February 2013 VOL 4, NO 1
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Assuring Lung Nodule Surveillance: A Navigation Model
Gean Brown, RN, OCN
The American Cancer Society reports that lung cancer is the leading cause of cancer death for both men and women and that more people die each year from lung cancer than from cancer of the colon, breast, and prostate combined.1 With all cancers, early detection is the key to preventing death. In a recent study, known as the National Lung Screening Trial (NLST), it was shown that high-risk individuals, ie, those with a strong smoking history, who received a low-dose spiral computed tomography (CT) screening had a 20% lower mortality from lung cancer than those who were followed with chest x-rays.2 The acceptance of CT lung screening as a standard of care for high-risk individuals is forthcoming. Physician and patient demand warrants that CT screening programs be accessible to those individuals who fit the high-risk criteria. Until CT screens are accepted as standard of care and covered by major insurance carriers such as Medicare, programs need to be in place to follow up on incidental lung nodules. The nurse navigator is the ideal person to coordinate surveillance, and with many self-pay screening programs being offered today, the navigation model has been used successfully.
The Fleischner Society is an international multidisciplinary medical society for thoracic radiology, dedicated to the diagnosis and treatment of diseases of the chest.3 This society developed guidelines for recommended follow-up for incidentally found lung nodules (Table).4 With the guidelines in place, the next steps are to ensure that when a lung nodule is found, the abnormality is communicated to the primary care provider, and that the guidelines are then implemented.
As described by C-Change, a nonprofit cancer collaborative, patient navigation is a program available for patients, their families, and caregivers to assist in overcoming healthcare system barriers and to facilitate timely access to quality medical and psychosocial care from prediagnosis through all phases of cancer care.5 Middlesex Hospital Cancer Center requires the oncology nurse navigators to be oncology certified nurses6; in addition, the thoracic nurse navigators are chemotherapy and biotherapy certified by the Oncology Nursing Society.7 Helping patients through the transition from suspicious finding, to diagnosis, to treatment, and beyond is the goal of the nurse navigator.
The improvement in diagnostic imaging in the past decade has led to an increase in the number of lung nodules found incidentally. A large number are found by emergency department (ED) providers using chest x-rays and chest/abdomen/pelvis CT scans. Patients are often discharged and told to follow up with their primary care provider (PCP). The PCP should be notified of the finding, but many times this is not the case. Communication often breaks down, and these findings are not communicated to the PCP, which may lead to lung cancer being missed at an early stage when cure is possible. Communicating the finding to the PCP is an integral part of ensuring follow-up, but sending copies of reports and instructing patients to follow up with their PCP does not guarantee the appropriate follow-up. Additionally, PCPs do not consistently follow guidelines adapted by radiology for lung nodule follow-up. A system is needed to ensure timely follow-up, and a quality assurance program (QAP) led by a thoracic nurse navigator is 1 solution.
In addition to navigating lung cancer patients through the complex cancer system, the thoracic nurse navigator at Middlesex Hospital Cancer Center assists with lung nodule surveillance. The nurse navigator meets with radiology and develops a plan to have access to the folder in the picture archiving and communication system (PACS), which is the radiology computer system used to store and view imaging studies. The thoracic nurse navigator reviews the folder on a regular basis and contacts the PCP to ensure follow-up. The nurse navigator faxes a form letter to the PCP with the basic information and a copy of the report. Services of the thoracic nurse navigator are offered to assist in obtaining further diagnosis or further surveillance. The nurse navigator also offers pulmonary, thoracic surgery, medical oncology, or radiation oncology consults as appropriate for further diagnosis or treatment. If the PCP doesn’t respond in a timely manner, a follow-up phone call is made to the PCP. For patients without a PCP, a list is provided. A follow-up phone call is made to the patient to ensure that a PCP has been selected. The nurse navigator then contacts the PCP to communicate the abnormal finding and the recommendations.
Buy-in from the PCPs was essential for the program to be successful. This was established through a visit to the PCP by the nurse navigator and a pulmonologist. Details and benefits of the program were provided. The majority of the PCPs stated that they thought the program was a valuable service and applauded Middlesex Hospital for providing the service.
