Primary Care to Oncology: Conversations for Change
Proceedings From the 2024 Memphis ‘Diversity Dinner’ Conference
This past March, Total Health, in collaboration with our partners at the West Cancer Center, presented an evening dinner conference: “Diversity, Equity, Inclusion: Primary Care to Oncology – Conversations for Change”. The program was designed to engage both primary care physicians and oncology multidisciplinary teams to encourage better collaborative relationships for the prevention, diagnosis, and treatment of cancer, with a particular focus on reducing cancer care disparities. We now know that, despite the many improvements in survival outcomes across many cancers, the benefits have not been uniformly observed across all racial and ethnic subgroups of patients.
Diversity, equity, and inclusion are critical to reducing cancer disparities, and all people, regardless of race or ethnicity should have the ability to benefit from advancements in the prevention, diagnosis, and treatment of cancer. The evening’s program was thus designed to engage relevant healthcare professionals to identify current disparities and potential barriers to care, and work towards practical and collaborative solutions.
Because Primary Care physicians represent a ‘gatekeeper’ of sorts across many paths to diagnosis, intervention, and managed care, this is a major sector of the healthcare continuum which can benefit from collaborative conversations across disciplines to bring about fundamental change. In partnership with this sector of medicine, we can also reach communities that have been disproportionately burdened by cancer, and who experience greater obstacles to cancer prevention, early detection, treatment, and survival.
Highlights from this conference can be freely accessed on our YouTube channel: https://www.youtube.com/playlist?list=PL7qLOdOdZwpHqzU36TTqS1W1Ep4KD9xK2
Memphis Tennessee: State of Health
Dr Tobi Adeyeye Amosun, Tennessee Department of Health
The evening’s program began with a special presentation by Dr Tobi Adeyeye Amosun, of the Tennessee Department of Health, on the state of health in Memphis, Tennessee, a unique microcosm of the United States that, in many ways, is illustrative of some of the key disparities in cancer care outcomes. She noted that while cancers, including lung, colorectal, breast and prostate, are the 2nd leading cause of death overall in Tennessee, notably, there is a higher incidence of both colorectal cancer mortality (in men) and breast cancer mortality (in women) when comparing Black to White patient populations. She further noted the differences in key cancer outcomes like breast cancer mortality, and the prevalence of modifiable risk factors for cancer (e.g., smoking, obesity) across the different regions of Tennessee. In the final portion of her presentation, Dr Amosun outlined a number of current efforts underway to increase critical interventions such as cancer screenings for disproportionately impacted populations, and highlighted some of the recent successes with these initiatives across the state.
Patient Centric Care-Shifting the Paradigm
Dr Valerie Arnold, University of Tennessee Health Science Center
In her presentation, Dr Valerie Arnold from The University of Tennessee Health Science Center provided a brief overview of some of the key principles of ‘patient-centered’ care. She noted that implementing a patient-centered care approach in your practice requires creating individualized treatment plans that are based on the patient’s needs, values, and preferences. It also encourages a collaborative decision making process, and emphasizes building a relationship with the patient through ongoing compassionate communication. It is important, for example, to have a good understanding of the patient’s unique family dynamics – who are the important family members that need to be engaged and brought into the conversations about treatment? What are this patient’s fears and traumas that might impact their care? She further noted the importance of providing patients with adequate emotional support from friends and family members to reduce their anxiety and depression, improve their treatment compliance and optimize their clinical outcomes.
“When the patient feels listened to and respected, they’re much more likely to trust their physician’s recommendations, and take responsibility for their journey… patients who are actively engaged in their journey are much more likely to adhere to their plans, advocate for their needs, and take preventative and proactive measures for their health.”
Patient Centric Care - Key Takeaways
Patient centered care is an approach that prioritizes each patient’s unique needs, values, and preferences.
It emphasizes listening to patients, educating them on their conditions, providing emotional support, creating a compassionate environment, and actively involves them in their care.
It empowers patients to collaborate with their clinicians and share in the decision-making process.
It focuses on physical comfort, mental health and well-being, and the patient’s individual goals for their treatment.
Core principles of patient centered care include:
Respect for each patient’s values, preferences, and needs.
Coordination and integration of care, with open communication across the care continuum.
Emphasizing clear information, education, and support.
Attention to physical comfort and environmental needs.
