Problem: At the time of this initiative, West Virginia ranked third and fourth in the country, respectively, for new cases of lung cancer and deaths from lung cancer.1,2
1West Virginia Cancer Registry. (2020). 2019 West Virginia Cancer Burden Report. Morgantown, WV: WV Retrieved from https://oeps.wv.gov/cancer/documents/data/burdenreport2019.pdf
2U.S. Cancer Statistics Working Group. (2019). U.S. Cancer Statistics Data Visualizations Tool, based on November 2018 submission data (1999–2016). Retrieved from www.cdc.gov/cancer/dataviz
PSE Change Solution: The Mountains of Hope Comprehensive Cancer Coalition prioritized lung cancer screening in the 2016-2020 West Virginia Cancer Plan and established a Lung Cancer Screening Workgroup that included more than a dozen academic, commercial, community, non-profit, and governmental entities. The workgroup adopted a multicomponent shared-vision strategy to complete activities promoting lung cancer screening, including a targeted newspaper advertising campaign; an online educational webinar for health care providers; and a pledge, designed for providers and community members, to educate and promote lung cancer screening.
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Each year, approximately 2,047 people are diagnosed with lung cancer in West Virginia, and approximately 1,460 die of the disease (2019 West Virginia Cancer Burden Report [WV Report], 2020; West Virginia Cancer Registry [WV Registry], 2019; U.S. Cancer Statistics Work Group [USCS], 2019). West Virginia ranks 3rd in the country for new cases and far exceeds the national average of 56 per 100,000 (WV Report, 2020; USCS, 2019). Similarly, the state ranked 4th for lung cancer deaths (53.1 per 100,000) compared to the national average of 38.5 per 100,000 (USCS, 2019). Additionally, only 22% of lung cancer in the state is diagnosed without metastasis (WV Report, 2020; WV Registry, 2019). In West Virginia, lung cancer kills more people than breast, colon, and prostate cancer combined (American Cancer Society, 2020). The introduction of lung cancer screening may increase early detection of the disease when it is most treatable (American Cancer Society, 2019).
The Mountains of Hope (MOH) Comprehensive Cancer Coalition is a group of individuals and organizations in West Virginia who are part of the effort to reduce the human and economic impact of cancer in the state. These cancer control stakeholders represent 20 years of collaboration. This statewide network is comprised of:
• state and local governments,
• private and nonprofit organizations,
• health, medical, and business communities,
• academic institutions,
• cancer survivors,
• caregivers, and
MOH prioritized lung cancer screening in the 2016-2020 West Virginia Cancer Plan. The coalition established a dedicated work group charged with developing strategies and activities to increase lung cancer screening for at-risk West Virginians. Coalition members self-selected work groups based on personal passions or organizational goals. The MOH veterans of the work group were joined by a new member, the West Virginia University Clinical and Translational Science Institute. The Lung Cancer Screening Workgroup (called Aim 14) included MOH members representing:
• West Virginia Department of Health and Human Services
• American Cancer Society
• West Virginia University Cancer Institute
• West Virginia Breast and Cervical Cancer Screening Program (WVBCCSP)
• American Lung Association
• West Virginia Lung Cancer Project
• West Virginia Program to Increase Colorectal Cancer Screening (WVPICCS)
• Charleston Area Medical Center
• Webster County Memorial Hospital
• West Virginia University Cancer Institute Bridge Survivorship Program
• West Virginia University Clinical and Translational Science Institute
Additional partners were recruited from outside of MOH. These included low-dose computed tomography (LDCT) screening facilities, primary care providers (PCP), media partners, the Governor’s office, and community groups.
The Aim 14 work group adopted a multicomponent intervention strategy to inform all lung cancer screening activities. This shared-vision strategy required a commitment to:
• Root work in data-informed decision making.
• Adapt and implement evidence-based interventions from past MOH or MOH partner organization projects, Evidence-Based Cancer Control Programs (EBCCP), or the Community Guide.
• Create a shared language for education materials, resources, and media. Language should be clear, low-health literacy, culturally appropriate, and use consistent terms to increase clarity and credibility.
• Nurture relationships both inside and outside the Aim 14 work group. (These collaborations build capacity by supporting partner organization goals, informing and supporting each other’s work, and sharing data and resources).
