• PROPOSAL TITLE: Reducing disparities in lung cancer screening in vulnerable populations 
• PROJECT LEAD(S): Joan O'Mahony
• EXECUTIVE SPONSOR(S): Laurel Bray-Hanin
• ABSTRACT - 

Findings from the National Cancer Institutes National Lung Screening Trial established that lung cancer mortality in specific high-risk groups can be reduced by annual screening with low-dose computed tomography (CT).  Access to these services can reduce inpatient/outpatient healthcare cost with patients being screened at an early stage.  Through community outreach, education, and the development of culturally relevant public health programs, greater support and awareness for screening can help to reduce disparities in screening, diagnosis, and treatment. This project proposal aims to partner with high risk patients, healthcare systems, and community providers to access screening services and offer resources (i.e. grant funding, surveillance, etc.) to high-risk patients in the absence of insurance or other appropriate funding source. If the patient does not fit the criteria, this proposal further aims to procure and utilize a system to track incidental findings to provide early lung cancer care, education, or intervention demonstrating a commitment to patient health and wellbeing. This project is in alignment with the National Institute of Nursing Research (NINR) 2022-2026 strategic plan to inform practice, optimize health, and advance health equity looking through the health equity, population and community health, prevention and health promotion, and systems and models of care lens. Using the center of excellence delivery framework, the Thoracic Surgery Oncology team would like to leverage this work to identify screening gaps, implement best practices, and support the patient and healthcare system positioning UCSF to become the epicenter for lung cancer screening for vulnerable populations in the Bay area.

• TEAM - Shaterra Davis (RN Nurse Manager), Andrew Mullen (PA), Dr. Johannes Kratz (MD)
• PROBLEM - Lung cancer is the third most common cancer in the United States.  Although the incidence of lung cancer has decreased over the past decades, disparities in survival and treatment modalities have been observed for black and white patients with early-stage non-small cell lung cancer. African Americans are one of the populations with a higher incidence and mortality for lung cancer. Like other cancers, most people with early stages of lung cancer do not have symptoms until the disease is well advanced.  Lung cancer can be cured if detected early with a proper screening method. Racial Disparities are predominant, as black males have the highest lung cancer rates of age- adjusted lung cancer incidence among all U.S. racial/ethnic groups, specifically 73.5 per 100,000, versus 63.5 per 100,000 white males.  This racial disparity in incidence persists in both smokers and never-smokers.  Black males also have the highest lung cancer mortality compared with other racial/ethnic groups and develop lung cancer at an earlier age. Black Americans with lung cancer were 15% less likely to be diagnosed early, 19% less likely to receive surgical treatment, 10% more likely to not receive any treatment, and 12% less likely to survive five years compared to white Americans. $23.8 billion was spent on lung cancer care in 2020.Approximately 1 in 4 lung cancer patients will be diagnosed in the earliest stage, when the disease is most treatable and the 5-year survival rate is much higher. In California, 1% of those at high risk were screened, which was significantly lower than the national rate of 6%. 29% of Black Americans with lung cancer in California did not receive any treatment, significantly higher than the rate of 22% among Black Americans nationally, and significantly higher than the rate of 25% among whites in California.
  Over the last five years, the early diagnosis rate in California did not change significantly, which is the opportunity for this proposal. 
• TARGET -  Reducing disparities in lung cancer screening in high-risk patients by increasing access to CT scans in the community and outpatient setting for early detection lung cancer. Expected benefits include improved health and wellness and decreased incidence of patients diagnosed at later stages with lung cancer. 
• GAPS - In 2021, the US Preventative Services Task Force (USPSTF) expanded the eligibility criteria for low-dose computed tomographic lung cancer screening to reduce racial disparities that resulted from the 2013 USPSTF criteria for lung cancer screening recommendations. The recommended changes will nearly double the number of people eligible for lung cancer screening.  Among smokers diagnosed with lung cancer, 32% of African Americans versus 56% of whites were eligible for screening with the previous screening criteria. This recommendations are not being consistently followed, especially during the time of the COVID-19 pandemic. Radiology access (e.g. appointment availability), prioritization of more acute scans, lack of education and awareness of new guidelines, and insurance/financial barriers complicate the problem. 
• INTERVENTION - The Thoracic Surgery Oncology clinic is an ambulatory outpatient clinic with 2 RNs, 2 APP, and 5 MDs who assess, diagnose, and treat all stages of lung cancer. The target population is African American and/or other adults at high risk for lung cancer. The proposed intervention would implement financial, clinical support, education, and advocacy for early lung cancer screening. Long term, we would like to purchase a Lung GPS program that can be integrated into apex system for incidental lung nodule findings as well as database for follow up and surveillance. Funding for CT scan screening for scans is the goal to help build a case for a longer term solution. Other interventions include patient & clinician education seminars and increased marketing. Long-term ideas include mobile units for screening in the community, equip satellite clinics in high risk areas to provide screening for lung cancer in the underserved community. Potential barriers include lack of funding to provide access to screening, lack of access to radiology. The possible adverse effect to the program is finding that with proactive screening, the volume will be high and there is not available funds to cover the volume for those without access to screening. Patient safety is promoted as we have the clinical support to see the patient. 
• PROPOSED EHR MODIFICATIONS- Lung GPS surveillance software integration. Clinical problems to solve with APeX- screening, and system to keep track of patients with incidental findings or smaller nodules. APeX tools (patient lists, reports) or workflows (orders, documentation, alerts) are you using now to achieve this goal? None.
• COST - TBD
• SUSTAINABILITY - If successful, this intervention will provide the baseline for a ROI proposal to sustain the project and seek government funding to use in high-risk and vulnerable populations. The number of incidental findings and level at which cancer is found could provide quantitative support for funding beyond the funding year. Key UCSF process owners are the Thoracic Surgery team, radiology? APEX team?
• BUDGET - Key areas of the project that will require funding include software, payment for CT scan, marketing and education material.