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IIR 16-003 – HSR Study

IIR 16-003
Lung Cancer Screening: Building Blocks for Effective Implementation and Partnership
Christopher G. Slatore, MD MS
VA Portland Health Care System, Portland, OR
Portland, OR
Funding Period: January 2016 - December 2018
Veterans have a high risk of lung cancer and VA is currently implementing CT screening for this population, making it imperative to improve our ability to deliver high quality care to this very large group. After 3 annual screening CT scans, 39% of individuals in a recent lung cancer screening trial had a pulmonary nodule detected that required further evaluation. Our ability to provide Veteran-centric lung cancer screening and pulmonary nodule care is hindered by several gaps in our understanding of the pulmonary nodule evaluation process.

Aim 1: Develop and validate a predictive model of lung cancer risk among a cohort of Veterans with incidentally-detected pulmonary nodules. Rationale: A prognostic model would enable clinicians and patients to improve counseling and access to knowledge by providing personalized, Veteran-centric care outside of specialty settings. Aim 2: Evaluate healthcare system resource utilization amongst a cohort of Veterans with incidentally-detected pulmonary nodules. Rationale: Understanding the resources utilized by Veterans and their clinicians will enable increased safety, efficiency, and standardization which in turn will allow increased access to quality care. Aim 3: Develop and validate an algorithm based on routinely collected clinical data to identify Veterans with a pulmonary nodule diagnosis.

We will conduct a comprehensive review of patients in pulmonary nodule registries at the VA Portland Health Care System and VISN 23 to address these knowledge gaps. These registries are linked to other routinely-collected administrative data and are currently clinically used to track patients with nodules.

Using the smoking status from the electronic health record (EHR) and VHA structured administrative Health Factor data we assessed the validity of using administrative data for determining smoking status. We found that there is substantial agreement between VHA administrative data and EHR records for current, former, and never smoking categories. There also substantial agreement for ever compared with never smoking categories. These kappas are in line with previous administrative data validation studies so these data can be appropriately used for research or clinical purposes. Importantly, targeting lung cancer screening to ever smokers using administrative data would only miss 8% of ever smokers, and only 1% of those are current smokers, so these data may be useful for medical centers implementing LCS.These results were recently presented at the American Thoracic Society conference as an abstract.

There are likely opportunities to improve the utility and safety of the nodule evaluation process which will become crucial when lung cancer CT screening is widely adopted. There is currently no mechanism for using administrative data to identify patients with pulmonary nodules because of a lack of a well-accepted diagnostic code. This information gap substantially hinders the ability of researchers, clinicians, and administrators to efficiently evaluate future screening interventions.

