0:02

Hello and welcome to Noon Conference hosted by MRI Online Noon

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Conference connects the global radiology community through free live educational

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webinars that are accessible for all and is an opportunity to learn alongside

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top radiologists from around the world.

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We encourage you to ask questions and share ideas to help the community learn

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You can access the recording of today's conference and previous noom conferences

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by creating a free MRI online account.

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Today we're honored to welcome Dr.

0:32

Ella Koni for a lecture entitled Lung Cancer Screening Radiologist Essentials.

0:38

Dr.

0:38

Kazarooni completed her radiology residency at the University of Michigan and

0:43

subspecialty fellowship training at Massachusetts General Hospital.

0:47

She's a member of the Cardiothoracic Radio Radiology division at the University

0:52

of Michigan where she specializes in lung cancer screening,

0:55

interstitial and obstructive lung diseases.

0:58

She chairs the National Lung Cancer Roundtable for the American Cancer Society

1:02

and was the inaugural chair of the ACRs Lung Rads and Lung Cancer Screening

1:07

registry. We're thrilled. She's here today to share her expertise.

1:11

At the end of the lecture, please join Dr.

1:13

Kazarooni in AQ and a session where she will address questions you may have on

1:17

today's topic.

1:18

Please remember to use the q and a feature to submit your questions so we can

1:21

get to as many as we can before our time is up. With that,

1:25

we're ready to begin today's lecture. Dr. Koni, please take it from here.

1:30

Thanks so much for that wonderful introduction. It's a pluck,

1:33

it's a pleasure to be with you out today at Radi new conference and to talk a

1:37

little bit about a topic that is very important to me and I think should be very

1:41

important to the field of radiology and that is lung cancer screening,

1:46

where radiologists can make a difference not only in how they practice radiology

1:50

in their lung cancer screening programs,

1:51

but how they can actually reach the patients in their community to improve their

1:56

survivorship from lung cancer as the leading cause of cancer death.

2:03

Oops.

2:10

So for about, for way of outline,

2:11

I'm gonna talk briefly about the impact of lung cancer on the population.

2:15

Why is this so important?

2:17

The science on which screening is based just briefly and how that science leads

2:21

to guidelines and insurance coverage in the us And this is a source of many

2:26

questions by radiology practices.

2:27

We're trying to understand the complicated quilt that we have of insurance

2:32

coverage and how people can actually get the preventative health and screening

2:36

services they need.

2:37

I'm gonna focus on some very radiology specific topics such as lung rads with

2:42

its 2022 updates, um,

2:44

approaching incidental findings on lung cancer screening cts,

2:48

given the age of the population and risks that they have of disease due to a

2:52

history of smoking,

2:53

there are many incidental findings that we have and how can you do your best by

2:57

your patients and manage this with your referring physicians when these

3:01

incidental findings occur in the chest.

3:03

I'm gonna talk about some of the tools from the American College of Radiology to

3:07

help you in your screening practice,

3:08

such as some new quality improvement tools that we've developed to help

3:12

practices use their own lung cancer screening registry data to see how they're

3:17

performing and step by step go through a guide to improve their practice.

3:21

Particularly regarding the last topic,

3:23

which is accelerating lung cancer screening uptake and making sure that people

3:27

who do have screening come back the next year and come back for those interval

3:32

tests that they may require.

3:33

There's so many different screening tests available now from breast and colon

3:37

and lung cancer screening, and they all have different time intervals.

3:41

So how do we make sure patients know this isn't a one and done test where colon

3:45

cancer screening, for example,

3:46

might happen every 10 years in lung cancer screening similar to breast cancer

3:50

screening, this is an annual test

3:55

by way of impact.

3:57

Lung cancer is the leading cause of cancer death in the United States,

4:01

both in men and in women, and many women are surprised to find that out.

4:07

October, the month we just had was breast cancer month.

4:11

It was breast cancer awareness month with pink everywhere in our communities

4:15

from the NFL football games to the sidelines with pink socks at soccer games and

4:20

so on.

4:20

And breast cancer screening is one that is a focus of community conversation or

4:25

cocktail conversation or sideline conversation,

4:27

but people not tend not to talk about lung cancer and lung cancer screening as

4:32

much,

4:33

and that's because lung cancer has this overarching stigma associated with

4:38

it related to cigarette smoking.

4:40

And over eight in 10 lung cancers are caused by

4:45

cigarette smoking.

4:47

This feeling that cancer may have been caused by an addictive habit that is

4:52

difficult to quit. The feeling that there's nothing you can do about it,

4:56

the damage is already done.

4:57

The stigma and nihilism surrounding lung cancer is very real and does not

5:02

surround other cancers.

5:04

So it's very important that we reach our communities with a message that we can

5:08

make a difference in the lives of people at risk for lung cancer today through

5:12

lung cancer screening and the lung cancer of the past that people used to

5:17

think of as a lethal disease with no hope has also really changed

5:22

due to advances in advanced therapies where people with stage four metastatic

5:27

disease are able to survive six,

5:30

10 plus years and thrive,

5:33

which is different than the way we thought about lung cancer just 20 years ago

5:37

if were to be mentioned.

5:41

Lung cancer screening and other cancer screenings have gotten a lot of increased

5:45

attention with the renewal of the Cancer Moonshot Initiative and as some of my

5:49

work through the National Lung Cancer, American Cancer Society,

5:53

we were able to participate in the cancer screening programming of this

5:56

initiative program.

5:57

The whole goal of this initiative is to close gaps in cancer screening and with

6:02

a low uptake of lung cancer screening to date.

6:04

This is particularly important and to do so by connecting people,

6:08

communities and systems to improve access and to improve equity

6:13

around cancer screenings in general.

6:16

And the focus of the president's cancer report in lung cancer in cancer last

6:20

year was around these four cancers, breast cancer, cervical cancer,

6:25

colorectal cancer, and importantly lung cancer.

6:31

As a chest radiologist,

6:32

I've often thought of myself as a public health radiologist because the leading

6:37

causes of mortality live in the chest.

6:41

The top three leading causes of mortality in the US population are

6:44

cardiovascular disease, cancer, and third is respiratory disease.

6:48

And certainly within cardiovascular disease, there's heart disease in the chest.

6:52

Whether you're doing dedicated exams to test for heart disease or you're finding

6:56

incidental coronary calcium,

6:58

you can make a difference for patients and their preventative strategies among

7:02

cancer.

7:03

We've already said that lung cancer is the leading cause of cancer death,

7:06

and the third leading cause of respiratory disease includes COPD,

7:09

interstitial lung disease and infections.

7:13

There are other things on a chest CT that contribute to morbidity and mortality

7:17

such as bone mineral density or finding epicardial fat.

7:20

So while we can look for features of heart, heart and lung disease,

7:24

we can also find other things on our exams that can contribute to morbidity and

7:28

mortality if they are not addressed or recognized as risk factors.

7:33

And each year in the US there are upwards of a hundred million chest cts

7:37

performed a year.

7:38

So it's a very important way to tackle the leading causes of death in the US

7:43

by looking for findings that could be related to these diseases.

7:46

And whether you're screening for lung cancer specifically and people are

7:49

eligible or finding incidental lung nodules,

7:52

you can contribute to reducing lung cancer mortality.

7:57

So I'm gonna leave with a a question or two and as I, I ask the question,

8:01

just think about what's your knowledge base, what do you know about the answer,

8:04

and then we'll go into what the information is.

8:07

So as we're going to do screening tests, it's important to know why we screen.

