When Glenna Courtney of Sanders, Ky., in the northern part of the state went to see her family doctor for her annual physical in 2019, she was asked to get a new test she’d never heard of. Due to her smoking history, Glenna met the criteria for a low dose CT (computed tomography) scan to screen for early signs of lung cancer. Her primary care physician wanted to establish a baseline result to use, as she would need to get the scan every year going forward.
Her initial scan was clear, but in 2020 the CT test revealed a nodule that her doctor thought was suspicious. A three-month follow up showed that the nodule was growing, and Glenna underwent surgery to remove it. The biopsy revealed lung cancer, but since the nodule was removed early and no spread was detected, Glenna did not have to undergo chemotherapy, radiation, or any other treatment.
“I tell everybody that I know to get the scan,” she said. “It’s well worth it, your life will be protected by having it.”
Glenna’s screening is one of over 20,000 that have been conducted by the team at St. Elizabeth Healthcare at their hospitals in northern Kentucky and southeast Indiana. St. Elizabeth started recommending low dose CT scans for lung cancer in 2013, and their program has become nationally recognized as a leader in adopting this preventive measure.
Early screening has been especially beneficial to Kentucky, which leads the nation in lung cancer deaths. Historically, most lung cancer patients were not diagnosed until the disease had spread to distant organs – Stage 4 – making it extremely difficult to treat and resulting in a high mortality rate. But over the past decade, the introduction of low dose CT screening in hospitals and clinics has resulted in earlier detection for many lung cancer patients, and as a result has saved lives.
“Through low dose CT lung cancer screening, we found a mechanism where we can go after it – we can find lung cancer in the early stages,” said Dr. Michael Gieske, MD, primary care physician at St. Elizabeth who is the medical director of its Lung Cancer Screening Program. “And when you find it in Stage 1, you can have a greater than 90 percent chance of cure.”
St. Elizabeth’s program has developed over the past eight years to the point where it was named a Care Continuum Center for Excellence (CCOCE) by the GO2 Foundation for Lung Cancer in 2020, one of around 30 such centers in the country. Their program brings together a team of physicians from several disciplines – oncology, radiology, thoracic surgery, and primary care – to work with nurse navigators and staff on a course of care that assesses each patient individually and also educates them about lung disease and smoking cessation.
Dr. Royce Calhoun, MD, was hired by St. Elizabeth to work as a thoracic surgeon as part of the program in early 2016. He said that since he arrived, the number of patients participating in the CT scan screening program who’ve had their cancer diagnosed at Stage 1 is over 50 percent, versus around 12 percent of patients who did not get the preventive screen. Dr. Calhoun’s goal, along with Dr. Gieske and the rest of the St. Elizabeth team, is to make lung cancer screening as commonplace as other more established tests such as mammographies and colonoscopies.
“There’s a lot of people who are at risk, but this is the way we can really move the needle and find it at earlier stages, as opposed to incidental and symptomatic,” he said. “Colon cancer screening and breast cancer screening are the paradigms that lung cancer screening is miles from, but we’re going to continue to work to get there, to make it mainstream.”
St. Elizabeth’s program follows the criteria set by the United States Preventive Services Task Force, which recommends that patients age 50 to 80 who have smoked a pack of cigarettes a day for 20 years (called 20 pack years) get the annual CT scan. If patients quit smoking anytime in the prior 15 years but smoked 20 pack years during their history, they still qualify for the scan.
Patients who meet the criteria are informed about the exam by their primary care physician, as happened with Glenna Courtney. As coordinator, Dr. Gieske said that it’s his responsibility to have all PCPs within St. Elizabeth educate their patients about the value of early detection, which can be difficult due to the stigma of lung cancer as a smoker’s disease that’s often detected after it’s too late.
According to Dr. Gieske, some patients are initially hesitant, “but when you tell them that 50 percent of the patients who are diagnosed with lung cancer are traditionally dead within one year, and the key is to fight this when it’s small instead of waiting until it’s moved along and become symptomatic… it makes a big difference.”
As part of St. Elizabeth’s program, a team of physicians convene a nodule review board. This board, which both Dr. Gieske and Dr. Calhoun sit on, examines all suspicious nodules that turn up on the CT screens and determines whether more testing is needed. Around 97 percent of pulmonary nodules are benign, according to Dr. Calhoun, so considerable expertise is required to assess the imaging of any nodule that is found and determine whether it warrants either further monitoring or intervention.
Dr. Calhoun also sits on a thoracic tumor board each week that plots a course of action for those patients who have been diagnosed with lung cancer. Patients diagnosed with Stage 3 or Stage 4 lung cancer have far more treatment options than existed a decade ago. Those may include chemotherapy, radiation, targeted therapy, and/or immunotherapy.
Although his main focus is on surgery, Dr. Calhoun consults with those patients he has who are smokers about the absolute necessity for them to quit their habit even as they continue receiving treatment. When reviewing patients’ scans, he also points out signs of other respiratory diseases such as emphysema to help convince them to make a difficult, but very rewarding, lifestyle change.
“It’s very clear, and I think this is well described by others, that most people make decisions emotionally,” he said. “And so I try to tap into that sometimes to get them to quit smoking. I appeal to their sense of, ‘What do you want out of this life?’… I’ll play whatever cards I can use to make that connection with them, that it’s time to make a change. The rewards of what I do, they’re innumerable.”
Both Dr. Gieske and Dr. Calhoun acknowledge that around 20 percent of persons who are diagnosed with lung cancer have never smoked. Radon exposure is the second-leading cause of lung cancer, and Kentucky is a high-risk region for radon, but folks with no history of smoking aren’t eligible to receive a low dose CT scan. Dr. Gieske said that medical researchers are currently studying biomarker tests that can reveal DNA fragments from cancer cells, which could lead to the future use of “liquid biopsies” or blood tests that identify different types of cancer.
For now, though, the mission of St. Elizabeth’s Lung Cancer Screening Program is to continue enlisting qualifying patients like Glenna Courtney to undergo low dose CT scans and catching more lung cancer cases before they spread.
“Now that we can find it early, it’s a tremendous reward – We know that these patients are going to see many more Christmases with their family,” Dr. Gieske said. “These patients are our coworkers, they’re our family, they’re our community, and we’re making a tremendous difference.”