow-up and lung cancer screening adherence, which we talked about that being extremely important in order to see that mortality benefit as it relates to lung cancer screening. So I'll highlight here a few papers, and so many of us that are in the lung cancer disparity space, we know that there have been numerous papers that have highlighted disparities in terms of stage-specific treatment. So what we mean by that is we have evidence-based guidelines that suggest what type of treatment patients should receive at various levels based on their staging. And these are just a few of those papers that have highlighted that social determinants of health impact treatment. And so the top left paper here essentially looked at social determinants of health in the management of stage 1 non-small cell lung cancer. We know that potentially curative surgery is a huge part of stage 1 treatment for non-small cell lung cancer. And this particular paper highlighted that those that were disproportionately affected in terms of lower social determinants of health, those individuals were less likely to receive potentially curative surgery, more likely to have a worse five-year survival. When they did receive surgery, they were more likely to have open surgery. And then they were also more likely to have a 90-day post-surgical mortality. And so reasons for that are things that we need to explore. Some of these other papers highlight the impact of virality, and we kind of spoke a little bit about that today. But we've seen that patients that are not living in metropolitan areas are less likely to receive potentially curative surgery. And so that's an important concept here. Also looking at patients' insurance status is also crucial in terms of looking at why are there disparities in terms of treatment, particularly for non-small cell lung cancer. And I want to highlight the paper at the top left here because I think when I am talking to other providers about lung cancer screening, I'm often hearing this that, well, black patients just don't really want surgery. Like I talk to them about it and they just say they don't want it. And so this particular paper highlights that blacks in this particular paper were less likely to actually want surgery when that particular surgery was suggested to them. And I think that I want to highlight this because I don't want us to kind of also fall into that trap where we are having our own implicit bias saying, well, I may not talk about surgery with black patients because they're more likely to not want it. But maybe instead use this as a what can I do to try to improve that shared decision-making with my black patients and make sure that when I'm talking with them about surgery, I'm answering all questions that they may or may not have to help them make an educated decision about their treatment. So this is just a figure here that kind of looks at overall survival and treatment. And you can see here highlighting various racial and ethnicity differences when it comes to surgical treatment, oftentimes treatment at all. So we're not talking about just racial disparities in treatment of early stage disease. There have also been racial disparities looking at advanced stage disease as well. And some of my own work has looked at that. And so we know that many times black patients and Hispanic patients are less likely as well to receive other types of treatment. And so that also may be related to shared decision-making as well. So moving on to management of next steps for suspicious findings. So I think it's really important here to talk with our patients about anticipatory guidance prior to and after completing lung cancer screening. And so I think when I talk to my patients, when I'm sending them to lung cancer screening programs, our program, I'm talking with them and letting them know upfront if they find something, you are going to be bombarded with next appointments and calls and those types of things. And if you have any questions at all, or you feel like the individuals in the program are not really answering those questions, well, please come back and talk with me about it. So I think it's really important to kind of let them know if they find something, what are the next steps? Who are they going to see so that they can anticipate that and not be overwhelmed with what comes at them. We've also talked about this. The patient navigator is really crucial in terms of communicating the results. Oftentimes in my program, one of the studies that we're currently doing is looking at how primary care, if primary care providers feel comfortable in discussing results, and oftentimes they really don't feel comfortable with that. And that's okay. I think a lot of education surrounding that is important, but really having that patient navigator, being able to communicate between the primary care provider and the patient is crucial in terms of communicating results and next steps as well. And then partnering and leveraging your PCP. So oftentimes as a pulmonologist, I see patients, you know, they have something concerning on their CT, looks like cancer, you schedule them for a PET scan, they've missed the PET scan more than once. You know, you schedule them for the CT guided biopsy and they missed that appointment. And it's important that maybe we try to leverage our relationships with the PCPs because they already have that established trust oftentimes with their patients. And so reaching out to them and letting them know I'm trying to reach out, reach Mr. Johnson who has this lesion concerning for cancer. I'm not able to reach him at that next appointment or could you call him to let him know that we're trying to reach him about next steps. Additionally, tobacco cessation as well. And so I'm just highlighting two papers here that looked at differences and racial differences in terms of tobacco cessation. And the top paper highlights that black individuals were more likely to have 24-hour and seven-day quit attempts but those rates of attempts did not translate to six months of abstinence. So that's an important piece here as we learn about difference in terms of racial behaviors of smoking patterns among different racial groups. And so targeted interventions are needed at the time of lung cancer screening to try to convert those quit attempts to sustained abstinence. The paper here at the bottom looked at race, black and white race, and they found even talking with patients about how they prefer to receive information about tobacco cessation. They found that white participants had a four times greater odds of preferring a digital format compared to black patients who prefer face-to-face support conversations, phone support, and