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COUNTERPOINT: Are There Cases in Which Physicians Should Deviate From Recommendations Not to Order a Chest CT Scan? NoDeviation From Recommendations on CT Scan? No FREE TO VIEW

Tamara Simpson, MD
Author and Funding Information

From the Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center at San Antonio.

CORRESPONDENCE TO: Tamara Simpson, MD, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center at San Antonio, 7400 Merton Minter Blvd, 111E, San Antonio, TX 78229; e-mail: simpsont2@uthscsa.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST 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. 2014;146(5):1147-1149. doi:10.1378/chest.14-1587
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A 54-year-old patient, former smoker (25 pack-year history, quit 10 years ago) states, “Doc, I know it is outside the guidelines. But I am worrying all the time that the residual scar from my pneumonia last year might be a lung cancer. And I am willing to pay cash for the study.” Should a chest CT scan be ordered with the diagnosis of abnormal chest radiograph?

This patient indeed has valid concerns. Lung cancer is the leading cause of cancer death in the United States, and smoking is associated with 85% of all lung cancer cases.1 In addition, lung cancer mortality is related to its stage at diagnosis, but only 15% of cases are diagnosed at early stages.2 Although lung cancer screening has been researched for many years, no screening test showed significant mortality benefit until the National Lung Screening Trial (NLST) published its results in 2011.3 The NLST concluded that annual screening with low-dose CT (LDCT) scanning in current and former smokers (cessation within prior 15 years), aged 55 to 74 years, with 30 pack-years leads to a reduction in lung cancer mortality of 16% and a reduction in all-cause mortality of 6.7%.4 Many professional organizations, including the American College of Chest Physicians (CHEST), the American Thoracic Society, the American Cancer Society, and the American Association for Thoracic Surgery, have since begun recommending annual LDCT scan screening.5 In addition, the US Preventive Services Task Force (USPSTF) recently published its final recommendation in favor of screening.5 However, all are in agreement that prevention of lung cancer through smoking cessation continues to be the best and most cost-effective strategy to decrease lung cancer mortality.5 Despite these recommendations for screening patients for lung cancer using LDCT scanning, most experts agree there are also concerns regarding the implementation of such programs.

One of the main concerns with annual LDCT scan screening is the large number of false-positive results that require additional imaging and/or invasive procedures.6 When nodules were detected in the NLST and other trials, no standardized protocol was used to determine the next course of action; it was at the discretion of the interpreting radiologist.4 Although a detected nodule usually triggered further imaging, some patients required procedures including needle biopsy, bronchoscopy, thorocoscopy, mediastinoscopy, or thoracotomy.4 In the NLST, complications and deaths resulting from these procedures were rare, although they did occur.4 It should be noted that many of the patients in the study were at a lower health risk and had better health than some of the chronically ill patients that may be subjected to screening as the practice becomes more widely implemented. There is also concern that in some patients with true-positive results where lung cancer is detected, there is an overdiagnosis of indolent tumors that would not have developed into advanced illness and for which treatment may not have been necessary.7 A recent study estimated that > 18% of all lung cancers detected by LDCT scanning in the NLST could represent overdiagnosis of these less aggressive tumors.8

The risk of radiation exposure must be considered as well. Although the radiation dose of LDCT scanning is significantly less than that of a standard chest CT scan, patients may require additional scans for positive results, as well as annual screening for years to come.6 Although the radiation dose of LDCT scans is estimated at only 1.5 mSv per examination, subsequent diagnostic examinations with chest CT scans (8 mSv) and PET-CT scans (14 mSv) rapidly increase the exposure.6 This cumulative radiation can be quite significant and inherently carries with it additional cancer risk, especially in younger patients.6 In addition to radiation exposure, there are concerns regarding the cost effectiveness of LDCT scan screening.9 Each annual CT scan currently costs approximately $300.9 There are additional costs for follow-up imaging and procedures for positive scans. Uninsured and underinsured patients could have a difficult time obtaining these studies, even if they are willing to pay out-of-pocket for the screening CT scans. The final cost analysis of the NLST is pending, but the current estimates show that LDCT scan lung cancer screening is approximately two to three times more costly than breast cancer screening with mammography.10 In contrast, lung cancer prevention through smoking cessation programs is estimated to be one-tenth the cost of LDCT scan screening programs.9

There are concerns that current recommendations are being based solely on the results of the large NLST.3 Three smaller randomized European studies failed to show a mortality benefit with LDCT scan screening.5 The Dutch-Belgian randomized lung cancer screening trial (Nederlands Leuvens Longkanker Screenings Onderzoek [NELSON]) has concluded, but the mortality data are pending, with plans to combine that data with data from the Danish trial in hopes of increasing statistical power.5 An additional concern is whether the NLST results can be replicated in a community practice setting.6 The NLST centers were large, multidisciplinary medical centers with specialized thoracic radiologists, thoracic surgeons, and support staff trained to run a lung cancer screening program.6 It is unknown whether the same mortality benefit would be seen in everyday practice.