External Links for this Project

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Journal Articles

  1. Golden SE, Ono SS, Melzer A, Davis J, Zeliadt SB, Heffner JL, Kathuria H, Garcia-Alexander G, Slatore CG. "I Already Know That Smoking Ain't Good for Me": Patient and Clinician Perspectives on Lung Cancer Screening Decision-Making Discussions as a Teachable Moment. Chest. 2020 Sep 1; 158(3):1250-1259. [view]
  2. Golden SE, Thomas CR, Deffebach ME, Sukumar MS, Schipper PH, Tieu BH, Kee AY, Tsen AC, Slatore CG, Early Stage Lung Cancer Comparative Effectiveness Research Consortium. "It wasn't as bad as I thought it would be": a qualitative study of early stage non-small cell lung cancer patients after treatment. BMC research notes. 2017 Nov 29; 10(1):642. [view]
  3. Melzer AC, Golden SE, Ono SS, Datta S, Triplette M, Slatore CG. "We Just Never Have Enough Time": Clinician Views of Lung Cancer Screening Processes and Implementation. Annals of the American Thoracic Society. 2020 Jun 4. [view]
  4. Zeliadt SB, Greene PA, Krebs P, Klein DE, Au DH, Slatore CG, Heffner JL. A Proactive Telephone-Delivered Risk Communication Intervention for Smokers Participating in Lung Cancer Screening: A Pilot Feasibility Trial. Journal of smoking cessation. 2017 Sep 7; 13(3):137-144. [view]
  5. Slatore CG, Falvo MJ, Nugent S, Carlson K. Afghanistan and Iraq War Veterans: Mental Health Diagnoses are Associated with Respiratory Disease Diagnoses. Military medicine. 2018 May 1; 183(5-6):e249-e257. [view]
  6. Triplette M, Kross EK, Mann BA, Elmore JG, Slatore CG, Shahrir S, Romine PE, Frederick PD, Crothers K. An Assessment of Primary Care and Pulmonary Provider Perspectives on Lung Cancer Screening. Annals of the American Thoracic Society. 2018 Jan 1; 15(1):69-75. [view]
  7. Sullivan DR, Golden SE, Ganzini L, Wiener RS, Eden KB, Slatore CG. Association of Decision-making with Patients' Perceptions of Care and Knowledge during Longitudinal Pulmonary Nodule Surveillance. Annals of the American Thoracic Society. 2017 Nov 1; 14(11):1690-1696. [view]
  8. Lammers A, Slatore CG, Fromme EK, Vranas KC, Sullivan DR. Association of Early Palliative Care With Chemotherapy Intensity in Patients With Advanced Stage Lung Cancer: A National Cohort Study. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer. 2019 Feb 1; 14(2):176-183. [view]
  9. Caverly TJ, Fagerlin A, Wiener RS, Slatore CG, Tanner NT, Yun S, Hayward R. Comparison of Observed Harms and Expected Mortality Benefit for Persons in the Veterans Health Affairs Lung Cancer Screening Demonstration Project. JAMA internal medicine. 2018 Mar 1; 178(3):426-428. [view]
  10. Lareau S, Moseson E, Slatore CG. Exacerbation of COPD. American journal of respiratory and critical care medicine. 2018 Dec 1; 198(11):P21-P22. [view]
  11. Sullivan DR, Ganzini L, Lapidus JA, Hansen L, Carney PA, Osborne ML, Fromme EK, Izumi S, Slatore CG. Improvements in hospice utilization among patients with advanced-stage lung cancer in an integrated health care system. Cancer. 2018 Jan 15; 124(2):426-433. [view]
  12. Rivera MP, Tanner NT, Silvestri GA, Detterbeck FC, Tammem├Ągi MC, Young RP, Slatore CG, Caverly TJ, Boyd CM, Braithwaite D, Fathi JT, Gould MK, Iaccarino JM, Malkoski SP, Mazzone PJ, Tanoue LT, Schoenborn NL, Zulueta JJ, Wiener RS, American Thoracic Society Assembly on Thoracic Oncology. Incorporating Coexisting Chronic Illness into Decisions about Patient Selection for Lung Cancer Screening. An Official American Thoracic Society Research Statement. American journal of respiratory and critical care medicine. 2018 Jul 15; 198(2):e3-e13. [view]
  13. Lammers A, Mitin T, Moghanaki D, Thomas CR, Timmerman R, Golden SE, Thakurta S, Dziadziuszko R, Slatore CG. Lung cancer specialists' opinions on treatment for stage I non-small cell lung cancer: A multidisciplinary survey. Advances in radiation oncology. 2018 Jan 31; 3(2):125-129. [view]
  14. Golden SE, Thakurta S, Slatore CG, Woo H, Sullivan DR. Military Factors Associated with Smoking in Veterans. Military medicine. 2018 Nov 1; 183(11-12):e402-e408. [view]
  15. Lewis JA, Samuels LR, Denton J, Edwards GC, Matheny ME, Maiga A, Slatore CG, Grogan E, Kim J, Sherrier RH, Dittus RS, Massion PP, Keohane L, Nikpay S, Roumie CL. National Lung Cancer Screening Utilization Trends in the Veterans Health Administration. JNCI cancer spectrum. 2020 Oct 1; 4(5):pkaa053. [view]
  16. Wiener RS, Koppelman E, Bolton R, Lasser KE, Borrelli B, Au DH, Slatore CG, Clark JA, Kathuria H. Patient and Clinician Perspectives on Shared Decision-making in Early Adopting Lung Cancer Screening Programs: a Qualitative Study. Journal of general internal medicine. 2018 Jul 1; 33(7):1035-1042. [view]
  17. Kathuria H, Koppelman E, Borrelli B, Slatore CG, Clark JA, Lasser KE, Wiener RS. Patient-Physician Discussions on Lung Cancer Screening: A Missed Teachable Moment to Promote Smoking Cessation. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco. 2020 Mar 16; 22(3):431-439. [view]
  18. Nugent SM, Slatore CG, Ganzini L, Golden SE, Zive D, Vranas KC, Sullivan DR. POLST Registration and Associated Outcomes Among Veterans With Advanced-Stage Lung Cancer. The American journal of hospice & palliative care. 2019 Jul 1; 36(7):564-570. [view]
  19. Slatore CG, Wiener RS. Pulmonary Nodules: A Small Problem for Many, Severe Distress for Some, and How to Communicate About It. Chest. 2018 Apr 1; 153(4):1004-1015. [view]
  20. Miranda LS, Datta S, Melzer AC, Wiener RS, Davis JM, Tong BC, Golden SE, Slatore CG. Rationale and Design of the Lung Cancer Screening Implementation. Evaluation of Patient-Centered Care Study. Annals of the American Thoracic Society. 2017 Oct 1; 14(10):1581-1590. [view]
  21. Burks AC, Gould MK, Silvestri G, Yarmus LB, Sears CR, Arenberg DA, Gonzalez AV, Slatore CG, Tanner NT, Vachani A, Nana-Sinkam P, Fuster MM, Wahidi MM, Tanoue LT, Rivera MP. Safely and Effectively Evaluating Computed Tomography-detected Lung Lesions. Much Work to Be Done. Annals of the American Thoracic Society. 2019 Nov 1; 16(11):1360-1362. [view]
  22. Heffner JL, Krebs P, Johnson H, Greene PA, Klein DE, Feemster LC, Slatore CG, Au DH, Zeliadt SB. Smokers' Inaccurate Beliefs about the Benefits of Lung Cancer Screening. Annals of the American Thoracic Society. 2018 Sep 1; 15(9):1110-1113. [view]
  23. Kathuria H, Detterbeck FC, Fathi JT, Fennig K, Gould MK, Jolicoeur DG, Land SR, Massetti GM, Mazzone PJ, Silvestri GA, Slatore CG, Smith RA, Vachani A, Zeliadt SB, Wiener RS, ATS Assembly on Thoracic Oncology. Stakeholder Research Priorities for Smoking Cessation Interventions within Lung Cancer Screening Programs. An Official American Thoracic Society Research Statement. American journal of respiratory and critical care medicine. 2017 Nov 1; 196(9):1202-1212. [view]
  24. Vranas KC, Jopling JK, Scott JY, Badawi O, Harhay MO, Slatore CG, Ramsey MC, Breslow MJ, Milstein AS, Kerlin MP. The Association of ICU Acuity With Outcomes of Patients at Low Risk of Dying. Critical care medicine. 2018 Mar 1; 46(3):347-353. [view]
  25. Yong PC, Sigel K, de-Torres JP, Mhango G, Kale M, Kong CY, Zulueta JJ, Wilson D, Brown SW, Slatore C, Wisnivesky J. The effect of radiographic emphysema in assessing lung cancer risk. Thorax. 2019 Sep 1; 74(9):858-864. [view]
  26. Sullivan DR, Eden KB, Dieckmann NF, Golden SE, Vranas KC, Nugent SM, Slatore CG. Understanding patients' values and preferences regarding early stage lung cancer treatment decision making. Lung cancer (Amsterdam, Netherlands). 2019 May 1; 131:47-57. [view]
  27. Golden SE, Hooker ER, Shull S, Howard M, Crothers K, Thompson RF, Slatore CG. Validity of Veterans Health Administration structured data to determine accurate smoking status. Health Informatics Journal. 2020 Sep 1; 26(3):1507-1515. [view]
  28. Melzer AC, Golden SE, Ono SS, Datta S, Crothers K, Slatore CG. What Exactly Is Shared Decision-Making? A Qualitative Study of Shared Decision-Making in Lung Cancer Screening. Journal of general internal medicine. 2020 Feb 1; 35(2):546-553. [view]
Journal Other

