So maybe we will go ahead and get started. I'm sure people are going to trickle in. Thanks for sticking around with us after lunch to talk a little bit about lung cancer screening. I think this is going to be a really cool session because I think we all come from different places and different roads, but central to all the topics is really how to build and sustain a lung cancer screening program in the community. So we will talk about some research aspects, but really we hope this is a very practical talk for you all. So we're going to start with Dr. Kapp, who's going to talk about inequities in lung cancer screening and outreach to eligible persons to enhance equity. So go ahead and get started. My name is Chris Kapp. I'm one of the interventional pulmonologists at Northwestern. So as for an agenda today, we'll really just three main data points. History of lung cancer screening, which spoilers, there's not a whole lot of history, a data-driven look at kind of the social determinants of health in lung cancer, and then improving screening and retention. So I have no relevant financial disclosures. So I think the evolution of lung cancer screening, as I was preparing this talk, I always like to give a historical look at things, and there really isn't much. And I highlighted some pop culture references in here, but from 1960 to about 2011, people were either doing none or they were using an annual chest X-ray, maybe some sputum cytology, but nothing as standardized as what we have now. And in 1960, you know, that was the first televised debate between Kennedy and Nixon, which tells you a little bit of how long ago and how little had advanced during that 50-year time period. In 1996, we started getting some data trickling in about low-dose CT scans detecting more cancers, and then the NLST in 2011 really obviously pushed that to the forefront. Way back in 1996 was when the Macarena was a craze, for those that remember that. And then in 2021, we had our updated lung cancer screening guidelines that increased the person's eligible, included more people with lower pacular smoking histories. And then the picture I have here is an NFT. Those were, you know, big back in 2021. This one sold for $69.3 million, and it's available for me to use in a talk, right? So I'm not sure how good of an investment that was. So now, and everybody in this room probably knows this, but, you know, the guidelines now recommend asymptomatic patients aged 50 to 80, 20-plus pacular smoking history, who continue to smoke or have quit in the last 15 years. And this increased our numbers substantially, and we do know that, you know, lung cancer screening does reduce mortality. So you know, I think this is a, it was a great start to kind of reduce some of the inequities that we see, but did these 2021 guidelines kind of go far enough? So 15 years from quitting, and you're home free, I'll draw your attention to the first figure on the right there. So this is your hazard ratio, the x-axis is years since quitting, and then the y-axis is your hazard ratio. So versus never smokers, your hazard ratio still remains pretty high, even as the bottom number is 40 on the far right. But versus current smokers, you certainly have a lower risk, but it's still not zero. So maybe those people should still be included, especially with your, you know, shared decision-making process. There's certainly an octogenarian bias. Not everybody who is 80 is the same, right? So there's a lot of healthy people who still have 10 to 15 years to live. Should we be excluding all of those people? And then these guidelines did narrow the racial gap, but did they go far enough? And I'll highlight more of this throughout the talk. And then these are some of the risk factors, you know, aside from smoking, nobody really is included. And, you know, I'll draw your attention to this. Current smokers obviously have the highest hazard ratio, and then you're looking at previous smokers. Age plays into this a little bit, but I think the interesting thing and where we're probably headed with this is particulate matter 2.5 was significant from an exposure standpoint. So I think that's probably where we're going to go. All of the other ones, you know, kind of were either insignificant or lean towards, you know, being beneficial to patients. So education and household income, as with a lot of the stuff we'll see, were benefits and lowered your hazard ratio. So who gets screened? So nationally, depending on what study you look at, only 5.8 to 14.4 percent of those eligible get screened. So we're not doing great, although this is improving. And then when you look at race, eligible black persons have a much, much lower odds ratio of being screened than their white counterparts. However, if lung cancer screening was brought up by their primary care physician or they were referred by a primary care physician, that odds ratio becomes insignificant. So we really need to do a better job of educating people on lung cancer screening. And then lower median income and government-based insurance are risk factors for lower uptake. And then former versus current smokers have a higher rate of lung cancer screening uptake. So taken all together, it's not the best picture. So we really need to do better. So touching a little bit more on how races differ with respect to lung cancer. So the first graph on the top right shows, again, blacks versus whites in the age they present for cancer. And as you can see with the distribution, the graph on the left shows that blacks present much younger. For lung cancer, which is what this is talking about, it's about a two-year difference. But for some other cancers, it becomes substantially longer than that. Eligibility for lung cancer screening, and this was a study that was a little bit older, based on 2013 guidelines, and it was only on Packier history alone, showed that 56% of the white population and 32% in the black population who presented with lung cancer were actually eligible for screening. So again, not hitting everybody kind of equally. And then the bottom graph, these are based on the 2021 guidelines. So it's eligibility for lung cancer screening and those diagnosed with lung cancer. So again, these patients all had lung cancer. And then whether they were eligible for screening, Native Hawaiian and white were the highest. But even still with the white population, it was still only, it was under half. And Latino and black were the lowest. So again, we still need some work on this. In terms of other factors that kind of play a role, so this is, I was at University of Illinois for a couple years before moving over to Northwestern, and this is our data from 2015 to 2021. And it looked at all of our patients, and this was not lung cancer screening, these were just all of our lung cancer patients. But the blue is the percent of patients that were black, and then the gray is the percent of patients that were presenting from a zip code that had a lower, a median income of $40,000 or less. And so as you can see, as you get to your stage three and stage four, those numbers both go up. And then you had, we had odds ratios that were predictive for presenting in stage four in both of those subgroups too. So especially in our patient population, and this has been reproduced in other literature, these two factors play a role. So shifting gears a little bit, what are some of the barriers to screening uptake? So patient awareness is a really big barrier. So lung cancer screening, in earnest, since the NLST is really kind of when we started publicizing it a little bit more, but only 52% of patients eligible had knowledge of its existence. And primary care physicians even, and this study came out in 2018, said