’Breathe Easy’ bus brings lung screening to areas where it’s needed most
J. Rob Headrick, MD, MBA, understands the psychology of smokers.
“I grew up in a family of smokers,” Headrick, chief of thoracic surgery and medical dyad leader of oncology services at CHI Memorial Rees Skillern Cancer Institute, said in an interview with Healio. “It’s not something a person is proud of — they feel like they’ve done something wrong. They’re scared to death to come in for a screening.”
Headrick, who practices in Chattanooga, Tennessee, said others at risk for lung cancer may not be aware that they should be screened. Living in an area of the country with high rates of lung cancer, Headrick said, these individuals cannot afford to forgo screenings.
“We’re located in one of the hotbeds of lung cancer, with one person dying of lung cancer every 2 hours,” Headrick told Healio. “I realized it’s fixable if we could just find them early, but they’re not coming for this scan that they don’t know they need and don’t really want.”
The U.S. Preventive Services Task Force seeks to further expand screening for lung cancer with draft guidance issued in July that lowers the recommended age at which individuals with a smoking history should begin annual scans, from age 55 years to 50 years.
Headrick and colleagues sought to make such screening available to a broader population by rolling out a novel mobile screening bus equipped with a low-dose CT scanner.
During the first 10 months that the “Breathe Easy” bus operated in 2018, clinicians performed 548 low-dose lung screenings at 104 locations, according to a report published in The Annals of Thoracic Surgery. Screening recipients had a mean age of 62 years, with a mean 41 pack-years of smoking.
The screenings revealed five lung cancers and a type B thyoma.
The prototype vehicle cost $650,000 to build, with funds from two nonprofit foundations donated through the CHI Memorial Foundation. The estimated cost of the commercially reproducible vehicle is $850,000.
A 5-year pro forma using 1 year of actual data plus 4 years of projected data showed the mobile screening program had a net present value of $1 million, an internal rate of return of 34.6% and a profitability index of 2.2.
Headrick spoke with Healio about the development of the bus and how it has improved lung cancer detection in an underserved area.
Question: How did you get the idea to create this mobile screening program?
Answer: We looked at the geospatial mapping of our state and realized many people live in rural areas where there’s no hospital or imaging center. To think Mr. Jones is going to drive an hour for a screening test, wait an hour and then drive back home for something he’s not even aware he needs seemed unrealistic.
I trained at Mayo Clinic and one of the concepts of Mayo is that doctors go to the patients. So, I said, “Why don’t we go to the patient?”
We asked companies, “Can we buy a mobile lung screening bus just like they use with mammography?” and they said, “Sure, except those don’t exist.” The difference is that a CT scan needs to be temperature- and humidity-controlled. You can’t operate it unless the machine is level. So, they placed them in 18-wheelers and parked them on concrete slabs, but nobody had taken it to the point of the mobile mammography buses, where you drove to a church parking lot that’s not level, scanned people and then drove back home.
I said, “Well, we went to the moon in 1969 on a calculator. We can do this.”
Q: It took some effort to bring this idea to fruition. How did you achieve this?
A: It became an engineering challenge to design a bus that would be affordable. Carolinas Medical Center and NeuroLogica, a Samsung company that makes CT scans, were testing the same concepts, serving the same rural area. Their model was more of an oversized ambulance. I needed a waiting room inside — an air-conditioned, climate-controlled space. I needed a place to do the counseling. What we could do quickly was buy a Freightliner chassis and run it through the assembly line, and Winnebago put the shell on it. Siemens put the CT scanner in it and did the balancing. We’re now over 2 years into the project.
Q: Has it been working well?
A: Yes. We’ve learned a couple of lessons along the way. If you don’t do the education before you show up at whatever church or business you’re visiting, it’s not going to be very successful. You also need to target the older demographic. We went to a health fair early on and didn’t get anyone over age 40 years. However, as we kept putting effort into it, the events became much more successful. We started scanning more people each day and having less paperwork because we preregistered them. We started working on how to screen the most people within the time we had at each event.
Probably the biggest lesson was that you can’t drive too far. We had calls from all over Tennessee. The problem is, if we drive 3 hours to an event and get positive findings, how do we get that person back for follow-up? We quickly learned to limit each bus radius to about an hour and a half, because that’s about the maximum distance somebody would travel to us.
Q: What is it about the mobile unit that makes people more comfortable getting screened?
A: If you’re driving down the road, you might stop for something to eat after seeing a billboard, but you’re not going to pick your health care that way. If I sat down at the local hangout and talked to people, I might be able to convince them to be screened. They’re all aware of the mortality rate with lung cancer, but they don’t understand that the survival rates are dramatically different if we find it early. If I can convince them in that conversation and the bus is right there, I can tell them it will take 15 minutes with no out-of-pocket cash. I wouldn’t say it’s an easy sell, but it’s near a 100% sell.
Q: What effect do you anticipate the draft USPSTF recommendation will have on your screenings?
A: The new USPSTF guidelines simply incorporate groups one and two of the NCCN guidelines. Group one included individuals aged 55 to 80 years with a 30 pack-year smoking history who quit within the past 15 years. This was the only group that both the USPSTF and CMS originally agreed on screening with no cost-sharing. Group two included those aged 50 years or older with a 20 pack-year smoking history. There are strong data suggesting both these groups are high risk and benefit from lung screening. We have been incorporating both groups from day 1 in our mobile screening program, group two just had to pay cash or go through our foundation’s grant funding. If the new recommendation goes through, it will open lung screening to even more patients, saving even more lives.
- USPSTF draft recommendation statement on screening for lung cancer. Available at: www.uspreventiveservicestaskforce.org/uspstf/. Accessed July 17, 2020.
For more information:
J. Rob Headrick, MD, MBA, can be reached at 2108 E. 3rd St., Chattanooga, TN 37404; email: email@example.com.