Jasmine
Hi everyone, and welcome to this evening's webinar, The National Lung Cancer Screening Program- What GPs Need to know. My name is Jasmine and I will be your RACGP representative for this evening. We are joined by our presenters Professor Dorota Gertig, Professor Samantha Ellis and Dr Kerry Hancock who is also our GP facilitator for this webinar. Before we get started, I would like to make an acknowledgement of country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to elders, past, present and emerging. I would also like to acknowledge any Torres Strait Islander and Aboriginal colleagues who have joined us online this evening. I would like to introduce you to our speakers for this evening. Dr Kerry Hancock is a GP and chair of the RACGP Respiratory Medicine Specific Interest Group. Kerry's active participation with respiratory organisations, government health services, research activities and the RCGP has enabled her to be involved in a number of activities across many different organisations. Professor Samantha Ellis is a thoracic radiologist and head of thoracic imaging at the Alfred Hospital, Melbourne. Over the last 18 months, Samantha has been at a steering committee member of the LCCS working Group within RANZCR and this working group have worked tirelessly alongside RANZCR, Cancer Australia and many other stakeholders to develop a robust nationwide LCCS program. Professor Dorota Gertig is a Medical Director of the National Cancer Screening Register, playing a key role in the implementation and operations of the Register. Dorota is a respected leader in cancer screening and a member of several key national and state committees on cervical screening, including the National Quality and Safety Monitoring Committee for the National Cervical Screening Program, and I will hand over now to Kerry Hancock for this evening.
Dr Kerry Hancock
Thank you. Jasmine, I presume that you can hear me. You let me know if you cannot. Good evening everyone. It is a pleasure to be here with you. I am hoping that on the screen there you can see the learning objectives. We are truly hoping that following this webinar this evening, you will have a greater understanding of the national lung cancer screening program and particularly your role as a GP to support your eligible patients to participate in this program that you will know how to manage screening results, and Professor Catherine Jones is with us and she will help us do that, and Professor Dorota Gertig will discuss the integration with the National Cancer Screening Register. We only have an hour, so understandably, we are not going to be able to cover all the aspects of the program, but we will try to answer as many questions as we can, as Jasmine said, and this webinar has been approved for one hour of educational activity, however, consider also self-logging any pre-reading or post reading that you do.
Four weeks today, 1st of July, people in Australia will be able to participate in the national lung cancer screening program. Over the next 15 minutes or so, I am going to provide a very general overview of the program and highlight where you can access more information about the program. This slide shows some context around lung cancer in Australia and the potential challenges and opportunities for a national lung cancer screening program. As you are probably well aware, lung cancer is a leading cause of cancer deaths, and sadly, the majority of lung cancer is diagnosed at a late stage and has poorer survival compared to many other cancers. Lung cancer also disproportionately impacts priority population groups, including Aboriginal and Torres Strait Islander people and those living in rural and remote areas. These groups are more likely to smoke daily as well. The National Lung Cancer Screening Program was announced in the 2023/24 budget with the Australian government committing nearly $264 million to establish the program. The Department of Health and Aged Care, which is now actually called the Department of Health, Disability and Aged Care has been designing and implementing this program in partnership with Cancer Australia and the National Aboriginal Community Controlled Health Organisation, The NACCHO, with input from many other organisations as well including the RACGP and information education materials have been focus tested with consumers and health professionals. The program aims to achieve better health outcomes for Australians by detecting lung cancer early and reducing deaths from lung cancer. Early detection can lead to a more effective treatment options and improved outcomes for our patients. The program has been designed to support those who are most at risk of developing lung cancer, with an emphasis on ensuring that it is equitable, accessible and culturally safe. In line with MSAC, the Medical Services Advisory Committee advice, the program involves low dose CT scans every two years for those that are aged between 50 and 70 years old, showing no signs or symptoms of lung cancer that is the asymptomatic of lung cancer, they might not be asymptomatic completely, but asymptomatic of lung cancer and have a history of at least 30 pack years of cigarette smoking and are still smoking or have quit in the past ten years. Healthcare practitioners will work with individuals to determine if they are eligible for the program and if they are, a medical practitioner, usually a general practitioner, will refer them for lung screening.
For the last two years, the Department of Health and Aged Care, as I said now the Department of Health, Disability and Aged Care has been designing and implementing this program in partnership with those people that I said before. All these listed work streams have been underpinned by program governance and stakeholder consultation, and the program governance has included two main committees. There is a Program Advisory Group, which has membership from all the state and territory health departments to prepare the secondary and the tertiary services for the workload associated and anticipated with the new program, and then there has been the Expert Advisory Committee, which is a key multidisciplinary advisory group, including representation from the RACGP as well as a number of working groups underneath that expert advisory committee. The clinical workstream includes the design and the operation of the screening and assessment pathway, the clinical guidelines the program materials, the workforce education, the data linkage that we will a little bit more about maybe from Dorota and the program research, the monitoring which is really important and the quality and safety, all these workstreams are incredibly important and the subsequent evaluation of the program as well.
