In 2011 with much fanfare the National Cancer Institute announced that lung cancer screening decreased deaths from lung cancer by 20%. In 2013, the American Cancer Society (among other organizations) published well-thought-out guidelines recommending high quality screening along with shared decision making so eligible patients could understand the risks and benefits of screening. In 2015 the Medicare program announced that lung cancer screening would be covered, along with the shared decision component.
With all of that evidence and support, one would think that lung cancer screening would see rapid uptake in the United States in an effort to reduce deaths from this all-too-frequent cause of cancer death.
If you thought that, you would be wrong. So the logical question is why? In the face of all this evidence, why are high risk current and smokers not being screened, and how do we make it right?
That question is the result of a spate of recent articles (links 1,2,3) in journals from the American Medical Association, along with a somewhat “direct” editorial that highlights the need to better understand how lung cancer screening works and the need to inform health professionals and their patients about lung cancer screening so they can make the best choices for their individual care.
The most detailed report reviews the experience of the Veterans Administration hospitals as they implemented a lung cancer screening program in eight academic-affiliated hospitals across the country. Say what you might about the VA, there are many things they try to do right and providing a consistent approach to healthcare and understanding the implications of that care is one of them.
The results showed how difficult such a program can be, especially when considering that there may be 900,000 veterans (out of 6.7 million served by the VA) who are eligible to get low-dose CT (LDCT) screening every year.
In this particular program, 93,000 patients were assessed for screening. About 4,200 were eligible for screening, 2,452 agreed to get screened, and 2,106 actually followed through. Of that group, close to 60% (1,257) had nodules on the scan, most of which required follow-up. Of those, 42 patients (2%) had further evaluation and were found not to have lung cancer. An additional 31 of the patients (1.5%) with a nodule were found to have lung cancer, of whom 20 patients were stage I (where the odds of cure are greatest). Two were stage II, eight were stage III and IV, and in one stage was unknown. Long term follow-up was not available, so we don’t know the ultimate outcomes for these folks.
Stated in a different way, in this study 97.5% of the mostly male current and former smokers screened for lung cancer in this population of older veterans (who have a higher percentage of current and former smokers than seen in other studies) who tested positive for a nodule on their chest x-ray did not have cancer.
Two other reports (links 1,2), including one from my American Cancer Society colleagues Drs. Ahmedin Jemal and Stacey Fedewa, show that the uptake of lung cancer screening in the general population has not been particularly great since the aforementioned NCI study and guideline recommendations were issued. In fact, according to Drs. Jemal and Fedewa there was virtually no change in the frequency of lung cancer screening from 2010 to 2015 (in 2010, 3.3% of eligible smokers had received screening in the past year while 3.9% had been screened in 2015). They estimate that of 6.8 million smokers eligible for screening in 2015 in the United States, only 262,700 had a screening CT scan.
So where does this leave us? It’s obvious that if we are going to get the benefits of saving lives from lung cancer we need to do something. The question is what should that “something” look like.
The VA study points out the complexity of making this happen. The VA is—as noted—an organized health care delivery system (some may question the “organized” piece, but at heart they do have a single, nationwide purpose). They paid attention to what needed attention: they established criteria for screening, the found “champions” at the centers involved in the program, they looked proactively for the right people who should be offered screening, they engaged the veterans and tried to standardize the screening process.
However, as the authors comment in their paper, this was not an easy process. And if it was difficult for the VA, with committed staff trying to do the right thing, one might imagine how that translates into the larger nationwide healthcare/consumer community.
The other reports point out that the recommendations for lung cancer screening don’t seem to be translating as well as we would like, even with insurance coverage through Medicare and other commercial insurance plans.
The reasons may be many, among them that health professionals either aren’t aware of the recommendations and insurance coverage or may be a bit skeptical (health professional behaviors are frequently slow to change). Consumers may not be aware of the benefits of screening for lung cancer, or they may have considered it and decided it wasn’t right for them. And we can’t ignore the fact that many eligible smokers and former smokers may have other medical conditions or life-limiting situations where screening either doesn’t make sense or is flat-out not indicated.
The JAMA Internal Medicine editorial, however, was pretty pointed starting with the headline noting that incidental/false positive findings on the lung scans outnumber proven lung cancer by 40:1. Those are pretty long odds. Still, lung cancer undetected and untreated until later stages is too often fatal. So maybe the odds should matter less if it means life or death.
That is what shared decision making is all about: you make your decisions based on what is important to you.
The editorial authors concluded:
“We urge other programs to conduct the same careful analysis (similar to the VA) of risks and benefits and outcomes of lung cancer screening to continue to inform the process and allow patients and their physicians as well as health systems to make the best choices”
The American Cancer Society recommends that:
“Clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about screening with apparently healthy patients aged 55 years to 74 years who have at least a 30–pack-year smoking history and who currently smoke or have quit within the past 15 years. A process of informed and shared decision-making with a clinician related to the potential benefits, limitations, and harms associated with screening for lung cancer with low-dose computed tomography should occur before any decision is made to initiate lung cancer screening.”
Notwithstanding the recommendation and the evidence, the reality is that if we are to achieve the goal of reducing the burden of lung cancer we need to do so in an effective and evidence based manner. To accomplish this goal, we will need to:
- educate consumers and health professionals about the benefits and risks of lung cancer screening
- be certain that high quality programs are in place where everyone is on board with how to provide shared decision making
- refer to radiologists who understand how to interpret the findings on the scan in a consistent and evidenced based manner
- make certain that follow-up of suspicious abnormalities is appropriate, and
- provide access for those who need additional care.
This won’t be easy, as the VA study shows us, however no one ever thought it would be. We have our work cut out for us If we are going to increase the numbers of people appropriately screened to find lung cancer early when it has a better chance of cure.
Not making that effort is not an option.