Partnered research with NCP to evaluate lung cancer screening in the VA

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Lung cancer is the leading cause of cancer-related death for men and women within the United States. Within VA patients, approximately 7,500 cases of lung cancer are diagnosed each year (~3% of US lung cancer cases; and 5,500 deaths occur. Screening high-risk patients with annual low-dose CT (LDCT) has been shown to decrease mortality by 20% as compared to annual chest radiographs in a large randomized clinical trial. Since the release of the National Lung Cancer Screening Trial (NLST) results in August 2011, numerous professional organizations have developed or endorsed guidelines in favor of lung cancer screening in high- risk populations. Given the importance of these findings and the heavy burden of tobacco use among the Veteran population, the Veteran Health Administration (VHA) has undertaken a lung cancer screening clinical demonstration project to assess the clinical and financial burdens on its healthcare system that may come from instituting screening. This project is being rolled out at 8 VHA sites nationally. The VHA lung cancer screening project evaluation team based at the VA Cooperative Studies Epidemiology Center-Durham has been tasked by the VA National Center for Health Promotion & Disease Prevention (NCP) to assess the potential patient population for lung cancer screening, level of patient and provider acceptance of screening, outcomes of screening including nodules suspicious for cancer, incidental findings (e.g. abdominal aortic aneurysms, thyroid nodules, etc.), and lung cancers diagnosed. We will also collect data on number of follow-up radiographic studies and procedures required as a result of screening and time burden on providers to implement screening. This information will be used to estimate the increased provider and equipment resources and budget impact that will result from lung cancer screening implementation. While the benefits of screening are now clearly seen, the cost-effectiveness of such an endeavor is less clear. With a high false-positive rate on LDCT (96.4% in NLST) and a significant number of incidental findings discovered that in turn require further evaluation, understanding the overall cost-effectiveness of such a significant change in routine care must be evaluated. Our long-term goal is to develop a Service Directed Proposal to 1) estimate the expenditure patterns of patients who undergo lung cancer screening and follow-up treatment; 2) estimate the cost-effectiveness of the lung cancer screening program implemented in the VHA healthcare system; and 3) evaluate whether lung cancer risk stratification algorithms can be used to maximize Veterans' health given limited screening resources. However, before we can engage in this research we need to collect patient- and provider-specific data that will be needed for the cost-effectiveness modeling. Because the demonstration project is not considered research, we cannot contact patients for data collection. Being that the project is multi-site also makes collection of time logs of provider tasks difficult. LDCT-based lung cancer screening is a wide-ranging, important task being undertaken by the VA. It will affect hundreds of thousands of veterans and require substantial additional resources to be implemented effectively. Our study will help NCP to promote and implement and lung cancer screening throughout the VA health system.