Episode #55 Lung Cancer Screening: A Decade of Lessons Learned with Dr. Mary Pasquinelli

Dr. Albert Rizzo: Welcome back to Lungcast, the monthly respiratory health podcast series from the American Lung Association and medical news site hcpive.com. I'm your host, Dr. Albert Rizzo, chief medical officer of the American Lung Association.

Before we introduce our topic and our guest today, just a reminder that Lungcast is available on all your favorite streaming platforms. Subscribe to Lungcast on YouTube to get new and archived episodes, as well as interview segments and episode highlights as they come out. A link to the show page as well as the American Lung Association and HCP Live homepages for Lungcast can be found in each episode description. For those of you who prefer a podcast, you can subscribe to Lungcast on Spotify, Apple Podcasts, and your favorite listening platforms. You can also register for more respiratory news and insights at both lung.org and hcpive.com.

Lung cancer is the leading cause of death from cancer worldwide, representing about 18% of all cancer deaths, and causes almost 2 million deaths—more than breast, colorectal, and cervical cancers combined, which are cancers for which population-based screening programs exist. Only 15% of patients with lung cancer are still alive about five years after diagnosis. This is mainly because approximately 70% of patients have advanced disease at the time of diagnosis.

This grim prognosis is, however, changing. The advent of targeted therapies for certain lung cancers and the addition of immunotherapy to the regimen for many patients have improved responses and disease-free survival in those with advanced lung cancer. Lung cancer screening with the low-dose CT scan is also improving prognosis because this test has been found to diagnose early-stage disease, when curative surgery is more likely.

The concept of using low-dose computed tomography to screen for lung cancer dates back almost three decades. Early observational studies on high-risk but asymptomatic subjects showed that low-dose CT detected more lung cancers than chest radiographs, and many of the detected cancers were early-stage, but a mortality benefit was not observed at that time.

This led to a definitive study in the United States: the National Lung Screening Trial, or NLST, a randomized trial of over 50,000 high-risk current and former smokers, comparing low-dose CT screening to screening with chest radiography. In 2011, the NLST reported a statistically significant 20% reduction in lung cancer mortality in the LDCT arm.

As a result, in 2013, the USPSTF made a level B recommendation for this screening technique, initiating coverage for the procedure by third-party payers through the Affordable Care Act, and Medicare coverage followed shortly thereafter. We are now just over a decade since coverage for low-dose CT screening for lung cancer was put into place—a procedure felt by most to be life-saving for those at risk.

The uptake of this screening by individuals, although increasing, has been slower than expected. Because of its ability to find early-stage lung cancer at a point in time when significant cures can be expected, this procedure is highly promoted by major public health and advocacy organizations. Several challenges or hurdles have been met along the way when screening centers are put into place and when population-level screening is initiated.

To discuss the landscape of low-dose lung cancer screening and how things have evolved over the last 10 years, we have with us Dr. Mary Pascinelli, who holds a doctorate in nursing practice and is a nurse practitioner in the Division of Pulmonary, Critical Care, Sleep, and Allergy at the University of Illinois Health System. She is also the director of the Lung Screening Program.

Dr. Pascinelli specializes in lung cancer, lung cancer screening, and pulmonary nodule management. She sees patients in the pulmonary clinic who have pulmonary nodules, those who are identified for screening for lung cancer, and also runs a smoking cessation program for those wanting to quit. She also sees patients after they are diagnosed with lung cancer in the medical oncology clinic.

Dr. Albert Rizzo: Thank you for joining me today.

Dr. Mary Pascinelli: Thank you so much for the invitation. I'm happy to be here.

Dr. Albert Rizzo: Well, at a level set for our listeners, please remind us of the current criteria to make someone eligible for low-dose CT screening for lung cancer.

Dr. Mary Pascinelli: Yes. You mentioned that in 2013, lung cancer screening was approved by USPSTF and then in 2015 by Medicare. The current guidelines include individuals aged 50 to 80—and for Medicare, 50 to 77. They must have a smoking history of 20 pack-years or more, which is equivalent to smoking one pack a day for 20 years or a half pack a day for 40 years. They must be currently smoking or have quit in the past 15 years, and they must be asymptomatic of lung cancer. Medicare also requires a shared decision-making visit discussing pros and cons, which needs to be completed and documented prior to the first scan.

It’s important to know that this criteria has evolved over time. Previously, it started at age 55 with a 30-pack-year history. The change to 50 years and 20 pack-years was made to better include populations at high risk, particularly women and African Americans, who tend to smoke fewer pack-years but are still at significant risk.

Dr. Albert Rizzo: Right.

