The Long Road to Recovery, Part II: Cancer Screening in the U.S. (St. Elizabeth Healthcare, Kentucky)

In the second post in our series on the impact of COVID-19 on cancer screening rates in the U.S., ACCCBuzz visits with ACCC Cancer Program Member St. Elizabeth Healthcare in Kentucky. Our first post explores changes in cancer screening rates at Mary Bird Perkins Cancer Center in Baton Rouge, Louisiana.

Lung cancer is the leading cause of cancer deaths in the U.S., accounting for nearly one-quarter (23 percent) of such deaths in 2019. For those at high risk for lung cancer, screening with low-dose computed tomography (LDCT) can detect disease at an early stage, when there are the most options for treatment and the potential for cure. Since 2013, the United States Preventive Services Task Force (USPSTF) has recommended LDCT screening for lung cancer for specific at-risk patient populations. But, despite this, national lung cancer screening rates are suboptimal. One 2021 study found that, in 2020, only 1 in 20 adults eligible for LDCT lung cancer screening received it.

There are outliers. Take Kentucky, for example. The Bluegrass State has achieved the second-highest screening rate in the nation. More than 17 percent of Kentucky’s eligible patient population has received LDCT lung cancer screening. This accomplishment is the result of a state-wide focus on lessening Kentucky’s disproportionate burden of lung cancer. The state has the highest age-adjusted incidence of lung cancer in the U.S. at 89.4 per 100,000 people, and the highest age-adjusted lung cancer death rate.  In 2018, 23.4 percent of Kentucky adults (aged 18 and older) reported being current smokers, compared to a national rate of 14 percent (2019 data).

Michael Gieske, MD, director of the Lung Cancer Screening Program at St. Elizabeth Healthcare, is passionate about improving lung cancer screening and outcomes. A primary care physician and Kentucky native, Dr. Gieske leads a nationally recognized program that has received recognition from the GO₂ Foundation in 2020 as a Care Continuum Center of Excellence. St. Elizabeth Healthcare’s imaging centers have earned Diagnostic Imaging Center of Excellence designation from the American College of Radiology.

Over the past eight years, St. Elizabeth’s Lung Cancer Screening Program has played an integral role in improving lung cancer screening rates in the state of Kentucky, said Dr. Gieske: “We’ve worked with the University of Kentucky through the KY LEADS Collaborative, a state-based research project aimed at improving the quality of lung cancer screening in Kentucky, and we work closely with the Kentucky Health Collaborative.” The latter comprises 10 hospital systems that encompass more than 70 hospitals and imaging centers. “Through our work, we’ve helped increase adherence to lung cancer screening,” said Dr. Gieske. “We’re looking very specifically at improving screening rates across our state right now.”

St. Elizabeth Healthcare’s mission is to improve the health of the communities it serves. In partnership with St. Elizabeth Physicians—a multispecialty physician group of 451 physicians, 244 advanced practice providers, and 1,500 non-provider associates—the health system delivers care to more than 364,000 patients in Kentucky, Indiana, and Ohio. The integrated network operates six hospitals and 169 St. Elizabeth physician specialty and primary care clinics. Lung cancer screening is offered in eight locations: Covington, Edgewood, Florence, Fort Thomas, Grant County, Hebron, and Owenton in Kentucky, and Dearborn in Indiana. The St. Elizabeth Healthcare Lung Cancer Screening Program participates in the White Ribbon Project, which seeks to raise awareness and destigmatize lung cancer.

A Dramatic Recovery

ACCCBuzz asked Dr. Gieske to share his perspective on how the shifting circumstances of the COVID-19 pandemic may have affected the progress that had been achieved through this highly successful, comprehensive cancer screening program.

In March 2020, St. Elizabeth’s Lung Cancer Screening Program—like others around the country—was significantly affected by the pandemic’s initial surge. “At that time, the program was providing about 350 to 400 LDCT screenings for lung cancer per month,” Dr. Gieske said. With the restrictions mandated by the national public health emergency, LDCT screening dropped precipitously—13 LDCT lung cancer screens were performed in April 2020. The program rebounded quickly, however. “Once things started to return to some semblance of normalcy, we had a pretty dramatic V-shaped recovery,” said Dr. Gieske. “We ended up finishing the year down just 5.8 percent in 2020, compared to what we had done in 2019. Looking at total volume of screens, we finished just shy of 4,000 screens for the year [in 2020].” 

Despite the relentless uncertainty of the COVID-19 pandemic during 2021, St. Elizabeth Healthcare has seen a “significant resurgence” in cancer screening rates, Dr. Gieske said. He credits St. Elizabeth’s ability to rebound successfully to multiple factors. “We really have gone after a lot of our outstanding orders,” Dr. Gieske explained, “and we’ve tried to impress on our patients in the community and our providers that we are returning to normal screening.” With cancer screenings a system-wide priority, St. Elizabeth’s continues to urge patients to come in for them. “We’re on track to do 6,000 LDCT screens this year,” Dr. Gieske said. “We have a very robust program, and we’re averaging 500 screens per month now.” As of November 2021, St. Elizabeth Healthcare’s Lung Cancer Screening Program has completed 20,000 screenings since its launch in 2013.

