Posts Tagged USPSTF

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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Preventive Health — Just the Right Amount

Preventive health is like the story of the 3 bears.  Too much results in excessive testing, too little misses widespread problems.  Prevention needs to be studied by experts to get just the right amount.  Above all, prevention is aimed at diseases the health care system can actually improve for a large number of people.  The worst case scenario for prevention is to check everybody (huge cost) for an incurable rare disease (no benefit).

Diagnosis of a disease is different from prevention.  Prevention is what is done when things are otherwise OK.  If a person has a heart attack lots of tests and treatments may be needed — this is not prevention.  If a person is doing well and has a cholesterol level checked it is a preventive measure.  Checking the cholesterol level is intended to find a condition unknown to the person.  Furthermore, if high cholesterol is found there is a proven treatment which is beneficial to reduce heart attacks.

What are good preventive measures for Americans?   Research has lead to several conclusions which have been assembled by the US Preventive Services Task Force (USPSTF).   The recommendations are available on the Internet.  The recommendations are clear yet many people do not get the recommended preventive measures.  Sometimes it is just as simple as asking your health care provider a question about prevention and the problem is solved.  But, asking this type of question can cause anxiety.  Actors have a script and sometimes patients need a script also.  How do you ask a provider a question about something seen on the Internet.  Take your choice:

John Wayne:  “Listen doc, I hear an ultrasound is a mighty good idea.  You got a good reason to the contrary?”  (John puts his hand on his hip and smiles)

John Modern:  “Doctor, I was searching the Internet about disease prevention and found some government recommendations.  It looks like a previous smoker at my age should  get an ultrasound to check for aneurysms.  Do you think an ultrasound is a good idea? (John puts his hand on his insurance card and smiles).

Based on the recommendations from the USPSTF here are some very good questions.  Feel free to write your own script.

Man, age 65-75 who has smoked:  Should I have an abdominal ultrasound?
Adult:  At least once a year I drink 4-5 alcoholic drinks in a day, is that a problem?
Pregnant woman:  Do I have iron deficiency anemia?
Man age 45-79:  Should I be taking an aspirin a day?
Woman age 55-79: Should I be taking an aspirin a day?
Pregnant woman:  When should I have a urine culture?
Adult: Is my blood pressure OK?
Woman with family history of breast or ovarian cancer:  Should I have BRCA testing?
Older woman with family history of breast cancer but no problems with blood clots:  Should I be taking medicine to prevent breast cancer?
Woman, over 40:  Should I get a mammogram at least every 2 years?
Pregnant woman:  Can I get counseling about breast feeding?
Woman:  Should I get a pap smear at least every 3 years?
Women:  Should I be checked for Chlamydial infection?
Adult:  Should I have my cholesterol checked?
Adult age 50 or older:  How often should I be checked for colorectal cancer?
Child 6 mo to 5 years:  Should they be taking a fluoride supplement?
Adolescent:  Do you think my child could have depression?
Adult:  Do you think I might have depression?
Adult with BP over 135/80:  Do you think I might have diabetes?
Woman of childbearing age: Should I take a folic acid supplement?
Newborn:  Did my baby get eye medication against gonorrhea?
Women with multiple sex partners:  Should I have a test for gonorrhea?
Adult or child with high lipids:  Should I have instruction on a special diet?
Newborn:  Does my baby have good hearing?
Newborn:  Does my baby have sickle cell disease?
Pregnant woman:  Do I have hepatitis B?
Adolescents and Adults with risky sex behavior:  Do I have AIDS?
Newborn:  Does my baby have a thyroid problem?
Baby age 6 – 12 months:  Does my baby need iron supplements?
Adult:  Am I overweight and do I need counseling or behavior interventions?
Child:  Is my child overweight and do they need behavior interventions?
Woman age 60 or older:  When should I be checked for osteoporosis?
Newborn:  Has my baby been checked for PKU disease?
Pregnant woman:  When do I get checked for Rh incompatibility?
Person with sexually transmitted disease:  Can I get behavioral counseling?
Smoker:  What can be done to help me stop smoking?
Pregnant women:  Do I get checked for syphilis?
Person with risky sexual behavior:  When do I get checked for syphilis?
Child, age less than 5 yrs:  When should my child’s eyes be checked?

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