8:12

So my first question to you all as you think about it is what are the two major

8:16

randomized controlled trials on which lung cancer screening in clinical practice

8:20

is based? And I'll give you a hint, there's two.

8:23

The first one was performed in the US and the second was performed in Europe.

8:31

Well,

8:31

here are the two trials in the us We had the National Lung Cancer screening

8:35

trial, which started in 2002.

8:37

I was fortunate to be our site PI here at the University of Michigan for NLST,

8:41

and it was the largest clinical trial and clinical trial recruitment we've done

8:45

in the history of our radiology department.

8:47

This was published in the New England Journal of Medicine in 2011,

8:51

randomizing over 53,000 subjects to either low dose CT or a

8:56

chest x-ray for three years in a row,

8:58

and then following them out for eight plus years to look at the impact of lung

9:03

cancer mortality. In this trial,

9:06

there was a 20% lung cancer specific mortality reduction.

9:10

And I was always impressed with this particular trial because it was so

9:14

impactful that the results were revealed at a press conference in

9:20

DC not waiting for a scientific venue for presentation or a

9:24

publication in a scientific journal because the results were so important to get

9:28

out there. The second trial was the Nelson trial.

9:32

The Dutch Belgian trial performed in Europe,

9:34

started about the same time and similarly published in the New England Journal

9:37

of Medicine a bit later. In 2020, they randomized 15,000 subjects.

9:42

They had annual ct, they had CT three times baseline one,

9:47

three and five and a half years as the last follow-up.

9:49

And they too showed a greater than 20% lung cancer specific mortality.

9:55

So if you ever wonder why we screened for lung cancer,

9:58

the primary scientific data points are the National Lung Screening Trial and the

10:02

Nelson trial in Europe.

10:04

The Cochrane Collaborative in the UK has done an analysis and includes all of

10:08

the scientific trial data looking at lung cancer screening, their analysis,

10:12

and these are the two largest contributors to the data points and

10:16

recommendations. So once you have science,

10:21

how do you get to practice? Well, that's through guidelines.

10:24

And guidelines drive insurance coverage.

10:27

You'd like to think that the trial results were out and now we can just go and

10:30

screen and we can make a difference in our population.

10:33

But every country has its own fabric of how you go from science to practice

10:37

guidelines and insurance coverage. And ours is no different,

10:41

although it may be a little more complicated. So looking at guidelines,

10:45

many of the major organizations from the American Cancer Society,

10:49

the U-S-P-S-T-F-C-M-S, coverage decisions,

10:53

eventually the American Academy Family Physicians in 2021,

10:57

the NCCN or National Comprehensive Cancer Network,

11:00

which updates a guideline annually and sometimes more frequently than that and

11:03

chest all recommend lung cancer screening using an age that is

11:08

somewhere in the 50 to 55 year age group, 30 pack years,

11:12

originally dropping to 20 in the most recent guideline updates since the minimum

11:17

criteria to get in and 15 years since quit if they

11:22

are currently not smoking.

11:25

Newer guidelines such as the NCCN guidelines have dropped the year since quit

11:30

recognizing that just because somebody quit 16 and 17 and 18 or 20 years ago

11:35

doesn't drop their lung cancer risk that much.

11:38

And I'll talk in a little bit about the newest American Cancer Society

11:41

guideline, which was just came out last week as new information.

11:46

Well, what do we do with these guidelines once they're out?

11:49

How does this mean that now people can get lung cancer screening through their

11:54

insurance coverage? Well, there's a couple things.

11:58

This was the new American Cancer Society guideline that I mentioned that has now

12:02

dropped the year since quit.

12:04

And this is important for me to let you know because there's going to be a lot

12:08

of advocacy needed for those organizations like U-S-P-S-T-F and

12:12

CMS to get them to adopt no years since quit.

12:16

And currently that is not the case.

12:19

So if your screening practice is doing lung cancer screening using the tradit

12:22

traditional guideline of 15 years since quit as one of the entry criteria,

12:26

you're probably gonna have to continue to do that.

12:28

And so we can get through the rounds of advocacy necessary to make some of the

12:33

changes so that insurance coverage comes.

12:36

It doesn't mean you can't screen those individuals,

12:38

but they may need to know they'll have out-of-pocket costs.

12:43

So what is the name of that major organization that determines in the

12:47

United States whether preventative and screening services are covered?

12:51

It's got a lot of initials.

12:53

It's the US Preventative Services Task Force.

12:56

This task force creates recommendations for primary care providers

13:02

developed by primary care professionals.

13:05

These recommendations from the U-S-P-S-T-F include everything from hypertension

13:09

screenings to cancer screenings

13:13

as to how preventative services should be done in the us.

13:17

The American Academy of Family Physicians, for example,

13:20

follows these guidelines very closely in their recommendations to their primary

13:25

care practice physicians.

13:28

So why do I need to mention this U-S-P-S-T-F organization?

13:32

How does that impact if we can offer lung cancer screening and patients have it

13:37

as a covered benefit? Well,

13:39

it's a really important linkage if we look at the history of the U-S-P-S-T-F

13:43

lung cancer screening guidelines in 1996, no recommendation at all.

13:49

In 2004,

13:50

they mentioned low-dose CT for the first time in the guideline and gave it an

13:54

eye recommendation. Indeterminate still no screening test for lung cancer.

14:00

In 2013,

14:01

they came out with their first lung cancer screening recommendation of 55

14:06

to 80 year old individuals, 30 pack years of smoking,

14:10

either currently smoking or quit in the last 15 years. And importantly,

14:14

they should be able to get the benefit of lung cancer screening, for example,

14:18

to have a life expectancy of generally five years or more.

14:23

And if they have an abnormal screen,

14:25

they should be willing to undergo curative intent treatment,

14:27

whether that's surgery or newer treatments like SBRT and this

14:32

grade B recommendation in green.

14:35

This B is really important In 2021,

14:38

the U-S-P-S-T-F update its coverage guideline, dropping the lower age to 50,

14:44

dropping the pack years to 20 as the only two changes.

14:47

And some of the reasons we're do for doing that were both the science but also

14:52

the disparities that were being seen with the initial recommendation.

14:56

Individuals, particularly who are African American or female,

15:00

have a higher risk of lung cancer with smoking histories that are at a lower

15:04

pack year amount by dropping both the age and the pack year number

15:09

more individuals who are women and African American are eligible for screening.

15:14

So in 2013, we had about 8 million eligible individuals in the US for screening.

15:19

And by 2021,

15:21

that number was up to over 14 million people now eligible for screening.

15:26

With that new U-S-P-S-C-F guideline of dropping the no year since quit,

15:30

that will add another 5 million people who are eligible or nearly

15:35

19 million people.

15:38

The USP SST F provides summaries of its guidelines on its website and

15:43

publishes it work,

15:44

its work including the scientific justifications on which their recommendations

15:48

are made. These are all freely available on their website as links.

15:53

And if this is something that is important for you to understand in more detail,

15:57

I'd highly recommend that you look at this reference.

16:00

This one comes from JAMA in 2021 with their latest update.

16:03

So now you got that grade B recommendation. What does that mean?

16:09

Why are private payers required to cover lung cancer screening CT for eligible

16:13

individuals with no copay? No copay particularly important.

16:19

It's because of that U-S-P-S-D-F language.

16:22

There is language in the Affordable Care Act that requires private payers

16:27

to provide services without a copay if they have a grade A or B

16:31

recommendation. And as I showed you,

16:34

lung cancer screening has a grade B recommendation.

16:37

That means because of this language in the Affordable Care Act,

16:40

lung cancer screening can be performed and the patient not have a copay

16:45

from their private payers. Now that's the private payer segments.