These are the fundamental and foundational elements of the program. You see that there are two program specific MBS item numbers. Importantly, these MBS items for the low dose CT scans will be mandatory bulk billing, meaning that there will be no out of pocket costs for the scan for participants. There will be one item for the screening low dose CT scan and one for the interval scans that may be necessary in between. The program will use existing low dose CT infrastructure in private and public settings, probably you will hear a little bit more about that from Catherine, and the people living in rural and remote areas and First Nations people, which are priority populations for this program, and because they are two of the most at risk cohorts that are being focused on so as part of the Cancer Australia feasibility work, the existing low dose CT scan infrastructure was reviewed, and this has been used as a base to undertake further analysis and identify potential gaps in areas with a high correlation of for lung cancer, smoking incidence and the priority populations. It is probably no surprise to those of you who are here with us this evening. Since we all know that access to CT services can be limited in rural and remote communities. The department has commissioned the Heart of Australia to deliver mobile lung cancer screening services in rural and remote communities across Australia. The NCSR, which we will hear a little bit more from Dorota shortly, provides a single electronic record, as you know, for each person in Australia participating in national screening programs administered by the Commonwealth Government. As you know, it is the national bowel cancer screening and the national cervical cancer screening program already on the NCSR. So naturally the NCSR is being expanded to include the National Lung Cancer Screening Program as well, and there have been many resources for both health professionals and participants that have been developed as well as a heap of health professional education activities that are starting now rolling out over the last few weeks and continuing on and also public communication strategy that will roll out after the 1st of July. The screening and assessment pathway is associated resources are of course also essential components of the program. We will talk a little bit about that in the next slide. The program is structured around the screening and assessment pathway that is evidence based and tailored to the unique Australian context. The pathway supports the delivery of culturally safe, evidence based consistent care and maximises opportunities for primary prevention, especially smoking cessation. The key steps of the screening and assessment of Pathway include promotion and recruitment and eligibility to check and referral for the low dose CT chest scan, undertaking the scan and reporting of the results and then managing the results based on those scan findings and a suite of program materials and those resources have been developed to support us as health professionals and participants along each step of that screening and assessment pathway.
This shows in more detail the screening assessment pathway, and this overview is in the program guidelines and resources, let us look at some of it in a little bit more closely, and where GPs actually fit into it because it looks pretty complicated there. GPs will assess and confirm eligibility for screening and suitability for a low dose CT scan and facilitate the shared decision making that is necessary, and GPs are used to doing this in their day-to-day practice, this is nothing new. Other healthcare providers can assess eligibility and facilitate shared decision making, while health support workers can recommend an eligibility assessment so that as I keep mentioning, there are these suite of resources to support GPs and their patients in this shared decision-making process. The NCSR will support healthcare providers such as GPs to manage the participant's personal information and the participation in the NCSR for lung cancer screening, and as you know, the NCSR already supports those two other programs bowel and cervical program, and most practices are already integrated with the NCSR. Ideally the program would like GPs to enrol their patient into the program through the NCSR interface which is integrated with your clinical software or through the NCSR Healthcare Provider portal. We will hear more about that from Dorota shortly. GPs will then provide their patients with the low dose CT request form. This was created in consultation with GPs and radiologists so that has the essential information required by the radiologist, and we will hear about that from Catherine. The software vendors will at least best practice medical director community care and now MMX will be incorporating the request form into their native software prior to 1st July, and I have on good authority absolutely confirmed that best practice and medical director have already incorporated it. Look it up in your June software updates. I know someone who has actually seen it so I know it is there. General practice, as you can appreciate, will play a significant role and serve as the front door for this program. It is crucial for general practice that they recruit, assess the eligibility and manage participants in the program, and there are four ways that you can see here that participants can enter the program. Practices potentially their administrative staff or maybe or their nursing staff may identify patients which they think will be eligible and invite them to undertake a program eligibility check. We anticipate, though, that many potential participants will be recruited via general practice opportunistically when they are at an appointment for another reason and encouraged to consider the program. Some potential participants who may not have a regular primary care provider, might be approached through alternative access points, for example, a Quitline counsellor hopefully would encourage participants to see their GP, so we call that facilitated entry, and then there will be participants that might hopefully proactively seek an eligibility assessment from their healthcare provider. They might have seen the advertising that is going to be rolling out soon or been encouraged by a carer or a relative. To support organised entry GPs can start working with their practice to identify eligible patients. This might be by utilising existing clinical software integrated audit mechanisms that you already have in place. GPs and practices could establish electronic medical record-based prompts, they could check practice records, send invitations to potential participants for example, those patients aged between 50 and 70 whose record indicates that they smoke, you may not know the actual pack year history from the EMR until you actually see them, but it is certainly at least an opportunity to discuss smoking cessation and highlight their file for future reassessment, or they might be eligible at that time that you see them. There are GP practices who have already been working with their PHs and gathering information from their GP software, analysing it and feeding it back to the practice to support development of practice level registries. Just to emphasise that eligibility criteria again, the age range that was set by MSAC, the Medical Services Advisory Committee and they looked at a range of factors including ensuring cancer screenings offered to people for whom the benefits of screening have been shown to outweigh any potential harms, as well as the cost effectiveness, of course, of the program. The eligibility criteria requires