Lung cancer, which includes both non–small-cell lung cancer (NSCLC) and small-cell lung cancer (SCLC), is the second most commonly diagnosed cancer in both men and women. NSCLC comprises approximately 84% of all lung cancers.1 According to the National Cancer Institute Surveillance, Epidemiology, and End Results Program, there were an estimated 235,760 new cases of lung cancer diagnosed during 2021, with an estimated 131,880 attributable deaths. These numbers equate to approximately 12% and 22% of all cancers, respectively.2 The overall 5-year survival rate of lung cancer was 21% from 2010 to 2016.3 Notably, early-stage lung cancer has a better prognosis and is often more responsive to treatment than those identified at a more advanced stage.4
The most significant risk factor for lung cancer is smoking. Smoking accounts for up to 90% of all lung cancer cases, with the likelihood of developing lung cancer being 20 times higher in smokers when compared with nonsmokers.5 Another risk factor for developing lung cancer is increasing age, with the median age at diagnosis being 70 years.1 Other risk factors include environmental and occupational exposures, military deployment, prior chest radiation therapy, race/ethnicity, and family history.5
The majority of patients diagnosed with lung cancer present with advanced or metastatic disease, due in part to the low screening rates in the United States.6,7 The goal of lung cancer screening and incidental pulmonary nodule management programs is to detect lung cancer early in an effort to facilitate treatment that is likely to be curative.4 Screening recommendations have been published to contribute to earlier detection, improve patient outcomes, and decrease the burden of lung cancer.8-10
Lung cancer navigators have various roles and responsibilities: patient education, care coordination, assessing patients for barriers to care, and offering resources to address identified barriers. The purpose of this paper is to provide insight into the importance of lung cancer screening, to describe management strategies for incidental pulmonary nodules, and to discuss best practices for lung cancer navigators to incorporate into practice, with an additional focus on biomarker testing as an area of interest, while acknowledging the challenges and intricacies of navigation in early-stage lung cancer.
Impact of Lung Cancer Screening
Data from randomized trials have demonstrated a significant association between reduced lung cancer mortality and low-dose computed tomography (CT) screening.11,12 According to the National Lung Screening Trial eligibility criteria, low-dose CT screening should be completed annually for 3 years on patients aged 55 to 74 years who are at higher risk, including those with a 30-plus pack-year cigarette smoking history and current smoking status, or those who quit in the past 15 years.11 Such screening has led to a 20% reduction in risk in lung cancer mortality and a 6.7% reduction in all-cause mortality compared with the use of chest radiographs.11 According to Pinsky et al, an updated analysis demonstrated an estimated lung cancer mortality risk reduction of 16%,13 while de Koning et al cited results demonstrating a 24% relative risk reduction in lung cancer mortality among high-risk current and former smokers randomly assigned to 4 rounds of low-dose CT screening compared with men who did not undergo screening in the NELSON trial.12 Applying the 2013 US Preventive Services Task Force (USPSTF) criteria, Zahnd and Eberth noted current data from a study of 10 states determined <15% of individuals eligible for lung cancer screening had undergone screening in the previous 12 months.7 Conducting more frequent discussions on lung cancer screening along with actively recommending screening to eligible individuals are key steps to enhancing the potential benefit of lung cancer screening.
Lung Cancer Screening: Best Practices
Current best practices in lung cancer screening recommendations include the USPSTF Lung Cancer Screening recommendations and the Lung Imaging Reporting and Data System (Lung-RADS).
