Category: Blog

In half a century, knowledge and technology have transformed breast cancer from a death sentence to a condition that is usually manageable, with an average five-year survival rate of 90 percent. It’s unarguably one of the greatest success stories in the history of medicine. Can even more be done?

Yes! Which is why I’m eager to tell you about how Eon is expanding survivability even further.

First, a quick look at some of the technological and organizational advances that have gotten us to this point, and likely saved my life as well as those of several family members:

• The ubiquity of screening. Regular mammograms are essential. They must be done earlier and more frequently when there’s a family history of breast cancer and/or other cancers that follow the same genetic lines. The success of breast screening is a model for other screening programs.
• Breast self-exam. Super important for all women (and men with a family history of certain cancers), speak with your doctor about the appropriate technique and do it monthly! This is how I suspected I had a problem.
• Imaging technologies. Most recently, 3D mammography (breast tomography) is now a standard of care with increased sensitivity and specificity, especially for women with dense breasts. I was able to play a role, as a physicist at GE, when my team helped create magnetic resonance breast imaging and biopsy – I am super proud that these technologies are used today in high risk patient care. I’m also happy to have helped a little bit with advancing digital mammography image quality.
• Imaging standards. A crystal-clear image is important, but is only useful if the imaging technologists fully capture the breast tissue, in the correct position, at every visit. Likewise, the interpreting radiologist should keep up to date on current technologies and contribute to national benchmarking. These are some of the advances in standardization that the MQSA (mammography quality standards act) helped accelerate.
• The surgical techniques and treatments are totally different than even 20 years ago. These approaches minimize the disfigurement and complications of a complete mastectomy with lymph node removal. These improve not only length of life, but also the quality of breast cancer survivorship.
• The discovery of cancer hormone receptors and molecular markers for cancers, leading to individualized chemotherapies.
• New care models. I love the under-one-roof women’s health center, where they literally don’t let you leave until your test results are ready. This way if another image is needed, you can get it immediately – without any additional care delays or trips back to the imaging center. Making sure you have time to wait for results is a good idea because every time a patient transitions from one space to another, the chances of successful follow-through decrease.

“As a survivor, I marvel at the gains that have helped so many of us to be here. As a scientist, I am concerned that there are still people who are missing the benefits of early detection.”

That’s a lot of progress! So, what remains to be done, and how does Eon help?

For all our achievements, lack of coordination in U.S. healthcare—among providers and between providers and patients—remains a huge problem. This is precisely the problem that Eon solves by 1) identifying abnormalities that might otherwise be overlooked, and 2) managing guideline-based treatment plans with greater efficiency and a higher patient return rate than hospitals do alone. We use a proprietary computational linguistics engine to analyze imaging reports and, when we find an unanticipated abnormality (an “incidental finding”), our software system springs to life, recommending action steps to the patient and notifying their entire care team. The Eon software then tracks the patient follow-up to ensure care, if appropriate, for the abnormality has been performed. This service (Care Management) sends out letters and communicates allows the local team to focus on the high risk patients

I first encountered Eon while working at Cleveland Clinic because we needed a new lung cancer screening vendor. (We became Eon’s second client; there are now hundreds.) Like many Americans, I was frustrated by under-insurance (among adults; American children have good insurance) and inadequate care coordination. An integrated national system like Britain’s or Canada’s had some appeal but wasn’t the answer. Eon, I recognized, could unite the loose ends in the existing U.S. healthcare industry, saving lives and aiding hospitals’ finances to boot. I joined the company in 2020.

Which brings me back to: How many more lives can we save? A strong indication came shortly after I joined Eon, when I teamed with my colleagues Parthiv Mehta and Natalia Rodnova to analyze 5.6 million radiology reports generated at a large health system over 18 months. We set aside standard screening reports that were intentionally looking for breast cancer and concentrated on reports that, as far as the patient and their doctor were aware going in, had nothing whatsoever to do with a breast.

We uncovered 32,693 incidental breast findings, mainly in CTs and X-rays of the neck, chest and abdomen. Many were in women who were too young or too old to participate in regular screening. Others were in women who were eligible for screening but weren’t going. Eight percent were in men. Forty-five percent of the women and 100 percent of the men were not in a screening program and their breast lesion likely would have gone unnoticed until symptoms appeared.

The upshot is so simple to grasp: Look for more abnormalities and you’ll find some! And use guidelines to drive patient care plans. Alas, deploying this information to actually get more patients into monitoring or treatment is devilishly difficult. Without energetic care coordination such as what Eon provides, health systems still struggle to make the connections that result in patients coming back.

As a survivor, I marvel at the gains that have helped so many of us to be here. As a scientist, I am concerned that there are still people who are missing the benefits of early detection. As an Eon employee and chief science officer, I’m overjoyed to be doing something about this.

According to the 2022 “State of Lung Cancer” report ⁽¹⁾, someone is diagnosed with lung cancer every 2 ½ minutes, and 356 lung cancer patients die every day. Lung cancer has one the lowest 5 year survival rates – 25% – despite significant improvement in treatments. This is in great part due to late stage diagnosis.  Forty-four percent of cases are diagnosed at a late stage, where survival is only 7%. And only 5.8% of high risk individuals are screened.