they had no patients who asked about lung cancer screening. So there definitely needs to be an education to patients, and we'll talk a little bit more about that, how to go about that. Provider awareness, these are survey studies looking at lung cancer screening and talking to primary care physicians. So they were presented with a 50-year-old patient who had a 20-pack year history, 36% said no screening, 17% said chest X-ray, and then 47% appropriately said low-dose CT. So again, provider awareness is a big role in this too, how are patients supposed to know if their primary care physician doesn't know? And then insurance issues with prior authorizations and lack of coverage for low-dose CT scans, these were some of the barriers that were identified by patients. And then transportation and financial challenges, if you remember back to the slide I just presented, a lot of these patients come from an income that is less than $40,000. So imagine trying to make an appointment or make a CT scan without some help. And then patient beliefs and attitudes, there's a lot of mistrust of the healthcare system, there's a lot of fatalism or would rather not know. So again, you have to kind of, and that's where primary care physicians come in, because they have this longitudinal relationship with patients, and it kind of needs to come from them, because there's that trust that's been built up. So how do we promote uptake? So educating your clinical staff, so making sure that your MAs, your nurses, and everybody who is in your clinic, and kind of going around to the internal medicine clinics and the family medicine clinics too, and just educating them on questions they should be asking patients or just referring for them. This goes a long way to getting more referrals and more patients who are appropriate for lung cancer screening the testing that they need. Understanding and educating your referral base. So who refers to you? And the nurse practitioner-driven program at University of Illinois, they presented an abstract last year and they looked at about 33% come from family medicine, about 30% comes from internal medicine, another 20-25% came from our pulmonary group, and then the rest were outside referrals. So understanding your referral base and seeing where you get your patients from and providing education for those will also, again, go a long way to kind of improving patient access. Next, promoting awareness. So the picture on the bottom right shows this big lung, obviously, with the clinic staff at one of the clinics that is in a traditionally underrepresented minority-heavy patient population area within the city of Chicago. A lot of this stuff people just don't know. And then the bottom, or the far right picture there shows one of our nurse practitioners at an event at a Latino cultural center talking about lung cancer screening and providing information in Spanish for patients. And then also streamlining the referral process in your EMR. I know that can be a difficult undertaking, but there is probably an epic super user that you can get in contact with about just streamlining it and just understanding how that even works, because that can take a lot of the barriers away from it. Again, boots on the ground, understanding your patient. A lot of the patient populations that are resistant to lung cancer screening or who don't know about lung cancer screening, because they're just not aware and kind of going to community engagement and events like Marisol is doing there at the Latino cultural center, can be very helpful. And then, again, speaking the language, knowing if there's a high Spanish-speaking population or Mandarin-speaking population, again, providing information in the patient's native tongue can really be helpful. And then a couple of other things. So hiring or having a tobacco treatment clinic, because at the same time as they're counseling about tobacco treatment, you can also counsel about lung cancer screening, because obviously those go very much hand-in-hand. Lung cancer navigators are very useful tools if you have the resources to pay for one. And then harnessing social media for the positive can be helpful. And I have some examples of that. So at the top left of the screen is American Lung Association walk that a lot of people in our department participated in. And again, this is out in the community, and it's promoting awareness. Northwestern has developed a YouTube video or YouTube series about a lot of different things. But one of them is talking about lung cancer screening journey. And it's a minute and a half video, but it provides everything that you need to understand if you're eligible or if you should be asking your PCP. And then I stole this brochure from Temple, but they provided the lung cancer screening guidelines in Mandarin. And then at Northwestern, there's a thoracic surgeon who opened a clinic for people who are Spanish-speaking only to kind of help educate them on these things. So kind of breaking down some of those barriers that we talked about earlier. There's not a ton about lung cancer screening and social media, but this was one abstract that was presented either a year or two ago at American Thoracic Society that showed that by kind of sending Instagram and Facebook banners as well as direct mailers, you can really increase the amount of patients that get referred to you for low-dose CT scans. And then they looked at the page views for their lung cancer screening website, and it exponentially went up. It went from like 250 to over 8,000 in a short period of time just by this kind of small increase in awareness. And then I'll highlight this because this is a clinical trial that is underway, but they're looking at randomizing people to social media intervention. So stay tuned for that. That should be a very interesting paper on how we figure out how to best get these patients in and screened. Do these things work? For the most part, a lot of the stuff that we've talked about does work, although, again, it has not been super well studied in the lung cancer arena. So the graph on the top right is the percent of patients presenting with stage four lung cancer at UIC. And it's steadily ticked down over time to below 50% and even below 40% in 2022 with a spike in 2021 that I think is probably related to COVID and just a lot of patients not wanting to come to the hospital during that time period. There was a study by Dr. Galliatsatos at Hopkins. Then they enrolled 74% of screening eligible patients in tobacco treatment clinics. So again, having a tobacco treatment clinic can really increase your awareness, and those are the patients that really should be getting screened. And then navigator, having a lung navigator, it increased your first LODO CT scan significantly with 31% of the group with a navigator versus 17.3% without. And then the chart on the bottom right there shows essentially what a lung navigator does. So they're chart reviewing, they're patient educating, they're emailing PCPs, they're helping schedule stuff, they're arranging transportation, they're helping with smoking cessation. So these are all things that a lung navigator can be helpful for. And I think as you're talking to your administrators, this can really help, and you can present a good business model that suggests that the lung navigator will pay for itself. So with that, I'll conclude just with a couple of conclusions here. So the lung cancer screening guidelines obviously in 2021 helped mitigate some of the things and I hope some of the things that eliminate some of the disparities, but probably haven't gone quite far enough. And then I think as we can harness social media and then do other things, I think patient