Lung Cancer Screening Pilot for People at High Risk – Referral Form & Criteria

This page tells healthcare providers how to refer patients at high risk of getting lung cancer to a pilot site hospital to determine if they are eligible for screening.

Current and former smokers ages 55 to 74 may be referred to the Lung Cancer Screening Pilot for People at High Risk (the pilot) if they have smoked cigarettes daily for at least 20 years (not necessarily 20 years in a row, which means there could be times when they did not smoke).

Not everyone who meets the referral inclusion criteria will be eligible for lung cancer screening in the pilot. Determining eligibility for the pilot is a 2-step process. Only people who meet the criteria in steps 1 and 2 will be eligible to get screened for lung cancer through the pilot.

• Step 1: Physicians refer current and former smokers ages 55 to 74 who have smoked cigarettes daily for at least 20 years (not necessarily 20 years in a row, which means there could be times when they did not smoke) to a pilot site hospital. People can also contact the pilot site hospital on their own to have their age and smoking history criteria assessed.
• Step 2: A pilot site hospital screening navigator conducts a risk assessment with anyone who meets the age and smoking history criteria in step 1. The results of the risk assessment in step 2 determine whether someone is eligible to get screened for lung cancer through the pilot.

When physicians refer their patients to a pilot site hospital in step 1, they must complete the pilot referral form to authorize the use of low-dose computed tomography in case their patient is found to be eligible for the pilot in step 2.

People who contact a pilot site hospital directly and are found to be eligible in step 2 will still need a referral from a physician to participate in lung cancer screening in the pilot.

Download the referral form from the side bar.

For details about the pilot, see Lung Cancer Screening Pilot for People at High Risk.

Pilot Site Hospitals

The pilot is based out of the following hospitals in Ontario. Contact the hospitals directly with questions about the pilot or to submit referrals. This contact information has been provided by the pilot site hospitals.

PILOT SITE HOSPITAL	LOCATION	AFFILIATED SITES	PHONE	FAX
The Ottawa Hospital	Ottawa	Renfrew Victoria Hospital Cornwall Community Hospital	1-844-394-1124	613-728-6333
Health Sciences North	Sudbury	n/a	705-523-7301 1-844-703-0164	705-523-7306
Lakeridge Health	Oshawa	n/a	1-905-576-8711 ext. 34449	905-721-4864
University Health Network	Toronto	n/a	416-340-4154	416-340-4137