Superior Reporting on a Complicated Topic — Lung Cancer Screenings

Earlier this month, the New York Times wrestled with the thorny issue of lung cancer screenings, and whether people who are entitled to certain screenings through their Medicare coverage should get them. As the paper pointed out, “… screening will not help everyone who is eligible, experts warn. Like any medical test or procedure, it will subject some patients to harm.”

According to HealthNewsReview.org (HNR), which rates media on how well they cover health and medicine news, The Times did a superior job of explaining why a yearly computed tomography (CT) scan is a good idea for some people, and maybe not for others.

Smoking, of course, is a huge risk for contracting lung cancer, and Medicare recently approved subsidizing a low-dose CT scan every year for people 55 to 77 years old who have a smoking history of at least 30 “pack years”; that is, they smoked a pack a day for 30 years, or two packs a day for 15, etc., and still smoke or have quit only within the last 15 years. (See our blog about the advisory panel’s analysis that informed Medicare’s decision.)

That means more than 10 million Americans are eligible for screening, although many of them aren’t old enough to qualify for Medicare coverage.

Medicare’s approval of CT scans speaks to the fundamental desire to find lung cancer early enough to treat it efficiently and successfully.

Compared with a chest X-ray, having a yearly low-dose CT scan for three years reduced the likelihood of dying from lung cancer by about 20%. “Depending on one’s perspective,” HNR noted, “a 20% relative reduction or 0.5% absolute reduction, may or may not be important. And that is the focus of [The Times] article. How do you educate individuals who are eligible for this test so they can make a personal choice that’s right for them?”

As we’ve often written, the default for medical care in the U.S. has been that more testing is better, that patients generally accept their doctors’ recommendations for diagnostic tests despite overwhelming evidence that overtesting is expensive, stressful and poses clear risks of complications.

The Times article reinforced that in addition to a small potential for benefit, there is also a real potential for harm or at least inconvenience in lung cancer screening. Almost 1 in 3 people will have an abnormality on their CT scan that will require follow-up testing, but only 6 in 100 of those abnormalities actually will be something serious enough to require a biopsy or treatment.

“So patients and doctors are going to need to find ways to communicate these potential risks and benefits and help individuals assess preferences and other health or life issues that may influence the choice to screen,” HNR said. “How well we do this will determine whether translating the results of a research study done under strict controls by experienced investigators translates into the same benefits in the broader population.”

Here’s how HNR rated The Times’ story on the criteria people should use to determine how well a news medium covers a medical topic.

Does the story adequately discuss the costs of the intervention?

HNR found The Times unsatisfactory in its examination here. The reporter wrote about one patient who paid $95 out of pocket for a lung cancer screen in 2013, but the cost of the initial scan is not an issue for Medicare-eligible patients. And the real costs to individuals and society aren’t addressed by the cost of one person’s scan.

“The story notes high up that the number of Americans who would be eligible for Medicare-funded scans would be in the millions,” according the HNR. “So the cost to Medicare and private insurers to fund this program will be, well, gargantuan at that scale. There is the cost of the initial test, annual testing if negative, and potentially more testing if an abnormality is found. This is not going to be a cheap program.”

Does the story adequately quantify the benefits of the treatment/test/product/procedure?

Yes, said HNR. It does an admirable job of explaining the modest benefit of these scans, and tries to interpret the statistics in several ways that other journalists could learn from and, therefore, consumers could become more informed about. For example, the story said:

In the national trial, those screened with chest X-rays had about a 1.7 percent chance of dying from lung cancer during the study period; in the CT scan group, it was about 1.4 percent. For every thousand people screened with a low-dose CT, three fewer died of lung cancer.

We’ve encourage readers to understand the concept of number needed to treat (NNT) – the number of patients screened to prevent, in this case, one lung cancer death. For CT screens, the NNT appears to be around 1 in 400, considerably better, said HNR, than other screening approaches for breast or prostate cancer.

Does the story adequately explain/quantify the harms of the intervention?

It does, thanks to its comprehensive explanation of the potential problems invoked by false positives. The Times referred to an elderly retiree whose scan showed a “hot spot” on her lung. But after significant worry and pain caused by additional diagnostic procedures, her lung was found to contain no cancer.

Also covered was the potential harm of radiation exposure from X-rays. Although these CT scans are “low dose,” they’re not “no dose.” If some screenings can prevent death from cancer, others will contribute to the risk of it, because radiation exposure is cumulative – the more you have over the course of your life, the higher your risk of cancer.

Does the story seem to grasp the quality of the evidence?

Yes. It discusses a large screening trial involving more than 53,000 smokers and former smokers. Although HNR would like to see more information about how the study was conducted (emphasizing that to achieve the benefit seen in the trial, you need a yearly CT scan until either you age out or, if you’ve stopped smoking, you reach 15 years since quitting), there’s still plenty of information about the types of patients enrolled and the harms observed in the study.

It also noted that treatment for people who were found to have cancer was provided by major medical centers with specialized radiologists and surgeons; in other words, the ideal kind, which might mean it would be difficult to get the same results at less specialized centers.

Does the story commit disease-mongering?

“In some ways,” said HNR, “this story is an example of a way to avoid disease-mongering.” That’s a practice many medical interests, especially pharmaceutical companies and screening facilities, engage in to fatten their bottom lines. It has little to do with concern for patients or their health, but presents their services or wares as something consumers need to determine and/or improve their health status.

The Times helped readers understand the idea of disease-mongering in this story. Medicare-approved procedures by definition pertain to elderly people, who tend to have multiple chronic diseases. This leaves them vulnerable to the “competing mortality” of which problem is more important to address. Lung cancer is an important disease, but, as one physician/researcher told The Times, “If I find a teensy lung cancer in a 77-year-old with heart disease, I may not have done him any favor.”

Does the story use independent sources and identify conflicts of interest?

The Times did a satisfactory job, said HNR, of clearly identifying its sources, but it did not indicate either the presence or absence of conflicts of interest. Maybe that’s because the paper looked and found none, and deemed no news not worthy of mention. HNR did a quick review and found no major conflicts among the sources.

Does the story compare the new approach with existing alternatives?

Mostly, yes. The Times did a satisfactory job with this criterion even though the single study it discussed (the National Lung Screening Trial) compared low-dose CT scans with more traditional X-ray diagnoses. “But in reality,” HNR said, “the comparison is between low-dose CT and not doing one at all. No one is recommending a regular X-ray of the chest.”

Does the story establish the availability of the treatment/test/product/procedure?

It does, because the point here is whether low-dose CT scans are available for older, heavy smokers to screen for lung cancer – the main topic of the story. Still, it isn’t entirely clear from the story if screening actually has begun or when it will. Medicare programs to implement the shared decision-making haven’t been established, and no billing codes for the initial visit, when the issue is reviewed, are missing. Also, it’s not clear if insurers other than Medicare will cover these scans, and if so, for whom.

Does the story establish the true novelty of the approach?

The story is clear that low-dose CT scans are being used, and that the novelty is Medicare’s decision to cover the cost for current or former heavy smokers who meet specific criteria.

Does the story appear to rely solely or largely on a news release?

Too many health and medicine stories covered in popular media are told strictly from news releases; that is, reporters don’t dig behind the information crafted specifically to get their attention. HNR regularly finds fault with shallow stories that are little more than promotional material served up as news. But that’s not what happened here. “We see no evidence that this analytical narrative relied on a news release,” HNR concluded.

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