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Point and Counterpoint |

Rebuttal From Dr YankelevitzRebuttal From Dr Yankelevitz FREE TO VIEW

David F. Yankelevitz, MD
Author and Funding Information

From the Icahn School of Medicine at Mount Sinai.

CORRESPONDENCE TO: David F. Yankelevitz, MD, Icahn School of Medicine at Mount Sinai, 1428 Madison Ave, New York, NY 10029; e-mail: david.yankelevitz@mountsinai.org


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST the following conflicts of interest: Cornell University has had a licensing agreement with General Electric related to intellectual property on lung nodule analysis since 2006, and as a faculty member, Dr Yankelevitz was entitled to a share of the monies. He also is involved in research funded by the Flight Attendant Medical Research Institute through Mount Sinai regarding screening and risks of second-hand tobacco smoke. Dr Yankelevitz is director of the Lung Biopsy Service at the Icahn School of Medicine at Mount Sinai and an I-ELCAP Investigator.

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


Chest. 2015;147(2):292-293. doi:10.1378/chest.14-2813
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In the Counterpoint Editorial by Drs Courtright and Manaker,1 the pattern I had expressed concern about regarding overstating the harms and underestimating the benefits continues. Notably, the evidence regarding harms refers solely to National Lung Screen Trial (NLST) data, neglecting all the progress made in the past decade in technology as well as in developing more-efficient and safer protocols. Although the NLST was performed primarily at academic centers, there was no requirement that the follow-up studies or treatments be performed at these centers or that a certain protocol be followed. Concerns expressed about implementation in the community setting, including an inability to use best practice guidelines, seem unwarranted given the success demonstrated in developing quality standards for mammography. There is every reason to believe that similar types of implementation, by the same organizations, can also be accomplished for CT screening. Support for this also comes from the International Early Lung Cancer Action Program (I-ELCAP) report showing no difference in performance between the academic and community setting.2

What is even more striking is the difference in views regarding the understanding of the core result of the NLST. The view I presented was that fundamentally, the NLST demonstrated increased curability for the smaller cancers found by CT scan compared with the larger cancers found by chest radiography. Given this, there should be no doubt that each round of screening produces a benefit (not limited to three rounds) and also that the benefit exists for people in the Medicare age range. There is no reason to believe that early cancer becomes less curable once a person reaches age 65. The opposing idea is that because a statistically significant mortality reduction could not be demonstrated for the small subgroup in NLST meeting Medicare criteria that this lends credibility to the idea that more evidence is needed to prove screening beneficial, ideally another randomized clinical trial, in essence, implying that the cancers in that subgroup were somehow less curable than the other ones in the study. Were this type of reasoning to be accepted, there would be innumerable numbers of subgroups where a significant difference could not be demonstrated (eg, only men).

Also stemming from that interpretation of the core results of NLST is the assertion that the number of participants needed to screen to save a life is 320. This too is misleading because the estimate reflects not only the curability of lung cancer found early by CT scan but also the design parameters of the study. The results would have been different had the number of rounds of screening and length of follow-up been different. This becomes apparent when looking at different screening scenarios. For example, using a modeling approach with NLST data, and even with some highly conservative assumptions, the Cancer Intervention and Surveillance Modeling Network (CISNET) demonstrated in a report to the US Preventive Services Task Force that with increased rounds of screening among those meeting NLST enrollment criteria, only 42 people are needed to be screened to save a life,3 and even this would be substantially lower when focusing on the higher-risk Medicare population.

The difference in the way the core result of the NLST is viewed is at the heart of any rational decision regarding screening.4 I believe that the view taken in the counterpoint piece as well as by several guideline organizations5 is seriously misguided and has the potential to affect policy on what is, in my view, the most important breakthrough in the war on cancer for the foreseeable future. There is an urgent need for this difference in views on how the results of randomized clinical trials are to be interpreted to be further examined in the scientific literature because it affects not only lung cancer screening but also all other screenings and not just those limited to imaging.

References

Courtright K, Manaker S. Counterpoint: should lung cancer screening by chest CT scan be a covered benefit? No. Chest. 2015;147(2):289-292.
 
Henschke CI. Lung cancer screening with low-dose computed tomography: presentation to the Centers for Medicare & Medicaid Services Medicare Evidence Development and Coverage Advisory Committee, April 30, 2014. Centers for Medicare & Medicaid Services website. http://www.cms.gov/medicare-coverage-database/details/medcac-meeting-details.aspx?MEDCACId=68. Accessed August 21, 2014.
 
de Koning H, Meza R, Plevritis S, et al. Modeling report: lung cancer: screening. US Preventive Services Task Force website. http://www.uspreventiveservicestaskforce.org/Page/SupportingDoc/lung-cancer-screening/modeling-report. Accessed October 30, 2014.
 
Yankelevitz DF, Smith JP. Understanding the core result of the National Lung Screening Trial [published correction appears inN Engl J Med. 2013;368(18):1757]. N Engl J Med. 2013;368(15):1460-1461. [CrossRef] [PubMed]
 
Bach PB, Mirkin JN, Oliver TK, et al. Benefits and harms of CT screening for lung cancer: a systematic review [published correction appears in JAMA2012;308:1324.]. JAMA. 2012;307(22):2418-2429. [CrossRef] [PubMed]
 

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References

Courtright K, Manaker S. Counterpoint: should lung cancer screening by chest CT scan be a covered benefit? No. Chest. 2015;147(2):289-292.
 
Henschke CI. Lung cancer screening with low-dose computed tomography: presentation to the Centers for Medicare & Medicaid Services Medicare Evidence Development and Coverage Advisory Committee, April 30, 2014. Centers for Medicare & Medicaid Services website. http://www.cms.gov/medicare-coverage-database/details/medcac-meeting-details.aspx?MEDCACId=68. Accessed August 21, 2014.
 
de Koning H, Meza R, Plevritis S, et al. Modeling report: lung cancer: screening. US Preventive Services Task Force website. http://www.uspreventiveservicestaskforce.org/Page/SupportingDoc/lung-cancer-screening/modeling-report. Accessed October 30, 2014.
 
Yankelevitz DF, Smith JP. Understanding the core result of the National Lung Screening Trial [published correction appears inN Engl J Med. 2013;368(18):1757]. N Engl J Med. 2013;368(15):1460-1461. [CrossRef] [PubMed]
 
Bach PB, Mirkin JN, Oliver TK, et al. Benefits and harms of CT screening for lung cancer: a systematic review [published correction appears in JAMA2012;308:1324.]. JAMA. 2012;307(22):2418-2429. [CrossRef] [PubMed]
 
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