When lung nodules do not require immediate diagnostics, the surveillance program is implemented. The nurse navigator uses a medical information data analysis system, or MIDAS, which is a computerized care management program. Patients are entered in the system to be followed per the Fleischner guidelines.3 When repeat CT scans are warranted, the nurse navigator calls the PCP to ensure that imaging is ordered. The nurse navigator follows up on the results and continues surveillance or diagnostic workup if required.
Emergency department providers are another source of referrals to the program. An electronic referral system was implemented so the ED providers could send a referral to the thoracic nurse navigator. Follow-up is initiated by the nurse navigator in the same manner as with the QAP (Figure 1).
A self-pay low-dose screening program was recently implemented with the nurse navigator at the hub. The cost of the CT screening is $125.00, which is paid in advance when the patient is scheduling the appointment. Patients must have a PCP and may not self-refer. The PCP sends the order to radiology, and when the scan is completed the results go to the nurse navigator and to the PCP. The nurse navigator follows up with a letter to the patient after the PCP has communicated the results to the patient. The nurse navigator letter outlines needed follow-up, offers smoking cessation information (if warranted), and offers the patient information on the Lung Cancer Alliance Give a Scan program.8 The Give a Scan program was set up to increase lung cancer research and is offered at no cost to the patient.8
The QAP, managed by the thoracic nurse navigator, provides a seamless referral system to the Lung Pathway. The Lung Pathway has 3 components: diagnosis, supportive care following diagnosis, and surveillance. Since its inception in July 2010, close to 900 patients with abnormal lung findings have been entered into the PACS; however, not all of the imaging reports were appropriate for the program. Occasionally, findings such as pancreatic or colon masses have been placed in the lung cancer folder by the radiologists. Although these findings require follow-up as well, they are removed from the folder, and an e-mail is sent to the radiologist explaining that the thoracic nurse navigator is not the appropriate person to follow up on that particular finding. Most radiologists comply with the program, and this pathway has led to approximately 50 lung cancer diagnoses in 1 year. This is 5% of all the cases referred to the QAP yearly.
Transitioning patients through to treatment in a timely manner is an important part of the program as well. The average time from scan to diagnosis is 21 days. Those patients who are being evaluated for cancer will have the thoracic nurse navigator involved to coordinate services and appointments as needed and to remove any barriers to care, as well as to offer support and education. In addition to the timely diagnosis of lung cancer, suspicious lung nodules are being followed more consistently. Radiologists have adopted the Fleischner guidelines and have integrated them as part of all reports on abnormal nodules.4 Additionally, the nurse navigator works closely with pulmonary and thoracic surgery to get advice and recommendations on the acuity of the finding and appropriate follow-up. In some instances, the PCP will call to ask for further guidance, and the thoracic surgeon or pulmonologist is able to guide the diagnostic workup.
The goal of the QAP at the Middlesex Hospital Cancer Center is to ensure the appropriate follow-up for incidentally found lung nodules. We found that fewer patients were lost to follow-up and there was an increase in the diagnosis of lung cancer at an early stage. Many of the patients with an abnormal lung finding are on surveillance and are followed according to the guidelines set by the Fleischner Society.4 The surveillance portion of the Lung Pathway has increased markedly since the inception of the QAP (Figure 2).
The QAP gives PCPs guidance and assistance in following patients for 2 years, or longer if warranted. MacMahon and colleagues noted that nodules with ground glass opacity features tend to grow slowly, with a mean volume doubling time on the order of 2 years, whereas solid cancers grow rapidly, with a mean volume doubling time of 6 months.4 Because of the many difficult aspects of lung nodule surveillance, the nurse navigator will usually offer a pulmonary consult to the PCP to ensure appropriate follow-up.
One barrier faced by the nurse navigator starting the QAP was the PCPs’ reluctance to expose patients to radiation from CT scans. The Middlesex radiologists are currently using low-dose CT scans whenever possible in lung nodule follow-up. The radiation in a low-dose CT scan is 25% less than a full CT scan of the chest. Another issue is reminding the radiologists to consistently put the abnormal reports into the designated folder.