that the participants be asymptomatic of lung cancer, as smoking is a leading behavioural risk factor for numerous health outcomes, and participants enter the program via an appointment with a healthcare provider, it is quite likely that potential participants may have signs and symptoms of other illnesses you know, cough, for example, in patients with COPD or shortness of breath in those with ischaemic heart disease. It is important to make the distinction that participants experiencing signs and symptoms of other illnesses, but it is not lung cancer are not excluded from the program, so eligibility is determined by signs and symptoms of cancer, not the general health of the participant. If a patient does have signs and symptoms suggestive of lung cancer, then as a GP, we would expect that you investigate those symptoms in accordance with the Cancer Australia guide for investigating Symptoms of Lung cancer, and that is a really lovely guide to look at, and there are some educational resources around that as well. The program guidelines note that smoking status is only assessed on entry into the program. If a participant becomes a former smoker and that history exceeds ten years while they are still in the screening process, they are eligible to continue screening until they exit the program. The single biggest risk factor, as you are well aware for lung cancer is tobacco smoking and evidence of benefits of lung cancer screening has been shown to be strongest for programs focused on people with a history of smoking. With this in mind, requesting practitioners are advised to advise to use clinical judgement and best estimates to confirm eligibility when calculating participant pack year smoking history that we know it is not an exact science, so you just do the best you can in estimating that pack year history. There are a number of variables that come into play when calculating the pack year history and we understand that you know it can be quite challenging. The program supports a bias for inclusion, so if you have any doubt just include them. If it is 29 years or eight years and you think well it could really be 30, just pop them in and acknowledge the importance of that GPs should exercise their clinical judgement when assessing an individual's eligibility. We are used to doing this all the time. We are currently considering trying to access a pack year calculator to make it a little bit easier. For those who do want to use something like a pack year calculator, but there is those just Google one, there is plenty out there at the moment. Just use your clinical judgement as to whether you think a patient should be included in the in the program. Participant suitability involves the consideration of general health factors and physical ability to access and use CT scanners and the suitability. Somebody might be unsuitable just temporarily and that can change over time. Do not forget about them if they are unsuitable. Make sure that they eventually do get their scan. As there is no program specific MBS item numbers being introduced for eligibility, assessment or enrolment in the program. As GPs, you would use your existing consultation items to support that eligibility assessment, but it might be that you or your staff can also assist participants to make a radiology appointment and provide advice on radiology providers as well as identify and arrange support to get to that low dose CT scan, PH might be able to help with that as well. At each touch point along the screening and assessment pathway does provide healthcare workers, in particular GPs, an opportunity to offer smoking cessation support. This is an important component of an effective and equitable lung cancer screening program. Participants in lung cancer screening programs do have higher quit rates than the general population. There are no requirements, though, for patients to actually quit or participants to quit smoking or attempt to quit smoking to participate in the program, but everyone can offer smoking cessation support, so there will not be any specific smoking cessation resources since there is already plenty of existing materials out there already, but it is well known that stigma can negatively impact on how people who smoke or have a history of smoking engage with lung cancer screening. Specific education modules and brochures have been developed and are currently available to address this, and I will highlight those in a minute. Through these resources, health professionals are encouraged and guided to minimise that stigma and shame associated with tobacco use. I better get cracking because I know that I am at the end of my time, but there is a lot of work that has been undertaken to develop resources associated with the screening and assessment pathways. There are the program guidelines, there is the nodule management protocol, there is the e-learning modules through the Lung Foundation Australia. There are also the additional findings guidelines as well, and there has been a number of webinars as well, and the Royal Australian and New Zealand College of Radiologists has lots of things on their website too. These are, what I am going to show you now, are the ones that I think are the really GP orientated resources. There is a GP resource guide. There is getting your practice ready for the National Lung Cancer Screening Program. There is a FAQ document as well and lots of brochures such as discussing participation and discussing results. The e-learning modules are on the Lung Learning Hub of the Lung Foundation Australia and they cover a number of different topics. It has been lots of work put into trying to roll this program out and making sure that everybody is up-to-date with it. There are a number of resources for participants as well, which you can access on the website, but there is a package of information going out to all GPs as well. I know that as GPs, you are already involved in other national cancer screening programs and you are familiar with the National Cancer Screening Register and supporting patients to findings, you do routinely discuss risk factors such as smoking with your patients, and you manage people with symptoms of lung cancer already to have a further investigation. The only new thing here is that you will be managing patients without symptoms to undertake screening, but you can be well equipped to do this by engaging with the program resources, in particular the e-learning modules and the other resources on the government website and ensuring you are aware of your local referral pathways, check your integration with the National Cancer Screening Register, review the program guidelines, continue to update smoking histories of your patients, identify potential participants by utilising your existing clinical software integrated audit mechanisms, establish prompts in your EMRs as well for current and future potential participants, and consider sending out invitations to potentially eligible participants. As GPs, we want the best for our patients. This screening program is an amazing opportunity to improve lung cancer outcomes here in Australia. GPs and their practice teams can make this program a success, an enormous success by embracing the program and making that difference for our patients and our communities. I am just going to finish here by saying that there is more information about the program available on the government website and there is an email if you have any questions. Thank you for taking the time out to be here with us tonight and let us hear more from Dorota and then from Catherine, and I will finish there because I am a few minutes over time.