  1. Vranas KC, Myers T, Lin A, Zive D, Tolle S, Slatore CG, Sullivan DR. Association of Physician Orders for Life-Sustaining Treatment with Inpatient Healthcare Resource Utilization. [Abstract]. American journal of respiratory and critical care medicine. 2019 May 22; A4875. [view]
  2. Shenk JL, Vranas KC, Lin AL, Slatore CG, Sullivan DR. POLST-Discordant Care among Patients Presenting to the Hospital: A Qualitative Analysis. [Abstract]. American journal of respiratory and critical care medicine. 2019 May 19; A1085. [view]
  3. Golden SE, Slatore CG. Response. [Abstract]. Chest. 2020 Oct 1; 158(4):1796. [view]
  4. Vranas KC, Slatore CG, Badawi O, Marhay MO, Sullivan DR, Kerlin MP. The Association of ICU Acuity with Adherence to Evidence-Based Practices is Variable. [Abstract]. American journal of respiratory and critical care medicine. 2019 May 23; A7377. [view]
  5. Vranas KC, Chan B, Slatore CG, Sullivan DR. The Association of Palliative Care with Indicators of Quality Cancer Care Among Patients with Advanced-Stage Lung Cancer. [Abstract]. American journal of respiratory and critical care medicine. 2019 May 19; A1072. [view]
Online News Media Articles

  1. Slatore CG, Melzer A. Lung Cancer Screening is a Process, Not a Scan. American Cancer Society's TheoryLab on Apple Podcasts [Internet]. 2021 May 17: Available from: [view]
Center Products

  1. Slatore CG. American Thoracic Society and American Lung Association Lung Cancer Screening Implementation Guide. American Thoracic Society and American Lung Association American Thoracic Society and American Lung Association; 2018 May 31. [view]

DRA: Cancer
DRE: none
Keywords: Best Practices
MeSH Terms: none

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