. Author manuscript; available in PMC: 2019 May 27.
AbstractLung cancer continues to be the leading cause of cancer mortality in the United States across all races and ethnicities, but it does not affect everyone equally. Individuals with serious mental illness (SMI), including schizophrenia and bipolar disorder, experience two to four times greater lung cancer mortality in part due to high rates of smoking, delays in cancer diagnosis, and inequities in cancer treatment. Additionally, adults with SMI experience patient, clinician, and health care system–level barriers to accessing cancer screening, such as cognitive deficits that impact understanding of cancer risk, higher rates of poverty and social isolation, patient-provider communication challenges, decreased access to tobacco cessation, and the fragmentation of primary care and mental health care. Despite the proven benefits and mandated coverage by public and private payers, lung cancer screening participation rates remain low among eligible patients, below 4% a year. Given disparities in other cancer screening modalities, these rates are likely to be even lower among individuals with SMI. This article provides a brief overview of current challenges in lung cancer screening and describes a pilot collaboration between radiology and psychiatry that has potential to improve access to lung cancer screening for individuals with serious mental illness.
Keywords: Disparities, health equity, lung cancer screening, serious mental illness
INTRODUCTIONLung cancer continues to be the leading cause of cancer mortality in the United States across all races and ethnicities, but it does not affect everyone equally. Individuals from low socioeconomic status, underrepresented minorities, and individuals with serious mental illness (SMI) have worse lung cancer outcomes because they present at an advanced stage of disease at the time of diagnosis [1–8]. For individuals with SMI, worse lung cancer outcomes and mortality are due to a combination of increased lung cancer risks secondary to higher smoking prevalence, in addition to inequities in cancer treatment and challenges navigating a fragmented, complex health care system [9–11]. This article provides a brief overview of the current challenges in lung cancer screening (LCS) and underscores how radiology-led outreach initiatives can increase access to LCS for individuals with SMI.
PATIENTS WITH SMI: A POPULATION VULNERABLE TO LUNG CANCER INEQUITIESSMI, specifically schizophrenia and bipolar disorder, affects nearly 13 million US adults who die 15 to 30 years earlier than individuals without SMI [1–3]. Eighty percent of that premature mortality is due to medical illness, and cancer is the second leading cause [9,10]. Individuals with schizophrenia are two to four times more likely to die from lung cancer due to delays in diagnosis and inequities in cancer prevention, screening, and treatment [11]. This health care gap will continue to widen without the development of targeted interventions. For example, although smoking prevalence has declined to 18% nationally, more than 50% of individuals with SMI currently smoke [12]. Patients with SMI are equally motivated to quit smoking, yet they have less access to smoking cessation and cancer screening programs [13,14]. This is due to multiple factors, including cognitive deficits related to their disorder, increased poverty and social isolation, lack of clinician expertise tailoring communication about cancer care and tobacco cessation to patients with SMI, and the fragmentation of mental health and cancer care [15]. These factors may also influence LCS participation rates for these individuals.
LCS AND PERCEIVED BARRIERS TO SCREENINGLung cancer is the leading cause of cancer mortality in the United States among both men and women, accounting for over one-quarter of all cancer deaths in 2018 [16]. Over 57% of patients with lung cancer present with advanced-stage cancer at the time of diagnosis, which is associated with a 5-year survival rate of 5%. In 2011, the National Lung Screening Trial demonstrated that annual screening for lung cancer in high-risk current and former smokers with low-dose CT (LDCT) reduced lung cancer mortality by 20% [17]. Thus, in 2013 the US Preventive Services Task Force issued a grade B recommendation for LCS with annual LDCT for high-risk individuals aged 55 to 80 years [18]. Furthermore, section 2713 of the Patient Protection and Affordable Care Act has required private insurers to cover LCS without cost sharing since January 2015 [2]. Additionally, CMS has covered LCS shared decision-making (SDM) visits and screening LDCT for eligible members since it issued a coverage directive in February 2015 [19].