Professor Dorota Gertig
Thanks Kerry, and good evening everyone. I will be speaking today about how the National Cancer Screening Register will support the lung cancer screening program as of the 1st of July. I do hope the NCSR is familiar to many of you and that you interact with us regularly to support screening for your patients. The NCSR was enabled by the NCSR legislation in 2016 and presently supports the National Cervical and Bowel Cancer screening programs and is on track to support the lung screening program. It is much more than the name implies, that is more than a register because it really is an interoperable digital platform that supports all of the operations of these cancer screening programs to maximise participation as well as to facilitate timely diagnosis. As a failsafe backup to your follow up processes. The next slide shows how the NCSR supports connected care across the screening ecosystem, and we will be leveraging all of this digital functionality to support lung cancer screening. The participant record is really at the heart of the NCSR. There is a single record across the screening programs, and that record is based on the Medicare record which forms the master record, and we receive a daily feed from Services Australia that updates that demographic information. We support healthcare providers to enrol patients and engage with the program at each step of the screening journey, and there are two main ways for healthcare providers to integrate digitally with the NCSR and the lung cancer screening program, and we know that digital adoption is high when there is a benefit for your patients, as an example, more than 99% of screening histories for the cervical screening program are now accessed digitally. The first channel is the healthcare provider portal where you can submit the relevant eligibility and program forms, update participant information and view the low dose CT scan results. For the cervical program, you can download the screening histories and for the bowel program, you can also order the bowel kits. The same functionality is available through our integrations with clinical information systems and that is best practice medical director and Communicare. We are integrated with 80% of the software used in medical practices, and this method of integration tends to be preferred by GPs as it is more seamless because you can view the NCSR hub within the patient record without a separate login. We are also digitally integrated with all the major pathology laboratories and will leverage this for lung screening. We are in the process of integrating with radiology information systems to receive the structured low dose CT scan reports. They will be electronically received by HL-7 messaging. There are also a range of other functions that support the screening programs described at the top of the slide here, that contact centre and also the participant portal which is accessed via myGov. Patients can access their own information, they can update it. They can view program correspondence, select communication preferences and see their next screening action. There are business intelligence and reporting functions for authorised users as well to access data and reports, and also a range of other government integrations, in particular Medicare and of note for lung cancer screening is that we will be receiving both of the MBS items for screening that Kerry described. The next slide shows a number of the key functions and benefits of the NCSR. The register maximises participation by inviting and reminding participants to screen. It is that call recall function and that is based on Medicare eligibility, but of course lung cancer screening is a targeted screening program. It differs from the other cancer screening programs. We will be inviting and reminding participants after they have been enrolled by their GP. We perform an important failsafe function for following up screen detected abnormalities, and we do this by applying automated and nationally consistent rules that are in line with clinical guidelines. The register also informs continuous improvement and evaluation of the programs and we provide reports to the Commonwealth, the State and Territory program staff and the Australian Institute of Health and Welfare to generate data to support program safety, quality and evaluation as well as to inform policy development and service planning, and then of course, we are connecting all relevant cancer screening stakeholders to enable real time, secure access to participant screening information for all screening stakeholders. The next slide shows how the NCSR will receive program information by leveraging those digital channels that I have described. At the GP visit, the enrolment form is submitted to the NCSR via either the portal or your clinical software integration, and it is an important step and one we hope to make as easy as possible. The radiologist will then conduct an assessment of the low-dose CT scan using the program nodule management protocol that you hear about shortly from Samantha, and they will submit a structured report via electronic messaging which will be sent to the NCSR, and we have been working closely with the radiology sector to ensure that all providers are integrated, but there will be some transitional arrangements for six months if there is a delay in that integration. If the participant is at high risk of lung cancer based on their scan results in other words, a category 5 or 6 result, they will be referred to a specialist or an MDT and the referral form can be submitted via the portal or the clinical software integration. The specialist will send a diagnosis form to the NCSR through the portal, and this will be the main way we receive information on staging and this will also trigger exclusion of participants where relevant, once there is a cancer diagnosis and that form can also be submitted by the MDT coordinator or occasionally may be submitted by the GP and the other way will receive information on the diagnosis is through histopathology reporting and these will be transmitted electronically from integrated laboratories to the NCSR to support reporting of outcomes. We are committed to ensuring high quality and complete data, so we will be using the NBS item numbers for screening as a benchmark and will be actively following up missing information. The NCSR will support the entire screening pathway as shown here based on the program's protocol of action, and this determines the nature and timing of communication to healthcare providers and participants for the program. We are not only capturing the information along the journey, but also sending communications on behalf of the program at those key touch points and they will be by either SMS, mail or occasionally follow up phone call depending on participant preferences, but also upon the urgency of the communication. I will not go through the entire pathway here, but just for example, when you enrol the participant in the program, the NCSR will send a welcome letter. When the scan is completed, we will send correspondence to the healthcare provider and the participant with next steps depending on the scan result and if specialist referral is required, we will trigger failsafe follow up which may include a phone call if we do not receive the necessary information. When the participants are due to rescreen, we will be sending a rescreen invitation and reminders based on the risk rating on the right there. In this way, we are supporting all of the key stakeholders along that screening journey. As mentioned earlier, the program enrolment form contains important information for the program and the reporting radiologist, and it can be completed via the NCSR Healthcare Provider portal or through your clinical software integration. In the next couple of slides, I will show you just some test data within the portal to give you a sense of what to expect when the lung program goes live. This form will open automatically after you have searched for the participant. The provider details will be pre-populated if you are using the portal, and the consultation date will also auto populate, but you can select a different date if you need. Under the organisation details, you can select 'yes' if you work within an ACCHO. Then when you scroll down, you will need to complete the eligibility and participation portion of the form. Based on the eligibility criteria, you will select whether your patient is eligible or not. If you select 'no', the form will finish there. Otherwise you can continue completing the form. You will then confirm whether the patient has received the NCSR privacy information, and whether they want to share their data with the NCSR and receive those notifications. If they choose to opt out or decline having their data stored, they will still be able to claim the MBS item numbers. The NCSR will not receive any of the screening results and will not send any correspondence. They can also choose to suspend NCSR correspondence and remain a program participant. Next, you will confirm whether the patient is suitable for a low dose CT scan, and if not, as Kerry explained, this could be temporary and you can add a date after which they may be suitable.