Dr. Mary Pascinelli: The USPSTF criteria are covered by insurance without cost sharing under the Affordable Care Act and Medicare, removing financial barriers. Still, a large number of people diagnosed with lung cancer would have never met the screening criteria if they were screened. The NCCN guidelines are broader and include people over 50 with 20 years of smoking. Risk prediction models such as PLCOM 2012 can also be used to refine eligibility.

Dr. Albert Rizzo: Thank you for clarifying.

Dr. Albert Rizzo: Lung cancer screening centers seem to come in a variety of shapes and sizes. Could you explain centralized, decentralized, and hybrid models, and describe the one you run?

Dr. Mary Pascinelli: Absolutely. A centralized model involves primary care providers referring patients to a screening program run by specialists or nurse practitioners, who handle everything from shared decision-making to follow-ups—a high-touch experience. A decentralized model has the primary care provider ordering and following up on the screen themselves, with oversight at a macro level. A hybrid combines both approaches.

At UI Health, we run a hybrid model. Primary care providers can order a screen and follow up, or refer to our lung screening program. For Lung-RADS 4 nodules suspicious for cancer, our program intervenes. We present these cases at our multidisciplinary thoracic tumor board and guide patients through next steps like PET scans or biopsies. We also have centralized scheduling, which improves adherence.

Dr. Albert Rizzo: Thank you. Some centers report that the required shared decision-making session can be a hurdle. How do you handle this?

Dr. Mary Pascinelli: Shared decision-making is required for CMS coverage. At our institution, we educate primary care providers and provide a templated note to ensure documentation. If patients come to our program, we provide an in-depth visit discussing screening, smoking cessation, and addressing anxiety. Patients often feel more informed and confident after this session. For example, a patient who had delayed screening for 10 years was reassured and able to proceed after our discussion.

Dr. Albert Rizzo: That’s a great example. How about nurse navigators?

Dr. Mary Pascinelli: Navigation has transformed our program. Our lung screening coordinator ensures patients are scheduled, verifies eligibility, addresses barriers like transportation or parking, and supports follow-up. We use grants from the American Lung Association and Coleman Foundation to assist patients with access issues.

Dr. Albert Rizzo: How important is smoking cessation in this context?

Dr. Mary Pascinelli: It’s a cornerstone. I use motivational interviewing to help patients understand their relationship with smoking and develop action plans. Stopping smoking reduces risk for lung cancer and other cancers, improves treatment outcomes, and decreases recurrence risk for those already diagnosed.

Dr. Albert Rizzo: Return rates after screening can be low. How have you improved adherence?

Dr. Mary Pascinelli: We track adherence using “optimal,” “acceptable,” and “overdue” categories. Since 2021, our proactive scheduling and navigator support have improved optimal adherence from 40% to 71%, with acceptable adherence bringing total adherence to over 85%. Addressing barriers and calling patients promptly when they miss appointments has been key.

Dr. Albert Rizzo: Let’s turn to risk prediction models and biomarkers.

Dr. Mary Pascinelli: Many companies are developing serum biomarkers to reduce false positives and stratify risk. Most are not FDA-approved or covered by insurance yet, so at our institution, we participate in research protocols to include diverse populations.

Dr. Albert Rizzo: What about incidental findings like emphysema or coronary calcification on LDCT?

Dr. Mary Pascinelli: We use these findings as teachable moments. For emphysema, I explain the damage and discuss prevention. Coronary calcification prompts review of statin therapy and coordination with primary care. Visualizing their lungs often motivates patients to quit smoking.

Dr. Albert Rizzo: You’re also part of the CIVIL consortium at Mass General. Can you explain?

Dr. Mary Pascinelli: CIVIL is an AI tool developed at MIT and Mass General that predicts lung cancer risk over six years from a single LDCT scan without additional clinical information. We are validating it across diverse populations in a consortium of four sites. It may guide follow-up and stratify risk in the future.

Dr. Albert Rizzo: With lung cancer rising in never-smokers, why isn’t screening more widely recommended?

Dr. Mary Pascinelli: Current screening focuses on heavy smokers. Lung cancer in never-smokers likely involves genetics, environmental exposures, and socioeconomic factors. Emerging tools like AI and biomarkers may expand screening eligibility in the future.

Dr. Albert Rizzo: Thank you for this comprehensive discussion. Anything else to add?

Dr. Mary Pascinelli: Screening truly saves lives. Advances in therapy and LDCT screening allow earlier detection and improved outcomes. Innovation, awareness, and hope are growing, and anyone with lungs can be at risk for lung cancer.

Dr. Albert Rizzo: Thank you for your work promoting this life-saving screening. To our listeners, subscribe to Lungcast, visit lung.org and hcpive.com for more resources. Until next time, I’m Dr. Albert Rizzo reminding you that if you can't breathe, nothing else matters.