False Positives and Real Dollars: Why $88 won’t effectively screen for lung cancer

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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.

The Histo-belt

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…

Knowing When to Say Yes to Medical Technology

Screen Shot 2014-11-17 at 8.00.40 PMIn 2011, the New England Journal of Medicine reported results of the National Lung Screening Trial (NLST). Screening trials have to be big, because almost all the people who are screened don’t have the disease being investigated, and screening only helps people with silent disease.

The NLST had over 50,000 participants, all with a history of abusing their lungs through heavy smoking. Half were randomly assigned to have three annual low-dose helical chest computed tomography (CT) exams, and half were assigned to have three annual chest x-rays

All earlier trials had shown screening with x-rays to be ineffective, so many of us were surprised when CT screening proved to be effective, reducing death from lung cancer by 20 percent over the six years of the trial. Apparently, the CT proved to be effective at finding much smaller tumors than could x-ray.

Since publication of this study, the American Society of Clinical Oncology and other medical organizations have recommended screening for those at similarly high risk for lung cancer. The United States Preventive Services Task Force gave such CT screening a grade B recommendation, making coverage by private insurers mandatory and by public insurers likely.

Continue reading…