16:50

Medicare admits its own decisions and they followed with those two USPS staff

16:54

recommendations with their own coverage decisions,

16:56

both in 2015 and 2021 to use the same 20 pack years and 50

17:01

age bound, lower age bound. They however,

17:04

stopped their recommendation at 77 years of age, not 80,

17:09

creating a little bit of twist where an individual's got Medicare coverage while

17:13

U-S-P-S-T-F and others still recommend they be screened.

17:17

So we do have some disconnects and then other entities have their own

17:22

decision making authority.

17:23

Medicaid is a state-based program and it took until about last year,

17:28

almost a decade after the first U-S-P-S-D-F recommendation for every state

17:32

Medicaid program to cover lung cancer screening.

17:35

And they don't even all cover it with the latest guidelines,

17:39

more advocacy necessary.

17:41

The Veterans Health Administration Department of Defense covered individuals

17:44

similar, they make their own decision.

17:46

And it's wonderful to see all the progress that's been happening at VA

17:50

facilities through the Lung Precision oncology program to increase screening

17:54

access across veterans health facilities.

18:01

Something that people always ask in the lung cancer screening coverage

18:04

requirements is this concept of shared decision making.

18:08

It doesn't exist as a requirement in any other Medicare provided radiology

18:13

services or screening services.

18:15

But Medicare requires that for the first time a patient gets screened,

18:19

there be a shared decision making visit.

18:22

And this be documented in their very first recommendation back in 2015,

18:27

they required it be done by a licensed professional,

18:30

a physician or advanced practice provider.

18:32

And in 2021 they realizing that this was an obstruction to being able

18:37

to get patients through practices to have the time to educate patients.

18:41

They widened it to include any staff who are incident to the physician's

18:46

professional service, meaning you could have nurses,

18:49

tobacco cessation experts or other team members in a primary care practice or

18:54

screening program provide the service to increase the likelihood that it's gonna

18:58

be performed so that patients get can be screened.

19:00

And many primary care practices have said that the obstacle of shared decision

19:05

making is a reason that it's hard to recommend people through lung cancer

19:10

screening.

19:11

Primary care physicians are very busy with their practices and large patient

19:15

panels. And if they have patients coming in one after the other, after other,

19:18

and they're practicing now,

19:19

one might be eligible for lung cancer screening or now another one,

19:23

a 15 minute conversation happening multiple times a day just prevents them from

19:27

giving care to the next patient, the next patient,

19:30

the next patient who's scheduled.

19:31

So this helps a lot in making this now something that can be done by many

19:36

staff on a team, not just by providers.

19:39

And there are many efforts underway to develop easier, shorter,

19:43

faster shared decision making tools to minimize the time it takes yet still be

19:47

effective. In fact,

19:49

the National Lung Cancer Roundtable with the Cancer Society is working on such a

19:52

project with the American Academy Family Physicians.

19:58

Many radiology practices and screening programs have asked, you know,

20:02

all of this is so confusing. What can I bill for? What codes do I need?

20:07

What are the definitions of who use this what that the ACR developed an

20:11

economics one pager for lung cancer screening available in both English and

20:14

Spanish.

20:15

That takes people through all of the definitions and all of the requirements

20:19

that go with the CT scan or follow-up CT scans with different types of

20:24

insurance coverage, billing requirements, et cetera,

20:27

so that everybody can have a common set of information to understand how these

20:31

are used. Some of these things are particularly important,

20:34

such as shared decision making, coding, tobacco cessation counseling,

20:39

which is very important as an intervention in those who are currently smoking to

20:43

reduce their lung cancer risk.

20:46

And the last thing I'm gonna talk about on kind of the policy space is this uh,

20:51

um, court case in the state of Texas referred to as Braidwood versus Becerra.

20:56

And the only reason I mention it is because it has looked at

21:01

that linkage of what the preventative services task force does.

21:05

The U-S-P-S-T-F to the Affordable Care Act,

21:08

which is so important in private payer coverage.

21:11

And in the court ruling said that the U-S-P-S-T-F recommendations are

21:16

unconstitutional because the task force isn't appointed by the president and

21:21

confirmed by the Senate. This has been appealed,

21:25

does not under stay, but it's,

21:27

it's caused some confusion in the marketplace because some private payers are

21:31

saying, well, because of this ruling, I don't have to get,

21:35

I don't have to offer that copay anymore. And that is incorrect.

21:39

This court act,

21:40

this court case is under appeal and the stay of that ruling is on hold

21:45

while it goes through that process. Some good news, however,

21:50

is that research indicates that over 80% of employers and employer insurance

21:55

companies will not impose cost sharing even if that should remain over

21:59

overturned because of its importance to the populations that they serve.

22:05

If you're looking for more information on lung cancer screening and this

22:09

BRAIDWOOD versus Becerra, um, court case,

22:12

I refer you to the University of Michigan Center for value-based insurance

22:15

design, which provides a lot of information.

22:18

This affects almost all preventative services that have been

22:22

recommended by the U-S-P-S-T-F since 2010.

22:27

Any changes that have been made since then because that's when the Affordable

22:30

Care Act went into place.

22:31

And this could have a rippling effect on patients not just for their lung cancer

22:35

screening, but other preventative and screening services too. And of course,

22:40

those who would be the hardest hits are those who have the least money,

22:44

the least funds,

22:45

the most socioeconomically disadvantaged to being able to get these screening

22:49

and preventative services. So question number four,

22:52

what's the name of the structured reporting and management tool that we use to

22:56

interpret lung cancer screening CT exams? I'm sure our,

22:59

you'll all get this one right? We all know this to be lung rads.

23:03

Lung RADS was put in place in 2014 due to concerns in the practice

23:08

community that radiologists would recommend too many positive tests,

23:13

too many positive tests, and therefore too many followup tests.

23:16

Too many PET cts unnecessary biopsies and harm would happen to patients.

23:21

And so the ACR team sprung into action and we developed lung rads to provide a

23:26

common lexicon of terms to be used in lung cancer screening as it's reported so

23:30

that anybody getting a lung cancer screening report should have a Lung RAD score

23:35

with a recommendation and that be standardized based on the findings.

23:39

We are now in version 2022, which I'll talk a little about today. Um,

23:44

it's been in use now since 2014 for nine years.

23:47

We have a very wonderful multidisciplinary, uh,

23:50

lung RADS committee led by Jerry Christiansen from Duke University with

23:54

multidisciplinary members from pulmonary medicine thoracic surgery that really

23:58

contribute extensively to the Lung RADS recommendations.

24:02

And I just did a quick update on the literature view and there's now over 220

24:06

publications that use long rads and Long RADS is used around the world in many

24:11

countries in their lung cancer screening programs as well.

24:16

So this common lexicon helps us define a positive screen.

24:20

It helps us to address in certainty that might exist in what you do if you have

24:24

a positive screen with recommendations for next steps. Importantly,

24:29

it can be used to facilitate quality assurance and improvement in your

24:32

practices.

24:33

You can look similarly as you do at your breast cancer screening reports and do

24:38

second reads on a subset to see if there's consistency.

24:42

You can look at if you have readers that tend to be high positive readers or

24:46

high negative readers and see is it really just the cases that they happen to

24:50

read or is there something neat you need to do in terms of education adjustment

24:54

to get everybody to a a a similar level of practice performance.

24:59

And importantly,

25:00

lung rats is stated and will always evolve with new evidence,

25:05

which is why you're seeing, uh,

25:07

the new release that happened at the end of last year.