Despite the proven benefits and insurance coverage for LCS, only 2% to 5% of the eligible population has been screened [20]. Analysis of 2015 National Health Interview Survey data estimated that 3.9% of 6.8 million eligible smokers in the United States underwent LCS [21]. An analysis of the ACR LCS registry estimated that only 1.9% of 7.6 million eligible individuals were being screened [20]. The slow uptake of LCS is due to patient, clinician, and health care system–level barriers. Barriers identified by patients included lack of awareness of a new cancer screening examination, fear of a cancer diagnosis, challenges in accessing LCS sites, and social stigma from smoking [22–34]. Some of the perceived barriers by providers include unfamiliarity with eligibility criteria, difficulty identifying eligible patients, insufficient time or knowledge to conduct SDM, and skepticism about the benefits of LCS [35–43]. The social determinants of health, a combination of sociodemographic factors (eg, lack of transportation, low socioeconomic status, limited English proficiency), health care system (eg, lack of cost transparency, fewer covered providers, navigating the complex health care system), and cultural factors (eg, perceived stigma, health literacy, cultural competency from providers), are cited as barriers to LCS and may contribute to inequities in LCS for patients with SMI [44].
EARLY DATA: INDIVIDUALS WITH SMIPrevious research conducted at a community mental health clinic affiliated to our institution showed that one-third of older patients with schizophrenia were eligible for LCS (versus 13% in the US elderly population), yet eligible patients had limited knowledge about lung cancer risk [45]. Most participants underestimated how much smoking increased their risk of lung cancer. Additionally, most current smokers reported no assistance by psychiatrists or primary care physicians with smoking cessation. Without the development of multidisciplinary targeted outreach efforts, individuals with SMI will continue to suffer from preventable mortality.
RADIOLOGY 3.0: LCS OUTREACH TO PROMOTE HEALTH EQUITY BY PILOTING A NEW CARE MODELTypically, primary care clinicians have been responsible for leading public health efforts to engage their patients to participate in health preventative services, including cancer screening. They have also been responsible for educating and counseling their patients and conducting SDM encounters. With LCS, radiologists have a unique opportunity to lead population health initiatives to raise awareness about the benefits of LCS and provide value-based care by leading outreach interventions that are designed to reach underserved populations. Specifically, LCS is an opportunity for radiologists to collaborate with psychiatry and primary care to pilot new integrated care models that are tailored for individuals with SMI and have the potential to bridge gaps in care delivery while decreasing preventable mortality.
SDM for LCS and Its ChallengesCMS requires SDM between the patient and the ordering clinician for LCS coverage [46,47]. The SDM process includes recognizing that a decision is required, knowing and understanding the available evidence, and incorporating the patient’s values and preferences into the decision [48,49]. Elements for the SDM counseling include (1) determination of eligibility; (2) discussion of the benefits and harms of LCS; (3) counseling on the importance of adherence to annual screening and ability or willingness to undergo diagnosis and treatment; and (4) counseling on the importance of smoking cessation or maintenance of smoking abstinence, as well as referral to smoking cessation treatment as appropriate. The SDM counseling typically includes the use of a decision aid, and it can be conducted by a physician or a nonphysician practitioner (eg, physician assistant, nurse practitioner, or clinical nurse specialist) [50]. Radiology practices, including physicians and physician assistants, can potentially engage in this SDM process for LCS in collaboration with primary care, because SDM has been successfully utilized in the interventional radiology setting when discussing preprocedural sedation [51].
The purpose of SDM is to promote optimal care by increasing patient engagement in health care decisions, and it has been deemed to be the “pinnacle of patient-centered care” [40]. However, there are challenges to conducting the SDM counseling for LCS. For instance, clinicians have expressed concerns with conducting SDM, including insufficient time to provide LCS counseling, unfamiliarity with the SDM process, insufficient reimbursement, and inadequate LCS knowledge to provide necessary counseling [26,42,43,52,53]. Furthermore, vulnerable patient populations, such as individuals with SMI, report less interest in SDM [54,55]. Potential LCS barriers for people with SMI include difficulty with abstract thinking to consider cancer risk, limited health literacy, lack of access to transportation, limited social supports, and the lack of integration of mental health care with radiology and primary care [15]. To promote equitable access to LCS for patients with SMI, it is paramount that we modify the SDM process to the capacities and needs of this population.
A Pilot of Person-Centered LCS for Individuals With SMITo promote equitable access to LCS for individuals with SMI, we have developed a partnership between psychiatry and radiology to increase LCS participation for individuals with SMI. By leveraging the trusted setting of a mental health clinic with familiar mental health providers, we are piloting a new integrated care model in which we combine (1) SDM counseling sessions performed in a mental health clinic and tailored to the needs of individuals patients with SMI (eg, utilizing concrete language, repetition, images, and patient stories) and (2) screening LDCT ordered by mental health providers through a streamlined radiology referral process.
