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Improving Adherence to LungCancer Screening GuidelinesAshley Prosper, MDHannah Milch, MDAssistant Professor of RadiologyThoracic & Diagnostic Cardiovascular ImagingDepartment of Radiological SciencesDavid Geffen School of Medicineat UCLAAssistant Professor of RadiologyBreast ImagingDepartment of Radiological SciencesDavid Geffen School of Medicineat UCLAThe health benefits of screening eligible patients for lung cancer with low dose computed tomography (LDCT)have been well established. The National Lung Cancer Screening Trial — led by Denise Aberle, MD, professorof radiology at UCLA — demonstrated a 20 percent relative risk reduction compared to chest radiography.In a subsequent European trial (NELSON), lung cancer screening with LDCT reduced mortality in women by33 percent and in men by 24 percent compared to no screening.“By a large margin, however, not enough of those who wouldbenefit from getting regular, low dose CT screening for lungcancer are doing so,” says Hannah Milch, MD, assistantprofessor of radiology at UCLA. “Five to 10 percent, essentially,of eligible current and former smokers are being screened.”that has been around for a while that has very high adherenceand on the other hand a newer type of screening modality —LDCT for lung cancer screening — also shown to save lives,but with a much lower percentage of eligible patients adheringto those guidelines,” says Dr. Milch.Adherence to breast cancer screening recommendations,by contrast, is between 76 and 81 percent. Dr. Milch,in collaboration with Ashley Prosper, MD, assistant professorof radiology at UCLA, is exploring the possibility of leveragingthe high adherence to screening guidelines for breast cancer toimprove the poor adherence to lung cancer screening guidelines.“We have, on the one hand, an image-based screening practiceDr. Milch recently conducted a pilot study at UCLA in whichover 800 women being seen for breast cancer screening weresurveyed to determine their eligibility for lung cancer screening,their awareness of lung cancer screening and their adherenceto lung cancer screening guidelines. She found that about aquarter of the women presenting for screening mammographyhad a history of smoking, and about one in seven of these women“Any way that we can facilitate or normalize the process of gettingscreened for lung cancer will be beneficial.”– Dr. Prosperuclahealth.org/radiology310-301-68005

“By a large margin, not enough of those who would benefit fromgetting regular, low dose CT screening for lung cancer are doing so.”– Dr. Milchwere potentially eligible for lung cancer screening. Yet the majority(63 percent) of these eligible women had never heard of lungcancer screening with LDCT.“If we could use screening mammography as a way to identifywomen who could really benefit from lung cancer screening, thatcould potentially have a significant impact on adherence to lungcancer screening guidelines,” explains Dr. Milch. Drs. Milch andProsper speculate about the possibility of combining even moreimage-based screening exams to improve adherence and offerbetter convenience to patients. They point out that additionalimage-based screening services that might be considered forinclusion in a radiology-based wellness package could includeCT coronary calcification scoring, DEXA scans for bone densityand CT colonography. “It may be easier for patients to take thesepreventive measures if they were coordinated into a single visit.That could be very helpful for patients’ overall health,” addsDr. Milch.Dr. Prosper is also pursuing another research project basedon her analysis of the National Lung Screening Trial data.“African American men have the highest rate of morbidity andmortality from lung cancer of any group. In the NLST, whenAfrican Americans were screened with low dose CT, they hadthe greatest reduction in lung cancer mortality as well as allcause mortality.”Dr. Prosper was recently awarded an Innovation Fund grantfrom the American College of Radiology to devise educationaland outreach tools to improve lung cancer screening adherenceamong African Americans to help address the disparity in theirhealth care outcomes. In collaboration with a group of communitystakeholders, she is working to develop education and outreachtools specifically for the African American community that areculturally relevant and culturally competent.The end products of Dr. Prosper’s one-year project, which beginsin September of this year, will include videos, a website, outreachtools and a guide on forming community partnerships that willbe made available to other radiology centers. “We have a lot oflung cancer screening programs that are accredited through theAmerican College of Radiology across the country who I hope willbe similarly interested in engaging their communities and workingwith their surrounding populations to make sure that patients areaware of their screening programs and feel that they can accessthem and will be welcome,” explains Dr. Prosper.6Improving adherence to lung screening guidelines requiresaddressing psychological barriers unique to lung cancerscreening. “Lung cancer screening is different from just aboutany other cancer screening exam in that patients face stigma ascurrent or former smokers,” explains Dr. Prosper. “That can be areal barrier to patients coming in to get screened for lung cancer.”Smoking stigma and fatalistic views about their lung health cankeep this group from getting screened. “Any way that we canfacilitate or normalize the process of getting screened for lungcancer will be beneficial to these patients,” says Dr. Prosper.Updated Guidelines Could Benefit AfricanAmerican MenCurrent guidelines from the United States PreventiveService Task Force (USPSTF) recommend annual lungcancer screening with low dose computed tomographyfor adults 55 to 80 years of age who have a 30 packyear smoking history and who currently smoke or havequit within the past 15 years. The USPSTF has recentlyproposed changes to lower the age range to 50 yearsand the smoking history to 20 pack-years.CurrentGuidelinesProposed 2020RevisionAge55-8050-80Pack-years3020Years since quiting1515GradeBBThis could prove particularly helpful in the early detectionof lung cancer among African American men, as they tendto develop lung cancer at a younger age and with a lowerpack-year smoking history. “A lot of us have felt that theexisting guidelines are not inclusive enough — that we’renot catching African American smokers in time,” saysDr. Prosper. “Seeing the USPSTF acknowledge this andwiden the age range and widen the smoking history shouldreally help us in terms of improving that inequity.” RUCLA RadiologyAutumn 2020