25:11

Fundamentally nodules get into the different lung rats categories based on their

25:16

size at baseline and if they're grown versus

25:20

stable over time. We look at nodule consistency,

25:24

primarily the solid part solid to nonsolid or ground glass spectrum

25:29

because each of these has a different cancer risk of a cancer that will impact

25:34

the life of the host that has the lesion.

25:37

The most recent update includes categorizing cystic nodules.

25:41

There is not as much data around on cystic nodules and this was a very

25:44

thoughtful discussion through review of the data and multidisciplinary

25:48

collaboration to bring the cystic nodule recommendations in the lung rats.

25:52

And then certainly there are nodules that are definitely benign like fat

25:55

containing hematomas and specific benign patterns of calcification that would be

26:00

called um, negative screens,

26:03

long rats includes within it the concept of benign nodules and

26:08

benign behaving nodules versus clinically active cancer.

26:12

So you'll notice it in a negative screen.

26:15

A category two with small nodules doesn't mean a patient does not have cancer,

26:20

but it means that that nodule being either stable or so small is not likely

26:25

to be a clinically active cancer that will impact the person who has that nodule

26:30

by using lung rads.

26:31

We have reduced the false positives that were occurred in about one in four

26:36

screens to less than one in 10,

26:39

which means less follow-up interval tests that are unnecessary.

26:44

And as people use lung reads and publish on lung reads and how it works in

26:47

practice,

26:48

we're seeing very good practice performance including in a recent paper from the

26:53

ACRs Lung Cancer Screening Registry.

26:55

But we look at the first million screens entered into the registry,

26:59

which just shows you the power of a clinical practice registry to inform how we

27:04

practice. So question number five,

27:08

which nodule type has the highest risk of being a lung cancer?

27:13

Is it a solid nodule, a part solid nodule or a ground glass nodule?

27:17

So if I gave you a CT scan with one nodule and one image of each,

27:23

which one would have the highest risk of being cancer?

27:28

And no, this is a different question from what is the most common nodule type,

27:32

the most frequently found nodule is a solid nodule, but hint hint,

27:36

that's not the highest likelihood of being a lung cancer.

27:41

Here we have examples of solid nodules here,

27:46

a pure ground glass or nonsolid nodule through which you can see the vessels

27:51

and a part solid nodule.

27:52

It's solid in the middle and ground glass on the outside,

27:55

it's this nodule that has the highest risk of cancer.

28:00

And if you have a nodule that starts out ground glass and develops a new solid

28:05

component in it,

28:07

that is particularly at high risk for becoming an active cancer,

28:11

something that's gone from non-invasive to invasive.

28:17

This categorization of nodules is based on the international classification of

28:21

lung adenocarcinoma in which there are four types of lesions.

28:25

And these first types are just ground glass.

28:27

The smallest ground glass nodules are adenomatous hyperplasia.

28:32

The bigger pure ground glass nodules up to three centimeters in size

28:36

are considered adenocarcinomas in situ.

28:39

So over five millimeters but under 30 millimeters ground glass nodules.

28:43

So this little faint 20 millimeter ground glass nodule in here compared

28:48

to a little five millimeter ground glass nodule here.

28:50

If you take out an adenocarcinoma in situ,

28:54

a pure ground glass nodule up to 30 millimeters in size resection

28:58

achieves 100% percent disease specific survival,

29:02

meaning nobody has recurrence due to that lesion.

29:06

And that always should raise a flag of,

29:08

well were they really all cancers that needed to be resected.

29:11

So in general in Lung Rad you'll see that long RADS two to three

29:16

differentiation for a ground glass nodule is under 30 millimeters.

29:20

We can we call these negative screens category two with a recommendation

29:25

that they continue their annual screening journey.

29:28

Not that they don't go away and do nothing,

29:30

they should continue to annual screening so we can keep a check on them,

29:34

but when they're over 30 millimeters, they go up higher in the lung ran score.

29:40

Your minimally invasive cancers like this are a part solid nodule and resecting

29:45

them has a nearly a hundred percent disease specific survival,

29:50

but not 100%.

29:51

Meaning that even with resection some of these will come back as recurrence.

29:56

So nodules that are ground glass with a solid component are particularly

29:59

worrisome. They don't yet invade lymphatics. Blood vessels are pleura,

30:04

but they start to become more invasive in the adjacent lung tissue.

30:10

And then we have the frankly invasive adenocarcinomas.

30:13

These tend to be more solid nodules.

30:15

They may be spiculated nodules like the one that you see it, right?

30:21

And this is an example of a pure ground glass nodule which developed a solid

30:25

component baseline screen ground glass a year later still ground glass,

30:30

two and a half years new solid component.

30:33

That's where you should make sure to say, Hmm,

30:36

now I'm really worried this has become a minimally invasive lung cancer.

30:39

And this was a resected stage one a adenocarcinoma.

30:45

The nodule size thresholds for solid nodules are based, uh,

30:49

importantly on some of the work like this in the NLST four

30:53

millimeters was a threshold for a solid nodule or any nodule actually in

30:58

calling it a positive screen. But in doing so,

31:01

there were lots of follow-up tests done that really didn't add benefit because

31:05

the risk of cancers was quite low.

31:08

This data from over 21,000 individuals comes from the LCAP program, uh,

31:13

headed by Claudia Heskey and David Yitz in New York,

31:17

and they looked at different size thresholds to call a positive screen and

31:22

what the impact would be on the screen positive rate and the reduction in

31:26

workups. So they started with a five millimeter size nodule,

31:31

solid nodule as the definition of a positive screen.

31:34

And with that 16% of their screens would be positive when they went up just

31:39

one millimeter to six millimeter 10% of screens would be called positive

31:44

and it would be 36% less workup needed in terms of follow-up

31:49

tests. And as you go up the nu each size threshold,

31:53

of course the positive screen rate keeps dropping and you do less follow-up

31:57

tests.

31:58

But wherein there is a sweet spot between finding cancer early that's not gonna

32:03

progress and be harmful to doing too many tests and having too many positive

32:06

screens.

32:07

They also looked at the nine month delay in cancer between each category

32:12

and between categories five and category six with this reduction in positive

32:16

screens and reduction in workup.

32:18

There was no case that had a nine month delay in the lung ca or longer in the

32:22

lung cancer diagnosis, but when they went up one higher to seven millimeter,

32:27

5% of people had a nine month or longer delay in their lung cancer being

32:31

diagnosed. And as they continued to go up by each millimeter,

32:35

more and more people had a delay in a positive cancer diagnosis.

32:39

And so this is one of the strong reasons that six millimeters is used on the

32:43

first lung cancer screen to decide whether a lung nodule is a positive or

32:48

negative.

32:51

The new additions to lung rads include atypical pulmonary cysts and

32:55

cavitary nodules,

32:57

as well as some clarifications around nodules that abut the pleural surface

33:01

nodules in the airways, the definition of nodule growth, um,

33:06

how infectious and inflammatory lesions are managed,

33:09

and this new concept of stepped management,

33:13

as well as some more information about the use of the S modifier for significant

33:18

or potentially significant other findings.

33:22

I'm gonna talk about a few of these that I think are particularly important.

33:28

So the long rads table is available on the ACRs webpage.

33:32

Each of the categories similarly as it used to in the earlier versions,

33:35

has the findings by each nodule type.

33:38

You'll see solid part solid nonsolid airway nodules and juxta pleural nodules

33:43

that are all in the benign category.

33:45

With the recommendation being continuing annual screening in 12 months.

