Progressing towards implementation of lung cancer screening in the VHA

对退伍军人医疗保健的预期影响：由VHA服务的退伍军人遭受更高的患病率 肺癌的死亡率也比普通人群高。最近的国家肺筛查试验 （NLST）显示肺癌死亡率降低20%，全因死亡率降低7%， 55-74岁吸烟者和既往吸烟者的年度胸部CT筛查。因此，一些新的临床 实践指南建议对中年吸烟者进行CT筛查-这一群体将包括 数百万退伍军人。肺癌的CT筛查具有降低肺癌死亡率的令人兴奋的潜力， 此外，如果不实施，VHA的巨大成本和退伍军人的不良后果的潜力， 体贴的时尚拟议的工作对我们的业务伙伴，即国家人权委员会， 肿瘤学和肺病学项目办公室和国家健康促进与疾病中心 卫生局副局长委派他们进行临床示范， 在VHA实施肺癌筛查项目。 背景：尽管CT筛查在降低肺癌死亡率方面有令人印象深刻的效果， 也有缺点CT组中几乎40%的NLST参与者检测到肺结节， 需要进一步评估以排除癌症-其中95%的结果是假阳性结果。 肺结节评估的指南很复杂，需要临床医生在CT 监测、PET扫描、经胸穿刺活检、支气管镜活检和手术切除;以及 无论是在VHA内部还是在私营部门，都是如此。同时，需要手术的病人 如果在胸外科专业中心进行手术，切除术的效果会更好。鉴于这些 由于这些因素，指南建议肺癌筛查应在具有“全面 这是一个“过程”，用于筛查以及潜在癌症的下游评估和治疗。无论VA 提供者认为筛选的证据是可靠的，哪些站点具有适当的本地环境， 确保成功实施全面的肺癌筛查计划是未知的。 目标：为了满足我们的业务伙伴的需要，并遵循经修订的伙伴关系框架，我们 建议评估与肺癌筛查实施相关的证据、背景和促进因素 在VHA的节目。这将为选择实施肺癌筛查计划的研究中心提供信息， 为这些研究中心定制基于需求的实施策略，并规划和执行临床 我们的业务伙伴正在领导的肺癌筛查示范项目。 方法：目标1：我们将对所有VAMC肺病学家进行在线调查，以评估 在其研究中心实施肺癌筛查的证据和当地背景。目标2：我们将 诊断形成性评价2个VA研究中心已经实施了肺癌筛查计划， 通知临床示范项目的规划和实施，然后进行第三次， 在6个临床示范项目地点之一进行以实施为重点的形成性评价，以评估 实施的成功。

Anticipated Impacts on Veterans Health Care: Veterans served by the VHA suffer both higher prevalence and higher mortality from lung cancer than the general population. The recent National Lung Screening Trial (NLST) demonstrated a 20% reduction in lung cancer mortality and a 7% reduction in all cause mortality with annual chest CT screening among current and former smokers aged 55-74. Accordingly, several new clinical practice guidelines recommend CT screening for middle-aged smokers - a group which would encompass millions of Veterans. CT screening for lung cancer has the exciting potential to reduce lung cancer death, but also the potential for huge costs to the VHA and adverse outcomes for Veterans if not implemented in a thoughtful fashion. The proposed work is of critical importance to our operational partners, the National Program Offices for Oncology and Pulmonology and the National Center for Health Promotion & Disease Prevention, who have been tasked by the Under Secretary for Health with conducting a clinical demonstration project of implementation of lung cancer screening in the VHA. Background: Despite the impressive efficacy of CT screening at reducing lung cancer mortality, CT screening also has downsides. Almost 40% of NLST participants in the CT arm had a pulmonary nodule detected that required further evaluation to rule out cancer - and 95% of those turned out to be false positive findings. Guidelines for pulmonary nodule evaluation are complex, requiring clinicians to choose between CT surveillance, PET scan, transthoracic needle biopsy, bronchoscopic biopsy, and surgical resection; and are not consistently followed either inside the VHA or in the private sector. Meanwhile, patients who require surgical resection have better outcomes if operated on in centers with expertise in thoracic surgery. In light of these factors, guidelines recommend that lung cancer screening be conducted in centers with a "comprehensive process" for both screening as well as downstream evaluation and treatment of potential cancers. Whether VA providers perceive the evidence for screening as robust and which sites have the local context in place to ensure successful implementation of comprehensive lung cancer screening programs is unknown. Objectives: To meet the needs of our operational partners and following the revised PARIHS framework, we propose to assess the evidence, context, and facilitators relevant to implementation of lung cancer screening programs in the VHA. This will inform selection of sites for implementation of lung cancer screening programs, tailoring of needs-based implementation strategies for these sites, and planning and execution of the clinical demonstration project of lung cancer screening that our operational partners are leading. Methods: Aim 1: We will conduct an online survey of all VAMC pulmonologists to assess perceptions of evidence and local context for implementation of lung cancer screening at their site. Aim 2: We will conduct diagnostic formative evaluations 2 VA sites that have already implemented lung cancer screening programs to inform planning and implementation of the clinical demonstration project, and then conduct a 3rd, implementation-focused formative evaluation at one of the 6 clinical demonstration project sites to assess success of implementation.