Let me be clear. I think lung cancer screening is a good thing. The National Lung Cancer Screening Trial (NLST) had air-tight design and was impeccably performed. Those who have paid attention know that the NLST demonstrated a 20% relative reduction in mortality from low-dose CT screening (as opposed to chest x-ray). Plus, the all-cause rate of death in the low-dose CT group was 6.7% lower than the radiography cohort.
But the details reveal concerns – those with financial and geographic-specific implications that have, until now, mostly escaped public debate. The fanfare that accompanied the glorious NLST quest has supplied perverse financial incentives for entrepreneurial types – and has put patients in places such as the Ohio River Valley at potentially increased risk from exploitation of our interminable fear of cancer. It has also given providers in these regions the unenviable and perhaps impossible task of balancing costs, patient expectations, and disease prevalence.
I took this picture while driving along a rural southern Indiana highway during a recent trip to visit family. Southern Indiana (and neighboring northern Kentucky) are known for blue-collar shipping industries, steamboats, and high school basketball. They also rest squarely in what is colloquially known as the “Histo-belt.” Histoplasma capsulatum is a fungus endemic to the Ohio and Mississippi River Valleys. It is everywhere. You get it by breathing. Prior studies suggest that >80% of those living in these regions have contracted the fungus. The majority of people with histo don’t get sick. But – they get lung nodules. Lots of them. The nodules are benign but often indistinguishable on imaging from “early” lung cancer. Continue reading…