Providing emotional support by involving family and friends.
Facilitating continuity of care and smooth transitions in care.
Providing rapid and reliable access to care, and minimizing wait times.
“I want you to think about – what is one thing that you can do tomorrow to make you, or your organization, more patient centered?”
You can view the full presentation by Dr Arnold here.
The Primary Role for Primary Care
Dr Michelle Kitson, Methodist Le Bonheur
In this session, Dr Michelle Kitson from Methodist Le Bonheur discussed the “primary role for primary care”, noting that the most important role one can have as a primary care physician is to be what she calls a “patient champion”. To do this, Dr Kitson emphasized, requires establishing trust, and being willing, especially, to listen to your patients; “We have 1 mouth and 2 ears…” she noted, “because listening supersedes talking!” She further emphasized the importance of finding a point of connection with the patient so they can be open with you, and establish trust. Communication is paramount, Dr Kitson noted; “Don’t speak in jargon, use plain language, and then check in to make sure they are receiving the information you are providing.”
Dr Kitson also stressed the importance of having a level of patience and persistence, to determine any barriers that may exist which can impact the patient’s care. For example, she noted, when talking about the role of diet and exercise in cancer prevention, “this will not resonate with a patient who does not have access to healthy foods.” Similarly, in the case of cancer screenings like mammography, it’s important to understand critical barriers like transportation that may exist for the patient, and equally important, are your patients with a cancer diagnosis able to afford their treatment, and do they understand what is being articulated to them?
“A lot of times… patients will hear the big ‘C word’… and that’s the last thing that they hear… When these [cancer] conversations are taking place… being in the room with just the patient is inadequate, it’s inappropriate… you often want to have a support system… be it a family member or a trusted friend there, when these conversations are taking place…”
Dr Kitson noted it is also important to remember that patients may have health conditions such as diabetes, hypertension, and obesity, unrelated to cancer, that can impact their treatment course and/or increase their risk for other complications, like heart attack or stroke.
Dr Kitson further noted that mental health is also important to consider – not just depression, but also stresses of work and family life, or, especially in minority communities, patients may be responsible for elder care and have the added stresses of caregiver responsibilities. In addition, Dr Kitson noted that things like fear of the unknown and poor medical literacy can impede patients’ engagement with their care, and there is a need to ensure adequate psychosocial support for the patient. She also noted the importance, in the face of a cancer diagnosis, of maintaining the patient’s age-appropriate vaccinations and regular health screenings: “As physicians, it is important to be the voice of reason to encourage healthcare screenings that support oncologic care.”
Dr Kitson also emphasizes the need for appropriate advanced care planning, the importance of normalizing discussions about death and dying, and managing optimism and expectations in the face of a cancer diagnosis with her patients. She noted that connecting patients and their families with appropriate services for legal, medical, and financial decision making, living wills and trusts, etc. is another area where primary care physicians can help be a champion for their patients.
“Healthcare is a team sport… It’s not an individual sport… the patient, physicians and support personnel, family members, and community - all need to be involved.”
You can view the full presentation by Dr Kitson here.
Multi Cancer Screening Testing: Ready or Not?
Dr Dax Kurbegov, Sarah Cannon Cancer Institute
In his session, Dr Dax Kurbegov from Sarah Cannon Cancer Institute gave an overview of the emerging technology of multi cancer early detection screening. Multi-Cancer Early Detection, or MCED, is an emerging technology that holds the promise of enabling earlier and non-invasive methods for detecting cancer using a simple yearly blood test. The title of Dr Kurbegov’s talk – ready or not – is particularly applicable to MCED technologies, as clinicians are likely to be encountering patients with MCED testing results in the near future, and will have to navigate some of the implications (and ambiguities) of a negative, or especially a positive, MCED testing result.
The premise of the testing is fairly straightforward – because a majority of cancers do not have established, evidence driven screening methods and recommendations (unlike, for example, breast, colon, and cervical cancer) – an MCED result, obtained with a simple blood test, would 1) detect the presence of a cancer ‘signal’ in the body, and, perhaps more importantly, 2) give a reliable estimate of the tissue of origin, to enable a more focused strategy for further assessment and diagnostics.