The USPSTF recommends annual lung cancer screening with low-dose CT in adults aged 50 to 80 years who have a 20 pack-year history of cigarette smoking and currently smoke, or who have quit within the past 15 years (Table 1).8 Screening should be discontinued when a patient has not smoked for >15 years, have developed a comorbid condition that substantially limits life expectancy, or if the patient does not have the clinical ability or personal willingness to undergo curative treatment. These recommendations have been updated from the previous version published in 2013.9 Similar screening recommendations have been provided by the Centers for Medicare & Medicaid Services in 2015, with updated recommendations currently in development (Table 1).10
Lung-RADS: To minimize the uncertainty and variation regarding the evaluation and management of lung nodules, standardize the reporting of screening results, and decrease confusion in lung cancer screening result interpretation, the American College of Radiology (ACR) developed the Lung-RADS classification system and endorsed its use in lung cancer screening (Table 2).14,15 Lung-RADS provides guidance for clinicians regarding which findings are suspicious for cancer and the suggested management of lung nodules detected on CT.15
Navigators involved in lung cancer screening programs should be aware of the USPSTF lung cancer screening recommendations and the Lung-RADS classification system. Understanding and identifying the appropriate patient population along with following the aforementioned guidelines for managing nodules allow for more streamlined care coordination. Additionally, having buy-in from the multidisciplinary team and a consistent way to assess metrics (eg, Lung-RADS) contribute to a stronger screening program. Many navigators are involved with the ACR Lung Cancer Screening Registry, which enables them to achieve quality reporting requirements and receive reports each quarter that may help improve and refine screening.
Smoking Cessation as a Component of Lung Cancer Screening
The targeted population for lung cancer screening includes a high prevalence of current everyday smokers.3 Using data from the National Lung Screening Trial, current smokers who underwent screening that was suspicious for, but not diagnostic of, lung cancer were significantly more likely to stop smoking within 1 year.16 Brain et al noted patients undergoing low-dose CT demonstrated a significant increase in both short- and long-term smoking cessation, with the greatest impact among those patients with a positive initial screening test,17 further suggesting that all current smokers enrolled in a screening program should receive information about and access to smoking cessation interventions. Having access to a robust tobacco cessation program will allow cancer risk reduction not only in lung cancer but also in other cancer types. The National Comprehensive Cancer Network guidelines for smoking cessation highlight its inclusion as an integral part of oncology treatment and should be continued throughout the care continuum.18 Additionally, the guidelines provide detailed algorithms on assessment, evaluation, and management, including a relapsed/sustained smoking algorithm.
Lung Cancer Screening: Gaps
Not all lung cancer screening programs have a physician champion who can contribute to the implementation of guideline use across the multidisciplinary team. However, such physician leadership has been identified as a primary component of a successful lung cancer screening program.19 Because of the multimodal approach to lung cancer care, effective communication with patients and with other members of the multidisciplinary team is key. For this reason, thoracic oncology requires a multidisciplinary approach to ensure optimal care. This is best served through multidisciplinary tumor or nodule review boards, which represent an essential component of cancer care in the contemporary era.20
Financial considerations may also contribute to barriers to care through billing issues and coverage gaps. USPSTF recommendations are covered by private health plans, with many also being covered by Medicare. In contrast, Medicaid coverage varies by state for preventive services for lung cancer.21 As a result, many individuals who rely on Medicaid plans, and those who are uninsured, remain without access to screening programs.22,23
Best Practices and Gaps in Incidental Pulmonary Nodule Management
Incidental Pulmonary Nodule Management: Best Practices
Incidental pulmonary nodules are frequently detected on thoracic and abdominal CT imaging completed for various reasons: cardiac symptoms, abdominal symptoms, or trauma.24 To mitigate unnecessary follow-up diagnostic imaging, the Fleischner Society published guidelines for managing pulmonary nodules detected incidentally with CT examinations not performed for lung cancer screening.25,26 The guidelines for solid and subsolid nodules, including multiple solid pulmonary nodules, are summarized in Table 3.26
Incidental Pulmonary Nodule Management: Gaps
Not all incidental pulmonary nodule management programs have a physician champion who can contribute to the implementation of guideline use across the multidisciplinary team. However, such physician leadership has been identified as a primary component of a successful program. Because of the multimodal approach to lung cancer care, effective communication with patients and with other members of the multidisciplinary team is key. For this reason, thoracic oncology requires a multidisciplinary approach to ensure optimal care. This is best served through multidisciplinary nodule review boards, which represent an essential component of cancer care in the contemporary era.20
The inclusion of a pulmonary nodule in a radiology report is helpful, but evidence demonstrates that <40% of patients with incidental nodule findings receive follow-up.27,28 Therefore, improved systems for appropriate identification and follow-up of incidental pulmonary nodule findings are needed, demonstrating an opportunity for navigators in this space.