Spreading the Word

“Taking advantage of multiple touchpoints is key,” Dr. Gieske said. As was the case with the outreach and screening program at Mary Bird Perkins Cancer Center in Louisiana, the marketing team at St. Elizabeth’s was instrumental in spreading the word about its lung screenings. This included promoting cancer screening on the health system’s website, communicating to patients about COVID-19 safety precautions, and reaching out to the St. Elizabeth provider network. “We have a leadership meeting every month where all the managers and directors get together,” explained Dr. Gieske. “Once you get the word out to that team, they get the word to their providers and medical assistants as well. And there is also a lot of communication with our providers through either primary care leadership or through all-provider meetings.”

Dr. Gieske is an advocate for engaging and involving primary care physicians from the start to develop a successful lung cancer screening program. “I’m a huge proponent of primary care input and influence, involving primary care in the process, and identifying a primary care champion for the program,” he said. At the start of the lung screening process, Dr. Gieske supports a “fairly decentralized” approach, so that any provider (primary care, advanced practice provider, pulmonologist, or specialty care provider) can order the screening test. But once that test is ordered, the process transitions to a more centralized, programmatic path for managing scans and incidental findings.

A key component of this comprehensive multidisciplinary approach is nurse navigation. “We’ve had navigation in place at St. Elizabeth for four years,” said Dr. Gieske. “If a patient presents with a lung cancer screen with a lung-RADS category 4 (i.e., highly suspicious), they are presented to our nodule review board, which meets every Monday morning at 7:00 am. If the radiologist sees something on either an incidental or a symptomatic scan, the scan is tagged [in the EHR with] code ‘lung management,’ and the patient’s scan is included for nodule review on Monday morning.”

One early challenge was getting buy-in and gaining the confidence of the primary care community and specialist providers. “That was a little bit of a culture change,” Dr. Gieske acknowledged. “We encourage our providers once the test has been ordered to let the nodule review board, the panel of experts, and the nurse navigators take the reins on the care and the direction of that patient. At this point, we have gained the confidence and buy-in of our providers. We encourage them to take their hands off the wheel and allow a programmatic approach for these patients, especially patients with scans categorized as Lung-RADS 4 or a significant nodule detected through the incidental or symptomatic pathway.”

By the Numbers

At St. Elizabeth Healthcare, screening rates for breast cancer have not yet returned to pre-pandemic levels, Gieske noted. In contrast, screening rates for colon cancer have continued to improve year over year from 2018 through 2021. (See table.)

¹Fedewa SA. Chest. Aug. 3, 2021. https://journal.chestnet.org/article/S0012-3692(21)01364-7/fulltext
²CDC. National Center for Health Statistics. Health, United States, 2019. Hyattsville, MD. 2021.https://dx.doi.org/10.15620/cdc:100685
³CDC Colorectal Cancer Statistics | CDC
*The “eligible St. Elizabeth patient population” referenced above is specific to patients in the St. Elizabeth Healthcare system who are attributed to primary care physicians in St. Elizabeth Healthcare and who meet the 2015 CMS criteria as determined in the EHR.

Among the factors that may account for the slower return to pre-pandemic breast cancer screening rates is patients’ fear of coming into health facilities during the pandemic. One side effect of a patient’s immune system response to the COVID-19 vaccine may be temporary swelling of the lymph nodes under the arm that received the shot. For that reason, the Society for Breast Imaging issued Screening Mammograph Recommendations for Women Receiving the COVID-19 Vaccine, which recommend that patients try to schedule their routine mammograms either before their first vaccination shot or four to six weeks after their last shot.

Remarkably, St. Elizabeth Healthcare has achieved a steady increase in colon cancer screenings over the past four years. “In 2018, we were at 63 percent [of the eligible St. Elizabeth patient population screened],” said Dr. Gieske. “In 2019, we increased to 73 percent, and in 2020, we increased that to 74.2 percent—despite the pandemic.” Improving colon cancer screening is a system-wide priority for St. Elizabeth Healthcare. The successful increase in colon cancer screening may be attributable, in part, to the health system-wide uptake of non-invasive Cologuard tests and FIT tests that do not require individuals to come into a facility for screening, Dr. Gieske said.

The team-based approach implemented for the lung cancer screening program is now being adapted to mammography and colorectal cancer screening, along with a centralized process for outreach data collection. Under the umbrella of the health system’s value-based performance team, in August 2021, St. Elizabeth’s established an eight-person, full-time team of nurse outreach specialists. “They’ve had 938 outreaches for lung cancer screening; 13 outreaches for mammography; and 800 outreaches for colon cancer screening,” Dr. Gieske said. Each outreach effort is documented in the patient’s EHR. For example, a nurse may make note that an appointment is scheduled, the patient refused screening, the nurse left a message, etc.

Data on outreach results will be used to guide future screening approaches. “It’s a very orchestrated approach, and it’s going to be integral to making sure patients don’t fall between the cracks,” said Dr. Gieske. “If you schedule a patient with an appointment and you get them plugged into the system, it’s much more likely they’ll come in for screening.”