Guiding Patients through Cancer Screenings

It’s well-known that early detection saves lives yet an estimated 50% of cancers aren’t found until later stages, leading to worse outcomes and higher healthcare costs. To reduce cancer mortality risk, Cleveland Clinic launched an advanced practice provider (APP)-led clinic as part of an Early Cancer Detection Program that brings together five pillars:

• Standard-of-care screening: Helping patients access breast, cervix, colorectal, lung and prostate cancer screening
• Actionable findings: Ensuring concerning results from a scan or blood test are reviewed and assessed promptly and supporting patients during this frighting time
• Guidance with early detection tests: Helping patients weigh the pros and cons of these blood tests
• Germline genetic testing: Guiding patients on when it’s appropriate to undergo these screenings
• Preventative medicine: Supporting patients in making healthy lifestyle choices to reduce their cancer risk

Overseen by pulmonologist Peter Mazzone, MD, MPH, the program offers a comprehensive approach to evaluating patients in a dedicated clinic, identifying cancer early in its course and guiding patients through the complexities of screening.

Increasing screening for eligible patients

There are a variety of factors that can stand in the way of cancer screening. “If a patient hasn’t seen a primary care provider for several years, they might not know they’re eligible,” says Dr. Mazzone. “Other people are told they’re eligible but may be concerned about the outcome of the screening test or worried that their insurance may not cover it. Or they may live in a rural location or be working long hours and it’s a burden for them to get to a facility to be screened. Our hope is to have screening available across the health system closer to patients to address those barriers.”

The Early Cancer Detection program team is also building registries for each screening program, creating a dashboard to identify eligible patients, reaching out if they’re overdue for screening and ensuring they’re aware of all screenings that are appropriate for them.

Addressing actionable findings

In some instances, a patient may have had scans for other reasons that reveal incidental findings. The team works with the Actionable Findings Program, which has established protocols and action alerts to ensure those signs are investigated promptly. Through internal alliances with physician champions for each type of cancer, they connect patients to specialists who can guide them in what other testing, observation and/or treatment is appropriate. “We’ve teamed up with specialists who can guide patients and minimize testing for findings that are nothing to worry about, while expediting care for those at higher risk of early cancer,” says Dr. Mazzone.

Patients can be referred to the Early Cancer Detection program through the Cleveland Clinic Health System or by anyone who uses EPIC.

Stewarding use of multi-cancer early detection blood tests

Several blood tests can now be ordered to identify multiple types of cancer before symptoms emerge. None of these tests are yet FDA-approved but given their general availability, the program team felt it was prudent to guide patients who do choose these tests in weighing the pros and cons of getting testing and helping them in interpreting results.

“Several of these tests have substantial research behind them,” says Dr. Mazzone. “Many of us believe some of these tests will ultimately prove to have more benefit than harm and we’re here to guide patients in understanding the tradeoffs so they can make informed decisions that fit their value sets. We want people to be fully informed about the potential benefits and downsides of tests, and also ensure they don’t use these tests in lieu of standard-of-care screenings.”

Currently, the sensitivity of these blood tests is around 40%, meaning that the tests won’t correctly identify cancer in roughly six out of 10 individuals. Thus, people should not ignore symptoms or skip a recommended screening if the test is negative. The flip side is that some patients may have a positive result despite there being no cancer present.

Given the chances of false positives, the program is developing protocols to evaluate positive results in the most efficient way to minimize unnecessary or invasive testing as well as resulting anxiety for patients.

Cleveland Clinic is also working with several test developers to explore the appropriate use of these diagnostics in certain patient populations.

Providing germline genetic testing and counseling

The program team ensures that individuals and families with personal or family histories of cancer with a potential hereditary cause have access to germline genetic testing. Genetics counselors and Genomics Institute colleagues across the enterprise follow National Comprehensive Cancer Center Network and American Society of Clinical Oncology guidelines for when to recommend germline genetic testing based on a patient’s personal or family history traits.

Most patients getting this testing have a strong family or personal history of certain types of cancer leading to concern about their cancer risk. When positive tests occur, the program team connects patients with appropriate specialists for ongoing monitoring based on the type of cancer susceptibility they and their close family members may have.

In the future, the team hopes to use molecular testing of proven cancers to automatically identify patients with potential germline variants.

Reducing lifestyle risk factors

The program staff also meets with patients one-on-one in a judgment-free way to increase awareness about how current lifestyle choices may affect cancer risk and counsels them on ways to reduce that risk. Preventative measures include smoking cessation, skincare, exercise and nutritional guidance.

The program clinicians and counselors are also keenly aware of the emotional factors that may prevent patients from getting recommended screenings. They’re sensitive to patients who may worry about being judged for lifestyle choices like smoking. “Particularly in the lung cancer field, the stigma around smoking can sometimes prevent people from reaching out to get screenings or care. It’s our job to make sure everyone feels valued and is not blamed if they develop a disease,” says Dr. Mazzone.

“There’s also a fatalism some people have around certain types of cancer that may cause them to forgo screening out of the belief that there would be no hope if the screening reveals cancer. The team is working to educate patients about the importance of early diagnosis. “There have been tremendous treatment advances, even for some aggressive cancers if you can find them early,” says Dr. Mazzone”