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Original Investigation
January 30, 2017

Implementation of Lung Cancer Screening in the Veterans Health Administration

Author Affiliations
  • 1Veterans Health Administration National Center for Health Promotion and Disease Prevention, Durham, North Carolina
  • 2Veterans Health Administration National Radiology Program Office, Durham, North Carolina
  • 3Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina
  • 4Department of Medicine, Duke University Medical Center, Durham, North Carolina
  • 5Department of Medicine, Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota
  • 6Department of Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon
  • 7Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
  • 8Pittsburgh Veterans Engineering Resource Center, Pittsburgh, Pennsylvania
  • 9Veterans Health Administration National Oncology Program, Durham, North Carolina
JAMA Intern Med. Published online January 30, 2017. doi:10.1001/jamainternmed.2016.9022
Key Points

Question  What are the implications for patients and staff of implementing a proactive, population-based, comprehensive lung cancer screening program in a large, multi-site health care system?

Findings  This clinical demonstration project showed that, in Veterans Health Administration facilities, development and implementation of a comprehensive lung cancer screening program is a complex and challenging undertaking and that most patients will have findings that require follow-up; however, few patients will have early-stage lung cancers.

Meaning  Implementation of a comprehensive lung cancer screening program requires significant clinical effort for as-yet uncertain patient benefit.

Abstract

Importance  The US Preventive Services Task Force recommends annual lung cancer screening (LCS) with low-dose computed tomography for current and former heavy smokers aged 55 to 80 years. There is little published experience regarding implementing this recommendation in clinical practice.

Objectives  To describe organizational- and patient-level experiences with implementing an LCS program in selected Veterans Health Administration (VHA) hospitals and to estimate the number of VHA patients who may be candidates for LCS.

Design, Setting, and Participants  This clinical demonstration project was conducted at 8 academic VHA hospitals among 93 033 primary care patients who were assessed on screening criteria; 2106 patients underwent LCS between July 1, 2013, and June 30, 2015.

Interventions  Implementation Guide and support, full-time LCS coordinators, electronic tools, tracking database, patient education materials, and radiologic and nodule follow-up guidelines.

Main Outcomes and Measures  Description of implementation processes; percentages of patients who agreed to undergo LCS, had positive findings on results of low-dose computed tomographic scans (nodules to be tracked or suspicious findings), were found to have lung cancer, or had incidental findings; and estimated number of VHA patients who met the criteria for LCS.

Results  Of the 4246 patients who met the criteria for LCS, 2452 (57.7%) agreed to undergo screening and 2106 (2028 men and 78 women; mean [SD] age, 64.9 [5.1] years) underwent LCS. Wide variation in processes and patient experiences occurred among the 8 sites. Of the 2106 patients screened, 1257 (59.7%) had nodules; 1184 of these patients (56.2%) required tracking, 42 (2.0%) required further evaluation but the findings were not cancer, and 31 (1.5%) had lung cancer. A variety of incidental findings, such as emphysema, other pulmonary abnormalities, and coronary artery calcification, were noted on the scans of 857 patients (40.7%).

Conclusions and Relevance  It is estimated that nearly 900 000 of a population of 6.7 million VHA patients met the criteria for LCS. Implementation of LCS in the VHA will likely lead to large numbers of patients eligible for LCS and will require substantial clinical effort for both patients and staff.

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