33:49

I think it's important to have this kind of information at your fingertips,

33:52

whether it's integrated into the software tools you're using at your reading

33:56

cockpit or a link available to you or a paper copy on the wall,

34:01

whatever works best in your practice so that you can remember what these are.

34:04

And having been with lung ran since it started in 2014,

34:08

I still have these at my fingertips for some of the ones that we see less

34:12

commonly.

34:14

And then categories three four A and four B are the positive screens with the

34:19

recommendations of six and three month follow-up for the first two categories

34:23

with low dose CT and then the more aggressive management for the very suspicious

34:27

nodules. I will call out this four x category at the beginning,

34:32

which we initially put into lung rads for patients who had something else

34:36

besides what goes into those criteria above of different nodule sizes,

34:41

growth and and density.

34:43

And that is features that are worrisome to the radiologist. For example,

34:47

the categories of solid part solid cystic and ground glass do not

34:52

include speculation.

34:54

They do not include hyler lymph node enlargement,

34:58

pleural effusion, evidence of lymphic tumor spread around the lesion.

35:03

So we know that radiologists,

35:05

as has been shown in the literature that a radiologist probability that a nodule

35:10

is cancer is very impactful and meaningful.

35:13

And so in some studies of four x one in particular,

35:17

the four x rate of lung cancers as used by radiologists,

35:22

these lesions over 50% of the time were lung cancer,

35:26

which is a very high lung cancer diagnosis rate.

35:29

So we recognize the value that radiologists bring in additional to these

35:33

individual categories of other findings that you see features of the nodule that

35:38

are not captured in these categories that make you say I'm particularly

35:41

concerned.

35:42

And this is a fourex and that goes into the same high risk diagnostic management

35:47

as the most suspicious four B category.

35:49

You'll see we've added in here the criteria for cysts.

35:53

So what's a juxta pleural nodule?

35:57

In the earlier lung rides we had peri fial nodules,

36:00

which were lymph nodes along the fial surfaces.

36:03

But there's new evidence that shows no matter what pleural surface,

36:07

peri mediastinal costs along the ribs or per diaphragmatic,

36:11

if you have nodules of the features of a benign inter pulmonary nodule,

36:16

no matter what pleural surface they're on, you can use the same criteria.

36:20

So it's not just peri bro, uh, peri fial inter pulmonary nodules,

36:25

it's along any pleural surface. The original, um,

36:29

lung Rad use of peri fist nodules use this classification that came from

36:34

that del that, uh,

36:36

Dutch Nelson group that I mentioned at their lung cancer screening trial.

36:39

And typical peri fial nodules are triangular ovoid quadrilateral

36:44

and they're centered on a pleural surface in this case on fissures.

36:48

And those that were excentric, uh,

36:51

to the fissure were atypical and shouldn't be called benign.

36:55

And lesions that were, um, larger bowing,

36:58

they were more round than they were long, uh,

37:01

that had acute angles with a fial surface or were speculated should not be

37:05

considered peric or juxta pleural nodules at all.

37:08

And here on the right we see examples of a nice triangular peri fial nodule

37:13

Ajax pleural nodule here,

37:15

a triangular shaped nodule on the mediastinal pleura and on the right examples

37:19

along the cosal pleura,

37:21

these are all benign intra pulmonary nodules.

37:25

They are under 10 millimeters in size. They are solid with smooth margins.

37:30

They're oval lent to form a triangular in shape and can be called lung rads two.

37:35

So that reduces a lot of unnecessary lung rads threes and re and

37:40

increases the positive screen via negative screen rate lesions like this

37:45

of round nodule acute angles to the pleural surface,

37:49

A lobulated nodule acute angles to the pleural surface.

37:52

And this one that is part solid. These are not juxta pleural nodules.

37:57

These would be categorized by their usual lung rat score.

38:03

The pulmonary cyst is one that I mentioned,

38:05

not as much data behind because there are not many large series.

38:10

So we looked at case studies that were published in the literature,

38:14

we looked at cases that came from individuals on the Lung rats committee,

38:18

and we've been partnering with the LCAP group and the atypical pulmonary cyst

38:22

that they have in their practice to try and come up with a recommendation

38:26

schema.

38:27

And so cysts that are pure thin walled cysts with no sub

38:32

taste or nodularity, those don't even make it into the Lung RADS criteria.

38:35

A benign thin walled simple cyst,

38:38

those are just not even covered in lung rans and don't impact any of your lung

38:43

rads scoring, but it's the atypical cyst that we're concerned about.

38:48

Category three is a thick walled cyst with a growing cystic components.

38:52

Category four is thick walled or multilocular baseline that can become

38:57

multilocular.

38:59

And a category four B are thick walled cysts with growing wall thickness or

39:03

nodularity, a growing multilocular cyst,

39:07

a multilocular cyst that gets more lod or has new opacity with

39:12

it, whether it's nodular ground glass or consolidative.

39:15

And so we've tried to pick increasing features essentially of wall thickness and

39:19

nodularity as reasons to go from three to four A to four B.

39:23

When you get to a cavitary nodule, these are managed in their total size,

39:28

just like solid nodules are.

39:31

And then if you have a nodule where the dom a cystic lesion where the dominant

39:35

lesion is a nodule, then they can be managed by the size of the nodule.

39:42

So here are some examples of benign thin walled cysts, thin walled,

39:46

nice thin walled, no nodularity. These are benign cyst.

39:50

They don't even go into long reds anywhere at all.

39:53

But a caveat is you should miss,

39:55

you should make sure that a vessel that's along one part of a cyst wall isn't

40:00

called wall thickening.

40:01

And by scrolling up and down and maybe looking in multiple planes,

40:04

you can easily make that discrimination.

40:07

So here's a couple of examples.

40:09

And these come from the Lung-RADS paper that is now online at JCR R-J-A-C-R.

40:15

This is an atypical seven millimeter cyst on a baseline screen.

40:19

It's thick around the edges with a thin, thick focal area posteriorly.

40:23

So it's a category four A, it goes for three month follow-up, low dose ct.

40:28

It's no change. So it's gonna step down in management to a category three.

40:32

And the new step management criteria

40:37

here is another cystic lesion. It's a category four A lesion.

40:41

It's atypical.

40:42

It's got a thick septation in the middle and some thickening on the outside

40:45

edge. It's a four A,

40:47

it goes to the category of three month low dose CT follow-up at three

40:52

month follow-up. It now has a growing exophytic nodule with it.

40:56

This increases its risk of cancer.

40:58

It's now a four B and goes into the most aggressive diagnostic management

41:02

pathway,

41:03

usually being referred to a pulmonary medicine physician or the appropriate

41:07

practitioner in your practice area.

41:09

And this turned out to be a squamous cell carcinoma.

41:13

And here's another four B cystic lesion.

41:15

It looks like a cyst with a big nodule sitting right next to it.

41:19

This is a 16 millimeter nodule that is the dominant feature of the lesion.

41:24

This would be a category four B lesion and go into the diagnostic workup

41:28

pathway. And this was an invasive lung adenocarcinoma.

41:32

So thickness of the cyst wall,

41:34

increased thickness or nodule dominance are the driving features of category.

41:39

We do recognize that these are a heterogeneous group of lesions,

41:43

particularly these multilocular cysts. We have a,

41:46

a cyst here with very thin walls that's multi Ladd.

41:50

Here we have a multilocular cyst with a tiny little bit of nodularity who we've

41:54

got lots more tiny cysts with tiny little patients in nodularity.

41:58

And then here a big frothy looking multilocular cyst.

42:02

So there's a lot of things that fall into this definition of multilocular cysts

42:08

in four A.