The most disturbing issue with lung nodule surveillance is patient anxiety, but finding an early cancer, when it may be curable, greatly outweighs the anxiety. The thoracic nurse navigator is available to support patients who may be anxious about their findings. The nurse navigator does not contact patients on the surveillance portion of the program unless specifically requested by the PCP.
Appropriate follow-up of suspicious lung nodules is an important step in lung cancer surveillance. The future adoption of Medicare coverage for CT lung cancer screening of high-risk individuals may aid in improving outcomes through early diagnosis of lung cancer when it is treatable and curable.
WF is a 66-year-old female with a smoking history of greater than 50-pack years. She quit smoking 8 years ago. WF presented to the emergency department with a complaint of shortness of breath and left-sided chest pain, which has worsened over 2 days. She has no previous heart or lung disease but has a history of high blood pressure. A CT angio pulmonary embolus study was performed, and it revealed bilateral lower lobe pulmonary thromboemboli, a small left pleural effusion, and left lower lobe atelectasis. In addition, the radiologist noted biapical and pleuroparenchymal densities. The radiologist recommended follow-up with a 3- to 6-month CT scan. The abnormal scan was put in the nurse navigator QAP folder. The nurse navigator contacted the PCP and put the patient on the Lung Surveillance Pathway.
Three months later, the PCP was reminded by the nurse navigator to order a follow-up CT scan of the chest; this was done and was read by radiology as having essentially stable lung findings. A repeat examination in 4 to 6 months was recommended. Again the exam was stable, and it was stable for a subsequent imaging study as well; but on the following CT scan, which was 18 months after the first abnormal CT results, the radiologist read the study as a possible slight increase in 1 of 2 right upper lung opacities. He further stated that given the location of the finding, a percutaneous biopsy would prove to be extremely difficult and therefore to consider either a PET scan and/or follow-up CT chest scan in 6 months.
The nurse navigator discussed this report with the lung physician champion, a pulmonologist who decided the patient should be seen by the thoracic surgeon. The PCP agreed to the plan, and WF was seen by the thoracic surgeon, who recommended a thoracoscopic wedge resection of the lesion with frozen section. Results were positive for adenocarcinoma of the lung, and a right upper lobectomy was performed. Her surgical stage was IB (stage pT2a pN0 Mx).
Acknowledgments: The author gratefully acknowledges Molly A. Brewer, DVM, MD, MS, for her help, support, and mentoring. The author also wishes to thank Sarah Jeffrey, BA, for her continued guidance.
Disclosures: Gean Brown, RN, OCN, is on the speakers bureau of Pfizer Inc.
Corresponding author: Gean Brown, RN, OCN, Oncology Nurse Navigator, Middlesex Hospital Cancer Center,
536 Saybrook Road, Middletown, CT 06457; e-mail: firstname.lastname@example.org.
1. Cancer Facts and Figures 2012. American Cancer Society Web site. http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/
documents/document/acspc-031941.pdf. Accessed February 25, 2012.
2. The National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409.
3. Fleischner Society for thoracic imaging and diagnosis. Fleischner Society Web site. http://fleischner.org/. Accessed January 21, 2013.
4. MacMahon H, Austin JHM, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005;237(2):395-400.
5. C-Change. Cancer Patient Navigation Overview. http://www.cancer
patientnavigation.org/index.html. Accessed March 6, 2013.
6. About ONCC. Oncology Nursing Certification Corporation Web site. http://www.oncc.org/about. Accessed November 2, 2012.
7. 2-Day chemotherapy & biotherapy course. Oncology Nursing Society Web site. http://www.ons.org/CNECentral/Chemo/Main. Accessed November 2, 2012.
8. Give a scan. Lung Cancer Alliance Web site. http://www.lungcanceral liance.org/get-involved/help-increase-lung-cancer-research/give-a-scan/. Accessed November 2, 2012.
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