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Frank C. Detterbeck, MD, FCCP; Peter B. Bach, MD, FCCP
Author and Funding Information

From the Yale University School of Medicine (Dr Detterbeck); and Memorial Sloan-Kettering Cancer Center (Dr Bach).

Correspondence to: Frank C. Detterbeck, MD, FCCP, Yale School of Medicine, 330 Cedar St, PO Box 208062, New Haven, CT 06520-8062; e-mail: frank.detterbeck@yale.edu


Financial/nonfinancial disclosures: Dr Detterbeck is a member of the International Association for the Study of Lung Cancer International Staging Committee and a speaker in an educational program regarding lung cancer stage classification; both activities are funded by Lilly Oncology (Lilly USA, LLC). He has participated on a scientific advisory panel for Oncimmune (USA) LLC; an external grant administration board for Pfizer, Inc; a multicenter study of a device for Medela; and formerly a multicenter study of a device for Deep Breeze. Compensation for these activities is paid directly to Yale University. Dr Detterbeck also served on the executive committee of the Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-based Clinical Practice Guidelines. Dr Bach has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(5):1737-1738. doi:10.1378/chest.13-1736
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To the Editor:

We agree with Dr Lamb and colleagues that the cost to the consumer is a major issue, especially for lung cancer screening, because a disproportionate number of those who smoke are in low-income strata. Free screening may sound nice and has important social benefits in making access more equitable, but the fact remains that the actual costs of screening must be covered from some source.

We believe that it is important to be clear about the business model. For example, are the costs covered by an institutional grant or a social fund to support disadvantaged patients? Currently, the most common institutional business model is to make up the discrepancy between what is collected for screening and what it actually costs from profits arising from interventions done for screen-detected nodules. It is important to recognize that this represents an inherent conflict: Optimal patient management calls for limited, judicious further intervention, whereas optimal financial management calls for maximizing the number of additional interventions performed. This conflict is particularly poignant because the rate of finding a nodule is high (10%-50% of those screened), the level of anxiety of those with a nodule is high, yet the proportion of inconsequential nodules is high (about 96%). The issue is further magnified when screening is extended beyond the National Lung Screening Trial criteria (currently unsupported by data or modeling studies of efficacy), which increases manyfold those being screened and needing further interventions with a much lower impact on actually preventing deaths from lung cancer.1 It is certainly possible for this conflict to be managed appropriately, but this business model increases the potential for intended or unintended overuse of subsequent interventions.

We stand by the statement Dr Lamb and colleagues take issue with: “establishing a discounted rate as a strategy to capture patients…creates a structure that can increase harms from excessive investigation of benign nodules.”2 The statement is not cited as evidence; it occurs in the discussion of issues regarding screening. We support making screening accessible to those who need it but stand by the opinion that we need the health-care system to appropriately cover the costs of screening (not just the scan itself) with appropriate quality metrics. It would be a poor health policy decision to provide no other structure for lung cancer screening than an inherently conflicted business model with the assumption that it will always turn out to be managed well. We note that our view is consistent with federal policies enacted as part of the Health Insurance Portability and Accountability Act legislation (§1128A(a)(5) of the Social Security Act), which forbids gifting services to patients to garner their business.

In the absence of a health-care system structure, we support the efforts of institutions, including the laudable example of the Lahey Clinic, to find a way to appropriately implement screening. We believe that clarity about actual costs and potential conflicts is useful in finding good ways to manage these issues. We have to be careful because it can be difficult to navigate the thin line between superficial statements and attractive sound bites that are motivated primarily by a personal agenda and arguments about how it is best for us to proceed with bringing a potential significant health benefit to those who need it.

References

Bach PB, Gould MK. When the average applies to no one: personalized decision making about potential benefits of lung cancer screening. Ann Intern Med. 2012;157(8):571-573. [CrossRef] [PubMed]
 
Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB. Screening for lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):e78S-e92S.
 

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References

Bach PB, Gould MK. When the average applies to no one: personalized decision making about potential benefits of lung cancer screening. Ann Intern Med. 2012;157(8):571-573. [CrossRef] [PubMed]
 
Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB. Screening for lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):e78S-e92S.
 
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