awareness, provider awareness is going to improve. And I think some of this naturally will occur over time just with more uptake, but I think there are a lot of things that we can do to help with that. So I'll take, are we doing questions at the end? Okay. All right. Thank you. Thanks, Chris. That was great. So my talk is going to build a little bit off what Chris was talking about as he described the disparities. I'm going to talk a bit more about how to actually build in screening interventions that meet the community needs from some of my community-based participatory research projects. So I'm an associate professor. I'm based at the Fred Hutch Cancer Center and the University of Washington, and I direct our multi-site lung cancer screening program. Objectives are really just threefold. One is to talk about what the heck community-based participatory research is, because it's kind of a buzzword these days. And why community engagement and that type of research are essential for lung cancer screening engagement. I'm going to talk about key themes that kind of have emerged from various community-based lung cancer screening research studies. And I think what's important for this talk is really to say, how can we learn from that and then integrate community needs into lung cancer screening practice? So this is a slide from my perspective, but there's probably a lot of answers to this question, right? Why is community engagement important for lung cancer screening? So to me, the most important thing is that lung cancer screening is really unique among most cancer screening modalities. And the eligibility is not defined solely by age, but really by health behavior, in this case, smoking. And as the smoking rates in the United States have declined, which is great, you know, maybe 14% of US adults smoke now, during that same time, smoking has become increasingly concentrated in particular communities and social groups in the US. So I present three examples here, groups I'm going to talk about my community work with further. One is people with HIV. So a staggering more than 40% of people with HIV who are adults currently smoke in the US. LGBTQ Americans, so somewhere around 17%, though I've seen that number as high as 24% of LGB adults smoke, 35% of trans adults smoke, so about twice the rate of the cisgender population. And there's a lot of diversity within the LGBTQ population around smoking behavior. And then American Indian, Alaska Natives are actually the highest smoking rate of any racial or ethnic group in the United States, but it's really highly variable across communities and parts of the country. So you know, the other thing is even within communities, smoking is increasingly related to social determinants of health. So for us to expect that our patients are not going to have barriers in a lung cancer screen process is a little misguided. So to me, the other thing Chris talked about that I think is essential is that LCS presents an opportunity that most other screening modalities don't, and that we can actually combine it with screening being secondary prevention. Here we can combine it with primary prevention through smoking cessation. So thinking about what is community engaged participatory research and why I'm advocating that we need to do this in order to best serve our communities in lung cancer screening. I like this quote from AHRQ defining CBPR as a collaborative research approach that is designed to ensure and establish structures for participation by communities affected by the issue being studied, representatives of organizations, and researchers in all aspects of the research process to improve health and well-being through taking action, including social change. So when we think about what community engaged, what the whole spectrum of community engaged research is, it turns out the majority of things that are described as community-based are probably falling a little bit lower down. Oh boy, is this thing working? A little bit lower down on this. And so the goal is usually to shift over to the right if you really want your communities involved in your research. So if you have a completely researcher-driven program, then obviously the community is having no influence on the research process, and that includes the study design or the receipt of the study results and avenues that fit them best. And then going further and further to the right, you can see a lot of aspects of studies that have kind of penetrated into the research environment. So a lot of people are recruiting with community partners, so that would be community-placed. A lot of people are engaging a set of community advisors to help inform their study throughout the study process, and that's great. But when you think about community-based participatory research, what I think is really different is that you're considering community members as equitable partners in all aspects of the research project. And probably the most important time to do that is when you even have an idea, or even before you have an idea, right? Because you wanna figure out what the needs of the community are so that you can partner with them to build the project. So I'm gonna talk a little bit about three CDPR projects that I did in the King County area of Washington State from 2019 to 2023. The first is HIV-LCS, which is partnering with King County HIV Clinical Services to develop and pilot a shared decision-making tool tailored for people with HIV. The next is Project Sassy. And when you work with community partners, sometimes they get to name your study. So we're Project Sassy, partnering with Seattle's LGBTQ Center and other King County LGBTQ orgs to understand needs and build cessation screening programs. And then ASIST, which is partnering with the Seattle Indian Health Board, which is the major provider of primary care for urban AIAN population, also serves as kind of a center for wellness and community to really help them help us build and pilot patient navigation programs. So I'm gonna present some key themes, which took some integration on my part because these communities are different and they have different needs and different themes emerge, but I kind of picked kind of six common themes that emerged from all the studies that I think can then easily kind of translate in how you adapt and build your own programs. So community, the first community partners, patients, providers, stakeholders, I'm considering them all partners here, often care more about smoking cessation resources than LCS. And existing awareness and knowledge of LCS is low. So that can be your way in to these communities is to be able to provide that. So a quote from Seattle's LGBTQ Center director, we used to have a program but lost funding a few years back. We don't really have anywhere where we can send folks to smoke. And from a participant, I've heard of this screening and I've never taken the test. I don't even think I've had the conversation with either one of my providers either. So the second theme, people in minoritized and marginalized communities can face numerous barriers related to LCS care. And some of those that are most often highlighted are financial and access related, including transportation. So from an assist participant, honestly, I think the reason why I've never requested one is because there's a fear of the price, the cost, because it sounds like a really, really expensive procedure. And from another participant, yes, most of these people are either taking the bus, but I do think transportation is the other thing I myself can't drive. So beyond thinking of these logistical barriers, and Chris talked about this, and this certainly emerges, many participants avoid LCS due to fear of lung cancer