The next part of the form includes smoking cessation and clinical history, and you can select whether they have been offered smoking support and what type, whether they have a family history. The last part of the form is some demographic and cultural information, and you can select if they need an interpreter service. Once the form is completed, you click on 'Review and Submit' and your patient will be enrolled in the program. This is a targeted screening program. The department would like to closely monitor the operation and reach of the program, which is enabled by this form. It will help improve the program and help the program evaluation. If the form is not completed, there is a backup process to enrol the patient automatically. That is, if an MBS claim for the scan is received by the register without the form, and importantly, the CSR will also follow up if a person is assessed as eligible and enrolled by the GP but then does not complete the scan, so there is a failsafe backup there. Telstra Health also has a range of support materials for GPs, including user guides and videos to help GPs get started with the NCSR and to complete these screening actions. As we prepare for Go Live of the program, I strongly encourage you to register for digital access to the NCSR if you have not done so already. To register for the Healthcare provider portal, you will need a PRODA account and a Medicare provider number. Importantly, you can delegate access to administrative staff to better plan for your clinics obviously with your authorisation. You can integrate your clinical software with the NCSR. Again, compatible software as best practice MedicalDirector and Communicare. This is a one-off registration process to enable you to access the NCSR hub through your clinical software integration. We are continually improving this. I did see a question in the chat I will respond to, but it is a process that we are continually improving. For support, please visit our website where you can access step by step information for integration as well as a video and if you do require additional support, we can arrange to guide you or your practice administrator through the process individually if you contact our contact centre. Thank you, and we look forward to working with you on this important initiative. I would now like to hand to Professor Samantha Ellis.
Professor Samantha Ellis
Thank you, Dorota. Thank you both to Kerry and Dorota for two very comprehensive overviews of both the program and the National Lung Cancer Screening Registry. I am just going to dive a little bit sideways, more into the radiological aspects of the program and how that will impact GPs who are referring hopefully their participants into the program.
What I am just going to try and cover in sort of 20 minutes here is just very briefly what the stepped nodule management means, looking at the low dose CT request form, the additional findings guideline and finally the structured clinical radiological report. I am not going to look in detail at the program entry enrolments, etc. This has been covered comprehensively by Kerry earlier on, but I will just focus on one thing, the suitability for low dose CT. We know about eligibility but we do have to also assess suitability. What that means is assessing each participant from different aspects. One is their weight. If you have got a patient that could be over 200 kg, they may well be above the weight threshold for a CT scan. You do not know what the weight capabilities are of your local provider. If you have any question or any doubt, it is worthwhile ringing that provider rather than having the patient turn up and then be turned away because they actually cannot perform the CT. There are certainly many practices that do have tables that can take over 200 kg, but it is just something to keep in mind. Also, if you have got a patient that cannot lie flat and importantly, if they have got a symptomatic lung infection. If you do think there is a lower respiratory tract infection, please do not refer them straight for their CT because invariably if we find an infiltrate or something that could be masking a nodule, we are only going to end up having to refer the patient back again and repeat CT in anywhere between one and three months' time once the infection has cleared. The other thing also to keep in mind is a patient that has had a CT in the last 12 months prior to the onset of the program, particularly if they had a normal CT chest that can be considered a normal baseline, in which case they are not due again for 24 months or another 12 months on top of that. Similarly, if they have got a scan scheduled for a CT chest for another cause within the next three months, then that can be deferred as well until that scan is performed and that can become their baseline.
This is just a simplified version of the nodule management protocol. All I am really going to focus on here is that there are six main categories from very low risk, which are those that go back to 24 month screening with essentially a normal scan or some very, very tiny nodules that might be 1 to 2 mm in size all the way through to the high risk and the very high risk, which are called category 5 and 6, and they are referred to a respiratory physician linked to an MDT. The risk groups in between, from low to moderate risk, have got nodules that have been found and dependent on the nodule morphology, they will be reassessed at an interval that is deemed appropriate by the nodule guidelines. They are very strict guidelines and they are very detailed in terms of what to do with each nodule. The patient will then fall into a follow up scheme for that nodule until it is eventually either they refer upwards to the multidisciplinary team because they have got a growing nodule or they actually end up de-escalating back down to routine biennial scans when it is deemed to be benign or it actually resolves.
