Expanding lung cancer screening to achieve excellence (EXHALE) - annual low-dose computed tomography (LDCT) has the potential to reduce lung cancer mortality by ~20% and has been a US preventive…

Kaiser Foundation Hospitals, doing business as Kaiser Permanente, received a Cooperative Agreement award of $1,684,165 from the National Cancer Institute under the 21st Century Cures Act - Beau Biden Cancer Moonshot program (CFDA 93.353) on September 12, 2025, with an ultimate completion date of August 31, 2027. The award supports the Expanding Lung Cancer Screening to Achieve Excellence (EXHALE) project, which develops and evaluates evidence-based implementation strategies to increase lung cancer screening adoption across Federally Qualified Health Centers (FQHCs). The project forms a partnership of seven FQHC systems—including the largest in the United States—with three National Cancer Institute-designated Comprehensive Cancer Centers and a major healthcare system research center to address multilevel barriers to lung cancer screening implementation.

Under this Cooperative Agreement, Kaiser Permanente and its sub-awardees—University of Arizona, University of New Mexico Health Sciences Center, and University of Washington—will adapt and scale a proven multicomponent implementation strategy using learning collaboratives and practice facilitation modeled on the Project Extension of Community Health Outcomes (Project ECHO) framework. The project encompasses a two-year UG3 Planning Period (September 12, 2025 – August 31, 2027) to develop tailored implementation support and ensure readiness for a subsequent pragmatic randomized clinical trial, followed by a future UH3 Pragmatic Trial Period (September 1, 2027 – August 31, 2031) to conduct a two-arm pragmatic cluster randomized clinical trial across 108 clinics serving approximately 22,000 lung cancer screening-eligible adults. Primary research activities include health equity assessments, FQHC engagement and site selection, and scientific workgroup coordination to evaluate guideline-concordant care improvements.

Expanding lung cancer screening to achieve excellence (EXHALE) - annual low-dose computed tomography (LDCT) has the potential to reduce lung cancer mortality by ~20% and has been a US preventive services task force (USPSTF) recommendation for 10+ years. However, lung cancer screening (LCS) currently falls well below thresholds to achieve population-level benefits and clinics are unprepared for the introduction of LCS national quality metrics. Widespread adoption of LCS has multilevel barriers, including a complex, multistep process spanning patient identification to follow-up testing for abnormal results and repeat annual screening. Federally qualified health centers (FQHCS), which serve a high proportion of LCS-eligible adults and have relatively low LCS rates, struggle with these barriers. Our proposed project, expanding lung cancer screening to achieve excellence (EXHALE), will develop evidence-based, pragmatic and scalable implementation strategies to increase LCS in representative practice settings. We will form a partnership of 7 fqhc systems-including the largest in the US-with 3 NCI-designated comprehensive cancer centers and a major healthcare system research center. We will adapt, SCALE and evaluate a proven multicomponent implementation strategy to increase guideline-concordant care using learning collaboratives and practice facilitation (PF) based on the project extension of community health outcomes (project echo) model. EXHALE is guided through the phases of implementation by the exploration, preparation, implementation, sustainment (EPIS) framework. In the implementation phase, we will conduct a 2-arm pragmatic randomized clinical trial (RCT). Our study setting includes 7 fqhc systems with a total of 108 clinics and ~22,000 LCS eligible adults. Our primary outcomes will be measured at 12 months into sustainment. Further, we will RE-randomize clinics in a micro-trial to test audit and feedback reporting of LCS to compare differences in sustainment at 18 months. We propose three aims for both UG3 (PLANNING) and UH3 (SCALE): UG3-aim 1: define data processes and clinical workflows to identify eligible patients and track LCS outcomes; UG3-aim 2: use validated approaches to adapt an existing resource library, echo learning collaborative curriculum, and embedded PF strategies; and UG3-aim 3. Assess clinical care processes, readiness, and capacity in recruitment of >60 fqhc clinics in 7 states. UH3-aim 1. Assess the SCALE-up of LCS; UH3-AIM2. Compare the effectiveness of LCS implementation strategies across LCS; and UH3-AIM3. Evaluate contextual factors affecting sustainability of LCS interventions, and track adaptation to interventions and implementation strategies. We will implement a practical, high-frequency/low-intensity strategy for scaling LCS with minimal provider and system effort. By collaborating with FQHCS, we ensure our strategies are flexible and sustainable to reach people at high-risk for lung cancer. In all aims, EXHALE addresses rigor through study design, methods, partner engagement, and dissemination of study findings.