Best Practices and Barriers to a Multidisciplinary Approach to Care
Multidisciplinary Care Approach: Best Practices
Because thoracic oncology requires a multidisciplinary approach to ensure optimal care, multidisciplinary tumor boards represent an essential component of cancer care in the contemporary era.20 However, nearly 40% of survey respondents from a recent advisory board indicated that <50% of lung cancer patient cases are presented at multidisciplinary tumor boards. With a large proportion of cases not presented at multidisciplinary tumor boards, there may be less coordination of care and cooperation among disciplines. Decisions resulting from multidisciplinary tumor boards have been shown to contribute to changes in diagnosis leading to a more accurate assessment and staging and survival, although unanimous improvement has not been shown.29
A multidisciplinary approach to pulmonary nodule management is also an essential care component. This multidisciplinary approach has been shown to streamline care, optimize follow-up, and improve adherence to recommendations from healthcare providers.30 The management of pulmonary nodules is complex and can be confusing for patients. Navigators provide education, ensure adherence, and facilitate the transitions from the multidisciplinary clinic to individual specialists’ care, which is thought to be a primary driver of high adherence rates that have been observed.
Communication with healthcare providers is crucial for lung cancer navigators and is carried out by any means necessary. Although there are challenges faced in gathering accurate and informative patient information, these are essential elements to ensure the lung cancer navigator is able to assist the patient in timely access to services. The healthcare institution’s information technology department may also help to capture information, such as incidental pulmonary nodule detection, tracking, and treatment. Outside vendor-specific software platforms are also in use (ACR-approved vendors found at www.acr.org/Practice-Management-Quality-Informatics/Registries/Lung-Cancer-Screening-Registry) that will identify, manage, and submit low-dose CT screening patients to the ACR as well as identify areas of growth through analytics. Other software vendors identify, track, and manage independent practitioner networks. Then other vendors assist with nodule clinic and nodule review/tumor board preparation and documentation. Nurse navigators may also compile reports, order genomic testing if needed, determine who is involved in the consult, and ensure the proper people are in place.
Multidisciplinary Care Approach: Barriers
Challenges to creating a functional multidisciplinary team include time commitment, dedication, communication, resources, and leadership.19 Establishing a competent lead clinician is required for the efficiency of the team and to ensure diversity and equal representation of opinions from various specialties. Members of the multidisciplinary tumor board should have broad representation of the varying members of the healthcare team, which may include a pulmonologist, medical oncologist, radiation oncologist, thoracic surgeon, interventional pulmonologist, radiologist, interventional radiologist, pathologist, palliative care specialist, clinical nurse specialist/nurse support, team coordinator, psychologist, clinical trials coordinator, nutritionist, and physical/occupational therapist.19 In the community setting, participants depend on the available specialists and whether there is a dedicated nodule review or tumor board discussion. At some institutions, navigators are not permitted to be in attendance to multidisciplinary tumor boards. Other navigators are unable to contact physicians directly. Providers resistant to accessing navigation services for their lung cancer patient population may see the creation of the navigator role as a ploy to divert patients from their care. In contrast, navigators are well received at some institutions, and their role is widely recognized and understood. Without access to navigators, patients may experience a delay from the identification of abnormal findings to treatment/coordination of care. Earlier navigator involvement may contribute to shorter time frames from initial diagnosis to treatment.