If you are thinking about starting or have already started a lung cancer screening (LCS) program, that should be applauded. The goal is to diagnose lung cancer while it’s still potentially curable. So screening high risk patients – to find nodules that may be cancerous or evolve into lung cancer – makes perfect sense.

But screening high risk populations to find lung cancer is only finding the tip of the iceberg. Submerged below – and commonly missed until it’s too late – are incidental pulmonary nodules (IPNs) that become lung cancer. IPNs are just as important – and deadly – and 9 times more common than pulmonary nodules/cancers found by screening ⁽²⁾. 

Less than 10% of health systems have some type of IPN program ⁽³⁾. If you do NOT have a well designed and implemented IPN program to complement your LCS program, you are missing a lot of lung cancer (and are likely not even aware).

• over a 3rd of chest CTs will have an IPN ⁽⁴⁾
• the rate of malignancy for IPNs overall is about 5% (similar to the malignancy rate in lung cancer screening) ^(5,6)
• follow-up IPN care fails in about 70% of cases ⁽⁷⁾.

What does that mean in very practical terms? It means that for every 90 chest CT scans you read (as a radiologist) or order (as a provider), one lung cancer will be missed. For an average hospital that performs about 2,000 chest CTs a year, that translates into about 22 lung cancers missed, or at the very least a significant delay in care- potentially missing the opportunity to provide curative intent therapy. Realizing a true system-wide stage shift in lung cancer demands that IPNs are captured and managed appropriately.   

If you IMPLEMENT a well-designed incidental lung program, you will find 7-8 times as many lung nodules AND lung cancers as you will find with your LCS program ⁽⁸⁾. 

Well-developed IPN programs are showing improvements in both clinical processes and outcomes – diagnosing patients with earlier (curable) stage lung cancer ^(9-12) and retaining patients in their network for the care they need. 

And there you have it.

• Incidentally found pulmonary nodules and cancers are 9 times more common than those found through lung cancer screening programs.
• Without a well-designed and implemented IPN program, about 70% of nodules are missed, and 5% of those missed nodules are or will become cancer.
• Comprehensive Lung Programs that include tracking and management of IPNs alongside Lung Cancer Screening can lead to stage shift and generate significant downstream revenue
• And there are many other cancers that start as incidental findings that need reliable follow-up as well – thyroid, pancreas, liver, and breast to name a few. 

How do I get started?

Innovative organizations realize the importance of comprehensively managing both screening and incidental pulmonary nodules to catch and treat as many potential cancer patients as possible. But how do I make the internal case for an incidental findings program at my facility? Here’s how to get started:

• Pull together lung cancer incidence data for your area
• Find the right lung coordinator and/or navigator – Seek out a leader who is a master communicator and can train others on processes that will help ensure the long-term success of your program 
• Build a multidisciplinary team – Coordinate a multi-faceted team of experts who specialize in different aspects of care and meet regularly in a nodule board to discuss suspicious IPNs
• Seek out the right technology partner – Find a technology partner that can accurately identify abnormalities with few false positives and offers workflow automation to help your team save time
• Understand the downstream impact – Calculate the potential downstream revenue to areas such as pulmonology, interventional pulmonology, thoracic surgery, radiation oncology, medical oncology, and radiology

Interested in understanding the clinical and financial impact of a comprehensive lung cancer screening and incidental program at your facility? Contact us for your custom opportunity assessment.

Click here to learn more about how leading health systems built their lung screening and incidentals program and the results they are seeing.

References:

1. State of lung cancer: 2022 report. American Lung Association. November 15, 2022. Accessed November 16, 2022. https://www.lung.org/getmedia/647c433b-4cbc-4be6-9312-2fa9a449d489/solc-2022-print-report
2. Osarogiagbon R, Miller E, Faris N, Pinsky P.  Incidental pulmonary nodules, lung cancer screening, and lung cancer in the Medicare population. Journal of Clinical Oncology 40, no. 16_suppl (June 01, 2022) 6536-6536. DOI: 10.1200/JCO.2022.40.16_suppl.6536.
3. Based on Eon data.
4. O’Sullivan J, Muntinga T, Grigg S, Ioannidis J. Prevalence and outcomes of incidental imaging findings: umbrella review.  BMJ 2018;361:k2387 http://dx.doi.org/10.1136/bmj.k2387  
5. Gould MK, Tang T, Liu IL, Lee J, Zheng C, Danforth KN, Kosco AE, Di Fiore JL, Suh DE. Recent Trends in the Identification of Incidental Pulmonary Nodules. Am J Respir Crit Care Med. 2015 Nov 15;192(10):1208-14. doi: 10.1164/rccm.201505-0990OC. PMID: 26214244.
6. McWilliams A, Tammemagi M, Mayo J, et al.  Probability of Cancer in Pulmonary Nodules Detected on First Screening CT.  N Engl J Med 2013; 369:910-919 DOI: 10.1056/NEJMoa1214726
7. Lee J, Lisker S, Vittinghoff E, et al. Follow-up of incidental pulmonary nodules and association with mortality in a safety-net cohort.  Diagnosis (Berl). 2019 November 26; 6(4): 351–359. doi:10.1515/dx-2019-0008.
8. Number of patients who were diagnosed with lung cancer through lung cancer screening or incidental lung program at a 10-hospital system in the Midwest between Q4 2022 to Q1 2023
9. LeMense GP, Waller EA, Campbell C, Bowen T. Development and outcomes of a comprehensive multidisciplinary incidental lung nodule and lung cancer screening program. BMC Pulm Med. 2020 Apr 29:20((1)):115
10. Roberts TJ, Lennes IT, Hawari S, Sequist LV, Park ER, Willers H, et al. Integrated multidisciplinary management of pulmonary nodules can streamline care and improve adherence to recommendations. Oncologist. 2020 May;25((5)):431–437. 
11. Van Gerpen R. Creating an incidental pulmonary nodule safety-net program. Chest. 2021 Jun;159((6)):2477–2482. 
12. Carr L, Dyer D, Zelarney P, Kern E.  Improvement in Stage of Lung Cancer Diagnosis With Incidental Pulmonary Nodules Followed With a Patient Tracking System and Computerized Registry.  JTO Clin Res Rep 2022 Mar;3(3):100297.