• Build interventions that address social determinates of health to increase benefit and create sustainable change.
• Use policy, systems, and environmental change when possible to connect community members with clinical services.
• Measure the benefit of interventions and share best practices to build lung cancer screening capacity state-wide.
Using the shared-vision strategy as a template, MOH completed key activities to promote lung cancer screening in West Virginia. The Aim 14 work group began by creating a targeted newspaper advertising campaign for the counties with the highest lung cancer mortality rates (Step 5: Promote). MOH members created these ads using shared language that promoted lung cancer screening, using information about the influence of perceived norms and an individual’s perceived ability to take action based on the Theory of Planned Behavior and the Theory of Reasoned Action. To influence behavior change, messages were crafted to influence the culture of lung cancer screening by promoting the acceptance of cancer screening; all messages included a call to action. The group used low-health literacy guidelines, keeping information simple, visual, and useful. This messaging also informed later educational outreach activities.
New data from the West Virginia Lung Cancer Project, an MOH member, outlined gaps in provider knowledge about lung cancer screening and shifted priorities for the group in Year Two (Step 2: Scan). This information included the identification of gaps in provider knowledge of screening guidelines, processes for referral, and insurance reimbursement. The group identified that prior to more patient outreach, primary care education had to be completed. Several Aim 14 work group member organizations tackled these barriers independently. To support their efforts, MOH decided to create an online educational webinar for physicians and nurses, with video vignettes of the shared decision-making process as that was an identified provider weakness. MOH provided free continuing education credits for any provider who completed the online webinar.
To complement the provider education, MOH created the White Button Pledge; a pledge to educate and promote appropriate lung cancer screening in the community. To date over 63 providers and community members have signed the pledge. Mountains of Hope also hosted several education sessions at membership meetings to provide lung cancer screening education for the coalition membership (Step 5: Promote). In 2018, the Coalition pooled resources with the WVU Cancer Institute, WV Lung Cancer Project, and the Bridge Survivorship Program to conduct a larger lung cancer conference entitled, Catalyzing Change to Address Lung Cancer. This large conference and an additional half-day event included a focus on lung cancer policy, screening, treatment, and survivorship issues.
At each MOH membership meeting, partner activities related to lung cancer were highlighted. In addition, MOH successfully petitioned the Governor’s office to proclaim November Lung Cancer Awareness Month in West Virginia from 2017-2019.
To promote Lung Cancer Awareness Month, work group members created a Lung Cancer Awareness Month Toolkit. The toolkits are updated each year and distributed in October. To date, over 1,800 toolkits have been distributed to MOH members, clinics, and providers via the MOH listserv, WVBCCSP listserv and individual member dissemination.
An assessment of LDCT screening capacity completed by the WV Lung Cancer project allowed the Aim 14 work group to utilize maps of LDCT screening providers who could bill Medicare and Medicaid. The free exchange of information by contributing partners informed the group about common barriers and best practices. While clinics were prepared to conduct screenings, for example, it was determined that patients did not know about lung cancer screening, if they should get it, or where to go. To address such barriers, MOH promoted the WV Lung Cancer CareLine, which provides patient navigation to lung cancer screening and support for those seeking treatment or survivor services for lung cancer. Additionally, MOH created and distributed several video public service announcements (PSA) starring a local celebrity. These PSAs are available for co-branding with partners and used for local promotion. Multiple versions with 30- and 15-second cuts are available, formatted for use on television, websites, and social media. In partnership with Nexstar Communications, the PSAs aired in two targeted areas of the state. Besides the paid advertising, Nexstar donated airtime, effectively doubling the purchased advertising spots.
Feedback and assessment of previous projects culminated in the establishment of a lung cancer screening pilot program (Step 6: Implement). For this activity, MOH focused on building relationships between the coalition and LDCT screening facilities, offering the facilities guidance and resources to increase lung cancer screening. MOH promoted building sustainable referral networks and processes with primary care providers, using targeted community advertising, and adapting evidence-based interventions such as community clinic linkages to increase lung cancer screening.
To implement this project, the Aim 14 work group:
• Identified counties with high incidence rates that had a LDCT screening facility that could bill Medicare and Medicaid within 20 miles of primary care providers.
• Recruited two LDCT screening facilities through partner organization networks.