UCLA’s Radiology Practice at Martin Luther King, Jr. CommunityHospital Offers Rewards that are as Great as its ChallengesMartin Luther King Community Hospital (MLKCH) is a private, non-profit, facility governed and operated by theBoard of Directors of Martin Luther King, Jr. – Los Angeles Healthcare Corporation (MLK-LA). As part of thecoordinating agreement between the County of Los Angeles and the University of California, UCLA plays a leadingrole in developing and maintaining medical care and quality standards. As a result, the UCLA Department ofRadiological Sciences has provided technologists, image management staff, nurse practitioners and physiciansfor MLKCH’s radiology service since the new hospital opened in 2015. The vision of MLKCH is to be a “leadingmodel of innovative, collaborative community healthcare.” MLKCH’s mission is “to provide compassionate,collaborative, quality care and improve the health care of our community.” MLKCH has developed an innovativecommunity learning and resource center that serves as a link between the hospital and community residents,providers, and organizations.Planning and Initiating Radiological Services at MLKCHThe UCLA Department of Radiology has been heavily involvedin the formation of the new MLKCH with Jonathan Goldin,MD, PhD, executive vice chairman for the UCLA Departmentof Radiology, appointed to its Medical Advisory Committee(MAC) in April 2014. The MAC, which was composed of sevenphysicians, was charged with many responsibilities — includingdrafting of the medical staff bylaws, numerous forms used forthe medical staff application process and a large number of thehospital policy and procedures. The first medical staff electionuclahealth.org/radiologywas held on April 16, 2015, and MAC evolved to be the currentMedical Executive Committee (MEC) once the hospital waslicensed by the Department of Public Health on April 28, 2015.Dr. Goldin, and Edward Zaragoza, MD, professor of radiologyand vice chief of Staff at Martin Luther King, Jr. CommunityHospital, were elected to the MEC and continue to serve on thatcommittee to the present day.UCLA Radiology played a number of important roles in readyingMLKCH to provide clinical care. UCLA helped identify imaging310-301-68007

equipment that would be needed to provide diagnostic andinterventional radiology services. UCLA radiology personnelalso helped MLKCH develop and implement their electronicmedical records system, which is a different platform from theone used at UCLA Health’s own hospitals. “We were involvedin the validation of that platform, the build and the editing,so it would function as needed for the radiology environment,”says Brenda Izzi, senior director of clinical operations for theUCLA Department of RadiologyAs chief of radiology informatics, Dr. Zaragoza played asignificant role in establishing the electronic workflow ofradiological services at MLKCH. “Once we were given themandate to add the interpretation of radiological studies fromMartin Luther King, we had to find new tools that would enableus to bring together the IT assets from UCLA and MLKCH,”explains Dr. Zaragoza. Once implemented, the changes enabledUCLA radiologists to bring elements from the two systems into acombined workflow. “The change was transformative,” continuesDr. Zaragoza. “In addition to the individual radiologists on siteat MLKCH, the full bandwidth of subspecialty radiology that weoffer at UCLA is available to the patients at Martin Luther King.It’s a major accomplishment to bring that level of subspecialtyexpertise to an underserved community.”All UCLA radiology faculty are credentialed at MLKCH. Some arecredentialed as on-site radiologists, while others are credentialedto provide only teleradiology.Jonathan G. Goldin, MD, PhDEdward J. Zaragoza, MDProfessor of Radiology and MBPExecutive Vice ChairmanChief of Radiology, Santa Monica-UCLAMedical CenterDirector, Computer Vision and ImagingBiomarkers Program UCLADepartment of Radiological SciencesDavid Geffen School of Medicine at UCLAProfessor of RadiologySection Chief Acute Care ImagingIT Clinical DirectorDepartment of Radiological SciencesDavid Geffen School of Medicineat UCLAAn Underserved Patient PopulationThe population of patients served at MLKCH is notably distinctfrom the patient population at UCLA Health’s two West LosAngeles hospitals. Many patients seen by UCLA radiologists atMLKCH arrive having no clinical history, no comparison studies,and frequently are presenting with diseases that have goneundiagnosed and untreated. Their delayed care can be duePatients at MLKCH often present with more advanced disease thando patients at the UCLA Health hospitals.8UCLA RadiologyAutumn 2020