Last month, I had the opportunity to present at the Advancing Early Lung Cancer Detection meeting hosted by Cleveland Clinic. As Eon’s second client to go live with Eon Patient Management (EPM) Lung Cancer Screening solution, we applaud Cleveland Clinic’s dedication to bringing representatives from academia, the federal government and industry together every year to collaborate on positively impacting early lung cancer diagnosis.

This year, I presented on the topic of racial disparities in follow-up adherence to lung cancer screening guidelines. As Chief Medical Officer at Eon and a physician, I share Eon’s belief that everyone regardless of race, health literacy, level of medical mistrust, stigma, language barriers, financial concerns, insurance status, or transportation issues deserves the opportunity to lead a full and healthy life. The 2022 American Lung Cancer Association Report showed alarming disparities in lung cancer rates amongst black and white patient populations. In comparison to white patients, black patients are 15% less likely to be diagnosed early, 19% less likely to receive surgical treatment, 10% more likely to not receive any treatment at all, and 12% less likely to survive 5 years. This is unacceptable.

Black patients, despite data that they actually may derive greater benefits than white patients from participating in a lung cancer screening program, do not enroll in, or adhere to follow-up screening recommendations at the same rates as white patients. Data published in the Annals of the American Thoracic Society supports our experience at Eon. The study notes that decentralized Lung Cancer Screening (LCS) programs were found to have a 27% adherence gap between black and white patients concerning annual LCS screenings. This difference, however, was not observed in centralized programs. At Eon, we have seen that deploying centralized care management services to coordinate follow-up for lung cancer screening or incidental findings can significantly reduce this gap.

“By automating complex workflows, and increasing the number of communication touchpoints, more patients, both black and white, are successfully returning for appropriate follow-up care.”

The reasons for the race-based disparity in Lung Cancer Screening are varied and complex- but it has become increasingly clear that a centralized approach that incorporates a highly structured omnichannel patient/provider communication strategy is effective. Our Eon Patient Management solution (EPM) identifies and triages patients that need a follow-up exam and then automatically flags the care team when exams are ordered, completed, missed, or overdue. Our tech-enabled care management team at Eon uses these workflows to reach out to patients and providers to coordinate care on behalf of our clients. By automating complex workflows, and increasing the number of communication touchpoints, more patients, both black and white, are successfully returning for appropriate follow-up care. Only when patients are adherent to the next step in their care can the promise of these screening programs become fully realized.

Whether you partner with an organization like Eon or use internal resources, centralized care management is a worthwhile investment to connect with those patients that are hardest to reach. It is not until everyone in a community has the opportunity to live a full and healthy life is a community truly healthy.

Without question, the goal in regard to cancer is prevention. Much progress has been made across the different types of cancer by decreasing risk factors, utilizing immunizations, and catching concerning precancerous findings before they become problematic. Nevertheless, not all cancers can be avoided by removing modifiable risk factors. Take lung cancer, for example. According to the American Cancer Society, as many as 20% of people who die from lung cancer in the United States have never smoked or used any other form of tobacco. Lung cancer in never smokers, if tracked as its own disease, would be the seventh-deadliest cancer worldwide. Although the focus on prevention for all types of cancer should not diminish, a dual focus, with just as much energy, should be provided to ensure that the cancer is caught at its earliest, most treatable stages.

At the Radiological Society of North America (RSNA) meeting in November 2022, encouraging data were presented which further confirms the importance of early diagnosis. The data revealed the 20-year survival rate in lung cancer patients diagnosed at the earliest pathologic stage, 1A, was 92%. Unfortunately, in the United States, only 16% of lung cancers are currently diagnosed at an early stage. When not diagnosed at an early stage, the five-year survival is only 18%.

In this country, 1.6 million incidental pulmonary nodules are identified annually. Fortunately, most do not represent cancer. A recent article by Vachani et al. (2022) attempted to answer the clinical question: Do nodule size and smoking history predict the incidence of cancer in patients with incidental pulmonary nodules? They found that nearly 10% of patients with a nodule measuring greater than 8 mm in size will receive a lung cancer diagnosis. Taking into account smoking status, lung cancer was diagnosed in 5.4% of never smokers, 12.2% of former smokers, and 17.7% of current smokers. This data further emphasizes the need to ensure that patients with incidentally found pulmonary nodules, regardless of smoking status, receive guideline-driven follow-up care.