Just look at it a little bit more. It is what we call stepped management. If you have got an individual who is come in, they have got a category 4 nodule which recommends a three-month CT. If they come back for that scan and that nodule is stable or has reduced in size, they step back a category and they keep stepping back a category until they end up back at category 1 and back to routine 24-month biennial screening. You will notice, however, that there is a repeat cycle in category 2 or at the 12-month level, and that is actually to mimic our routine clinical practice where we do not deem a nodule benign until it has shown stability over 24 months. Even if someone has had a three, a six and a 12-month scan, they have not reached the 24-month window yet. They need to repeat the 12-month scan and then we can happily and confidently put them back into the routine 24-month screen.
We are just moving on to the low dose CT request form. Some important pointers here and I will show you the request in a moment. It is the requesting practitioner's responsibility to ensure the participant is eligible. It is not the responsibility, for instance, of the clerical staff at the radiology practice to confirm that. On that request form, you will also need to tick a box to confirm whether it is a baseline scan, their first scan for the program or just a routine two-year scan. In other words, their baseline is normal and they are just having a routine two-year follow up or it is a follow up scan. The reason I make that distinction is there is two different MBS item numbers and the two yearly scans. The baseline and the two-year follow up have a different number to the follow up scan which is a shorter interval scan and we need to know that for billing purposes. A standardised request form is available. This is on either the DOHAC website or it can be integrated into your software. The request can be written in advance and they do not expire.
Next one is an important point and I will reiterate it again when we look at an example of the request form. We need to know when the date of the prior CT was. That is because if the patient is having a follow up scan and it has been recommended for instance they have a six-month scan, if you just write follow up and tick the box, they have no idea what follow up interval you are talking about be it 3, 6 or 12 or also when that month is due because we do not know the date of the prior scan from the prior report. Again, I will show you that on the request in a moment. Lastly, again, always defer the CT if they do have an active current chest infection and wait until that has cleared. Similarly, do try and look back to see if they have had a CT chest in 12 months so that we do not need to do a repeat scan and we can defer it for another 12. Also, similarly, if they are having a routine chest done within the next couple of months.
This is the form. This box here, I want to emphasise this tick box. It says family history of lung cancer in a first-degree relative, and it gives you a definition of what a first-degree relative is there. This must be ticked for the first scan as the patient enters the program. The way we triage patients on their initial study is that we use a risk prediction model, and by that we have multiple tick boxes that we have to put into a calculator that will calculate the risk of a particular nodule becoming malignant in the next two to four years. For instance, if I am looking at a 6 mm nodule, I put in that size, but I also have to say in what lobe the nodule is located, the sex of the patient, the family history of lung cancer, and whether there is radiological evidence of emphysema. All of these factors are put into the calculator, and it puts out a risk prediction for that specific nodule, and then we use our guidelines to know when to recommend that patient come back for a follow up study. If we do not have the family history, we cannot use the risk prediction model and we cannot report that baseline CT.
This is the second thing I want to emphasise. I just mentioned it on the prior screen, the interval scan. You can see there the DOHAC request just has it as a tick, and that is fine. Underneath it says 1, 2, 3, 6 or 12-month interval scan as determined by the report, but because we are looking at this scan on its own, we do not know when or what the date was of the last report. We do not know what interval you are looking for. We need you to write what month interval. Let us say it is a six-month interval scan, but also put the date of the prior report, so the clerical staff know actually when to book that scan for. These are just important small points because otherwise the clerical staff are going to have a lot of trouble trying to work out when to issue this patient's appointment for the scan. It will probably require them going into the registry, pulling up the last report and seeing what the recommendation was. If we can avoid those extra steps, it will make the process a lot more efficient.
Now just moving on to the additional findings guidelines. There has been a lot of fear around these guidelines. That is not just from the GP sector but also from the speciality sector where they think they are going to be seeing a lot more patients for workup of incidental findings or additional findings. These were developed to assist radiologists in reporting low-dose CT when they encounter abnormal findings unrelated to lung cancer.
These have been purpose built for our screening population by both local expert radiologists in consultation with multiple other speciality groups. We are looking at cardiologists, endocrinologists, hepatobiliary surgeons, respirologists. It has been a really a huge amount of work to get these guidelines together and for everyone to agree and have a consensus agreement on what to do with these findings. All of the reporting and management recommendations have been based on evidence and expert consensus.
It is not like other screening. If you think about bowel cancer screening, the faecal occult blood test you really do not find any other extraneous or additional findings, similar with breast screening. Very rarely you might find a skin lesion, you might find something in the axilla, but for the most part you are really just looking at breast lesions. You can see just on the imaging below those that you can see a multitude of other things on a CT scan of the chest. That is ranging from things in the mediastinum, in the ribs in the lower neck and in the upper abdomen. It is fraught with all sorts of problems with overreporting. Keep in mind also it is a low dose CT, so the spatial resolution is not the same as that of a normal diagnostic CT. Also, we do not have any intravenous contrast on board which also can assist in characterising lesions. We really are sort of stuck between a rock and a hard place as to how to report these findings. Just to give you an idea of numbers, in the Australian International Lung Screening Trial cohort, which is just a recent trial, they found that 73% of cases actually had an additional finding. Most of those would not be actionable. They are just findings that have just been found like a simple renal cyst, for instance. When you look at those that are considered actionable, they actually require a recommendation. The American College of Radiology Screening Registry, which has been running for a decade. They found 20% of their cases actually have an actionable finding. That is 1 in 5, and that is really quite significant. You can imagine the impact that this might have on the health service and on cost. We also have to look at the benefits, for instance, in cardiovascular disease and osteoporosis. We have to really balance over reporting with low value care. We do not want to increase cost. We do not want to over diagnose. We do not want to cause increased stress for the participants. We do not want to increase the clinical burden.