• Created implementation toolkits that included letters to PCPs with local statistics about lung cancer incidence, and co-branded and tailored marketing for Facebook, Twitter, websites, and print materials. These toolkits encouraged use of appointment reminders and provided links to continuing education materials, resources, and reporting tools.
• Work group volunteers provided training and technical assistance to participating facilities.
LDCT Screening Facilities:
• Committed to holding a dedicated lung cancer screening day/week in November 2019.
• Reached out to local primary care providers to provide customized toolkit resources and promote lung cancer screening.
• Completed program training and outcome reporting.
• Received and used tailored resources from LDCT screening facility.
• Referred and followed patients receiving LDCT lung cancer screening.
This project resulted in LDCT facility policy and protocol changes, such as:
• Outreach to primary care provider.
• Use of resources to implement lung cancer screening marketing strategies. These resources used shared language, adaption of evidence-based reminders, and data-driven targeted messaging that were branded by MOH. Work group members offered training and technical assistance to tailor resources and inform marketing strategies.
• Change to electronic medical record reporting.
• Review and evaluation of screening rates.
• Expand LDCT appointment hours to include evening appointments (structural barrier addressed
• Establish referral, follow-up, and reporting procedures between the screening facility and the PCP (systems changes).
The MOH lung cancer screening activities engaged more than 297 partners including 11 member organizations; 47 media outlets; the Governor’s office; and over 200 providers, including clinics and healthcare facilities. Key results of these activities included:
• 113 people enrolled in the Lung Cancer Screening CE education module. An unexpected outcome of this project involves two community members who volunteered as actors for the video. Since filming, both have quit smoking and one received lung cancer screening that found early-stage lung cancer in time to successfully treat the disease.
• The televised public service announcement directly led to patient navigation and completion of lung cancer screening for one high risk woman; she contacted MOH within 24 hours of the PSA airing.
• For the two participating LDCT facilities, the pilot program increased their average lung cancer screening by 24% as compared to the previous year’s monthly screening rates.
Success Factors and Key Questions Addressed
Which stakeholders needed to be included in your efforts and how did you assemble them?
To create a state-wide effort, MOH needed to engage representatives from the state cancer centers, non-profits and grant programs dedicated to lung cancer screening, the West Virginia Department of Health and Human Resources, and the American Cancer Society. Many of these stakeholders participate in MOH, or have existing partnerships with MOH members. Leveraging and building on already existing partnerships enhanced the reach and participation of the project.
How did the missions of diverse stakeholders align for the purpose of the PSE change effort?
Members of MOH and its partners chose lung cancer screening as a priority aim from the state cancer plan. Members volunteered for this effort due to personal or professional interest in lung cancer screening and/or the early detection of cancer.
What resources (tangible and intangible) were needed that stakeholders could provide?
MOH members and their extensive network of partners built on previous collaborative experience. The adaptation of the shared-vision strategy created a framework for implementing the activities. Some stakeholders contributed national program level educational resources, and others created or adapted materials to meet individual project needs. WVU Cancer Institute wrote funding support for MOH lung cancer screening activities into a grant with the Patient Advocate Foundation and these dollars allowed for the creation of PSAs, the webinar, and many of the costs associated with creation and dissemination of materials.
For information about evidence-based initiatives for cancer screening, visit the Community Guide and CDC’s Screen Out Cancer website. Also see the West Virginia Cancer Plan 2016-2020.
Project materials include:
American Cancer Society. (2019). Can Lung Cancer Be Found Early? Retrieved from https://www.cancer.org/cancer/lung-cancer/detection-diagnosis-staging/detection.html
American Cancer Society. (2020). Key Statistics for Lung Cancer. Retrieved from https://www.cancer.org/cancer/lung-cancer/about/key-statistics.html
U.S. Cancer Statistics Working Group. (2019). U.S. Cancer Statistics Data Visualizations Tool, based on November 2018 submission data (1999–2016). Retrieved from www.cdc.gov/cancer/dataviz
West Virginia Cancer Registry. (2020). 2019 West Virginia Cancer Burden Report. Morgantown, WV: WV Retrieved from https://oeps.wv.gov/cancer/documents/data/burdenreport2019.pdf
West Virginia Cancer Registry. (2019). Retrieved from https://oeps.wv.gov/cancer/Pages/default.aspx#data