Dr Kurbegov noted that, overall cancer outcomes remain suboptimal, and that, while they continue to be important for early detection, even our existing single cancer screenings have not shown that they can reduce mortality from these cancers at the population level. He also emphasized that about 70% of all incident cancers have no established screening, which speaks to the need for new screening approaches that can, not only detect more cancers, but also detect them at an earlier stage that is more amenable to curative intent therapy. Dr Kurbegov also noted the importance of distinguishing MCED testing, which aims to determine if cancer is present in the body at the time of testing relative to genetic testing, that screens for specific mutations that are associated with increased risk for developing certain conditions, including cancer. Dr Kurbegov emphasized one of the ongoing questions and a current topic of research with MCED testing is whether such testing can help detect cancers earlier and improve outcomes for patients.
Reviewing some of the early data for MCED testing, Dr Kurbegov noted that, using a blood based test to detect DNA and protein signals, a cancer signal could be detected for a range of different cancer types. Importantly, he noted that while early stage cancers (e.g., Stage I) could be detected, the assays perform better and detect more late stage cancers (e.g., Stage II and III); in addition, the ability to detect the cancer signal varies across cancer types, suggesting that cancers may differ in their ability to shed these cancer signals into the blood.
An important concept in MCED testing is, if a cancer signal is detected in the blood, determining the tissue of origin (i.e., where is the cancer) so that appropriate screening/interventions can be performed. In this regard, Dr Kurbegov noted that determining methylation patterns in DNA, or analyzing the ‘epigenome’, is one way to determine the tissue of origin which has been utilized. He noted some data from a recent study in a population of patients with known cancers, showing that methylation-based MCED testing performed with very good specificity (99.5%), meaning that there were very few false positive results, and a more variable sensitivity (51.5%) to detect different types of cancers. Also, as would be expected, there was again a greater sensitivity to detect cancers at later stages for most of the cancer types examined, for example 21.9% sensitivity for Stage I lung cancer, as compared to 90.7% for Stage III lung cancer.
Dr Kurbegov also described results from a larger prospective cohort study of adults 50 years of age or older either with or without additional cancer risk factors. The subjects received the MCED test and those with a positive cancer signal were informed and the provider then determined the appropriate follow up; those without a cancer signal continued their regular screenings and all patients were followed for 1 year to determine their cancer status (cancer present or not present). The results continued to show very good specificity (99.5%) for the testing modality, and in 88% of the positive cases, the cancer identified corresponded to either the first or second predicted tumor site based on the MCED testing result. The benefit of the predicted site, Dr Kurbegov noted, is that it allows the clinician to prioritize and focus the subsequent diagnostic workup.
An important source of debate with more widespread application of MCED testing across thousands of patients is what to do with the very low number of “false positives” that will occur – that is – those patients with a positive signal in whom no cancer can be detected with appropriate diagnostics. Dr Kurbegov noted that, while there are very limited data at present, one report showed that among 98 patients with a false positive result, 96 remained cancer-free after a 4.3 year follow up, and the study concluded that, following an initial evaluation, returning to standard screening and routine care for such patients was appropriate and safe for the majority of patients. Nevertheless, because this could be a source of anxiety for patients, he noted this as an area where much more data, in larger numbers of patients, will be needed.
Summarizing some of the practical considerations for MCED testing, Dr Kurbegov noted that thus far MCED testing shows very high specificity of over 99%, meaning that such testing could be applied across a very large number of patients at the expense of very few false positives which can lead to unnecessary patient anxiety, workups, and/or diagnostics. He noted that, at present, the strongest evidence for MCED testing is in those individuals 50 or older, and in those 40 to 49 years with some cancer risk factors (e.g., prior smoker, history of a previous cancer). He also noted the pitfalls of MCED testing, including lack of insurance coverage at present, which could amplify disparities in cancer care over the short term due to the cost. It also remains to be seen whether MCED testing will be clinically useful – that is – will it help to improve cancer specific survival? Dr Kurbegov noted that while assessing survival outcomes will require very long periods of follow up, one potential surrogate outcome in this regard could be, can we reduce the stage at which the cancer is detected, thereby making it more amenable to curative treatment? There also remain obstacles with incorporating MCED testing into regular clinical practice, but despite these challenges Dr Kurbegov emphasized that, with more widespread use, clinicians will need to be aware of this technology and the associated implications for the patients they treat.
Multi Cancer Screening Testing: Key Takeaways:
MCED technology is available now and patients will likely be presenting in the near future with testing results that will have implications for their care.