We want to restrain, and that was our first motto when we were putting these guidelines together that we want to limit the reporting of findings where further workup is unlikely to result in clinical benefit to the participant and this includes things like thyroid nodules, simple liver and renal cysts.
We want to focus our attention on things that are going to provide value. These are things that we actually do not commonly report on CT chests quite absurdly. Things like coronary artery calcified plaque, aortic valve calcification, interstitial lung abnormalities and even reduced bone density.
We have put them into eight systems, nicely colour coded. They are listed in the additional findings guidelines which are very comprehensive. Let us just look at a couple of those just to show you what I am talking about.
This is just one box out of a very long guideline. Let us look at something like emphysema which is obviously going to be quite commonly seen in this patient cohort. Our reporting recommendations are very strict. What you see here is what has to be word for word verbatim put in the report. There is no room to move for the radiologist to go and put in their own words and their own descriptive terms. It is really mild, moderate or severe. There are also explanatory notes for the radiologist in these guidelines into how to quantify these things as well.
In the management recommendations, they are also to be strictly adhered to. You can see the recommendation here for emphysema. You can also see in the far side in the far column, the reference of the source that has been used to derive that recommendation.
Things like interstitial lung abnormalities. The respiratory physicians are very scared about these, but we have been very prudent in only reporting and recommending further intervention on those with what we consider high risk features. Otherwise, those with low risk features for an interstitial lung abnormality will just be reviewed again at next screening CT.
Cardiovascular is important, and as I said, more often than not is not commented on a routine CT chest.
Coronary artery plaque. This has shown to be an independent risk for poor outcomes, both for cardiovascular events, cardiovascular mortality and all-cause mortality. In fact, this particular high risk patient cohort are more likely to die from cardiovascular disease than they are from lung cancer. This increasing severity confers a higher risk and it is underreported on CT.
We will put recommendations. We will classify it as mild, moderate or severe, and we will give a recommendation accordingly.
Just to show you not everything is going to require a further investigation.
Simple liver cysts, do not report. Simple renal cysts, do not report. Anything that looks slightly complex, we will ask for the patient to be referred for a liver ultrasound, for instance, or a renal ultrasound.
Thyroid nodules and multinodular goitre, and I will not go into that in any detail.
Lastly, the structured reporting template. This is important because this is what you are going to see that is going to be coming into your email or your inbox. This has been developed by the Thoracic Society of Australasia as part of the College of Radiologists. It is incorporating the nodule management guidelines and the additional finding guidelines into a reporting template. This is mandated for use for all reports in the program. We cannot deviate. The structure, the layout is mandated and has to be followed.
This is how a sample report might look in a patient who has no nodules. This is going to be the vast majority of participants in the program. About 75% or more will be normal and they will be going to routine biennial screening. You can see it is quite a simple report. You have just got clinical notes, family history of lung cancer, yes or no, which is only relevant for the baseline study. There is a bit on the study information, and then we move into the nodule findings. In this case, if there are no nodules, you answer no to all of those questions and then you move to the additional findings section 'no', and the conclusion straightforward, category 1, recommend 24-month low dose CT. You will note there is a little footnote under the nodule findings which will appear on every report. This is to answer someone's question in the chat box that we are reporting nodules 4 mm and above. The minimum reportable size is 4 mm. They are tiny. We are talking very-very early lung cancers. The second footnote right at the bottom under the conclusion is going to be on every report, where possible, the participant is recommended to return to the same imaging provider for future studies to facilitate image comparison. That is because there is no imaging repository for the program. They are all going to be held by the radiology practice that perform the scan. To facilitate comparisons when they come back for the next study, it is important that they try and stay with the same imaging provider. Otherwise, we are having to look at the registry, see where the last one was done trying to pull it across. If we cannot find it, we really just have to go by the previous report, which is suboptimal rather than actually looking at the scan itself to see if there has been a change in that nodule.
Just a slightly busier report and I have tried to just squeeze it onto one slide, but this is someone that has got two nodules for follow up. Just to show you it is called observed nodule A in the left column and observed nodule B in the right column. There are just more descriptors there because they are being followed up. In this case, we are looking at the volume of the nodule. What volume of the nodule has changed, and in nodule A that is a 33% volume change or a doubling time of 218 days. That is significant and that is considered growth. You can see in red, type of change for that nodule is growing and it has been upstaged to a screening category 5. That means referral to a nodule MDT. The second nodule B, however, has remained stable. You can see its location, its volume measurements and that has been de-escalated from a category 3 to a category 2 because it is stable. In the additional findings, in this particular person, there was some cardiovascular calcification and that has been commented upon. Finally, the conclusion. The highest grade nodule or the highest risk nodule dictates the follow up for this patient. This one has a category 5 nodule. The recommendation is refer to a respiratory physician with links to a lung cancer MDT. In the actionable additional findings, the coronary plaque has been commented upon with a recommendation of clinical review with lifestyle modification and pharmacologic therapy.