Best Practices and Gaps in Lung Cancer Biomarker Testing
Biomarker Testing: Best Practices
Obtaining biomarker analysis on patients with adenocarcinoma histology may aid in defining further treatment decisions28 (Table 4). According to 67% of recent advisory board participants and 79% of survey respondents, biomarker testing in resectable NSCLC was determined to be best practice and is a high priority at many of their respective institutions.31
Biomarker Testing: Gaps
Gaps regarding biomarker testing for patients with lung cancer pertain to insurance coverage, tissue acquisition and tissue adequacy, and provider and patient/caregiver education. Navigators provide financial advice or assistance with communication to the insurance companies about the medical necessity for biomarker testing. Furthermore, obtaining enough tissue sample to complete all recommended and necessary testing adds an element of challenge. Small lung cancer tissue samples sent for testing can make it difficult to assess mutation status across multiple genes to guide treatment decisions using traditional, sequential, single-gene testing.30 One study demonstrated that 67% of CT-guided core needle biopsies and 46% of fine-needle aspirations had sufficient tumor to successfully determine EGFR, ALK, and KRAS mutation status.33 Physicians are challenged by the increasing number of genes requiring testing with small amounts of available tumor tissue. Different labs have different requirements, emphasizing the need to determine how and what to biopsy to ensure enough tissue is available for all testing requirements. Tissue source may also provide some questions, where some institutions may send the original resected tissue at the time of recurrence, and some perform testing using the newest, most recent tissue.31
Navigator Roles and Responsibilities: Support from Screening Through Treatment
Navigators involved in lung cancer screening and incidental pulmonary nodule management are often respiratory therapists, nurses, and other specialists.34 Disease-specific lung cancer navigators care for patients across the continuum and may be social workers, lay health workers, or nurses.34 Navigator responsibilities are variable but include patient/caregiver education across the care continuum, identification of and removal of patient barriers to care (ie, financial/insurance, transportation, work, child/adult care, social support), recognition and elimination of health system barriers, coordination of care, referral of patients to community resources, and providing emotional support.35-40
Navigators may also serve as an advocate and establish a relationship with the patient and family to ensure the patient makes it to their next appointment. This is of particular importance due to the 55% lung cancer screening adherence rate after a baseline screening.41 Current smokers were less likely to be adherent, whereas white patients, people aged 65 to 73 years, and people who had completed 4 or more years of college were more likely to be adherent. Shusted et al noted that the impact of navigation on compliance with screening programs demonstrated improvements in breast and colorectal cancer; however, no studies to date have assessed the navigation impact on compliance with follow-up in patients with lung cancer.42 Some institutions with larger lung cancer patient populations require navigators to select and focus on patients who need the most multidisciplinary care, usually those with late-stage disease; however, newly diagnosed patients may also present with a high need of care.
Lung cancer navigators may also assist with management of patients with incidental pulmonary nodules. Navigators strive to make things understandable for patients, schedule patients for the next step as quickly as possible, and hand off the patients to a navigator following the procedure for diagnosis of the incidental pulmonary nodule. Navigators may communicate with coordinators of lung cancer screening programs. At some institutions, navigators may receive patients with incidental pulmonary nodules from the hospital, requiring follow-up with the hospital to order diagnostic testing, including scans and biopsies, in anticipation of taking over care coordination moving forward.
It has been proposed that navigation for cancer screening programs should include 3 main phases: navigation to screening, navigation to diagnostic evaluation, and navigation to treatment.42 During screening, navigators reach out to patients to identify those who meet screening eligibility criteria, offering services such as education, shared decision-making, smoking cessation counseling, and scheduling screening appointments. During diagnostic evaluation, navigators assist patients to complete follow-up assessments after receiving abnormal screening tests and facilitate guideline-directed screening follow-up appointments. Navigators may compile reports and order genomic testing for patients. Navigators also monitor follow-up among patients with suspicious findings and help resolve complications resulting from diagnostic assessments. During treatment, navigators help ensure that patients with a diagnosis receive prompt treatment and care to maximize recovery and quality of life.42
Tools and Resources Across the Lung Cancer Care Continuum
It is important for navigators to prepare patients for consult and provide procedural information regarding lung cancer screening/diagnostics and cancer-related information. However, navigators at some institutions are not permitted to distribute branded patient education materials. Another consideration is that patients may not have access to phones/Internet, particularly in rural areas. Therefore, it is necessary to meet patients where they are, assess their literacy, provide information in small pieces, and build on the relationship/trust throughout the continuum of care.
Lung cancer resources for navigators can be found through the American Society of Clinical Oncology (https://education.asco.org), the GO2 Foundation for Lung Cancer (https://go2foundation.org), and LUNGevity (www.lungevity.org).