printed materials. And so one of our studies that we're doing now in terms of reaching out to patients for lung cancer screening in order to not only improve screening but also to decrease or to improve in terms of health disparities is we're using this by trying to communicate with our patients through phone calls, through printed materials being mailed to their homes, as studies have shown that this is more effective in black patients. And then annual follow-up and lung cancer screening adherence. So there are various barriers. Patients perceived risk about undergoing screening. So if patients hear lung rats, lung rats one or two, the provider says follow up in a year, they are kind of thinking I'm kind of out of the window. And so sometimes that can be a barrier in terms of getting people to come back year after year for the screening. Another one I want to point out here is the third bullet. And so many of our patients who are getting lung cancer screening are also those patients that have COPD. They're probably going to be utilizing the ED services more often and are getting CT scans. And many times as a result of them getting these CT scans, they're now ineligible for lung cancer screening because they've already received their CT within the year. So being able to communicate with providers and letting them know thank you for referring the patient to the program, they're no longer eligible at this time. But in a year, should they not receive another CT, that would kind of push them back to another CT or being eligible for screening at that point. And then these last two papers here are just highlighting factors associated with non-adherence. And there are various factors here. Race is one of those factors related to non-adherence. Gender as well. And then also marital status, which is an important. Many don't look at that as a social determinant of health. But marital status has also been linked to cancer patients deciding to go through treatment, also deciding to go through surgery, and then even deciding to go through annual follow-up. And so I think that these are those target groups that we should be looking at when we're trying to focus on who we really need to reach out to to improve our annual adherence. And so now another interactive portion here, we're going to talk a little bit about our patient barriers to follow-up. So these are some of the ones that we kind of discussed as a group, but I kind of wanted to open it up to the audience and kind of see if you all have any other patient barriers to follow-up. And then I'm going, in the short time we have left, kind of talk with you a little bit about some of those things that we're trying to do at our home institution. Any thoughts? Any barriers that your patients have kind of talked with you all about? Absolutely. Yes. Absolutely. Absolutely. And I think we're going to kind of get to that when we talk about the physician barriers as well, too. Because many times I hear that physicians are not talking about it because there's just not enough time in the appointments that they're having with patients. That's a lot of the things that I hear in terms of the time it takes to have the shared decision making surrounding lung cancer screening and the tobacco cessation conversation as well. So that's also a very important barrier. Any others? Yeah. I was just going to add to that. We've been using this lung cancer knowledge assessment called the LCS-7 to ask kind of question or assess knowledge after shared decision making. And the one question that is the most likely for people to get wrong is a question around once I have one or two CTs that are normal, I don't need any more. Very likely that people say yes to that. So obviously in shared decision making, we're not doing a great job telling patients, oh, there is, you know, annual follow up is involved. And not only that, you know, it really is what translated to the benefits in the NLST. The majority of cancers were found on the subsequent scans. Right. Absolutely. I think, lastly, some of the physician barriers to kind of follow up. We mentioned not enough time to really discuss things with patients. But I think one of the things that we've kind of done is kind of creating a unified script, so to speak, so that the providers can use that and make sure that it kind of highlights the big points using some of the language that we talked about here. Kind of giving providers a script so that they can feel a little bit more comfortable when discussing screening. I think many of us have these EMR reminders as well. But oftentimes how those pop up and how that kind of impacts our providers as well. Lack of knowledge about the importance of annual, so Maddie just kind of alluded to that. And then this last one, concern about patient's insurance coverage. So I feel like a lot of primary care providers say, well, I didn't refer because they don't have insurance. And so I don't think that insurance covers lung cancer screening. So there's that lack of information knowing about that. And even with some of our hospitals, if our patients are self-pay, there are mechanisms in place to be able to get lung cancer screening a little bit more affordable for them. And so I think that's something that we need to get that information out to our providers as well. So I'm going to wrap up here with our summary. And then I think we might have 30 seconds for one last question. So we need to consider lung cancer disparities and associated outcomes as we discuss screening with those at higher risk for the development of this disease. And we need to ensure that providers are knowledgeable of the current screening guidelines and that is discussed with every patient. That's a way that we can reduce implicit bias. We need to identify barriers to lung cancer screening and mitigate those with patients. So not trying to tackle all 10 barriers, 20 barriers, pick one and try and see if you can alleviate that for your patient. And that can start with you just being kind, considerate, coming to them as someone that's not a smoker but someone who has a history of smoking. And our health care system should be aware of provider barriers and actually present them with evidence to get them to do things to potentially change and provide solutions to those barriers and discuss tobacco cessation strategies and the importance of annual lung cancer screening follow-up with low-dose CT with all patients. And so with that being said, thank you so much for listening.

lung cancer screening

underserved communities

screening barriers

racial and ethnic disparities

individual-based screening approaches

patient barriers

opportunity barriers

intervention strategies