diagnoses and stigma and ambivalence related to smoking. So from one participant, I mean, you know, but that it's anything nowadays, because judging, so yeah, you still smoke? Yeah, I still smoke, sorry, my body, I can do what I want with it. And then for an assist participant, too scared to go, frightened, I know I'm afraid that if someone told me I had that cancer stuff and everything, I'll be afraid to go see their doctor about it. And then one theme that's emerged from these different studies because we did present things differently is that a lot of people strongly support kind of an either or, or both, a targeted and a tailored approach. So when I talk about targeted, I'm talking about emphasizing the community, right? That we're targeting a certain community with our screening programs, with our screening outreach. And then tailored, you're really talking about things that are tailored to the individual. So thinking about individual risk, individual barriers. And so both can be elements of programs that are endorsed. So from a HIV LCS participant, I also think if you could just make the different variables, just like check boxes or options that you could check off on the tool, and then you could play around with using different risk factors and determining what you want, what their lifespan is, I would love something like that. And from an assist participant, this would be cool. And I mean, I would like to be able to be screened, and I would wanna be a part of, to create something that's tailored to Native American indigenous people. Utilize this program to help us become better as a culture and as a people. The fifth theme is that people strongly support longitudinal engagement along the LCS continuum through services like navigation. So ongoing community engagement and individual engagement are linked, which I think is interesting to us because we often think about this very personal shared decision making and this one-on-one relationship between a patient and provider. A lot of people wanna see this work done in community settings with a lot more community involvement. And so from an assist patient, that's what I was just thinking, like social support need really good support, especially if you're going through a process. I think someone should be there just to be there. And from a SASE participant, because ideally it's about engagement, right? And it's engagement over time, much like the trusted doctors that people already have and then supporting people, right? And then the final theme, kind of two messages, one around community, that having visibility and affirming language around the communities that you're working with is important and the other is common to all these communities that we're talking about a patient population that smokes. And so destigmatizing messaging around smoking. So those two elements emerge as things that people are actually looking for in their healthcare programs and looking for in their screening programs. So from a SASE participant, yeah, and also any active signs on the door or wall that says, you know, we don't tolerate any isms. And whenever, that can go a long way to making, because when people walk through that door, especially to a service, you know, medical and things like that. And from an ASIST participant, indigenous people were not always helped whatsoever in any direction in our lives. And that's what started. And now I'm so glad there's programs, there's healthcare, there's directions. So here's a review of the themes. And I'll leave that up there for a second. While I get you all thinking, because I want to ask you all questions and you're either gonna have to come to the microphone or you're gonna have to yell back at me, which is fine. But are there things similar to the quotes that I gave? Are there things that you didn't see on there that you all have heard from your patients or community partners to help you all meet needs around screening? Don't everybody yell at me at once, come on. I can wait up here for a little while. I'll throw you a moment. Oh, no, Doug, Doug Ehrenberg, Doug Ehrenberg really wants to talk. No, no, no, no. Second. Abby, it's in alphabetical order. Yeah. You take that one. All right. Alphabetical order of reference. I'll just, I'll wait to share all my complaints. Yeah. Well, this sort of mirrors what you said, but I'll just kind of amplify it, which is that we were talking about it sort of mirrors what you said, but I'll just kind of amplify it, which is that we did some similar work in Minnesota with indigenous communities. And the same thing, it was a communal thing. People were like, this is a scary test for me to go into this big hospital, which you think is a big, beautiful, fancy cancer center with a CT scanner is absolutely terrifying to me. And I would only want to do it if I have someone that I know and that I trust who is going to actually walk through the process with me, walk into the door with me, go into the room, wait outside the CT scanner and be there with me, accompanying me. And that was one of the things that I learned that really knocked my socks off. I was like, wow, I never would have thought of doing something like that. So, yeah. Yeah, exactly. Yeah, my experience is more banging my head against the wall trying to get institutional resources. Yeah. Because, you know, in Ann Arbor, it's a fairly affluent community. We do have quite a few people in the surrounding areas that I think are lower income, lower health literacy. That's a challenge. And I think you guys did a great job of outlining the challenges associated with that. It's a, I think, you know, we look at this and that's the iceberg that's under the water. I've just been maddened by my inability, although I've written papers on how to do high quality research programs. I took that paper and I slapped it down on the CEO of our health system. I said, we aren't doing this. We wrote this paper 10 years ago and you endorsed it. And we don't have, I don't have lung cancer navigator. We have a screening navigator at the University of Michigan, right? We have, they try to do everything on the cheap. So I think I'm probably not the only one who struggles with making it clear to the administrators that investing in this is good for your community and is also good, you know, for the bottom line. We do make money if we do it, if we look at it from the right lens. So I'm really frustrated by that right now. But I think you guys really hit on some things that I hadn't thought about. And, you know, the cultural issues involved here are just so complicated. Yeah, thanks, Doug. And Doug brought up a good point about how do you build in these programmatic elements. And I'm the same. I usually put them in my research grants. And then when the grants run out, I say, are you gonna take this away from the community? And usually they say no, but not always, right? But that's a, you know, it's a challenging element. So does anybody have any programmatic elements that they wanna describe that they've really used to build the links with their communities? Yeah. I'll say one. I'm Deborah Swaller from Kaiser Permanente and the Prosper Screening Network. So we've been looking at a lot of these topics across five very different centers. So Penn, Marshfield, Henry Ford, and a couple of Kaisers. And we do see, you know, the range uptake from 6% to 30 plus, 30, 40% across these five. And navigation is important and reaching out and helping them schedule, et cetera, et cetera. But I would say at our side, and yes, we're a Kaiser, and then we've got this infrastructure, but what helps the physician at least get the patient talking about it is there's actually, and I know alerts are awful, but the EHR