Implementing Lung Cancer Screening and Prevention in Academic Centers, Affiliated Network Offices and Collaborating Care Sites.

Lung cancer is one of the deadliest and yet largely preventable neoplasms. Smoking cessation and lung cancer screening are effective yet underutilized lung cancer interventions. City of Hope Medical Center, a National Cancer Institute (NCI)- designated comprehensive cancer center, has 27 community cancer centers and has prioritized tobacco control and lung cancer screening throughout its network. Despite challenges, we are implementing and monitoring the City of Hope Tobacco Control Initiative including 1) a Planning and Implementation Committee; 2) integration of IT, e.g., medical records and clinician notification/prompts to facilitate screening, cessation referral, and digital health, e.g., telehealth and social media; 3) clinician training and endorsing national guidelines; 4) providing clinical champions at all sites for site leadership; 5) Coverage and Payment reform and aids to facilitate patient access and reduce cost barriers; 6) increasing tobacco exposure screening for all patients; 7) smoking cessation intervention and evaluation-patient-centered recommendations for smoking cessation for all current and recent quitters along with including QuitLine referral for current smokers and smoking care-givers; and 8) establishing a Tobacco Registry for advancing science and discoveries including team science for basic, translation and clinical studies. These strategies are intended to inform screening, prevention and treatment research and patient-centered care.

Augmented meaningful use criteria to identify patients eligible for lung cancer screening.

BACKGROUND: Lung cancer screening (LCS) with low-dose-radiation (low-dose computed tomography [LDCT]) saves lives. Despite recent US Preventive Services Task Force (USPTF) draft endorsement of LCS, a minority of eligible patients get screened. Meaningful use is a set of standards for electronic health records (EHR) established by the Centers for Medicare and Medicaid Services and includes reporting of smoking status. We sought to improve rates of LCS among patients treated at our institution by identifying eligible patients using augmented smoking-related meaningful use criteria. METHODS: We launched an LCS program at our institution, a National Comprehensive Cancer Network (NCCN) cancer center, in January 2013. We developed a "tobacco screen," administered by clinic staff to all adult outpatients every 6 months and entered into the EHR. This contained smoking-related meaningful use criteria as well as a pack-year calculation and quit date if applicable. Weekly electronic reports of patients who met eligibility criteria for LCS were generated, and EHR review excluded patients who had had chest computed tomography (CT) within 12 months or who were undergoing cancer treatment. We then contacted eligible patients to review eligibility for LCS and communicated with the primary treating physician regarding the plan for LCS. RESULTS: During the first 3 months of the program, 4 patients were enrolled, 2 by physician referral and 2 by self-referral. We then began to use the tobacco screen reports and identified 418 patients potentially eligible for LCS. Over the next 7 months, we enrolled a total of 110 patients. Fifty-eight (53%) were identified from the tobacco screen, 32 (29%) were self-referred, and 20 (18%) were physician referrals. Three stage I lung cancers were detected and treated. The tobacco screen was easily implemented by clinic staff and took a median time of 2 minutes to enter for current and former smokers. Lack of response to attempts at telephone contact and objection to paying out-of-pocket costs were the most common reasons for failing to screen eligible patients. CONCLUSIONS: Use of augmented meaningful use criteria containing detailed tobacco exposure history is feasible and allows for identification of patients eligible for LCS in a medical center. Barriers to LCS include lack of insurance coverage and lack of systematic referral of patients at high risk.

Longitudinal changes in function, symptom burden, and quality of life in patients with early-stage lung cancer.

BACKGROUND: Emerging evidence supports the integration of palliative care concurrently with disease-focused care in patients with serious illnesses, such as lung cancer. This paper describes how longitudinal changes in physical function, symptom burden, and QOL of patients with early-stage non-small cell lung cancer (NSCLC) informed the development of an interdisciplinary, tailored palliative care intervention. METHODS: Patients with early stage (I-IIIB) NSCLC were accrued into the usual care phase (Phase 1) of an NCI-funded Program Project Grant. Baseline and longitudinal (up to 52 weeks post-accrual) physical function, symptoms, and QOL were assessed in the thoracic ambulatory clinics of one NCI-designated Comprehensive Cancer Center. Outcome measures included geriatric assessments, psychological distress, symptoms, and QOL. The association between disease stage (I-II vs. III) and longitudinal changes in these domains was evaluated. RESULTS: A total of 103 patients were accrued. Stage I-II patients were significantly more likely to complete the study (p = 0.005). The stages (I-II vs. III) were equivalent at baseline on all demographic variables, clinical, and functional status. Physical function fluctuated longitudinally and was higher at 6 and 24 weeks than at baseline and 12 weeks. There was a longitudinal decrease in total number of symptoms (p < 0.001). Physical and social/family QOL fluctuated longitudinally (p < 0.001 and p = 0.016, respectively). CONCLUSIONS: Patients with early-stage NSCLC report a significant longitudinal decrease in physical QOL, and fluctuations in objective and subjective measures of physical function over time were observed regardless of disease stage category. An interdisciplinary palliative care intervention is currently being tested to decrease symptom burden and improve QOL.

