Given that lung cancer is a leading cause of death in the U.S., preventive care is critical. However, annual screening rates with low-dose computed tomography (LDCT) among eligible individuals remain low. A recent study explored a community-based educational intervention for lung cancer screening and the modifications made during the COVID-19 pandemic. Their findings were presented during the National Comprehensive Cancer Network Annual Conference (Abstract BPI22-010).
"National guidelines for lung cancer screening are relatively new compared to other cancer screening modalities," noted study author Sydney Beache, MD, at Washington University School of Medicine, St. Louis. "The United States Preventive Service Task Force recommended in 2021 that annual LDCT screening be offered to individuals aged 50-80 with a 20-pack year smoking history who currently smoke or who have quit within the last 15 years.
"Guidelines also require that clinicians engage their patients in shared decision making to discuss the risks and benefits of screening, as well as smoking cessation efforts," she continued during her presentation. "Despite these recommendations, national screening rates are as low as 13 percent among eligible individuals."
To address this quality gap, a research team at Washington University School of Medicine initiated a community intervention with the aim of increasing LDCT screening. I-STEP (Increasing Lung Screening Through Engaging Primary Care Providers) was conducted between 2019 and 2021. The program evaluated the implementation of a customizable education intervention that was administered to a consortium of six hospitals in Missouri and Illinois, Beache explained. The toolkit included information for clinicians and patients on screening guidelines, navigating screening referral, shared decision making, and smoking cessation.
Applying FRAME
The onset of the COVID-19 pandemic led to unanticipated changes to the health care landscape and delivery of care. Therefore, modifications to I-STEP were necessary to ensure optimal outcomes.
To better understand the scope and impact of the changes brought about by the pandemic, Beache and her colleagues used the expanded framework for reporting adaptations and modifications to evidence-based interventions (FRAME) to descriptively analyze qualitative data.
FRAME is a systematic approach that allows for the categorization of changes to interventions in eight key domains, according to the study authors. Those domains include the following: stage of implementation process in which modification occurred; if modification was planned; stakeholders involved in decision making; what was modified; nature of modification; for whom modifications were made; fidelity to original intervention; and justification for modification.
"Our primary aims with this report were to systematically categorize modifications to I-STEP implementation and lung cancer screening more broadly, and to contribute to an evidence base for modifying cancer screening programs to meet the demands of dynamic clinical environments," Beache noted.
The researchers collected data via reports and phone calls with consortium stakeholders, including frontline staff. They focused on modifications that took place from March 2020, the onset of the COVID-19 pandemic, until the completion of the trial in 2021.
When the pandemic began, the researchers reported that half of the sites had already entered the intervention phase of the I-STEP study and therefore made reactive modifications. The remaining sites were in the pre-implementation phase and were able to make proactive changes. The decision-making process for modification involved stakeholders at every level, including hospital administrators, primary care clinic personnel, clinicians on the individual level, and the research team.
Overall, Beache noted that there were few modifications to the I-STEP design with the most notable being its adaptation to a virtual platform for use in a remote health care model. This included creating systems to remind clinicians and patients of missed and rescheduled lung cancer screening through phone, mail, and electronic EMR alerts.
"Modifications of staff training were also essential given the efflux of personnel from the outpatient setting to the inpatient setting," said Beache. "This involved training navigators within lung cancer screening programs to oversee imaging scheduling, as well as diversifying the base of clinicians who engage in shared decision making for lung cancer screening and who also engaged in imaging follow-up discussions with patients."
While the intervention approach was multi-level, most modifications occurred at the hospital level, according to the study authors. "This suggests the optimization of hospital resources with consideration for pandemic-related resource constraints served as an important driver of change to intervention delivery and cancer screening protocols," they noted.
"In conclusion, the few modifications to the I-STEP trial and its fidelity-consistent nature suggest that this evidence-based intervention is versatile and optimized to meet the needs of many clinical environments," Beache stated.
"Novel modifications to lung cancer screening protocols highlight the importance of adapting strategies to fit the capabilities of available personnel," she added. "And finally, the focus on modifications at the hospital system level suggests that this is an important stakeholder group to engage in future implementation efforts."
Catlin Nalley is a contributing writer.