landing page, when they open it up, it just signals this patient is, you know, 50 to 80. And last time we looked, last time that he or she reported, they were a current or former smoker. So ask the question. And I would say as much as the navigation part, I think that's what at least has gotten us uptake and up to date a lot further along, that in conjunction with the navigation piece. Yeah, thanks, that's great. And, you know, at our center, we found there were even disparities in recording of smoking history, right, which is going to inform those EHR alerts. So one thing we employed was what we call a panel navigator. So way more upstream of a traditional navigator, just to do outreach to people who had missing or unknown smoking history. And that's why we're trying to kind of narrow that gap. But again, that's a time intensive thing. She's having to make repeated phone calls or MyChart messages, but more often phone calls to get that stuff updated. But yeah, that's great. So these are just some examples of how I thought about translating the things that we found and other people have mentioned in the clinical practice. I mean, one is just to think about your LCS catchment area. Where's the risk concentrated? Part of the reason that I focus on the groups I focus on is because I live in Seattle, Washington. If I lived in a different part of the country, I think I would be doing different things. Meet with the local stakeholders, not just your community health providers, which I think Chris had talked about your referring providers, but also community based organizations. So like your CBOs who we worked with in these studies. Match patient and community needs to your needs. And so for us, that has been a lot of focus on free nicotine replacement and tobacco cessation. That's what the CBOs want from us. Sometimes that's what the patients want from us. And our needs, right, are maybe to increase our LCS enrollment. Identify and organize the facilitators. I bet you already have a lot of facilitators in your institution. I just bet everybody involved in your program hasn't put them in one place or knows where they are. So what are the numbers to financial services, social work, what's your charity care policies? Do you have ride shares? Do you have transportation services? I bet you have these things. Just make sure that they're available to you all and everyone that works in your program knows about them. And consider more tailored approaches to LCS, like shared decision making tools potentially. Consider your website, advertisement brochures. Chris talked about this, but I would emphasize, are they welcoming? And are these at-risk communities and people that you're interested in, are they visible and centered in this imaging? And then consider building in longitudinal support, like it's so easy, right? Navigation, just do it. So what do the navigation components look like? Just to show you how it can look differently for two of the studies that have the navigation piece as the prospective second aims of the study. So for SASE, the way that people get into the program is they self-refer through community outreach. There's actually sexual orientation and gender identity data collection at the scheduling process, so that's uniform across the center. And then the center that we work with has an intake question. And then the shared decision making is performed by an NP with key language scripted around welcoming spaces. And then because of the really key in that community emphasis on tobacco treatment, it's actually a tobacco treatment specialist, a certified tobacco treatment specialist who's doing the navigation and frequent check-ins for LCS and tobacco treatment. In terms of ASIST, since we're working so closely with the SIHB, the Seattle Indian Health Board, most of it's done through tabling at their related community events and through PCP referral. And because, like Abby said, our folks also do not want to leave the center and come to us, all the shared decision making is performed on site, and it's actually done individually or in groups. And then the navigator is a well-known quantity to the community, a community health worker who has lots of experience with indigenous populations, providing frequent check-ins, support, and as Abby mentioned as well, accompanying to a lot of visits at Fred Hutch. So in conclusion, LCS eligibility is often concentrated in certain patient groups and is highly linked to social determinants of health. Engaging communities will be essential to improve overall uptake and build programs that address health disparities and meet individual and community needs. And there are some simple ways to incorporate these themes into your LCS program, meeting with your community leaders, offer long-term smoking cessation and screening support, and know your local resources for people who have barriers. And that's the end. So I'm really excited to introduce Dr. Weisham, who's going to talk to us about building the business case for lung cancer screening, which I think, yeah, we need a business case after all these things that we've discussed we want to do. Thank you. It sounds like the grants are a good way to get things started, but yeah. Never was very successful at that. So thank you for that introduction. This is me. I do have disclosures. I do some work with Intuitive and Verithon, which are bronchoscopy companies. And another really important disclosure is that previous to launching lung cancer screening, I had no training or interest in the business side of medicine at all. But what I hope I can convince you guys is that it is very important. There's lots of great things we can do in medicine, lots of competing priorities. And when you talk to one of your administrators, you need to know how to start the conversation. I am going to try to do some audience response just for some fun. And I'll leave that here for a second while I drone on for a minute, so you can get that QR code. All right, here are our objectives. So it's important to understand the sources of clinical revenues that support lung cancer screening in order to make this case, like I was saying earlier. And I want to familiarize yourselves with some business pro forma tools that weren't available when I launched our lung cancer screening program, but have been made freely available on the internet and are incredibly useful. In fact, I could probably just show that and be done with this topic, but I'm going to draw it out a little bit to help emphasize the point. I would like to also think about the concept of sustainability a little bit more broadly than just dollars and cents. Talk about certain program design elements that make your program efficient and also share methods that make this work sustainable and rewarding on a professional and personal level. So our first poll, hopefully it works, make things just set the stage. Pop quiz, what percentage, and this is not to pick on Hawaii or any particular place, but what percentage of eligible Hawaiians are screened for lung cancer? And actually this dovetails very nicely on the topics that were earlier discussed today and earlier this week. So I'm going to give one more second. All right, get it in. And yes, that's the answer. It is 3% and I'm just setting up the problem that's already been discussed and we're probably already familiar with. Nationally, about 6% of eligible patients are screened and that compares to 76% of breast cancer eligibles are screened and there's numerous reasons why. It is relatively recent. It is complex in terms of the documentation requirements and the reporting requirements, which have thankfully decreased somewhat. It requires staff. It requires navigation to do it