Care Management is successfully managing patients in seven different disease-state cohorts at more than 125 hospitals, impacting the care of well over 100,000 patients.

The difficulty of ensuring that patients with potentially early-stage cancer have an optimal chance at a cure has always been a twofold problem: The incidental finding must be captured and the patient must adhere to the next appropriate step in their care, all in a timely fashion. Radiologists in general do an excellent job of identifying incidental findings when present. With incidental pulmonary nodules, data would suggest that only 6 out of every 1,000 nodules go unreported (with the majority of these being less than 5 mm). However, in an emergency room setting, patients that have nodules identified by radiologists on chest CTs only successfully follow up for further care 29% of the time. The number of patients following up appropriately decreases further if the finding is only mentioned in the body of the report and not the impression. At the recent RSNA meeting, Dr. Jung H. Yun of Einstein Healthcare Network presented data that confirmed what we at Eon have already realized: Using an artificial intelligence (AI) system to send scheduling reminders to patients needing imaging follow-up significantly increases compliance success rate.

Eon solves both problems (capture and adherence) by combining Eon Patient Management, a software platform, and Eon Care Management, a service offering, to optimize the likelihood of a disease cure. Eon Patient Management uses a form of artificial intelligence called computational linguistics to capture the radiologist-reported finding with both an extraordinarily high sensitivity (patients with a true finding will not be missed) and specificity (only patients with a true finding will be captured). Following the capture of these incidental findings, systemwide improvement in disease-state outcome can only occur if patients follow up successfully for the next expected step in the management of this finding. Eon Care Management is laser-focused on maximizing the rate of successful follow-up to the next step. Our team of navigators combine complex workflow automation, guideline-driven decision analysis, and an omnichannel patient and communication strategy to accomplish this goal. Care Management is successfully managing patients in seven different disease-state cohorts (lung, lung cancer screening, liver, pancreas, abdominal aortic aneurysm, breast and thyroid) at more than 125 hospitals, impacting the care of well over 100,000 patients.

Although prevention of all cancers remains the goal, until this becomes a reality, a dual focus on prevention and detection of disease at its earliest state will be necessary. It has been identified across multiple disease states that detection of disease at its most curative stage, coupled with appropriate and timely follow-up care for these patients, can lead to profoundly improved outcomes and ultimately survival. Combining the computational linguistics power of Eon Patient Management with the proven track record of Eon Care Management allows this to happen.

Scott Skibo is Eon’s Chief Medical Officer. Heather Rasmussen is Eon’s Clinical Transformation and Advanced User Education Manager.

It’s no secret that our current healthcare system is fragmented at best. It’s not uncommon for information to become siloed, or even lost in the midst of endless administrative tasks and unrelenting workflows. Physicians do their best with what they have. But what if there was a way to work together to create better outcomes for everyone, including, most importantly, patients. The AABIP is working to do just that. We sat down with Dr. George Eapen of MD Anderson Cancer Center and current AABIP President to discuss a groundbreaking reporting tool that will advance the field of interventional pulmonology and ultimately save lives – the AABIP Pulmonary Procedures Registry, powered by Eon.
 

Q: To start at the beginning, what’s a registry and why do bronchologists and interventional pulmonologists need one?
A: A registry is simply a platform where physicians can share their procedural cases with one another. This sharing of information permits all physicians involved in the registry to understand more about the utility and application of these procedures, including the clinical outcomes and any complications. Registries help identify areas for quality improvement or additional resource allocation, and may also facilitate research by highlighting gaps in either knowledge or application across multiple different practice settings. 

Dr. George Eapen, AABIP President

Q: What other specialties are making good use of a registry?
A: Quality registries are very common in high stakes procedural specialties. Gastroenterology, thoracic surgery and breast imaging are but a few other specialties that make use of registries very effectively. As the field of Interventional Pulmonology matures, and Interventional Pulmonologists become an indispensable part of the lung cancer care continuum, the AABIP believes that the time has come for a pulmonary procedures focused registry that will promote and facilitate excellence in the field. 

Q: What about workflow – will this project make a lot of busy work for participants?
A: The best kind of registry is one that does not create any additional work for already busy clinicians. In partnership with the software and implementation experts at Eon, the AABIP hopes to deploy a registry that will require minimal effort on the part of clinicians while providing the data and tools to make patient care even more effective.

Q: What’s your aspiration for five years out – how should the field have changed as a result of the registry?
A: Our hope is that a registry will facilitate the exchange of information and foster innovation by stimulating research questions and supporting robust outcomes-based research in a real world setting. 

Q: Ultimately, of course, this is all about patients. How do patients benefit from a registry?
A: Our fondest hope is that with growth and wide adoption of the registry, the standards of clinical care available to patients all across the United States will improve. 

Q: Building and maintaining a registry involves considerable back-office expertise. Why did you elect to partner with Eon on that?
A: We elected to partner with Eon primarily for their demonstrated expertise in the creation and management of complex data systems and associated innovative computing solutions. Furthermore, the co-CEOs of Eon, Dr. Aki Alzubaidi and Christine Spraker, have clearly shown an unshakeable commitment to patient-centric, pulmonary-focused care, which completely aligns with the strategic mission of the AABIP.  

