Rural barriers and facilitators of lung cancer screening program implementation in the veterans health administration: a qualitative study.

Introduction: To assess healthcare professionals' perceptions of rural barriers and facilitators of lung cancer screening program implementation in a Veterans Health Administration (VHA) setting through a series of one-on-one interviews with healthcare team members. Methods: Based on measures developed using Reach Effectiveness Adoption Implementation Maintenance (RE-AIM), we conducted a cross-sectional qualitative study consisting of one-on-one semi-structured telephone interviews with VHA healthcare team members at 10 Veterans Affairs medical centers (VAMCs) between December 2020 and September 2021. An iterative inductive and deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual model to depict rural barriers and facilitators of lung cancer screening program implementation. Results: A total of 30 interviews were completed among staff, providers, and lung cancer screening program directors and a conceptual model of rural barriers and facilitators of lung cancer screening program implementation was developed. Major themes were categorized within institutional and patient environments. Within the institutional environment, participants identified systems-level (patient communication, resource availability, workload), provider-level (attitudes and beliefs, knowledge, skills and capabilities), and external (regional and national networks, incentives) barriers to and facilitators of lung cancer screening program implementation. Within the patient environment, participants revealed patient-level (modifiable vulnerabilities) barriers and facilitators as well as ecological modifiers (community) that influence screening behavior. Discussion: Understanding rural barriers to and facilitators of lung cancer screening program implementation as perceived by healthcare team members points to opportunities and approaches for improving lung cancer screening reach, implementation and effectiveness in VHA rural settings.

A Call for Better, Not Faster, Research Ethics Committee Reviews in the Covid-19 Era.

With the rapid spread of SARS-CoV2 has come a rapid proliferation of clinical research studies, resulting in considerable strain on research ethics committees (RECS), which need to review study proposals. RECs are pressured to move through the review process quickly so that studies can get underway to address the pandemic. These committees are also asked to increase efficiency without relaxing the standards for ethical review. RECs are accustomed to external pressure for approval from investigators; however, in the Covid-19 era, this pressure is coming from not only the sponsors and investigators but also many other stakeholders, including world leaders, the community, the media, and professional organizations. Drawing on the authors' experiences on a central REC reviewing complex multicenter Covid-19 studies, this commentary describes challenges that are inherent to Covid-19 research studies, such as the difficulty of obtaining informed consent from patients ill with the highly infectious virus. The commentary recommends several steps that RECs can take to ensure ethical review of research studies during the Covid-19 pandemic and future infectious disease outbreaks.

Centralized Lung Nodule Management at A Veterans Hospital Using A Multidisciplinary Lung Nodule Evaluation Team (LNET).

BACKGROUND: Lung nodules are frequently identified on imaging studies and can represent early lung cancers. We instituted the Lung Nodule Evaluation Team (LNET) to optimize management of these nodules by a lung specialist physician. All lung nodules identified by a radiologist prompted a direct consultation to this service. We report our initial experience with this process. METHODS: This is a retrospective review of patients with lung nodules at a single institution from 2008 to 2015. Since October 2014, lung nodules >3 mm identified on computed tomography (CT) scanning of the chest generate an automatic consult to LNET from the radiology service. Demographic, nodule and follow up data was entered into a surveillance database and summarized. RESULTS: There were 1,873 patients identified in the database. Of these, 900 patients were undergoing active surveillance. Consults increased from 5.5 to 93 per month after the start of the new consult program. Lung nodules were identified on 64% of chest CT scans. Prior to the direct radiology consult the average size of a nodule was 1.7 cm and 0.7 cm after. The overall time from initial nodule imaging to initiating a management plan by a thoracic specialist physician was 3.7 days. CONCLUSIONS: Assessment of lung nodules by a specialist physician is important to ensure appropriate long term management and optimize utilization of diagnostic interventions. A direct radiology consult to a specialized team of chest physicians decreased the time in initiating a management plan, identified smaller nodules and may lead to a more judicious use of health care resources in the management of lung nodules.

Antitumor effect of secreted Flt3-ligand can act at distant tumor sites in a murine model of head and neck cancer.

The Flt3 ligand (Flt3-L) manifests antitumor activity, presumably due to its capacity to recruit dendritic cells and cause their proliferation. To assess whether local production of Flt3-L can mediate a "distant bystander" effect, murine B4B8 squamous cell carcinoma cells were transfected with a plasmid encoding a secretory form of Flt3-L to produce B4B8FL cells. Similarly, B4B8FL and B4B8 cells were transfected with herpes simplex virus thymidine kinase (HSVTK) to produce B4B8TK and B4B8FL/TK cells, which should be sensitive to ganciclovir (GCV), to know whether the effects of Flt3-L and HSVTK/GCV would be synergistic. To test for a distant bystander effect in vivo, B4B8FL, B4B8TK, and B4B8FL/TK cells were injected subcutaneously into the left flank of syngeneic Balb/c mice, and naïve B4B8 cells were injected into the right flank. The formation of tumors derived from B4B8FL and B4B8FL/TK cells was significantly delayed in both flanks compared with naïve B4B8 and B4B8TK cells. Growth of B4B8TK tumors in the ipsilateral flank was retarded following GCV treatment, but in contrast to B4B8FL and B4B8FL/TK cells, no distant bystander effect in the contralateral flank was observed. Immunohistochemistry showed lymphocytic infiltrates in both flanks of the B4B8FL and B4B8FL/TK groups. The data indicate that in these cells, local secretion of Flt3-L is sufficient to evoke a distant bystander effect but that expression of HSVTK, even after GCV administration, is not. Furthermore, the combination of local Flt3-L and HSVTK production, together with GCV administration, does not enhance the distant bystander effect produced by Flt3-L alone.