Severe exercise-induced hypoxemia.

Exercise training is an essential component of pulmonary rehabilitation and is associated with improved function and other important outcomes in persons with chronic lung disease. A subset of pulmonary rehabilitation patients experience hypoxemia that may occur or worsen with exercise. For the purpose of this review, severe exercise-induced hypoxemia is defined as an S(pO(2)) of < 89% during exercise, despite use of supplemental oxygen delivered at up to 6 L/min. There is a paucity of evidence and clinical guidelines that address assessment and management of this important manifestation of chronic lung disease. This review presents background of this topic and suggests strategies for assessment, management, and safety measures for patients with severe exercise-induced hypoxemia.

Integrated disease management improves one-year quality of life in primary care COPD patients: a controlled clinical trial.

UNLABELLED: AIMD: To assess the long-term effectiveness of an integrated disease management (IDM) program (consisting of optimal medication, reactivation, education, and exacerbation management) in primary care patients with chronic obstructive pulmonary disease (COPD). METHOD: Controlled trial comparing the effects of IDM on quality of life--assessed by the St. George's Respiratory Questionnaire (SGRQ)--in primary care COPD patients. The minimal clinically important change on the SGRQ was accepted as being -4 points. Baseline and one year differences were compared using paired sample T-tests. The differential effects of an FEV1/FVC ratio <0.7 and dyspnoea as assessed by the Medical Research Council (MRC) Dyspnoea scale were investigated. RESULTS: The average age of subjects was 63 years, with an average post-bronchodilator FEV1 of 67% predicted, average FEV1/FVC ratio of 0.65, a mean of 35 pack-years smoking, and 63% were male. No significant differences existed between groups at baseline. After one year of IDM, SGRQ had improved by -4.6 points (95% CI, -7.2 to -2.0; p=0.001) in the intervention group, versus -0.7 points (95% CI, - 3.0 to 1.6; p=0.6) in the usual care group. In patients with an FEV1/FVC ratio <0.7, SGRQ improved by -5.9 points (95% CI, -9.6 to -2.2; p=0.002) in the IDM group, while in the usual care group SGRQ improved by -0.8 points (95% CI, -4.1 to 2.4; p=0.6). In patients with an MRC Dyspnoea score >2 and FEV1/FVC <0.7, SGRQ improved by -13.4 points (95% CI, -20.8 to -6.1; p=0.002) in the IDM group, versus -0.3 points (95% CI, -5.5 to 4.9; p=0.9) in the usual care group. CONCLUSION: In this study, IDM improved one-year quality of life in primary care COPD patients, compared to usual care. The improvement in SGRQ was both clinically relevant and statistically significant, and was greatest in patients with FEV1/FVC <0.7 and MRC Dyspnoea score >2.

How accurately can we predict forced expiratory volume in one second after major pulmonary resection?

Standard formulas for predicting postoperative forced expiratory volume in 1 second (po-FEV1) do not consider bronchi obstructed by tumor or chronic obstructive pulmonary disease, e.g., Formula 1 [ppo-FEV1 = (pre-opFEV,) x (# segments remaining)/(# of total segments)] whereas Formula 2 [ppo-FEV1 = (pre-opFEV,) x (# segments remaining)/(# of total unobstructed segments)] does. A retrospective chart review was conducted to determine accuracy of predicting po-FEV1, at a comprehensive cancer center. Predicted po-FEV, was calculated using different formulas and analyzed using regression analysis and Pearson correlation. We found good correlation between po-FEV1 and predicted po-FEV1 using Formulas 1 and 2. In patients with tumor airway obstruction or chronic obstructive pulmonary disease, predictive accuracy decreased for both formulas. Prediction of FEV1 in patients undergoing pulmonary resection was generally accurate, but major errors were observed in some cases; therefore, better predictive formulas are needed in patients with airway obstruction by tumor or chronic obstructive pulmonary disease.