Q: So why now? What prompted you to decide to make the AABIP PPR?
A: This is actually not a new project. The AABIP has been dreaming of creating such a registry for the last 5 years. Being a small organization with limited resources, we have not been able to realize this dream until we partnered with Eon.

Deep understanding of patient outcomes starts with high-quality data. And high-quality data starts with providers. If you represent an entity performing pulmonary procedures — including hospitals, physician practices, and outpatient surgical centers — please support this initiative to set higher standards for patient care. 

Visit the AABIP Pulmonary Procedures Registry or stop by our table at the AABIP annual conference August 11-13, 2022 in Nashville, TN to sign up for a registry demo and to learn more about how you can help improve pulmonary procedure quality nationwide.

Let’s create better outcomes together!

Dr. George Eapen. is a Professor of Pulmonary Medicine at Texas MD Anderson Cancer Center in Houston, TX, and outgoing President of AABIP. A published and award-winning physician, he has devoted his clinical and academic career to the care of lung cancer patients. As an interventional pulmonologist, he is committed to developing and integrating emerging advanced diagnostic and therapeutic techniques in cancer care, in particular focusing on early lung detection, mediastinal staging, treatment and chemoprevention for those at risk.

Optimization of the care of the incidental pulmonary nodule patient that ultimately leads to a system-wide stage shift and improved lung cancer outcomes is complex, and requires an integrated set of processes but without both capture of the incidental pulmonary nodule (IPN) and adherence to the next step in patient care, realizing this goal of improved lung cancer outcomes is not possible. Combining Eon’s proprietary Computational Linguistics and Care Management platforms allows capture and adherence to the next step in patient care respectively. It is only by combining both Computational Linguistics and Care Management that the 71% of patients that are identified to have an incidental pulmonary nodule by the radiologist- but then do not receive follow up for this finding – get the care that they deserve.

Successful capture of incidental pulmonary nodules requires a software solution that has several features. First, avoiding false negatives and minimizing false positives is essential. Second, nodules must be captured from more than chest CTs. In an analysis of more than 1.2 million radiology reports that identified a pulmonary nodule, it was revealed that 9.6% of nodules are identified on x-ray and 19.6% of pulmonary nodules are identified on abdominal exams. A system that does not capture nodules from other radiologic exam modalities (like x-ray) or non-chest exams is missing a significant opportunity to impact community wide lung cancer outcomes. Lastly, capturing these findings without asking the radiologist to change their workflow or dictation process is essential. Eon’s Computational Linguistics data science models have a sensitivity of 99.76% and a specificity of 98.12%, capture nodules from any radiologic modality or anatomic exam that includes any part of the lung, and does not require the radiologist to alter their workflow.

Combining IPN capture with Eon’s Care Management program has been shown to increase the total return rate for the next step in care.

 Capture of the incidental pulmonary nodule is only the first step required in being able to maximize the percentage of lung cancer patients that will be diagnosed with early stage disease, and thus be eligible for curative intent therapy. There is data that across the country, despite the radiologist identifying an incidental pulmonary nodule, that the average time to first work up of an IPN is 8-months. There are many reasons for this, however in an analysis of 906 consecutive radiologist reports from 52 geographically diverse hospitals and including only patients with IPNs >8 mm to 30 mm (high risk), it was revealed 47% of patient reports did not contain discrete guideline appropriate recommendations by the radiologist. Eon Care Management helps to solve this problem, and increase adherence to the next step by combining complex workflow automation and an intensive omni-channel communication strategy. Total patient return metrics for Care Management in 2021 is 81.3%, with several programs reporting total patient return rate exceeding 90% as we moved into 2022.

In summary, Eon’s Computational Linguistic solution allows efficient capture of the incidental pulmonary nodule with both high sensitivity and specificity from all radiologic modalities and in non-chest exams, without requiring the radiologist to alter their workflow. Combining IPN capture with Eon’s Care Management program has been shown to increase the total return rate for the next step in care. Although capture and adherence do not equate to improvement in lung  cancer outcomes on a system wide level by themselves, a successful argument can be made that a system wide improvement in lung cancer outcomes is not possible without successful capture and adherence to the next step in the management of the incidental pulmonary nodule

The pros and cons of cancer screening

It’s the same for any cancer. When discovered in the later stages, the prognosis is poor. When discovered in the early stages, treatment has a better chance to be effective, and the prognosis is much better. In fact, for some cancers like breast and thyroid, early diagnosis and treatment significantly improve patient outcomes and can lead to an actual cure. For breast cancer in particular, the 5-year survival rate is 98.9% when findings are localized (63% of cases). If, however, the cancer has metastasized to distant lymph nodes (6% of cases), the 5-year survival rate drops to 29% [1,2].

That’s why cancer screening programs have proven to be so effective in discovering cancer in early stages and reducing mortality rates, especially for breast and lung cancer. But screening programs are limited to patients determined to be at higher risk to the disease. If you don’t meet the criteria, then you’re not eligible for screening. Does that mean you’re completely not at risk? Of course not, you’re just at average or lower risk. Screening programs may also have other limitations, like being available only in specific areas, potential insurance coverage restrictions and/or out-of-pocket costs, exposure to ionizing radiation, and the risk of false positives or false negatives.

