Incidental Lung Nodule Programs: The Tip of the Iceberg for Pulmonary Practices
In this video roundtable discussion, Jaspal Singh, MD, MHA, MHS, interviews Jasleen Pannu, MD, Coral Giovacchini, MD, and Leisa Lackey about the design, growth, and importance of incidental lung nodule programs, including software programs used and a business argument for including a lung nodule program navigator to assist in patient care. This is part two of a three-part series on lung cancer screening.
Additional Resources:
- Tanoue LT, Tanner NT, Gould MK, Silvestri GA. Lung cancer screening. Am J Respir Crit Care Med. 2015;191(1):19-33. doi:10.1164/rccm.201410-1777CI
- Van Haren RM, Delman AM, Turner KM, Waits B, Hemingway M, Shah SA, Starnes SL. Impact of the COVID-19 Pandemic on Lung Cancer Screening Program and Subsequent Lung Cancer. J Am Coll Surg. 2021;232(4):600-605. doi:10.1016/j.jamcollsurg.2020.12.002
- Lake M, Shusted CS, Juon HS, et al. Black patients referred to a lung cancer screening program experience lower rates of screening and longer time to follow-up. BMC Cancer. 2020;20(1):561. doi:10.1186/s12885-020-06923-0
- Meza R, Jeon J, Toumazis I, et al. Evaluation of the benefits and harms of lung cancer screening with low-dose computed tomography: modeling study for the US preventive services task force. JAMA. 2021;325(10):988-997. doi:10.1001/jama.2021.1077
- Haddad DN, Sandler KL, Henderson LM, Rivera MP, Aldrich MC. Disparities in lung cancer screening: a review. Ann Am Thorac Soc. 2020;17(4):399-405. doi:10.1513/AnnalsATS.201907-556CME
TRANSCRIPTION:
Jaspal Singh:
Welcome, everybody. I'm your host, Dr. Jaspal Singh. Welcome to our next episode on lung cancer screening and incidental lung nodule program management. This is part two of our three-part series. This is the incidental lung nodule program aspect and we're titling this The Tip of the Iceberg for Pulmonary Practices. And I say the tip of the iceberg because it's a complex issue that we're starting to understand and unravel as we learn more and more about this. And so with me today are three fantastic guests. They're joining us again. I'm going to have them introduce themselves. Start with Leisa Lackey.
Leisa Lackey:
Hey, thanks for having me. My name is Leisa Lackey. I am a manager of the incidental lung nodule and lung screening program at Atrium Health in Charlotte, North Carolina.
Jaspal Singh:
And then Dr Jasleen Pannu.
Jasleen Pannu:
Hello. Thanks for having me again. I am an interventional pulmonologist at the Ohio State University Medical Center and I have led the lung nodule program development at my center, and I'm passionate about early detection of lung cancer.
Jaspal Singh:
And Dr Coral Giovacchini.
Coral Giovacchini:
Hi, everybody. I'm Coral Giovacchini. I'm one of the interventional pulmonologists at Duke Health and our clinical director. I also co-direct our lung cancer screening program and our incidental nodule and thoracic growth. It's across several sites in our health system.
Jaspal Singh:
Well, thank you all for joining us today. I think this is a very important part. We're talking about incidental lung nodules. So, I'm thinking about patients that I see a lot. For example, I'm a pulmonologist as well, and you have patients who get a CT scan for pulmonary embolism evaluation. You get a patient who gets nowadays, coronary CTs are very commonly done. And so as we do more imaging of the chest and more advanced imaging of the chest and it's become ubiquitous, we're finding things and some of these are nodules and some of them could be potentially malignant, which is a big concern. And so, Leisa, this is obviously something we've talked about for decades across the country in multiple spaces, but you've taken it to a whole new level, all three of you have, in terms of trying to understand the space. Tell us briefly what it means to have an incidental lung nodule program.
Leisa Lackey:
Sure. Here in our healthcare system, we knew that diagnosing lung cancer through screening was certainly an option, but we also knew that there were incidentally detected pulmonary nodules out there. These patients exist in our hospitals today, but how can we identify those patients? Identifying those patients is key and we have found that software has been an important component to identifying those patients. The software uses natural language processing, also referred to as NLP, or artificial intelligence, often referred to as AI. That is reading radiology reports or scanning the EMR and they're looking for language that says pulmonary nodule, pulmonary lesion, ground-glass lesion. That's identifying potential patients that have incidental lung nodules.