“With the opening of a dedicated IR suite, MLKCH will have a state-of-the-artplatform from which to deliver the level of care that the community really deserves.”to a number of causes, including economic disadvantage,less frequent access to care and lack of awareness on whento seek care. Patients seen at the two UCLA Health hospitalemergency departments, by contrast, include many tertiary carepatients with robust clinical histories that include the care ofmultiple subspecialty physicians and many prior imaging studiesfor comparison.In the absence of medical histories, UCLA radiologists workalongside MLKCH emergency room physicians to piece together adifferential diagnosis based on the information that is immediatelyavailable. “You train yourself to be more comprehensive in yourdiagnostic approach and use other information to constructa more relevant differential for your clinician,” explains NazaninYaghmai, MD, professor of radiology and chief of AcuteCare Imaging.In addition, patients at MLKCH often present with more advanceddisease than do patients at the UCLA Health hospitals. AcuteCare Imaging radiologists working with the MLKCH emergencyroom physicians frequently diagnose conditions that would havebeen caught much earlier in patients with more frequent accessto care. “A patient will come in with chest pain and — for variousreasons — the ER radiologist is going to be the first to see theuclahealth.org/radiologylarge tumor or advanced fibrotic lung disease, the cardiomyopathyor the destructive lesions in the ribs that are contributing to thechest pain,” explains Dr. Yaghmai.Nazanin Yaghmai, MDProfessor of RadiologySection Chief, Acute Care ImagingDepartment of Radiological SciencesDavid Geffen School of Medicine at UCLAFlexibility and Collaboration areKeys to Providing CarePart of providing radiology services at MLKCH has been buildingan interventional radiology practice from the ground up. MLKCHdoes not have a dedicated interventional radiology suite, so theteam has created an IR suite in the MLKCH operating room, usinga mobile C-arm imaging device. This is a common setup for anoutpatient setting, but a primitive one compared to UCLA Health’sadvanced interventional radiology suites. “I think it’s incrediblyexciting what we are able to do today in interventional radiologyat MLKCH — our interventionalists are doing incredible work with310-301-68009