Available results for MCED testing to date show very good specificity for cancer detection (i.e., very few false positives leading to unnecessary workup/diagnostics), although sensitivity to detect different cancer types is more varied.
MCED testing holds promise for more widespread detection of cancers for which no established screening methodologies are available.
MCED screening IS NOT intended to replace current standard of care screenings for patients (e.g., mammography, colonoscopy).
Whether MCED testing can promote a clinically meaningful reduction in stage at diagnosis and/or improve survival for specific cancers remains to be seen in longer term studies.
Costs associated with MCED testing are not currently covered by insurance and this could be a source of disparities in cancer care in underserved populations.
You can view the full presentation by Dr Kurbegov here.
Outcomes in Minority Groups: Drivers of Disparity
Dr Gregory Vidal, West Cancer Center
In his session, Dr Gregory Vidal from West Cancer Center highlighted some of the key drivers of disparate outcomes among minority patients with cancer. He noted that, with improvements in cancer prevention and screening as well as treatments, there have been better outcomes for cancer patients overall, but the benefits have not been uniformly observed across all racial and ethnic populations. In particular, he cited evidence for poorer cancer outcomes in Black patients as compared to White populations. Dr Vidal noted that the causes of these disparities are multifactorial, starting with racism, discrimination and segregation, leading to structural inequities and societal injustices, and differences in key social determinants of health, all of which can ultimately lead to cancer care disparities and poorer outcomes for minority populations. From a geographic perspective, he noted the greatest disparities in cancer outcomes are observed in the southern regions of the United States.
Causes of Disparities
One of the causes of disparate outcomes which Dr Vidal noted was racial differences in key cancer outcomes in Black patients, such as a lower rate of pathologic complete responses (pCR) following chemotherapy as compared to White patients. In this regard, Dr Vidal noted that patients who achieve a pCR, or no evidence of disease following chemotherapy, have a much better overall survival (OS), as compared to those who do not. In one study, this lower pCR rate could be attributed to Black patients having a significant delay in receiving their first chemotherapy treatment, and also, receiving a significantly lower number of chemotherapy cycles, relative to the White patients. In line with these findings, Dr Vidal noted that delays in chemotherapy can also result in worse outcomes. The group of patients most likely to have delays in their treatment also tended to be lower income patients, with no insurance, and those on Medicaid. Dr Vidal also cited results showing that Black patients presenting for chemotherapy tended to have higher baseline comorbidities, with greater physical symptoms, treatment related side effects, and acute distress, all of which can negatively impact their ability to tolerate the subsequent chemotherapy treatment. Similar findings were seen in a population of Black patients undergoing adjuvant endocrine therapy for breast cancer, with higher symptom burden at baseline for Black patients and lower adherence to the therapy. Dr Vidal noted that these differences in adherence to therapy could in turn, be attributed to sociodemographic and clinical factors, as well as higher baseline symptom burden.
Dr Vidal further noted that, in the setting of metastatic lung cancer, the use of next-generation sequencing (NGS) to determine treatment is an essential step in selecting the best treatment for patients, and NGS testing should be performed in a timely manner following diagnosis. Dr Vidal cited results from a large study showing a lower rate of timely NGS testing in Black versus White patients, which can, in turn, lead to worse outcomes for these patients. When examining the possible causes for this disparity in care, it was found that minority patients were going to oncology practices that performed less NGS testing overall, relative to White patients, who attended practices that regularly perform NGS testing for metastatic lung cancer.
How to achieve equity in cancer care?
Dr Vidal noted some proven steps to achieve better equity in cancer outcomes, including equal prevention and screening practices, and once diagnosed, equal access to care and treatment (i.e., equitable health insurance coverage); in addition, he noted the need for equal access and participation in clinical trials. Dr Vidal emphasized the significant impact of insurance coverage, using the example of colorectal cancer. In one study, those patients who were uninsured, with Stage I colorectal cancer actually had worse outcomes relative to those patients with private insurance who had Stage II disease. In this regard, Dr Vidal noted the positive impact of the Affordable Care Act (ACA), with Black patients having a greater decrease in the number of uninsured patients in states which enacted Medicaid expansion as a result of the ACA, whereas there was less change for those states that did not enact Medicaid expansion. Lastly, Dr Vidal noted the disparate participation in clinical trials, where data for the newest and most effective treatments is likely to come from. He noted a much higher rate of participation in clinical trials for higher income patients relative to lesser income patients, and in order to achieve better equity in cancer outcomes, greater minority participation in cancer clinical trials must be encouraged.