Whenever we find those incidental nodules early, we're looking to catch lung cancer early, that's the goal. Whenever we find those early, we can start managing them. We can start making sure that patients are getting scans or they're getting the follow-up care, they're getting the biopsy. We want to change the trend of lung cancer. We know that late stage is typically how we're diagnosing lung cancer or at least a great percentage of it is, but we want to change that to are nearly-stage diagnosis.
And so having software has been key, but a team approach is also important. I have a team where we register a patient, if they have a true incidental pulmonary nodule, we are going to track that patient. We're also going to notify a PCP or an ordering provider, "Hey, your patient has an incidental finding." And then we hand it off to a navigator depending on the size of the nodule. Once the navigator has contacted the PCP or the patient, then we're going to make sure we get the patient scheduled or make sure that the next piece of their journey with respect to that nodule is taken care of.
So, we have some care coordination that happens with respect to scheduling a patient or scheduling a scan. We must have pulmonary access. So when I talked about that team approach, we have the data registry, we have the care coordination and the navigation, but we also need access. So do we have enough pulmonary specialists? Do we need to add possibly a pulmonary advanced provider to see these lung nodule patients and make sure that they get seen in a timely manner, then we can hand off to our interventional pulmonary physicians.
Jaspal Singh:
Wow, that sounds like a complex thing, but I will dumb it down because I'm a simple guy. You have this software, this natural language processing or you call it NLP. This thing finds a nodule, sees a nodule that was detected, and it puts it into some algorithm and program or same secret sausage factory which spits out a report that the patient might see and be freaked out about and see that, "Oh, my god, I might have lung cancer." And they have to suddenly get coordinated in the backend to see someone to talk to them about this abnormality that was found.
The point is well-intentioned, to not ignore things that we were for years probably ignoring and probably missing, and we know that that has significant untoward consequences for some patients. The trick is to find the right patients. And so we're trying to figure out, sort of putting a lot of work into finding these patients, but there's a backend human end to some of this aspect.
And so, Coral, could you talk to us a little bit about how this works on your end from a receiving perspective, if you're patient, if you're a provider seeing your patient being managed by this network, what is that like?
Coral Giovacchini:
Yeah, I think the development of a nodule program, you probably need to make this as easy as possible for both the patient and the referring provider. And certainly, I would echo a lot of what Leisa mentioned there in having a navigator, a person who can help the patient, interpret some of that language that they're seeing as they get to different places and also understand that you might be also scheduled with a provider. For example, my clinic is in the cancer center. It doesn't necessarily mean that we think you have cancer, but you're seeing the interventional pulmonary program in the cancer center. And so I think that it's important to have an actual person there to help navigate rather than just some electronic communication or a letter in the mail that says you have a lung nodule, come see us. It's a little bit of a bulky lift in starting these nodule programs to have a navigator and some coordination there, but I think it's really important for both the referring providers and the patient.
On the receiving end, as the physician starting off, we learned very quickly that if you dump all these patients into the pulmonary referral queue, they're probably not going to get the speed of attention that is needed. And so we actually have a rapid-uptake clinic that's dedicated just to nodules, with a provider on that day who is just seeing nodules. So, their mind is in one direction, one focus, those patients are going to that nodule clinic and that makes things a little bit more streamlined, I think, for everybody. There are incidental findings that require somebody to be on alert for all of those things, that is what the navigator can help with. Certainly, as a provider, there's a little bit of an extra check behind as I'm going to see a lung nodule patient, and that I need to read through everything. And I think it's, again, that role of the navigator that hopefully you've got a multiple check system where you're helping navigate these patients through these multiple findings that they have.
Jaspal Singh:
That's great. So basically you have a way to get to someone relatively quickly because you can imagine the amount of fear, the amount of emotional distress somebody might have when they get these reports that are generated out of these systems. It's important and I think it's great that you've created access. On the same token though, I've seen these patients as well, and I sometimes find that they come in here all scared and fearful, and that nodule is really not a lot of concern for them. I'm more worried about other issues that they might have. They may not realize that they might have COPD, but there was a lot of emphysema on their CT scan. So, by the way, there are other sorts of aspects of their health. Jasleen, if you want to talk a little bit about how you manage some of your practice that way because the nodule is here, but there's a whole lot of other things, and you start to create this catchment of a broad range of patients this way.