very limited fluoroscopy equipment resources,” Says Dr. Zaragoza.“That’s soon going to change with the opening of a new IR suite.They’re going to have a state-of-the-art platform from which todeliver the level of care that the community really deserves.”Due in part to poor dietary habits, the community served byMLKCH has a high incidence of obesity and type 2 diabetes.The resulting prevalence of peripheral vascular disease and therisk of cardiac disease and stroke have fueled a demand formore advanced image-guided interventions.Adam Plotnik, MD, assistant professor of radiology, aninterventional radiologist who splits his time between RonaldReagan UCLA Medical Center in Westwood and MLKCH,describes the stark contrast in the two patient populations.“People come to MLKCH with, for example, complications ofdiabetes that are extremely advanced. While it’s very unusualto see such advanced cases in our Westwood or Santa Monicahospitals, people come into the ER at Martin Luther King with verybad gangrene — even wounds that are crawling with maggots.Such neglected care makes it very challenging to give advancedcare to this population,” explains Dr. Plotnik.With a medical staff that is very streamlined compared to therobust, super-specialized teams that care for patients at UCLAHealth — and with the challenge of treating patients who oftenpresent at the ER with end-stage disease and no prior work-upsor medical records — the treatment team at MLKCH tends to formespecially strong collaborative interdependencies. “At MLKCH,we are able to manage very complex patients with a small,multidisciplinary team,” says Dr. Plotnik.Adam Plotnik, MDAssistant Professor of RadiologyVice-Chair of Diagnostic Services,Martin Luther King, Jr. Community HospitalInterventional RadiologyDepartment of Radiological SciencesDavid Geffen School of Medicine at UCLAExciting Potential as aTraining EnvironmentThe same things that make practicing at MLKCH interesting andclinically challenging to UCLA faculty would make the MLKCHpractice extremely valuable in contributing to the developmentof UCLA radiology trainees. “The case load that comes throughMLKCH is very exotic. We see advanced presentation ofmalignancy, and advanced unusual infectious diseases,” saysDr. Zaragoza.MLKCH is committed to developing a teaching program, but theMEC has chosen to ensure the establishment of a successfulclinical practice before embarking on this next step. Recently they10opened an emergency resident rotation and UCLA Radiology iscurrently in discussions to bring interventional radiology fellowsto the MLKCH practice “Ultimately, I’d like to be able to open theworklist that the attendings use to our residents and fellows toread as part of their training experience,” continues Dr. Zaragoza.“it could give trainees used to the types of patients we typicallysee in Westwood and Santa Monica insight into what happens inmore disadvantaged areas.”A Uniquely RewardingRadiology PracticeIn addition to the professional enrichment provided by workingin a setting so different from their UCLA Health practices,UCLA radiologists frequently mention the emotional rewardsand satisfaction of providing care to MLKCH patients. BenjaminPlotkin, MD, associate professor of radiology and radiologydirector at Martin Luther King, Jr. Community Hospital practicesexclusively at MLKCH and has been practicing there since itopened for patient care. Dr. Plotkin enjoys caring for patients inthe community, which has not always had sustained and reliablehealth care. “I very much like MLKCH and the patients, and amhappy to help in any small way I can,” says Dr. Plotkin. “I try tokeep in mind that everyone has an unseen struggle — problemsor issues that they are dealing with. I try to think about how I canmake things more comfortable for them, alleviate their stress,answer their questions and explain at least what role I have intheir care.”Brenda Izzi points out that a number of the UCLA radiology staffworking at MLKCH have strong ties to the community. “Many ofthem were born at the old King Drew Hospital and still live in thecommunity. They know how hard it was in the community whenthe old hospital closed. To now have the ability to provide care atMLKCH — and provide care at the level of academic subspecialtythat we do — has been very rewarding for them.”“The department has opened up a practice within a very excitinghealth care environment, very different to UCLA hospitals and itoffers an opportunity to expose our faculty — and in the futureour residents — to the inequalities of health care,” sums upDr. Goldin. “There’s a tremendous amount of satisfaction providingcare to people and being educated in the disparities of healthcare in Los Angeles.” RBenjamin Plotkin, MDBrenda Izzi, RN, MBAAssociate Professor of RadiologyRadiology Director, Martin Luther King, Jr.Community HospitalDirector, Musculoskeletal ImagingFellowship ProgramMusculoskeletal and Acute Care ImagingDepartment of Radiological SciencesDavid Geffen School of Medicine at UCLASr. Director, Clinical OperationsUCLA Health, RadiologyDepartment of Radiological SciencesDavid Geffen School of Medicineat UCLAUCLA RadiologyAutumn 2020

DEPARTMENT HIGHLIGHTSUCLA Radiology Expands into CalabasasThe UCLA Department of Radiology brings world-class expertiseto the Calabasas community with the launch of our UCLACalabasas Imaging and Interventional Center. The new facilitywill open in October 2020 and occupy over 7,000 squarefeet. Over 100 UCLA radiologists bring a wealth of expertiseto the community, with subspecialists available to interpretspecialized studies.Our Imaging and Interventional Center brings the latest and mostinnovative technology to the community, including the SiemensMAGNETOM Vida 3-Tesla MRI. This machine has the latesttechnologies that adapt to the patient’s body and movement,resulting in higher-quality images while increasing patient comfort.The Siemens Flash CT has dual source capability, resulting inhigh-quality images, and supports specialty studies includinggout

UCLA Radiology provides diagnostic imaging and interventional radiology services 24 hours a day, seven days a week, 365 days a year. We do this because it was the “right thing to do” many years before the current heightened attention. This pioneering engagement in the UC sys