42:10

And here's an example of one that's kind of frothy multilocular cyst I just

42:14

showed you that earlier was much smaller.

42:17

It's increased in size and increased in the number of those small ations of

42:21

growing multilocular cyst.

42:23

And here is a multilocular cyst with a little bit of nodular in the middle of it

42:27

that grew on the next annual screen.

42:30

Both of these are gonna be considered category four B and have a high risk of

42:34

being lung cancer.

42:38

Switching to endobronchial nodules, we've clarified, uh,

42:41

some of the definitions of what's endobronchial nodule versus what's just

42:45

secretions or airway related abnormality.

42:48

Things are that are not even in a category, couldn't even, shouldn't,

42:52

shouldn't even really put category zero here.

42:54

They're just defined by what they are as being mucus and secretions with equine

42:58

impaction, linear, bubbly,

43:01

frothy material in the airway with bubbles of air in it,

43:04

branching and tubular with the airways as endobronchial secretions.

43:08

Those are all things that are not positive screens and don't get categorized in

43:12

lung rads.

43:13

But when you start to see a discreet subsegmental or larger airway, um,

43:18

within that airway, um, you're, if it's small,

43:22

we can continue annual screening. But when it gets to segmental and larger,

43:27

so submental,

43:28

smaller negative screen submental and larger in the airway,

43:32

we get more concerned if it's smoothly marginated. Um,

43:36

we would call a a category four A and would go for three month check.

43:40

But A four B is when we're getting into larger airway nodules that are

43:44

growing. And in that case they should be referred for evaluation usually with

43:48

bronchoscopy.

43:51

Here's some examples of things that are really not secretion,

43:55

that are not nodules. They're, they're frothy with air bubbles.

43:58

These are secretions. Here's one in a tiny bronchus,

44:01

little bits of air bubbles in the middle of it and hear multiple tubular

44:04

branching opacities of nuclear impaction.

44:08

But this is the kind of nodule that sometimes gets missed if you're strong a

44:12

little bit too quickly. It's a discreet solid nodule.

44:15

It's stuck against the wall.

44:17

It has no air bubbles in it and it's in a larger central airway.

44:21

So category four A and when this patient came back,

44:26

um, it was originally unchanged, then it began to grow.

44:31

So this would increase your risk if it were to grow.

44:34

And these are examples of other endobronchial nodules,

44:37

a larger one here in the left main bronchus, another one in a,

44:42

a proximal segmental bronchus. These are four A airway nodules.

44:47

And here's one that was not there before and then developed.

44:50

It's new on a next annual screen. So the size of the airway matters.

44:55

We've made some clarifications around infection in lung reds.

44:59

If you're looking at the CT and you think it's infection,

45:02

it's a low bar segmental consolidation or the innumerable, uh,

45:07

multiple new nodules that are related to airway center infection.

45:10

You can call it infection. It could be a,

45:12

you would call it a category zero if the lung was covered up enough by the

45:16

process that you can't score it for lung cancer or you could call it,

45:21

um,

45:22

a lung RADS positive if you really think you're concerned about lung cancer to

45:25

make sure that they come back. But generally if you think it's pneumonia,

45:29

you can call it a lung rat zero and have the patient come back after infection

45:33

treatment to see if the lung is cleared and there's no residual nodule.

45:39

And the last thing about lung rats I wanna mention is stepped management.

45:42

And instead of going from a stable four A at follow-up all the way

45:47

down to two a stable four A becomes a three and a three

45:52

becomes a two.

45:53

So you just always drop down to the next category below when somebody's coming

45:57

back for their follow-up testing.

45:59

And that's important because it means the higher risk lesions are getting more

46:03

close watch then the lower risk lesions. So if we look at a Lung-RADS three

46:10

in the past,

46:11

a Lung-RADS three under version 1.1 would get at six months ct.

46:15

And if it was unchanged, it would then come back in six months.

46:19

Well now if it's going back to a negative screen,

46:22

that next one will be 12 months from that interval ct, not six months.

46:27

These are lower risk lesions,

46:29

whereas we look at categories that are higher like four A a four

46:34

A, if it didn't change, was dropping all the way down to a two. Now A four A,

46:38

if it doesn't change on its follow-up becomes a three and then becomes the two

46:43

if it doesn't change again.

46:44

So we get more careful watch of the higher risk lesions.

46:49

And then here's an example of four B and we think this is a clarification.

46:54

It's important if you have a four B highest risk lesion that's confirmed to be

46:59

a benign diagnosis, um, or if it happens to have completely resolved.

47:03

So essentially you really do have proof that it's negative.

47:07

A negative four B on workup can go to a next annual screen in 12 months.

47:12

So if you have a specific diagnosis of a benign endobronchial hematoma,

47:16

for example, um, then that goes to a true negative screen.

47:20

Or if you have a lung nodule that's biopsied and it's proven to be sarcoid or

47:24

granuloma infection, then you can drop all the way down to a negative screen

47:31

screen. Um, I wanna mention the slar,

47:33

the S modifier in lung cancer screening.

47:36

It is for significant or potentially significant other findings in the chest.

47:41

Um, it occurs in about 10% of uh, patients.

47:44

That's what we had estimated it to be. When we originally developed lung rads,

47:49

we looked at the first 1.7 million screens in the ACR lung registry and

47:54

how you all are coding and using categories us.

47:57

And we found out that 15.6% of people had one

48:03

incidental finding. Uh, 2.2% had two of these significant incidental findings.

48:08

And just under half a percent had three or more incidental findings on their

48:12

cts. And if we look at what's most common, what you're reporting,

48:16

it's most commonly coronary art cell calcification, which is moderate to severe.

48:20

That's very important for the detection and manage and, uh,

48:23

management for preventive care, for coronary for cardiovascular disease. Um,

48:28

masses. Second category not otherwise specified, could be in the neck,

48:32

in the chest, a renal mass or a liver mass. Um,

48:35

the third most common category was interstitial lung disease combined with

48:39

pulmonary fibrosis.

48:40

The fourth most was emphysema and the fifth was aortic aneurysm.

48:45

So you're identifying a lot of significant or potentially significant findings.

48:49

We recommend that you use the category S the first time.

48:52

So if you have moderate coronary calcium on the first screening,

48:55

it's category S, but after that it's already known,

48:58

so it would no longer be an s finding on future exams.

49:04

And the ACR has put together a quick guide of incidental findings.

49:08

This is such a common, uh,

49:09

challenge and primary care practices and screening program navigators need some

49:14

sort of guidance on what to do with these findings. We recommend that you,

49:18

the radiologist, put your recommendation into the report,

49:21

not just the finding itself, but do you have a recommendation for it? Um,

49:25

absent that,

49:26

this guide serves for the primary care community based off of the ACRs

49:33

practice guidelines for lung cancer screening. For a, um, incidental findings,

49:38

uh,

49:38

we've extracted all the features you could see on a lung cancer screening CT so

49:42

that they can look them up and know what to do with them.

49:47

This was tested, uh,

49:48

with nurse navigators in lung cancer screening programs and felt to be useful or

49:52

extremely useful by the preponderance of them.

49:59

So where are we now?

50:01

We have this 2021 recommendation from U-S-P-S-D-F that is the most widely

50:06

adopted and used and links to private payer coverage.

50:09

There are about 4,000 screening facilities in the US outside of, uh,

50:14

veterans Health Administration facilities,

50:16

and yet less than one in 10 eligible individuals have been screened by the old

50:20

criteria, not alone, the additional 5 million, um,

50:24

based on the eliminating year since quit. And sadly,

50:29

only one in five people who've had lung cancer screening come back for their

50:33

next annual screening.