right, in my opinion. There's prominent social disparities as was previously discussed and is so, so important. Along those lines, we know that there's a discouraging mismatch between the need for lung cancer screening and where programs are located. So the tobacco belt per capita has fewer screening programs in places like Massachusetts, which by the way, they have 18% of their eligibles screened according to the National Cancer Institute. But I want to highlight the bottom problem is that there's this perception about this patient population. Even if you're in a relatively well-resourced community, patients that are eligible for screening tend to have a poor payer mix and until you study the problem, which I hope I will convince you to do, administrators might say, well, there's no possible way getting more of these patients into my healthcare system is going to pencil out. So just kind of listed the profit centers and loss leaders, if you will, and this is important to know depending on kind of what your setting is and I'll share a little bit about our setting and what makes it unique. But every, I think Doug Arnberg once said to me that if you know one screening program, you know on one screening program, they're all unique and you have different stakeholders that can help you get started. So surgery by far is the biggest profit center followed by imaging. Diagnostic evaluations are helpful. Not so many of these patients go to chemo or radiation, but there's a significant proportion of stage two and higher disease that's diagnosed through screening. The expenses are listed on the right side. I'm trying, I'll try to convince you that doing, you know, buying management software or being at a large enough institution that can continually support your own software is extremely important. Nurse navigation is costly, but pays tons of dividends, helps me sleep at night. You might have a PA or an NP that's doing shared decision making or seeing screen detected findings and you may need other clinical support. Office consultations, I'm sad to report, mostly in pulmonary medicine tends to be a loss leader as I've come to find out. So as we transition to the next topic, I found this statistic pretty striking. So how many eligible patients must be screened to detect one lung cancer? And I'm using this moment to segue into, you know, we talked about the various stakeholders and profit centers, and so how do we project forward if we're going to launch lung cancer screening? You know, what can we expect to come of that? And so this is, you know, screen one person for the three years that was done in the National Lung Cancer Screening Trial on average. So the actual answer is 25, one in 25 patients in a screening program based on the old eligibility criteria will be diagnosed with lung cancer within three years. I just found, I did that math a few weeks ago, I found that statistic staggering. It's incredibly prevalent. But the national, you know, go back and look at this trial, all this data is published either in the manuscript or in the supplemental appendix. You know, aside from the baseline CT, a third of patients needed a diagnostic interval CT outside of the annual scan. There's numerous PET scans, biopsies, and, you know, you can talk about different modalities, but here they are. Surgery occurred in 3% of patients. There's that statistic about how many cancers were diagnosed, and a lot of them, especially in current treatment paradigms, would require neoadjuvant or adjuvant therapy. So there's folks that would, that your med-ons will see as a result of your screening program. Very few, if you're doing this right, should be treated only with radiation therapy, right? Because ideally we're selecting patients that can undergo surgery, but that still does happen. And then there's other malignancies here that need multimodal therapies. And you find other things, too. You find vascular lesions, you find, you know, gallstones. There's lots of possible things you can find. Obviously that's not the point, but it does translate to a fair amount of downstream work. So unlike when I got started, there are now these Proforma tools, ones from the GoTo Foundation. And these are both, you know, nonprofits that have thoroughly studied this program and populated these Proforma tools based on the National Lung Cancer Screening Trial and other data points. They're incredibly detailed and incredibly useful. I'll just share with you the Proforma that we did, again, not using these tools. We're a large multi-specialty clinic. We have primary care, specialty care, and imaging. We actually don't have thoracic surgery in-house. We partner with a local hospital. They're great partners. They're killing it because of our work and that we're proud to share. But so we mostly modeled this off of revenues around imaging and pulmonary. And what I'd like to say is, if you have imaging, you can definitely make this work financially. And it's actually quite profitable on down the line. So we didn't quite accelerate to this level, as I'll show you our data. We're currently sitting at about 2,700 patients. But based on that, we're, you know, starting to push about a million dollars of profit at the end of the year, which is a dirty word, I know, but it does help support the program and we do a lot of good work. So this is our journey. We started back in 2019. We estimated our eligible population in our catchment area. We hired our wonderful nurse navigator, who we haven't scared off yet. She started as a 0.5, and then we scaled her up as we got more busy. And we were able to kind of really catch fire after we settled the dust a little bit from COVID. We've had a coordinator, and now a PA, and an MA for that PA. And we now have about two-thirds of our eligible population enrolled in screening, averaging about 70 new referrals a month, either from the PCP doing the shared decision-making. We do have a very easy-to-use order set in EPIC, as well as, you know, best practice advisories that are prompting this. And for primary care providers who want to have the shared decision-making conversation, that's fantastic. They can just order the scan and document that. If they'd rather refer to a PA for cessation counseling and enrollment, that's also an option. We've got, you know, over 70 cancers diagnosed, mirroring all the trials, half of them are stage one. And I'm especially proud of our follow-up. We've got greater than 90% on-time follow-up, and that's because our nurse navigator will not let any stone go unturned, and she's in the audience. We did build our own kind of, like, management software or dashboard in EPIC, and it was fantastic while it worked, and then COVID happened, and everybody who's smart in computers seemed to find some other jobs, and nobody knows how to maintain it anymore. And so it's a bit of a pain, but this window still works, and it just gives you a sense of the volume, and something I check on each day, just because I'm geeky that way. And here's our new referrals per month since inception. So the lessons from my experience, I believe that management software is very expensive. It shouldn't cost that much, but it does, but it's actually worth it. I don't think, unless you, again, I've heard of large, you know, nationwide hospital chains that have done a good job building and maintaining their own software. If you have that kind of scale, great. If you don't, I think these companies are probably worth partnering with. It offsets your labor costs, you know, maintaining the data and submitting it to ACR if you want to be, you know, most accredited and responsible screening program. It's a lot of work. When you're designing the program, again, back to the, you