Phase 1: Tailoring LCS SDM Counseling to the Needs of Patients With SMI.The SDM educational tool incorporates the necessary elements for LCS counseling, including (1) benefits and harms of LCS with LDCT, need for follow-up diagnostic testing, the risks of over-diagnosis, and total radiation exposure; (2) counseling on the importance of adherence to annual screening and ability or willingness to undergo diagnosis and treatment; and (3) counseling on the importance of smoking cessation or maintenance of smoking abstinence. Further modification of the tool was based on qualitative feedback gathered during multidisciplinary focus group discussions with radiologists, mental health clinicians, and primary care clinicians. Specific recommendations included promoting health literacy by using simpler language at an elementary grade reading level, including concrete information about radiation dose and lack of need for needles (noninvasive procedure) and distinguishing between an MRI and LDCT. This educational tool uses concrete examples and repeats key ideas in small, digestible pieces to promote understanding in a population with deficits in abstract thinking and difficulty with verbal memory and processing speed.
Phase 2: Piloting the Intervention in LCS-Eligible Patients With SMI.To decrease patient burden (eg, additional visits), promote patient trust, and support patient preferences, we proposed that LCS education and counseling sessions could be conducted in small groups in the community mental health clinic and led jointly by mental health clinicians and radiologists. We chose to embed the intervention in the community mental health clinic given this is the primary site where patients with schizophrenia were accessing care. The group format, used effectively for tobacco cessation in the past, could also promote scalability. The counseling sessions are divided into two 30-min sessions held 1 month apart to coincide with the patient’s monthly visit to the clinic. The first session focuses on LCS and the second session focuses on tobacco cessation. Next, participants who complete the SDM counseling sessions and are interested in enrolling in LCS will be offered a streamlined radiology referral pathway to LCS with LDCT, with options that include same-day screening and convenient appointments that are not restricted to a single time-slot.
Phase 3: Assessing the Impact of the Intervention.To assess changes in lung cancer risk knowledge, lung cancer prevention questions that were previously validated in the National Lung Screening Trial will be given to each participant of the SDM group counseling sessions before participating in the first session and after completing both sessions. The survey will assess changes in participant knowledge about lung cancer risk and screening. Additionally, we will track rates of scheduling and completing LCS in this patient population. This novel care model is currently being piloted at our institution and has the potential to increase LCS participation and contribute to decreasing disparities in lung cancer mortality for individuals with SMI.
SUMMARYDespite the proven benefits of LCS, only a small fraction of the eligible population has been screened. The low participation rates constitute a preventable cause of mortality and will widen disparities in cancer outcomes for individuals with SMI. Radiologists can play a vital role to increase equitable access to LCS for this patient population by fostering multidisciplinary collaboration with primary care and mental health clinicians to develop targeted, person-centered outreach. These radiology-led outreach efforts should be tailored to the needs of individuals with SMI to increase LCS participation and maximize the benefits of this potentially lifesaving test. Serving our patients and society by empowering radiologists to advance the practice of equitable radiology care is the core purpose of the ACR.
TAKE-HOME POINTS.As radiologists and stewards of the radiology experience, radiologists can be leaders in innovative approaches to provide equitable and high-quality care to all our patients.
Increased awareness of the LCS challenges faced by patients and referring providers allows radiology practices to develop multidisciplinary efforts to broadly and equitably implement LCS.
Radiologists can play a key role in ensuring that eligible patients have equitable access to LCS.
We thank Catherine R. Pappano.
This work was supported by the American Cancer Society Institutional Research Grant Award 128592-IRG-15-171-04.
Efren J. Flores, MD, reports an American Cancer Society Institutional Review Grant to conduct a pilot program described in this manuscript. Dr Flores also reports an ACR Innovation Grant that is not related to the preparation of this manuscript. The other authors state that they have no conflict of interest related to the material discussed in this article.
REFERENCESRetroSearch is an open source project built by @garambo | Open a GitHub Issue
Search and Browse the WWW like it's 1997 | Search results from DuckDuckGo
HTML:
3.2
| Encoding:
UTF-8
| Version:
0.7.3