That is it for me. I feel like I have done a very quick run through, but I am just mindful of our time. We will not have some time for questions if at all possible. I have just got three QR codes. All of these are found on the RANZCR website. They are publicly available. I would also just like to thank my steering committee as well for their immense effort in putting all of these guidelines together. Thank you very much.
Jasmine
Thank you so much, Samantha. Dorota and Kerry, I just wanted to bring you back. Kerry, I can see that you have got two questions that you wanted to answer.
Dr Kerry Hancock
Yes, I think so. I know we have only got a couple of minutes. Samantha, I sincerely apologise for calling you Catherine because I get you confused with Catherine Jones because you all do the same thing. My apologies for that. Just to keep you a little bit more then because that was wonderful presentation. We do have a couple of questions that I think are appropriate for you. Kate Davy has asked, "would a CT coronary artery calcium score in the last 12 months count as a CT chest?"
Professor Samantha Ellis
No, it will not. They often do not encompass the entire chest. They also may not keep the whole volume of data. I think someone asked about HRCT as well and about whether that is adequate and whether it is different for from what we do here with the CT chest for the screening population. What we do is we scan the patient, we do an entire volume of the chest. That entire data or volume is then kept on a workstation or kept in storage. You have got the full data. A high res is just a reformat of that data into thin slices like 1.25. We are looking at 0.6 or less millimetre slices for this program, tiny. It is just the full volume of data. You need to have all of that available. It has to involve the entire chest and it has to be done appropriately. Most coronary artery schools will not encompass the entire chest. No, I would say that that is not adequate for those purposes.
Dr Kerry Hancock
Another one for you. What happens if the family history information was incorrectly entered due to whatever reason? Will that affect screening?
Professor Samantha Ellis
It does because we have played around with some of the radiology education teaching. We have used the calculator and just altered various parameters while keeping others stable. One of the things we changed was if you had someone who was 70, smoker, nodule in the upper lobe, etc, and all you changed was the family history that risk percentage of that nodule being malignant goes up. There is a bit of a fudge factor. It does not necessarily always move them up into a higher risk category. There is a fair bit of flex to move. It does depend on the other parameters that are in that predictor or in that calculator. As best as possible, we need to have that data. We have already tried to troubleshoot what happens if that box is not filled in because someone does not know the answer or they have forgotten to fill it in. I think most people have said, look, they would probably take it as yes because you are probably going to, if anything, overestimate the risk of cancer in that specific nodule in that individual, but it is better than underestimating it. Again, these are teething problems. We are going to have to work out as we go along. All we can do is really just keep educating people about the importance of that information. But it does change does change.
Dr Kerry Hancock
That is really useful information. We might just do another question. One of our panellists in the background there has actually put something in our chat said "can a patient request a second opinion or a second reading by another radiologist or chest physician?" I have not come across that one before, so I am not sure.
Professor Samantha Ellis
No, it will not get rereported. Once it is reported, it goes to the registry. You cannot pull it back and rereport. No, I just have to say no.
Dr Kerry Hancock
Someone has asked about will there be a recommendation for further referral or MDT including the reporting? I think you have covered that there will be instructions under the nodule management protocol as to how the categories are followed up.
Professor Samantha Ellis
Yes, and if someone is referred to an MDT, it is up to that MDT to determine when that patient is safe to come back to routine screening as well. They might be out of the program for a while because many of the ones, the category 5 and 6, that go to an MDT will actually not have cancer. Sometimes you will find they have been done in regional centres, they have been done by some radiologists that are not that experienced in reading chest CT because we do not have a lot of radiologists doing this. A lot of it will be troubleshooting, I suspect, and that they will just be pushed back into routine screening, but will be evaluating them in an MDT session. Certainly, I think it is going to be less than 50% actually going to be end up being cancer that are come through to us for evaluation in category 5 and 6.
Dr Kerry Hancock
The next question is something we do get asked quite often. It would be worthwhile clarifying now that if a patient has had a low dose CT scan in the program and the CT coronary calcium scoring is subsequently considered, will those images be amenable to having a formal score calculated. Do they need to go and have another calcium score done?
Professor Samantha Ellis
No, it is interesting. One of my colleagues actually would have a good answer for that because he was on the additional findings subcommittee, but he said that we only categorise them as mild, moderate and severe. We have education materials so that we can work out how to classify into those three subgroups. In fact, it correlates extremely well with the with the dedicated coronary artery calcium score. It actually is quite accurate. I do not believe the patient would need to go and have an additional coronary artery calcium score, if they have had a scan in the program. I think they correlate very well.
Dr Kerry Hancock
I think you have answered this already. I do not know their family history of lung cancer, then what do we do on the form?
Professor Samantha Ellis
It is only first degree relative, so I am hoping most people would know.
Dr Kerry Hancock
Say, if they are adopted?
Professor Samantha Ellis
There is a box for unknown, but for the calculator, it is just a yes or no answer. It is up to us, and we have had this discussion. Where do you default? Do you default to 'no' which will maybe underestimate some or do you want to go on the overestimate the risk of malignancy side of things. I do not have an answer to that. I do not think anyone knows what they would do. It is up to the individual radiologist.