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Unfortunately, not all malignancies have established screening programs for early detection. Of the 1.9 million expected new cancer diagnoses in 2021 in the U.S., the top malignancies by rate have screening programs—#1 is lung and bronchus, #2 is colon and rectum, #3 is uterine, #4 is bladder, and #5 is skin [2]. Despite this, the 609,000 expected cancer deaths in 2021 are quite similar—#1 lung and bronchus, #2 breast, #3 prostate, #4 colon and rectum, #5 pancreas, #6 liver, and #7 ovary—because many people do not meet the screening criteria or simply don’t participate. Many malignancies have no routine screening programs, such as pancreatic, renal, and ovarian cancer. In addition, thyroid screening has been deemed more harmful than helpful for asymptomatic patients by the United States Preventive Services Task Force (USPSTF), and is not recommended.

The growing benefit of incidental findings

An incidental finding is an abnormality discovered on an imaging exam being performed for an unrelated reason. These findings in a normal population may represent an underlying malignancy, simply an anatomic variant, or a finding of no clinical consequence. A 2017 systematic review [3] of 20 studies involving 627,000 patients showed variability in the distribution of incidental findings across the most common radiology exams, ranging from quite often to rare. The prevalence was highest for computed tomography (CT) of the chest (45%), CT colonography (38%), and cardiac magnetic resonance imaging (MRI; 34%). The prevalence was intermediate for MRI of the brain and spine (about 20% each) and low for whole-body positron emission tomography (PET) and PET/CT (2%).

Overall, between 10-25% of radiology exams will contain an incidental finding [4]. Because over 250 million imaging exams are performed yearly in the U.S., this means 25–62 million incidental abnormalities may be detected annually. Most of these findings are benign and of little clinical significance. Some of the findings will represent known malignancies and/or metastases, whereas others are previously unknown malignancies or premalignancies. In every case, a clinical decision must be made if further testing and/or surveillance with longitudinal tracking is warranted. Numerous evidence-based guidelines exist to assist with this decision making.

Unfortunately, follow-up does not often happen in accordance with the guidelines. A study done in 2020 [5] found only 39% of findings requiring follow-up received it. Another 6-year study found only 58% were appropriately followed [4]. These publications call attention to the missed opportunity that appropriately-followed incidental findings may provide to identify cancer at an early, treatable stage. Equally concerning is the report of patients who have the most significant findings also have the least information and/or the lowest follow-up rates [6].

The vital role of incidental findings with lung cancer

Lung and bronchial cancers are the leading cause of cancer death in men and women in the U.S. The 5-year survival rate for non-small cell lung cancer is 25%, and 7% for small cell lung cancer [7]. In response to these statistics and the outcomes of several clinical trials, the USPSTF recommended that people at high risk for lung cancer have yearly screening with low-dose CT (LDCT) exams. While lung cancer screening (LCS) is effective in detecting cancer early for patients who participate, patients need to participate and need to adhere to the annual screening protocol to maximize their benefit. Unfortunately, LCS participation rates are quite low—just 2% in 2016 [8] and 5% in 2018 [9] of eligible patients who were enrolled—and adherence to the follow-up and screening protocol was less than perfect at 35% to 46% respectively.

A more recent report showed LCS participation rates had improved slightly, but they are still very low. Between 2019 and 2020, only 6.5% of the 8.51 million eligible adults received screening [10]. The USPSTF recently revised their LCS recommendations and expanded the age range (50–80 years) and lowered the smoking history (minimum of 20 pack-years). Even though the number of LCS-eligible patients will almost double, the overall low participation rate for screening is still a serious problem.

Because of this low participation, relatively few new lung cancers are detected in screening programs versus incidental detection. Incidental pulmonary nodules (IPNs) thus play a vital role in the detection of lung cancer. Over 1.5 million patients with IPNs are discovered each year and approximately 63,000 (4%) are estimated to be diagnosed with lung cancer within 2 years [11]. Most of these lung nodules are benign and require no or infrequent follow-up. However, those highly suspicious nodules and high-risk individuals—including the 4% with cancer—need to be tracked to ensure they are receiving proper follow-up. With appropriate evidence-based management [12] of these patients, the disease can be caught early when treatment is more effective. The problem is, only 30% of patients with IPNs receive the proper clinical follow-up [13]. That means the vast majority of patients with IPNs are not being tracked for the early detection of cancer.

Early detection of lung cancer has an enormous impact on the chance of surviving five years after diagnosis. For lung cancer, only 17.8% of patients are diagnosed at the local stage where the 5-year relative survival rate is 59.8%. That rate drops significantly to 6.5% when the cancer is distant [7]. If all IPNs were tracked according to the Fleischner Society guidelines [12], the number of lung cancer cases detected early would increase dramatically.

The fight against breast cancer needs to include incidental findings too

Breast cancer screening programs have greatly improved early detection and mortality rates since their incorporation into clinical practice in the late 1970s. But, like in lung cancer screening, there are millions of eligible women who don’t undergo routine breast care. According to the National Cancer Institute, in the U.S. in 2019, only 76.4% of women aged 50–74 years (the screening age range) had a mammogram within the past 2 years [14]. So, despite the relatively long history and broad dissemination of mammography, as well as the high participation rate in breast screening and success in detection of cancer, three significant populations still remain at risk. The first is screening eligible women who aren’t getting screened; the second is women who fall outside of screening eligibility criteria; the third population is men—yes, a small fraction of men get breast cancer, and usually with poor outcomes.

