Last July, Joe Cruz (his name has been changed) was diagnosed with metastatic lung cancer, which carries a very poor prognosis.
He was not very surprised: he read the labels on cigarettes. Joe has smoked cigarettes for 45 years, since he was 15 years old, averaging one pack per day. In the back of his mind, Joe believed that if he thought too much about the possibility of cancer, it might somehow cause him to develop cancer, so he did not seek medical help when his chronic cough started producing blood-tinged sputum 9 months ago. It wasn’t until he developed right sided hand and arm weakness that Joe sought attention, because he knew that unilateral weakness was a symptom of a stroke and that the key to treating a stroke was to seek out medical help right away.
The MRI scan of his brain did not show a stroke, but instead showed multiple metastases. A Chest CT confirmed that the likely primary was in his right lung.
Joe’s story is reflective of a disturbing pattern. In late 2014, the Cancer Committee at NorthBay Medical Center in Fairfield did a study comparing the staging of lung cancer with insurance status, and found that Partnership HealthPlan members are more likely to be diagnoses with stage 4 cancer, compared to those with commercial insurance. They further noted a very low rate of screening for lung cancer using the 2014 U.S. Preventative Services Task Force recommendation:
“The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.”
In 2015, Solano County oncologists reached out to major Solano County primary care providers to urge them to talk with smokers about early symptoms of lung cancer and to recommend CT scan screening where appropriate.
This is not a problem limited to Solano County. A PHC study of lung cancer diagnosis in Shasta county found a similar high rate of very late stage diagnosis.
The rate of lung cancer in the Medi-Cal population is higher than the state average. The smoking rate among adults with Medi-Cal is roughly double that of the population as a whole.
In 2015, we found that only 37 patients in all 14 counties had a CT scan to screen for lung cancer, out of an estimated 9000 non-dual eligible smokers between the ages of 55 to 80. We extrapolated smoking rates in the Medi-Cal population to generate this estimate.
These numbers are very disturbing: our patients smoke more, are diagnosed with Lung Cancer later and are barely being screened at all. Primary care clinicians (and some specialists) are in the best position to have an impact on this, in three ways:
- Help patients quit smoking. For patients who smoke, encourage them to quit, assess their motivation and readiness to quit and counsel appropriately. Use nicotine replacement if needed and consider referring to the state smoking cessation hotline (1800 NOBUTTS)
- Screen for lung cancer. Set up technology and workflow supports to identify adults between age of 55-80 with a history of 30-pack years or more of smoking. Flag and refer them for annual screening CT scans. Generate practice and clinic level reports to see how well this change is going. Let’s see if we can get 2016’s total over 100 individuals screened, at least!
- Warn smokers (and past heavy smokers) of the warning signs for lung cancer (which are non-specific), for which they should seek immediate medical attention.
Partnership Health Plan cannot reliably identify members who use tobacco from the data we have, and the interventions are best done by the health care provider they trust. We are counting on you. Help save lives by making these changes in your practice, this month!
By Robert Moore, MD MPH, Chief Medical Officer