50:35

So we've got low uptake and we have low rate of coming back.

50:39

Perhaps people don't understand this is not a one and done test.

50:42

A benefit from screening is done annually.

50:46

I think it's important that we reflect on the population of people who are at

50:50

risk for lung cancer

50:53

and what their perceptions are about lung cancer and lung cancer screening.

50:59

And I refer to this, this paper that looked at these attitudes.

51:04

And in general, a population at risk of lung cancers, lung cancer.

51:08

This was of a socioeconomically population community with heavy smoking,

51:13

supportive of lung cancer screening in principle,

51:16

but doubtful about its ability to deliver a long-term survival gen benefit for

51:20

their generation of heavy smokers.

51:22

And those that have come before them in their families and relatives that they

51:26

know have had lung cancer and have passed lung cancer is therefore

51:30

perceived as an uncontrollable disease because what people think of when they

51:35

think lung cancer, that is what we've had before. Early detection was possible.

51:39

There's fatalism worry and perceive lung cancer risk that's very high

51:44

among individuals who smoke.

51:46

There's perceived blame and stigma around lung cancer.

51:50

I mentioned this earlier as a self inflected disease that has been implicated as

51:54

a deterrent for them coming forward for care.

51:57

And individuals who smoke cigarettes who have lung cancer are known through,

52:02

through scientific research to be less likely to come forward for care,

52:06

to be less likely to stick with their lung cancer care.

52:09

And a lot of this is related to the language that we use that is not

52:13

patient-centered by calling people smokers as was done in this

52:17

2016 paper, instead of calling them a person who smokes as a risk factor.

52:23

There's also the belief that lungs are not a treatable organ as a common lay

52:27

explanation for poor survival that undermines the value of screening.

52:31

If you don't think that you can treat the lungs or take out a piece of the

52:36

lungs, you'd look at this and say, well, why should I get screened?

52:39

There's nothing you can do for it.

52:41

And I mentioned this because if we don't address and educate populations who are

52:46

at risk about what lung cancer screening to do and dispel some of these myths

52:50

that are built on decades of past beliefs around lung cancer and past

52:55

experiences, it's gonna be hard to increase lung cancer screening rates.

53:00

I'm fortunate to chair the National Lung Cancer Roundtable at the American

53:03

Cancer Society and our number one priority is accelerating the implementation

53:08

uptake in adherence of early detection of lung cancer,

53:11

both screening and importantly your incidental nodule programs,

53:16

as well as our other important priorities around care for people getting

53:20

biomarkers and appropriate guideline accordant staging if they're diagnosed.

53:24

And, um, addressing stigma and nihilism,

53:27

which I've now mentioned three times is important in lung cancer screening.

53:31

We've developed tools that you as a radiology practice can use. For instance,

53:36

lung plan.

53:37

If you're struggling to get the resources like a nurse care coordinator or

53:41

navigator or the software you need,

53:44

you need to make the financial case to your health system, um,

53:47

that it is worth their investment for this life screening service to be able to

53:52

do the right thing.

53:53

A lung plan is essentially a front end Excel sheet that you enter some

53:57

information into about what you're hoping to do with your lung cancer screening

54:01

program or even just to map out how many chest cts you do and what your lung

54:06

incident lung no program could look like.

54:08

And it essentially maps out for you a financial proforma on what the,

54:12

what the downstream is to your institution,

54:15

whether you're a freestanding radiology practice or whether you're a big

54:19

integrated health system and are doing everything from screening to

54:24

SBRT and surgery and biomarker testing and so on.

54:28

And while I hesitated to ever talk about the financial side of lung cancer

54:33

screening, when we develop this originally,

54:35

I think it's important that we do focus on this so that you can get the

54:39

resources you need to be able to do lung cancer screening successfully in your

54:43

practice.

54:46

We've also tried to understand what the barriers are to lung cancer screening

54:50

with this slow uptake. There are states that are down at the one to 5% range.

54:55

Um, there are states that are up at 18% of eligible individuals being screened,

54:59

and that's without including data from, uh,

55:02

some sources like the Veterans Health Administration.

55:06

The major barriers include the EHR and IT tools that

55:11

you have. And we've since, from the first summit that we held last year,

55:14

held a workshop specifically with the IT vendors at the table.

55:19

Uh,

55:20

groups like Epic and Cerner and teams that you develop lung cancer

55:24

screening and lung nodule follow-up tools,

55:27

1214 vendors at the table working with experts in screening and

55:32

pulmonary and surgery to help them know what we need to be able to do lung

55:36

cancer screening from those tools, from identifying people from screening,

55:41

tracking them after screening, educating patients and providers,

55:45

performing shared decision making,

55:46

and then tracking your performance and quality. So we are working on these.

55:49

It's great to have the ACR as a major partner in all of these efforts.

55:55

So we've,

55:56

we've mapped what the barriers are with leading experts around the country with

55:59

people from, uh, federal agencies. We know what the,

56:03

the obstacles are and we have strategic planning and plans that are in place to

56:07

try and address these so that we can get screening rates up. And our,

56:12

our,

56:13

our work with the IT vendors was particularly inform informative and some of the

56:18

things that we already have underway based on the conversations in the

56:21

informatics space, I think are gonna make a substantive difference.

56:24

And then lastly, to help you do quality lung cancer screening, um, we have,

56:30

uh,

56:30

have this lung cancer screening registry and we're so grateful to many of you

56:34

participating.

56:34

This came about from the original CMS coverage decision and we now have

56:39

5 million screening events in the ACRs registry from over 4,000

56:44

participating facilities, which is landmark.

56:46

No screening test rollout has ever had this.

56:49

And what we can do with this data is use it to change practice like lung rads by

56:54

looking at information, but we can also, um,

56:56

use it to see where we're going and what we need to do to help practices.

57:01

And so what the screening registry has done is formed a, um,

57:05

an education and quality improvement team,

57:08

and that team has developed some tools so that you can go into your ACR

57:12

registry, see your data and say, yeah, you know,

57:15

my adherence to annual screening or three month followup isn't so good.

57:20

And you can use the quality improvement templates,

57:22

which are based on a simple PDSA cycle with, you know, do a, do B,

57:27

do C so that you can try and get up your screening rates and your return to

57:30

annual screening, um,

57:32

so that you can also look at your radiation exposure if you have, uh,

57:35

doses that are high. And importantly, the third measure is looking at, uh,

57:40

non-smoking rates as a measure of smoking cessation over time, uh,

57:44

in people who are coming back to your screening program. So these, um,

57:47

screening templates have rationale.

57:50

They show you how to look at your data and they go through detailed

57:54

interventions of things that you can try as you look at your data to try and

57:57

address return to annual screening or return for those Lung Reds three and four

58:02

A exams. Uh,

58:04

a lot of the things I've mentioned today come from the ACR.

58:07

There's an ACR Lung Cancer Screening resources webpage,

58:10

just kind of Google ACR lung cancer screening resource.

58:13

And a page comes up with all the things I've talked about and more, uh,

58:18

this one just coming off the heels of lung of, um,

58:21

breast Cancer Awareness month in October and transitioning in November to Lung

58:25

Cancer Awareness Month, um,

58:27

has a tool that you can use in your mammography practices where you have women

58:31

who are coming in with,

58:32

who are demonstrating screening behaviors and some of them are at risk for lung

58:37

cancer and some of them know people who are at risk for lung cancer.