Summarizing his presentation, Dr Vidal noted that despite improvements in cancer outcomes overall, disparities in cancer care and outcomes exist for Black and minority populations. Some of the key drivers of these disparities are socioeconomic factors, lack of insurance coverage, and higher baseline comorbidities in minority populations which can adversely impact tolerability of treatment. In this regard, he noted the importance of considering baseline symptom burden to determine the best treatments, along with appropriate counseling and management strategies to improve tolerability of cancer treatments. Lastly, Dr Vidal noted that cancer outcome disparities will continue to exist if there continues to be disparate access to care.
Outcomes in Minority Patients: Key Takeaways
In oncology, it is important for different groups of patients to have similar outcomes, but this is not the reality – as worse cancer mortality rates are seen in Black versus White patients.
Overall cancer death rates are declining, but Black patients continue to do worse, across all cancer types.
Cancer health disparities can result from multiple factors, including socioeconomic factors.
Geographically, the greatest disparities in cancer mortality occur in the southern US for both males and females.
Studies show that Blacks have lower rates of key outcomes in cancer treatment, such as pathologic complete response (pCR) which is prognostic for endpoints such as event free survival (EFS) and overall survival (OS).
Racial disparities in treatment can result from delays in the use of chemotherapy from the time of first diagnosis, and a lower number of chemotherapy cycles received.
These disparities in treatment can adversely impact outcomes.
Compared to non-Hispanic Whites, Black patients have higher comorbid conditions and symptoms coming into therapy, which can translate into poorer outcomes.
Key testing strategies such as next-generation sequencing (NGS) which are essential for patients with non-small cell lung cancer (NSCLC) are performed in a less timely basis in Blacks compared to White patients.
Achieving equity in cancer care outcomes requires:
Equity in prevention and screening interventions for all patients
Equal access and insurance coverage, so patients can receive the treatments they need
Greater minority participation in cancer clinical trials
“We can strive for equality – meaning we all get the same things – but some communities may require a little bit more to close some of that gap – so we can get to the same outcomes.”
You can view the full presentation by Dr Vidal here.
Spotlight Discussion: Lung Cancer
Dr Matthew Smeltzer, right, moderates a panel discussion on lung cancer with Dr Jason Porter, left, and Dr Chris Jackson.
In this session moderated by Dr Matthew Smeltzer, an epidemiologist from University of Memphis, Dr Jason Porter, a thoracic medical oncologist from West Cancer Center and Dr Chris Jackson, an academic primary care physician from Regional One Health at University of Tennessee Health Science Center discussed issues relating to the diagnosis and treatment of lung cancer, the leading cause of cancer death in the United States. Dr Smeltzer noted that, although screening in high risk individuals (e.g., smokers) represents the best opportunity for early diagnosis and intervention which can save lives, the overall uptake for screening in eligible individuals is very low, and criteria for screening are somewhat stringent.
Changing Epidemiology
Dr Porter noted that, with people living longer in general, he is seeing more older patients with lung cancer (as would be expected), but also younger patients, patients who have never smoked, and patients on immunosuppressive drugs such as transplant patients, presenting with lung cancer. Importantly, he noted that, under current guidelines, these latter groups of patients do not necessarily qualify for lung cancer screening. Dr Jackson agreed about the changing demographics of lung cancer, noting the need for better risk assessment tools. He also noted the changes in survival with, for example, stage IV lung cancer, that in the past was akin to a death sentence – but now, with advances in care, patients are living for much longer periods, even with advanced disease. In these patients, Dr Jackson noted, it’s important to continue other cancer screenings (e.g., mammography, colonoscopy) and also to take into account other metabolic conditions like heart disease that can also impact survival in patients with lung cancer. Adding to that, Dr Porter noted that certain risk reducing interventions for cardiovascular disease (e.g., using baby aspirin) have the potential to impact life-saving treatments for lung cancer, such as immunotherapy, and as such now have to be considered in the context of the patient’s ongoing care plan.