Jasleen Pannu:
The way we try to deal with it is not to look at it like a problem but as an opportunity. So if there is some other finding detected, at our institution, we have a diagnostic clinic where any finding that is new and needs more urgent attention can be immediately referred and they can sometimes even see the patient the same day or the next day. Regardless if it's a more chronic finding like COPD and, say, a thyroid nodule or some other such finding that needs to be addressed but can be in a routine way, we prepare on our end to counsel patients on the first call with the help of a navigator as much as possible about the kind of finding that they have and to give them a plan already when they are called. Like, okay, this is your finding and this is the next step towards this. I think a lot of the anxiety from the patients is on the side of what to do next. So having a plan set, like a pathway set in the workflow according to each system and the local services available is key.
And on the same ground, since we started our incidental program, we started with one workflow, and I think in our initial three months we had to revise the workflow six or seven times because we learned so much that actually what we thought would happen may be very different than what is happening. We learned things like patients when they are first getting to know about the findings accidentally, they have another concern going on. Maybe they've just had a heart attack, maybe they've just had a car accident. So, a lot of times they're not very interested in hearing about the nodule, but more wanting to wait and wanting us to call back maybe in a week or two when they're better. So, we started having a more delayed follow-up at least so that we can get them into the system because there may be more urgent issues.
Local workflows are very important. What are the referral systems available? Do we have access to a clinic, like Coral said, how often is that clinic? What is the timeline we can offer? So, when we started, we were offering, we can see you within a week, but a lot of times patients especially at a tertiary center, if you're not in a satellite clinic, may need a longer time to try to schedule that kind of visit, but this may not be the case if this kind of program is being implemented in several satellite clinics, then you can capture the patients early on. So, a lot of local factors make that difference and to work a lot with your navigator as well as your local system on the workflows is extremely important ahead of time.
Jaspal Singh:
No, I think those are some great points. I'm stealing that idea as an opportunity instead of a challenge, right?
Jasleen Pannu:
It's an opportunity. Yes.
Jaspal Singh:
And I think that's fantastic. So, I'm going to summarize what we've talked about so far. Leisa started us out with an important point. It was that these incidental lung nodule programs are complicated, but they're growing. We're going to see more of them as we start to see more advanced imaging, we start to see more regular imaging on a routine basis for a whole variety of reasons. To manage all that though is a whole lot of work and complexities. It requires an understanding of the data coming in and making sense of it through some kind of natural language processing, some type of artificial intelligence, through some ways to extract the right patients to categorize them in terms of risk profile, ideally.
And then to make sure on a human end that the patient end has someone on the back end that they can go to, to manage their expectations a little bit, nuance them, depending on the local resources, depending on the available pathways, and start to test those and refine those as we learn more about these patients. Yes, we're going to potentially learn a lot about some of the challenges individual patients might have, but those are also opportunities to engage with them in other aspects of their health overall. Is that about right?
Jasleen Pannu:
Yeah.
Jaspal Singh:
Did I miss important points here from any of you? Anything else you want to add?
Coral Giovacchini:
Just going to add a little bit about how I think we talk a lot about the importance of a navigator or a structured system, and I think some people can see that as a barrier to starting a program, which, yes and no. I think there is a business case that can quite easily be made for a navigator. And so, in pulling in a lot of these incidental findings, in getting that patient through the health system and quickly navigating this, there's also upfront improvement in care in terms of getting them access to the services that they need, getting the patient into the system. And so that navigator, even though there's a cost upfront for that person, will actually pay dividends in the end to the system. And so there's a lot out there and there are resources for people just about the business case and building that argument into starting a program, which is an important part, and there are resources available for you as you launch into this.
Jaspal Singh:
That's a great point, Coral. Thanks for sharing that. The idea is that don't be intimidated by the idea that maybe mature programs might have more advanced resources. You can start this on a very local level, in your practice, however the case might be. And as long as there's someone kind of helping to navigate that patient's needs in a time-dependent manner, you have a lot of options here to really help people. Is that pretty accurate?
Coral Giovacchini:
Yep.
Jaspal Singh:
Awesome. All right, well, thanks. That was a very enlightening episode on our incidental lung nodule program. We kind of covered some of the highlights. I know we can talk forever, about some of these nuances and all the aspects of it. But on behalf of Consultants360, I want to thank our guests today for recording this episode and hope you join us for the third part of our series. Thank you all.
Jasleen Pannu:
Thank you.
Coral Giovacchini:
Thanks everyone.