Lung Cancer Screening — questionable

spot on ct

Recently published guidelines for lung cancer screening (USPSTF) lack sufficient consideration of side effects and give no consideration to cost.  Insurance companies, so far, don’t pay for it and the American Lung Association has many questions about the basis for the recommendations.

Is CT screening really helpful to people at risk for lung cancer?  Is screening driven by profit motives for hospitals and radiologists?  The latter question may seem harsh but the well documented price gouging by radiology on other CT tests forces the question.

The data are clear: chest CT scans can detect early lung cancer soon enough to allow successful surgical removal.   But, the devil is in the details.

Can the US healthcare system afford this screening — what health services should be eliminated to pay for this very expensive endeavor (like childhood immunizations)?  Can patients who eventually are found not to have lung cancer (the vast majority of those screened) afford the test and the side effects of the invasive tests screening causes?

The recommendation seems premature.  The formation of national guidelines without adequate considerations of cost is hard to believe given our national problem with excessive health care cost.

Many other countries consider the cost of a test or treatment needed to give a person a “quality year of life”.  How much is that year worth? a billion dollars, a million dollars, a thousand dollars, all your money, all the money you wanted your kids to inherit?  Tough questions, especially if you are not a billionaire.  Well, experts on national health care say that dollar figure should not exceed $50,000.

Whether you believe the $50,000 number or not, at least we need to know exactly what such screening will cost.  We purchase healthcare — we don’t get it by magic.

So, what are patients and health care provider to do?  At this point: follow the recommendations and hope less costly and less invasive means are discovered.  Here is what the American Lung Association advises:

The best way to prevent lung cancer is to never smoke or stop smoking now.

  • Q: Who is a good candidate for lung cancer screening?
  • A: The National Lung Screening Trial (NLST) criteria are:
    • a current or former smoker (former smokers having quit within the past 15 years)
    • and in the age group from 55 to 74 years
    • and with a smoking history of at least 30 pack-years (1 pack/day for 30 years, 2 packs per day for 15 years, etc.)
    • and no history of lung cancer
  • There is no evidence at this time that other high-risk groups should be screened. Patients with lung disease, particularly COPD should be evaluated by a pulmonologist regarding the advisability of CT screening in the context of the severity of their disease.
  • At this time, only Low Dose CT scans are recommended for screening. Chest X-rays are not recommended for screening.

Beyond the question of cost is the question of who pays.  Should smokers as a group pay for the screening or perhaps cigarette makers?  Given the lackadaisical attitude of congress about the risks of smoking, ostensibly representing US citizens, perhaps we should all gladly pay for the screening through insurance.

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  1. #1 by littleredmed on August 30, 2013 - 8:59 AM

    I found this decision very interesting as we talked about the 2010 paper this recommendation is based on in my second year of medical school. After reading the article, we read another article evaluating the cost-effectiveness of CT scans for lung cancer screening in smokers, which concluded that the scans are not cost-effective given the generally accepted limit of $50,000-$100,000/QALY. I wish I still had the article but I do not . . . Still, I thought it was strange when I saw these updated guidelines!

    • #2 by qualityhealthcareplease on August 30, 2013 - 1:39 PM

      Thanks for your input. I think the article you mention is Lung Cancer Screening With Low-Dose Computed Tomography: Costs, National Expenditures, and Cost-Effectiveness Bernardo H. L. Goulart, Mark E. Bensink, David G. Mummy and Scott D.Ramsey, J Natl Compr Canc Netw 2012;10:267-275 (http://www.jnccn.org/content/10/2/267.full).

      They do present cost data which is not very favorable. Screening could add $2 billion dollars to national health care costs if 75% of eligible people were screened . They estimate the cost to avoid 1 cancer death is $240,000.

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