Recognizing the Impact of Stigma and Bias
Dr Jackson noted that he is often wrestling with the issue of patients who are former smokers feeling that they “don’t deserve” screening or interventions for a lung cancer diagnosis. He noted often saying to patients, “Sure you might have smoked for multiple years, but it doesn’t mean that 1) you deserve lung cancer, and 2) it certainly doesn’t mean that if we can catch it early, and intervene where you don’t have problems from it, that we shouldn’t… letting go of that stigma becomes very important.” He further noted the impact of how primary care physicians refer to the testing, for example, calling it “breast cancer screening” versus “mammography” or “colon cancer screening” versus “colonoscopy”. Dr Porter agreed, noting the benefits of creating a more neutral and standardized terminology such as “lung health screening” which could be universally applied in both primary care practices and radiology/imaging centers.
“If you call it lung cancer screening, I think - the underlying tone is ‘oh, they want to find my lung cancer’… If everybody could just agree – let’s call it a lung health screening, that’s what it is from now on – and then, when we talk to patients about it, they understand what we mean…”
Barriers to Lung Cancer Screening Uptake
Dr Jackson noted the “dizzying” changes in screening criteria that have occurred over the years, particularly for the busy primary care physician, and the ongoing difficulties getting insurance coverage for lung cancer screening. He also noted the lack of attention that the lay press and social media have given to lung cancer screening, as compared to other screening such as mammography and colonoscopy. Dr Porter agreed, and emphasized the current complexity in screening criteria and a need for better standardization and risk stratification with lung cancer screening, noting that some patients may need more frequent screening relative to others. For example, an individual risk assessment for lung screening might consider whether the patient is a smoker or a non-smoker, are they on immunosuppression or not, and so on. While admitting that widespread uptake and standardization of screening protocols and risk assessment for lung cancer would of course take some time and be difficult to implement at the national level, Dr Porter noted past successes with interventions such as colonoscopy and establishing individualized follow up plans for colorectal cancer screening. He further noted the tremendous opportunity that primary care physicians have, seeing thousands of patients (before a cancer is diagnosed) to encourage screenings and early diagnosis, relative to thoracic medical oncologists (who see patients only after a cancer is already present). Dr Jackson agreed, and noted an opportunity for better interventions for follow up and cancer screenings in the inter-visit period (relative to the primary care visit, when PCPs are usually dealing with more pressing acute issues for the patient). Using tools like electronic medical record (EMR) generated screening checklists, and automated reminders for cancer screenings, he thought, could go a long way to improving follow up and screening uptake in the primary care setting.
The Power of Interdisciplinary Collaboration
Dr Porter and Dr Jackson then related several successful collaborations for specific patients whereby a primary care patient would be referred to Dr Porter to be evaluated for lung cancer, and vice versa, where a lung cancer patient now dealing with a longer term survivorship issue would be referred to Dr Jackson for follow up on a metabolic problem such as heart disease. Both acknowledged the power of these collaborations to establish better trust and continuity of care with the patient and “speak with a unified voice”. Dr Porter also emphasized the importance of having a primary care connection to consult for metabolic complications such as diabetes that can arise during cancer treatment, and also for end of life discussions where patients may no longer be responsive to treatment and goals of therapy might need to change. He noted, “Maybe I’ll call Dr Jackson and say, hey, Ms. X is not doing well… let’s talk to them together… those kinds of collaborations can really change the way patients experience cancer…”
Working Towards a Primary Care ‘Checklist’
As a final thought, Dr Porter advocated for a standardized “checklist” for primary care providers, that features all of the relevant screenings which should be performed and when, and which calls the screenings by the appropriate name. A slip of paper could be provided by the patient at check in detailing whether they have, or have not had the required screenings so that primary care can be aware, for example, if a patient has completed other screenings, but is still needing a colonoscopy. When it comes to cancer screenings, Dr Porter noted: “Lets agree and come to consensus on what that list [of screenings] is, and start talking about that list… let’s increase the lung health screening visibility, and make sure that we include that in the discussion…” He also noted the importance of including the payers and insurance companies in the discussion, so patients can get their required screenings approved and paid for. Dr Jackson agreed, and added, for his primary care colleagues, not to let an initial ‘no’ to a cancer screening be the end of the conversation, because screenings do have the potential to save lives, and, as time goes by patients may change their minds. “Revisit screening… early and often with patients” he said.
You can view the full panel discussion on lung cancer here.