know, initial thoughts about making the business case, really think about this, like, track the relevant outcomes. You know, you obviously want your patient-centered outcomes, you want the outcomes that you hold important, but also knowing that your actual financial return on investment is matching your performance is really important when you want to go hire that next person or expand in that next way. Definitely leverage your existing data, and this was mentioned by previous speakers. Really, you've got to know your patients, you've got to know your referral sources. I would also say, you know, thinking about the prior talks, know who you're not reaching and know who's not reachable in traditional manners. You know, it's one thing to have your PAC years accurately documented in the health record, but if you've never accessed the healthcare system, you're kind of being left out. We have done some work trying to, you know, smoking is terribly documented in Epic, but our RRTs are pretty detail-oriented people, and so we've actually found a bunch of eligible patients by, like, mining our PFT database, so just think about multiple sources of data. And then some more kind of general ideas around sustainability, you know, really think about everyone practicing at the top of their license. It allows decision-making at the right level, and these are buzzwords, I know, but it really allows for innovation and engagement. It's really rewarding to see people grow into these roles. Definitely collaborate across specialties, you know, radiology, once they realize how much work you're doing for them, they're going to become your best friends, your thoracic surgeons, and those collaborations are really rewarding. Don't be afraid to stand up here and share your successes. I don't consider it bragging, actually, because we owe all of our access to the team and the primary care folks, as well as the patients that continue to engage, and definitely make it fun. You know, when someone does some hard work, results in a good win, make sure you announce it to everybody who will listen. So in summary, lung cancer screening is underutilized, and I think it's likely due to too few and under-supported programs. Thank you, Doug Arnberg, for mentioning his struggles. I think that's really common. I think it's because people don't realize the financial return on investment, and it may deprioritize lung cancer screening relative to other initiatives, like that new cardiac tower or something. But it's true that lung cancer screening financially supports a broad range of specialties. So identify those stakeholders. Do this pro forma. You don't have to do the math on your own. And definitely think about investing in a good management system. Focus on quality. And try to replicate the trial results with 90-plus percent on-time follow-up, and work with your colleagues across disciplines. So concluding here real quick, I'd like to give a special shout-out to several really important women who are in the room. We've got Renee over there. Raise your hand. And where's Jen? Raise your hand. Great. And a few of my partners are also sitting next to Jen there, and it really takes a team. So I'm very grateful to be working with these fine people. And that's it. Please reach out if I can help. Thank you. Okay. I think we're going to need Nick to come back and talk next year about how he got to 90-percent follow-up in clinical practice. Like have we seen that ever before? Okay. Dr. Renee. So we're going to need Nick's team to come back next year. Okay. So next I'm excited to introduce Dr. Sharma, who's going to talk about kind of developing and building an innovative lung cancer screening program and model. So thanks, Dr. Sharma. Okay. So the title of my presentation is Case Study, Innovative Approach to Lung Cancer Screening in Community Practice. I'm Anuja Sharma, and I'm a pulmonologist. I co-chair the Lung Cancer Screening Program in the Thoracic Oncology Program Committees within Align Health in St. Paul, Minnesota. I have nothing to disclose. The lesson objectives are understanding the need for program evolution, understand the importance of primary care and specialty partnership, and understand the challenges in building a lung cancer screening program. Align Health is a large healthcare system in Minnesota based out of Twin Cities. It boasts 12 hospitals, 60-plus primary care clinics. It's fairly well-integrated, especially in terms of pulmonary, thoracic oncology, and thoracic surgery at the three metro sites. Everybody's aware of the science and the data behind lung cancer screening, but I usually like to share this slide in pretty much all my presentations to drive the point home. The first pictograph is from Journal of Thoracic Oncology. It highlights why lung cancer screening works. It highlights the stage shifts that occur with the vast majority of cancers being diagnosed in stage one and stage two in lung cancer screening. The second graph is the President's Cancer Panel shot, and this shows where lung cancer is standing in comparison with other screenings in the U.S. at this point in time. So our journey with lung cancer screening started in 2016, and at that time, the way it started was that the primary care physicians were asked to send screen-eligible patients for shared decision-making to three metro sites where the physician extenders, or APPs, were involved. By 2019, five more sites were added, and kind of in a haphazard manner, largely because of some entrepreneurial physicians within a variety of clinics. The geography was variable. So were the workflows. There was little to no central oversight, and it was pretty clear by 2019 when I took over this work that it was clearly ineffective and unsustainable into the future, even though it had provided us with valuable learning early on. Alaina Health is a complex organization, like many other healthcare systems, but it was pretty clear to me that despite different cultures at different hospitals, that a single program would work better than multiple programs in their organization. I leveraged the Thoracic Oncology Committee, which had been created in 2010, with a goal of streamlining care of patients with primary thoracic malignancies and extra thoracic cancer metastatic to the chest. It had already invested in promoting lung cancer screening, and the lung cancer conferences and nodule clinics at three sites in the metro region, with connections to other outlying hospitals that could send their patients or add their patients on to these conferences. The way I conceptualized this program would be a hybrid program, with primary care and specialty services along with their committees to form a care continuum. The primary care physicians are integral to preventive services, and actually quite, and had a huge buy-in that prevention was why many of them went into primary care. Also to minimize physician workload, with everybody in the program working on top of their licenses. Central quality and administrative oversight with intent of rapid cycle improvement where needed, and I really thought the program should be very nimble, so that it could incorporate and evolve the changes in lung cancer screening that would come in the future. With any program, you're going to think about the big bucket areas, which is clinical importance, and I involved myself very heavily in providing clinical evidence to improve patient outcomes and providing the clinical gaps, and thinking about the low screening rates across the country and demonstrating organizations' low screening rates. And I also involved myself heavily in operational plan, especially pointing out gaps and highlighting patient safety, access, experience issues, geographical