For the 23.6% of screening-eligible women who do not participate, the women too young for screening and the men with breast cancer, the missed opportunity of a cure is life-changing. This is where incidentally found breast lesions can play an increasingly vital role. Based on Eon’s review of about 5.6M radiology reports (all anatomic regions, all imaging modalities), the rate of unexpect breast findings was about 0.03%. Of these, about 50% of incidental breast lesions were found in women eligible for breast cancer screening. Of the remaining incidental findings, 42% were found in women either too young or too old for screening, and 8% were found in men. Thus half of the patients with incidental breast findings were not eligible for screening, and their findings would not have happened if not for the serendipity of an unrelated CT, MRI, or X-ray exam.

Just how important are incidental breast findings? The same 2017 systematic review found that 42% of incidental breast findings were malignant [3]. For patients outside of breast screening eligibility, the incidental discovery of a breast abnormality is their only chance to be properly diagnosed and receive the care they need. Just like with breast screening, if the malignancy is identified when still localized, the prognosis for these breast cancer patients is quite good.

Incidental findings in other cancers

For the many malignancies without screening tests—such as pancreas, renal, and adrenal cancers—incidental detection is the only chance for early diagnosis. For example, pancreatic cancer has a 5-year overall survival rate of just 10%, mainly because it is typically asymptomatic with 82% of patients presenting in late stages when the prognosis is very poor [7]. However, incidental pancreatic cysts are being detected at an increasing rate—in up to 13.5% of radiology exams, most commonly CT and MRI exams [15]. With Computational Linguistics (CL) to help identify and capture patients with incidental findings, and using evidence-based guidelines on when, how, and if to follow up as well as a patient tracking system, this will help identify cancers in these organs—hopefully while in the early stages when treatment is more effective.

Incidental findings—and the right software—can improve the early detection of cancer

The data shows that incidental identified findings are incredibly important to the early detection of cancer. By capturing and longitudinally tracking these patients to ensure appropriate follow-up, facilities can have a significant impact on patient outcomes. This was the genesis for the development of the family of Eon Patient Management (EPM) oncology solutions. EPM is a scalable, comprehensive software platform a program can use to capture and track patients with incidental findings—including embedded evidence-based guidelines for follow-up monitoring—so it can achieve a stage shift in patient care and the early detection of disease. EPM also enables facilities to add and manage screening populations to the same dashboard so navigators and providers have complete visibility. For example, a comprehensive lung cancer program can combine the EPM Lung Cancer Screening module with EPM Lung, which uses CL to identify IPNs documented in radiology reports with 98.3% accuracy and 98.1% precision, the best rates in healthcare. Another example is the new EPM Breast , a single solution for both screening and incidental patient populations—the first of its kind in healthcare—and a CL model that identifies incidental breast findings with up to 95% accuracy.

EPM also has solutions for Pancreas, Thyroid, Renal, and Adrenal diseases, for which incidental detection is the only chance for early diagnosis. In addition, EPM has a Liver solution similar to Breast, offering both screening and incidental findings technology and patient management. EPM enables patients with incidental findings in these disease states to be accurately identified so they can receive evidence-based follow-up care. These EPM modules also have the best CL accuracy rates in the industry—95.4% for Thyroid, 93.9% for Pancreas, and 94.2% for Liver. In fact, Eon’s technology is advanced enough to be applied to aortic aneurysms. The EPM Abdominal Aortic Aneurysm solution identifies patients with enlargement of the aorta and automates follow-up for the 90% of patients who require routine screening and longitudinal tracking. Lastly, the EPM Actionable Findings module works across all disease states as a safety net to capture those findings that require immediate intervention, ensuring that no patient is left behind.

EPM leads the way in incidental findings and patient management technology

Because the scalable EPM platform is cloud-based and fully integratable enterprise-wide, a facility can use any of the different modules together on the same dashboard to manage multiple patient populations. For all programs, EPM automatically triages patients into a high-risk category for provider review and into a low-risk category for routine follow-up. This feature enables care providers to focus on the high-risk patients, without ignoring the appropriate next step in treating each and every finding. Eon’s internal research combined 8 studies—this meta-analysis showed that patient tracking software and a referring clinician engagement program increases appropriate patient follow-up, often to over 90%. These findings were independently confirmed and support the use of an electronic patient tracking system as well as a centralized referral and care-coordination process [17].

EPM is now live in 270+ facilities, ensuring that patients with incidental findings are identified and tracking for evidence-based follow-up, so that no patient falls through the cracks.

With CL for incidental finding identification and Eon Patient Management, any finding could lead to the early identification of cancer or prevention of a catastrophic cardiovascular event—and a life saved.