Lung cancer is the second most common cancer and contributes to approximately 25% of cancer deaths. Lung cancer screening guidelines have been published to facilitate detection of these cancers earlier, improve patient outcomes, and decrease lung cancer burden. Lung cancer navigators have various roles and responsibilities, including patient education, care coordination, assessing patients for barriers to care, and offering resources to address those barriers. Communication with patients and with other members of the multidisciplinary team is key, using any and all possible methods. Physician champions are needed to contribute to successful lung cancer navigation programs. There is room for development of resources and materials to improve education surrounding lung cancer for navigators to share with clinicians and patients.
- American Cancer Society. Key Statistics for Lung Cancer. www.cancer.org/cancer/lung-cancer/about/key-statistics.html. Updated January 12, 2021. Accessed January 5, 2022.
- National Cancer Institute. Cancer Stat Facts: Lung and Bronchus Cancer. https://seer.cancer.gov/statfacts/html/lungb.html. Accessed January 5, 2022.
- National Cancer Institute. Non-Small Cell Lung Cancer Treatment (PDQ). www.cancer.gov/types/lung/hp/non-small-cell-lung-treatment-pdq. Accessed January 5, 2022.
- Midthun DE. Early detection of lung cancer. F1000Res. 2016;5:F1000.
- Alberg AJ, Brock MV, Ford JG, et al. Epidemiology of lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e1S-e29S.
- Howlader N, Forjaz G, Mooradian MJ, et al. The effect of advances in lung-cancer treatment on population mortality. N Engl J Med. 2020; 383:640-649.
- Zahnd WE, Eberth JM. Lung cancer screening utilization: a behavioral risk factor surveillance system analysis. Am J Prev Med. 2019;57:250-255.
- US Preventive Services Task Force; Krist AH, Davidson KW, Mangione CM, et al. Screening for lung cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325:962-970.
- Moyer VA. Screening for lung cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160:330-338.
- Centers for Medicare & Medicaid Services. Screening for lung cancer with low dose computed tomography (LDCT). www.cms.gov/medi care-coverage-database/view/ncacal-decision-memo.aspx?proposed= N&NCAId=274&NcaName=Screening%20for%20Lung%20Cancer%20with%20Low%20Dose%20Computed%20Tomography%20%28LDCT%29&TimeFrame=7&DocType=All&bc=AQAA IAAAAgAAAA%3D%3D. 2015. Accessed January 5, 2022.
- National Lung Screening Trial Research Team; Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409.
- de Koning HJ, van der Aalst CM, de Jong PA, et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382:503-513.
- Pinsky PF, Church TR, Izmirlian G, Kramer BS. The National Lung Screening Trial: results stratified by demographics, smoking history, and lung cancer histology. Cancer. 2013;119:3976-3983.
- American College of Radiology. Lung CT Screening Reporting & Data System (Lung-RADS). www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/Lung-Rads. Accessed January 5, 2022.
- Pinsky PF, Gierada DS, Black W, et al. Performance of Lung-RADS in the National Lung Screening Trial: a retrospective assessment. Ann Intern Med. 2015;162:485-491.
- Tammemagi MC, Berg CD, Riley TL, et al. Impact of lung cancer screening results on smoking cessation. J Natl Cancer Inst. 2014;106:dju084.
- Brain K, Carter B, Lifford KJ, et al. Impact of low-dose CT screening on smoking cessation among high-risk participants in the UK Lung Cancer Screening Trial. Thorax. 2017;72:912-918.
- National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Smoking Cessation. Version 1.2021. www.nccn.org/professionals/physician_gls/pdf/smoking.pdf. Accessed January 5, 2022.
- Hardavella G, Frille A, Theochari C, et al. Multidisciplinary care models for patients with lung cancer. Breathe (Sheff). 2020;16:200076.
- Spira A, Ettinger DS. Multidisciplinary management of lung cancer. N Engl J Med. 2004;350:379-392.