barriers, and creating a project plan to include the structure, required stakeholders, physician champions, high-level workflows, and required additional staff in how this future project would sort of improve what we do. I did not have to involve myself in finance as much, perhaps because by now it felt within our healthcare system that it was the right thing to do, and I do ask the finance people to sharpen their pencils when they work on this, and it does fit into the organization's overall strategy, especially with our Cancer Institute. And so what I created was a hub model, and we streamlined the care of these patients from kind of a scattered plot to a very streamlined approach where primary care physicians were responsible, and they had great buy-in to this. This just didn't happen overnight. There were plenty of conversations with the leadership, with primary care physician champions, and they complete the shared decision-making. One of the requests that they had was to keep it as simple as possible, and so the documentation requirements were made very simple, and we leveraged every Excelian tool that was available. We use Epic. We call it Excelian within our system. So every EMR tool that was available to help us achieve this, and we also expanded our radiology sites to sort of ring the twin cities to decrease the geographical barrier and access to CT scans. We created a hub, which consists of a group of schedulers and RNs who can manage these results and follow protocols. So I truly feel that lung cancer screening can be very protocolized with a physician backup in case there is a need to sort of ask them questions or patients are not kind of following into the protocol. And over the course of the last year, I finessed multiple, multiple protocols for pretty much every eventuality that might be there. I am the physician backup, along with a colleague of mine when I'm not there. And the way it works is that all the results, once the CT's ordered and done, then the results flow into the hub, and this hub takes over managing the results and getting the patients back in. I'm very, I'm very adamant that every patient needs care, and care is different depending on the lung RADS result. Some people may choose to think lung RADS 1 and 2, oh, I'm fine, but lung RADS 1 and 2 care is different. Their care is to bring them back every year for screening until they qualify for, until as long as they qualify for screening. And lung RADS 3 and 4 is a little bit different, and the RN, the RN is responsible for calling the lung RADS 3 and 4 patients and educating them about guideline concordant care and helping them navigate into the lung nodule clinics at the three metro sites. And she also communicates both with the primary care physician and the specialist on the patients. A very robust data dashboard that we're trying to validate has been built. The phase one, kind of including, you know, pretty simple measures like low-dose CT volumes, baseline versus annual, lung RADS category, follow-up with compliance, follow-up compliance, and those who had shared decision-making actually got their CT scans. It's not like there was a big gap between the shared decision-making and actually getting the low-dose CT. The phase two metrics are still pending to be done, but they're likely to include further compliance measures, especially adherence at state, at year one and year two, in my opinion, not just year one, on those who continue to be eligible for lung cancer screening and also demonstrating a stage shift. Just some data to show you. We were, about a year ago, in October 2022, we're doing about 350 to 400 scans every month that were low-dose CT, and by July, August this year, we're hitting over 700. Annualized, the annual and the baseline kind of mirror the same curve, and for RAD4 patients, just a brief snippet of data to show you from December 2022 until July 2023, 22% of all RAD4 patients had a positive cancer diagnosis in less than two months from low-dose CT, and only 1% of patients who were lung RAD4 were not compliant or declined referral to Lung and Arterial Clinic, which is stark contrast to the outcome of the first million patients in the registry published by Dr. Silvestri just a few months ago in CHEST. And we're sitting at a unique challenge at this point, which is identifying eligible patients using EMR. You heard the previous three speakers kind of allude to the 5%, 10%, 12% of screens. Where does the data come from? The data comes from public health databases, including the CDC's BRFSS, which does questionnaires every year. I think they do about 400,000 in each state. It's kind of interesting when you read on their website, and then the CTs that get done come from the radiology registries and perhaps the claims database, though I don't know much about the latter. And there is no way in the world to translate those public health databases accurately into your clinical practice. We are at the mercy of EMR to tell us about smoking history. And all of us know here how pathetic that is, despite the upgrade that happened in March 2022, at least in our EMR, which is epic. It still is very time consuming, and it's just very klutzy. Let's just put it that way. And there has been data in the literature that suggests that if we rely solely on EMR, we would be missing the vast majority of patients who are screen eligible. So we've done an opportunity analysis in our own system. And one of the things that EMR is accurate about is the age. So if you look at patients from age 50 to 77, which is sort of your target population, and then we looked at who were current smokers and quit within the last 15 years, which is somewhat accurate. We have about 190,000 in our health care system. And then because this program is very much primary care physician dependent because of the shared decision making at this point, if you tag on the fact that how many of these 188,000 patients do have a primary care physician identified within our health care system, it comes to about 70,000. So we lose 120,000. I think half of them belong to Abby here. And hopefully she is taking care of them. And then if you tag on that just having a primary care physician doesn't help. Patient has to show up in the clinic. So if you look at how many of these 67,000 actually have come to a primary care clinic in the last two years, we lose another 30,000. So now I have three buckets of patients. One is the 40,000. The other one is the 29,000 missing. And then it's 120,000. Well, you hope this 120,000 is getting care in some other health care system where they're identified with their primary care physician. The target population for me is the 38,500, which I think is being undercaptured on the basis of the back year calculator. And the 29,000 that I am also missing because people are not showing up, perhaps need a different targeted approach. So I think there's a lot of work cut out to get far. I don't have a very good sense, but I think we should be doing 2,500 to 3,000 screens every month. So 750, 800 is probably far on the lower side, but it sort of mirrors the public health databases that we are used to looking at. And so in conclusion, we've been able to demonstrate the workflow simplicity. We transitioned from a very fragmented centralized model to a very primary care driven model managed by a hub with robust specialty support within a large community-based health system. There's been a whole team of people involved with me, and the slide acknowledges them. Be happy to answer any questions.

program evolution

primary care

specialty partnerships

lung cancer screening program

Align Health

case study

hub model

data tracking

patient outcomes

electronic medical records