SOURCES:

1. National Cancer Institute, Surveillance, Epidemiology and End Results, SEER Stat Facts on Female Breast Cancer.
2. American Cancer Society (cancer.org).
3. O’Sullivan JW, et al. Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ 2018; 361: K2387. DOI: 10.1136/bmj.k2387.
4. Thusitha Mabotuwana, PhD, et al. Determining Adherence to Follow-up Imaging Recommendations. DOI: 10.1016/j.jacr.2017.11.022.
5. Shan S. Hansra, MD, Thomas W. Loehfelm, MD, PhD, Machelle Wilson, PhD, Michael T. Corwin, MD. Factors Affecting Adherence to Recommendations for Additional Imaging of Incidental Findings in Radiology Reports. DOI: 10.1016/j.jacr.2020.02.021.
6. Al Mutairi, A. Meyer, A. N., Chang, P., & Singh, H. Lack of timely follow-up of abnormal imaging results and radiologists’ recommendations. Journal of the American College of Radiology, 12(4), 385-389. DOI: 10.1016/j.jacr.2014.09.031.
7. SEER database (seer.cancer.gov/).
8. https://ascopubs.org/doi/abs/10.1200/JCO.2018.36.15_suppl.6504.
9. Stacey A Fedewa, PhD, et al. State Variation in Low-Dose Computed Tomography Scanning for Lung Cancer Screening in the United States. DOI: 10.1093/jnci/djaa170.
10. Stacey A. Fedewa, PhD, et al. Lung Cancer Screening Rates During the COVID-19 Pandemic. Published: July 19, 2021. DOI: 10.1016/j.chest.2021.07.030.
11. Bruce S. Pyenson et al. No Apparent Workup for most new Indeterminate Pulmonary Nodules in US Commercially-Insured Patients. DOI: 10.36469/9674).
12. Heber MacMahon, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. DOI: 10.1148/radiol.2017161659.
13. Denitza P Blagev, et al. Follow-up of incidental pulmonary nodules and the radiology report. DOI: 10.1016/j.jacr.2013.08.003.
14. Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 1987–2019.
15. Elta GH, et al. ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts. Am J Gastroenterol 2018; 113(4): 464-479. DOI: 10.1038/ajg.2018.14.
16. Incidental Pulmonary Nodules White Paper
17. Nichole T. Tanner, MD. et al. Screening Adherence in the Veterans Administration Lung Cancer Screening Demonstration Project. DOI: 10.1016/j.chest.2020.04.063.

Breast cancer is the most common cancer in the U.S., with about 1 in 8 women developing it over the course of her lifetime. It has impacted nearly every family, and some families more than once. In 2020 alone, 276,480 American women were diagnosed with breast cancer—15.3% of all new cancer cases. Right now, there are around 3.5 million women living with breast cancer in the U.S.

Fortunately, the survival rates are very high compared to other forms of cancer due to widely available breast cancer screening programs, early detection, and advancements in diagnosis and treatment:

• 63% are detected when localized to the breast, with a 98.9% 5-yr survival rate.
• 30% are detected with regional lymph node involvement, with a 86.7% 5-yr survival rate.
• 6% have metastasized before detection, with a 28.1% 5-yr survival rate.

The overlooked patient population—those with incidental breast findings.

When it comes to incidentally discovered breast findings, the challenge is the same—identifying abnormalities accurately and providing the appropriate treatment as early as possible. But there’s a problem. Only 50% of incidental breast lesions are found in women who are eligible for screening, but were discovered in an imaging report outside of a screening program. The other 50% of incidental breast abnormalities are found in patients not eligible for screening:

• 20% are found in women younger than 50 years old (before screening)
• 20% are found in women older than 75 years old (after screening)
• 10% are found in men

These incidental findings may include primary and secondary malignancies, as well as benign lesions including calcification, fibroadenomas, and lipomas. Even if a finding is determined to be benign, that patient still needs evidence-based follow-up to detect breast cancer early should it develop.

So where do these incidental breast patients go if a breast program is dedicated only to cancer screening?

They join the same program. Or, at least they should be able to, and receive the same follow-up management and patient care than any screening patient receives. But right now, existing breast programs focus on screening and are using traditional software that can only manage those patients. Eon has led the industry in developing incidental identification and management solutions, and is now offering the first breast patient management software that includes incidentally identified breast patients in the same dashboard as screening patients for capture, follow-up and longitudinal tracking.

Eon has the only solution available today for a comprehensive breast program.

Only EPM Breast has technology to identify and capture incidental breast findings. It uses proprietary Computational Linguistics (CL) to identify breast abnormalities—such as a mass, nodule, lesion, or cyst—in any non-breast imaging (mammography, ultrasound or MRI) radiology reports that have a measurement. In addition to findings in the breast tissue and if no other measured breast abnormality is found, CL also identifies enlarged axillary, interpectoral, supraclavicular, or mediastinal lymph nodes.

Using EPM Breast, a program’s staff can use just one dashboard to capture and track both breast screening and incidental breast finding patients. Because the volume of any comprehensive breast program can be overwhelming, the automated functions and advanced technology of EPM Breast will save hundreds of hours of FTE time. And because EPM follows evidence-based guidelines, it ensures that both patient populations are tracked for the follow-up care they need.

The next stage shift in the fight against breast cancer.

Until now, patients with incidental breast findings have been underserved by most breast programs. By adding this patient population, a breast program can become truly comprehensive and significantly improve its reach and follow-up care. EPM Breast makes this next big step in the early identification of breast cancer possible.