- Bloodworth R, Chen J, Mortensen K. Variation of preventive service utilization by state Medicaid coverage, cost-sharing, and Medicaid expansion status. Prev Med. 2018;115:97-103.
- Rivera MP, Katki HA, Tanner NT, et al. Addressing disparities in lung cancer screening eligibility and healthcare access. An official American Thoracic Society statement. Am J Respir Crit Care Med. 2020;202:e95-e112.
- American Lung Association. Lung Cancer Screening Coverage in State Medicaid Programs. www.lung.org/getmedia/cb086cfd-2fbb-4737-b518-e83cf1fcc411/lung-cancer-screening-1.pdf. Accessed January 12, 2022.
- Sethi S, Parrish S. Incidental nodule management – should there be a formal process? J Thorac Dis. 2016;8(Suppl 6):S494-S497.
- 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;237:395-400.
- MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology. 2017;284:228-243.
- Pyenson BS, Bazell CM, Bellanich MJ, et al. No apparent workup for most new indeterminate pulmonary nodules in US commercially-insured patients. J Health Econ Outcomes Res. 2019;6:118-129.
- Blagev DP, Lloyd JF, Conner K, et al. Follow-up of incidental pulmonary nodules and the radiology report. J Am Coll Radiol. 2014;11:378-383.
- Specchia ML, Frisicale EM, Carini E, et al. The impact of tumor board on cancer care: evidence from an umbrella review. BMC Health Serv Res. 2020;20:73.
- Roberts TJ, Lennes IT, Hawari S, et al. Integrated, multidisciplinary management of pulmonary nodules can streamline care and improve adherence to recommendations. Oncologist. 2020;25:431-437.
- Data on file, REF-135397, AstraZeneca Pharmaceuticals LP.
- National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Non-Small Cell Lung Cancer. Version 7.2021. www.nccn.org/professionals/physician_gls/pdf/nscl.pdf. Accessed January 5, 2022.
- Schneider F, Smith MA, Lane MC, et al. Adequacy of core needle biopsy specimens and fine-needle aspirates for molecular testing of lung adenocarcinomas. Am J Clin Pathol. 2015;143:193-200; quiz 306.
- Data on file, REF-135398, AstraZeneca Pharmaceuticals LP.
- Freeman HP. The history, principles, and future of patient navigation: commentary. Semin Oncol Nurs. 2013;29:72-75.
- Fischer SM, Sauaia A, Kutner JS. Patient navigation: a culturally competent strategy to address disparities in palliative care. J Palliat Med. 2007; 10:1023-1028.
- Shlay JC, Barber B, Mickiewicz T, et al. Reducing cardiovascular disease risk using patient navigators, Denver, Colorado, 2007-2009. Prev Chronic Dis. 2011;8:A143.
- Goff SL, Pekow PS, White KO, et al. IDEAS for a healthy baby – reducing disparities in use of publicly reported quality data: study protocol for a randomized controlled trial. Trials. 2013;14:244.
- Scott LB, Gravely S, Sexton TR, et al. Examining the effect of a patient navigation intervention on outpatient cardiac rehabilitation awareness and enrollment. J Cardiopulm Rehabil Prev. 2013;33:281-291.
- Darnell JS. Navigators and assisters: two case management roles for social workers in the Affordable Care Act. Health Soc Work. 2013;38:123-126.
- Lopez-Olivo MA, Maki KG, Choi NJ, et al. Patient adherence to screening for lung cancer in the US: a systematic review and meta-analysis. JAMA Netw Open. 2020;3:e2025102.
- Shusted CS, Barta JA, Lake M, et al. The case for patient navigation in lung cancer screening in vulnerable populations: a systematic review. Popul Health Manag. 2019;22:347-361.
In partnership with The Lung Ambition Alliance, Sponsored by AstraZeneca
The Lung Ambition Alliance, a global coalition with partners across disciplines in over 50 countries, was formed to combat lung cancer through accelerating innovation and driving forward meaningful improvements for people with lung cancer. We do this by advocating for improved approaches in three areas: screening and early diagnosis, accelerated delivery of innovative medicine, and improved quality care.