Some concern has also been raised regarding the potential for psychologic distress resulting from lung cancer screening programs. It remains unclear what impact LDCT scan screening could have on patients’ quality of life, and although the data are limited, patients may have psychologic distress from awaiting the results of screening and any further testing that may ensue.6 There are also potential negative psychologic effects over the costs of screening and subsequent studies, as well as potential emotional harms from the evaluation and treatment of false-positive scans and overdiagnosed cancers.6

Lastly, there are concerns that lung cancer screening programs could negatively affect patients’ smoking cessation efforts. Although some believe that screening could create more opportunity for smoking cessation discussions, others believe patients may develop a false sense of security with a negative scan and thus continue to smoke. All professional organizations and the USPSTF agree that LDCT scan screening programs should include smoking cessation programs to be most effective. Smoking cessation continues to be the most cost-effective strategy for decreasing lung cancer mortality.

So now back to this patient: If one chooses to follow the recommendations of the USPSTF, as well as several other societies, this patient does not meet the screening criteria by age or smoking history. In addition, if one takes into consideration the many concerns and controversies discussed, offering LDCT scan screening could be potentially harmful. A separate, well-recognized medical organization recently released a statement that there is insufficient evidence for or against lung cancer screening and recommends awaiting further studies.3 It goes on to recommend continuing open discussions with patients regarding the risks and benefits of screening, along with the importance and effectiveness of smoking cessation.3

In conclusion, a chest CT scan should not be ordered for this patient. This patient should be congratulated for his/her smoking cessation 10 years previously. The patient should also be reassured that continued smoking cessation decreases the relative risk of death from lung cancer and all causes, and this risk will continue to decrease even further over time.11

References

American Cancer Society. Cancer Facts & Figures 2013. Atlanta, GA: American Cancer Society; 2013.
 
Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63(1):11-30. [CrossRef] [PubMed]
 
Borgmeyer C. Evidence lacking to support or oppose low-dose CT screening for lung cancer, says AAFP. AAFP Newshttp://www.aafp.org/news/health-of-the-public/20140113aafplungcarec.html. January 13, 2014. Accessed March 1, 2014.
 
Aberle DR, Adams AM, Berg CD, et al; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. [CrossRef] [PubMed]
 
Moyer VA; US Preventive Services Task Force. Screening for lung cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(5):330-338. [CrossRef] [PubMed]
 
Bach PB, Mirkin JN, Oliver TK, et al. Benefits and harms of CT screening for lung cancer: a systematic review. JAMA. 2012;307(22):2418-2429. [CrossRef] [PubMed]
 
Veronesi G, Maisonneuve P, Bellomi M, et al. Estimating overdiagnosis in low-dose computed tomography screening for lung cancer: a cohort study. Ann Intern Med. 2012;157(11):776-784. [CrossRef] [PubMed]
 
Patz EF Jr, Pinsky P, Gatsonis C, et al; NLST Overdiagnosis Manuscript Writing Team. Overdiagnosis in low-dose computed tomography screening for lung cancer. JAMA Intern Med. 2014;174(2):269-274. [CrossRef] [PubMed]
 
Nanavaty P, Alvarez MS, Alberts WM. Lung cancer screening: advantages, controversies, and applications. Cancer Contr. 2014;21(1):9-14.
 
McMahon PM, Kong CY, Bouzan C, et al. Cost-effectiveness of computed tomography screening for lung cancer in the United States. J Thorac Oncol. 2011;6(11):1841-1848. [CrossRef] [PubMed]
 
Colditz GA, Wolin KY, Gehlert S. Applying what we know to accelerate cancer prevention. Sci Tranl Med. 2012;4(127):127rv4.
 

Figures

Tables

References

American Cancer Society. Cancer Facts & Figures 2013. Atlanta, GA: American Cancer Society; 2013.
 
Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63(1):11-30. [CrossRef] [PubMed]
 
Borgmeyer C. Evidence lacking to support or oppose low-dose CT screening for lung cancer, says AAFP. AAFP Newshttp://www.aafp.org/news/health-of-the-public/20140113aafplungcarec.html. January 13, 2014. Accessed March 1, 2014.
 
Aberle DR, Adams AM, Berg CD, et al; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. [CrossRef] [PubMed]
 
Moyer VA; US Preventive Services Task Force. Screening for lung cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(5):330-338. [CrossRef] [PubMed]
 
Bach PB, Mirkin JN, Oliver TK, et al. Benefits and harms of CT screening for lung cancer: a systematic review. JAMA. 2012;307(22):2418-2429. [CrossRef] [PubMed]
 
Veronesi G, Maisonneuve P, Bellomi M, et al. Estimating overdiagnosis in low-dose computed tomography screening for lung cancer: a cohort study. Ann Intern Med. 2012;157(11):776-784. [CrossRef] [PubMed]
 
Patz EF Jr, Pinsky P, Gatsonis C, et al; NLST Overdiagnosis Manuscript Writing Team. Overdiagnosis in low-dose computed tomography screening for lung cancer. JAMA Intern Med. 2014;174(2):269-274. [CrossRef] [PubMed]
 
Nanavaty P, Alvarez MS, Alberts WM. Lung cancer screening: advantages, controversies, and applications. Cancer Contr. 2014;21(1):9-14.
 
McMahon PM, Kong CY, Bouzan C, et al. Cost-effectiveness of computed tomography screening for lung cancer in the United States. J Thorac Oncol. 2011;6(11):1841-1848. [CrossRef] [PubMed]
 
Colditz GA, Wolin KY, Gehlert S. Applying what we know to accelerate cancer prevention. Sci Tranl Med. 2012;4(127):127rv4.
 
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