58:41

We know that women impact healthcare services and who and their families,

58:45

particularly their men, uh, come in for healthcare, their partners. Um,

58:50

and so having tools that you can,

58:52

a tool like this that's on the ACR website and you can put in your own

58:56

information,

58:57

you can use in your mammography practice to try and increase awareness among

59:02

these women who are already demonstrating screening behaviors to increase the

59:06

visibility of lung cancer screenings.

59:08

This is a quick and easy one you can do in your practice. So as we close,

59:12

the face of lung cancer is changing because of early detection through screening

59:16

and in sentinal nodule programs,

59:18

lung cancer kills more people than any cancer in the United States. In fact,

59:22

it kills more people than cancers of the breast, colon,

59:25

and prostate grant combined. Lung cancer can look,

59:30

anyone can have lung cancer, and we focus screening on high risk individuals.

59:35

But your incident nodule programs are also important for those who are not

59:39

eligible for screening who may have lung cancer as well.

59:42

This Saturday is National Lung Cancer Screening Day. It's our second year.

59:46

It falls on Veterans Health Day and the Veterans Health Administration is

59:50

engaged all the way up to the highest levels in Washington DC to be part of

59:54

National Lung Cancer screening Day. This year,

59:55

many practices are celebrating and opening their radiology facilities on

59:59

Saturday, uh,

60:00

for screening services and trying to make it a community event and a media event

60:05

to increase awareness about lung cancer screening.

60:08

We hold this the second Saturday of every year. So third,

60:12

we'll be holding this again next year, on the second Saturday of November.

60:15

And if you're not signing up this year, hopefully you can sign up next year.

60:19

Thanks so much for letting me chat with you today about lung cancer screening.

60:23

We look forward to a mastery series and lung cancer screening that I'll be

60:27

developing with modality and MRI online. That'll be coming next year, uh,

60:31

to go through more of the hands-on features about lung nodules and

60:35

interpretation of lung cancer screening exams. Thanks so much,

60:40

Dr. Koni. That was awesome and informative. Thank you so much.

60:44

Do you have time for a couple questions? We've got Absolutely. Oh, awesome. Um,

60:48

if you want,

60:49

you can pop open that q and a box and I can tee you up while

60:54

you do that. Um, the first question is,

60:56

should the Association of Occupational Lung Diseases be given priority?

61:02

Yeah,

61:02

we get asked a lot of questions about people with occupational health exposures

61:06

and their lung cancer risk. At this time, uh,

61:09

occupational risks are not included in the eligibility criteria for lung cancer

61:14

screening. We do hope in the future that by the development of risk calculators,

61:18

that can include other things such as occupational risk,

61:22

such as high levels of radon exposure or family history can be used in risk

61:27

cancer,

61:28

lung cancer risk assessment and help to bring in other risks into the screen

61:32

nodule population

61:41

In a follow-up of, uh, case of lung cancer, say post chemo,

61:45

is there a development of consolidation or clustered central lole nodules and

61:50

how confidently can we exclude a lipid tumor spread versus infection?

61:55

Yeah, lung cancer,

61:57

post-treatment cts can be very challenging to interpret whether it's

62:02

findings related to chemotherapy or as we now know,

62:04

immunotherapy which can mimic, um, can mimic lung cancer. And, uh,

62:09

and this question is very pertinent in that space or the post SBRT findings.

62:14

I think it's very important that when there is uncertainty,

62:17

you mention both of them that you described the finding. So first,

62:21

obviously we are very trained in description, um,

62:24

and that you mentioned that this could be either infection or post-treatment

62:28

related abnormality.

62:29

The oncologists are very attuned to medication related lung injury,

62:33

particularly after meant to immunotherapy.

62:35

And they will certainly do a detailed workup of their patient to look and see if

62:40

they have signs or symptoms of infection to help determine next steps. So our,

62:43

I think our job is to describe very well and to give the options and that allows

62:48

those, the,

62:49

the treating physicians to put that in context of the treatment they're having

62:52

in the patient's symptoms.

62:55

Thank you. If six millimeters cut off for solving nodule,

63:00

do you even mention nodules less than that in your screening reports?

63:04

That's a great question. I get this, uh, regularly. Um,

63:07

the reason we like to mention nodules that are under six millimeters is because

63:13

you want to be able to, one, pay attention to them in your followups and two,

63:17

because the,

63:18

the smaller nodules still makes somebody a category two and not a category one.

63:24

Just having nodules itself makes a patient at higher risk for cancer.

63:29

And if you screen somebody who has no nodules at all,

63:31

and that's the difference between category one and category two,

63:34

we do recommend in lung rans that you report up to the six largest or highest

63:39

risk lesions. Perhaps they're speculated or growing. Um, in the LCAP program,

63:43

they use a si have used six nodules as the number of nodules they recommend.

63:48

And we basically recommend having a, a sim a a list, you know,

63:53

the lobe, the size of the nodule, the density, uh,

63:57

the image number it's on,

63:58

and give that list if you're using some of the nodule detection tools,

64:02

you can in some cases set those up to directly import into your reporting

64:06

system. It all depends on what tools you have, but a minimum, you know,

64:11

lobe size density image number and up to six nodules.

64:15

I think once you're getting down to, you know, once you're,

64:17

once you're beyond four to six nodules reporting anymore as a declining benefit.

64:22

But it's basically to get on the record that this is a nodule form and that's

64:24

why they're category two

64:27

Got another category. Question for you from the chat.

64:30

What category would be one to two millimeter distal endotracheal nodule?

64:36

So if it's one to two millimeters and it doesn't have any air bubbles in,

64:41

it would be a category two because it's small by size.

64:46

Awesome. And the last question, um, lung,

64:50

lung nodule management in a case of known extra thoracic cancer. Drew,

64:55

what are your thoughts on that?

64:56

Yeah, this question is also a very common one. If somebody is, uh,

65:01

let's say they're in their disease-free surveillance state, and they, uh,

65:06

say they have melanoma and they're five years disease free or breast cancer or

65:10

prostate cancer, and now you have ale you're trying related,

65:16

uh, if they're being seen by oncologists, we feel pretty comfortable.

65:21

Um, or the cancer treatment team, if that's where the referrals are coming from,

65:25

we feel very comfortable describing the nodule and recommend it be followed

65:29

based on the nature of the underlying malignancy. In fact,

65:32

we even have a line in our reports as a standard pick list that way,

65:35

so that we put that in the hands of the oncologist.

65:38

They may be aware of other features that increase the risk of recurrence in that

65:42

patient. They might want to follow up more closely for that reason. Um,

65:45

and people certainly are on any active form of cancer treatment,

65:49

we always defer to the oncology practitioners or the, the,

65:52

the oncology team in making the decisions about how to follow up nodules in

65:57

patients with an extra thoracic cancer.

66:00

Awesome.

66:00

Thank you so much for answering all those questions and for the informative

66:04

lecture Dr. Ceroni. This has been awesome. I, I, I hope you enjoyed it.

66:08

Thanks so much for having me today and look forward to seeing some of you take

66:11

up the Master's program in the future.

66:13

Thank you for everyone else for participating in the NOOM Conference,

66:17

and you will be able to access the recording of today's noom conference and all

66:21

our previous ones by creating a free MRI online account.

66:24

Be sure to join us next week on Thursday,

66:26

November 16th at 12:00 PM Eastern for a Noom conference entitled Simplified

66:30

Approach to the Lymph Nodes of the Head and Neck with Dr. Resh McCury.

66:35

You can register for this free lecture@mriline.com.

66:38

Follow us on social medias for updates on future noon conferences.

66:41

Thanks again and have a great day.