Tens of millions of Americans who have not kicked the harmful smoking habit or who have only recently done so may want to keep a watch on the work of a blue-chip advisory group as its medical scientists consider how much lung-cancer screening best benefits tobacco users.
The panel is seeking expert comment on its proposal for a greater number of older smokers and recent quitters to undergo low-dose computed tomography. That is a diagnostic procedure that combines X-rays and computers to give doctors a better look at patients’ lungs with multiple views and cross-sectional images.
The U.S. Protective Screening Task Force — which advises the federal government on preventive care and issues recommendations that can affect patient costs and insurer coverage for procedures — says more patients should have tomography than the panel recommended in 2014 when it last considered evidence on it.
If the USPSTF formalizes its recommendations, more African Americans and women could benefit from earlier lung cancer detection and treatment. Black patients are at higher risk for lung cancer, just one of the many health disparities to which they are subject. Women patients often do not get screening for the disease as readily because they tend to smoke fewer cigarettes but may still suffer extensive harms from smoking.
The existing screening guidelines are based on age and extent of tobacco use. As the federal panel described the risk factors:
“Smoking and older age are the two most important risk factors for lung cancer. The relative risk of lung cancer in smokers is approximately 20-fold that of nonsmokers, increases with cumulative quantity and duration of smoking, increases with age, and for former smokers, decreases with increasing time since quitting. The USPSTF considers adults ages 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years to be at high risk and recommends [tomography] screening for lung cancer.”
The USPSTF proposes to alter a key criterion for lung-cancer screening: individuals’ number of “pack years.” As Stat, the science and medicine news site, reported:
“A pack year is a way of calculating how much a person has smoked. One pack year is the equivalent of smoking an average of 20 cigarettes, or one pack, per day for a year. The task force’s existing recommendation for eligibility is 30 pack years, but the new recommendation would drop it to 20.”
Tomography screening has been controversial. Choosing Wisely, an initiative that tapped into medical specialists and their expertise to reduce unnecessary and wasteful treatments and procedures, singled out lung-cancer screening as problematic. That’s because its benefits are not clear in wide use. It also exposes patients to radiation (albeit at lower levels than many exams), false positives, and a cascade of care that results. The test also is not cheap, costing around $300, and insurers may not cover it.
The USPSTF said wider use of tomography to detect lung cancer would have a “moderate net benefit,” explaining this also will be dependent “on limiting screening to persons at high risk, the accuracy of image interpretation being similar to or better than that found in clinical trials, and the resolution of most false-positive results without invasive procedures.”
Lung cancer persists as a significant health problem for Americans, the panel reported, noting:
“Lung cancer is the second most common cancer and the leading cause of cancer death in the United States. In 2020, an estimated 228,820 persons will be diagnosed with lung cancer, and 135,720 persons will die from the disease. The most important risk factor for lung cancer is smoking. Smoking is estimated to account for about 90% of all lung cancer cases, with a relative risk of lung cancer approximately 20-fold higher in smokers compared with nonsmokers. Increasing age is also a risk factor for lung cancer. The median age of diagnosis of lung cancer is 70 years. Lung cancer has a generally poor prognosis, with an overall 5-year survival rate of 20.5%. However, early-stage lung cancer has a better prognosis and is more amenable to treatment.”
In my practice, I see not only the harms that patients suffer while seeking medical services, but also the high value in their staying healthy and away from the U.S. health care system, including clinics, doctors, and hospitals. In better times, before the Covid-19 pandemic, patients already struggled with significant and persistent problems with infections acquired in hospitals, nursing homes, and other medical care giving facilities, as well as major challenges with medical error and misdiagnoses.
Over testing, over diagnosis, and over treatment all pose big and costly problems, adding hundreds of billions of dollars in unneeded costs for Americans. Doctors can order many ticky-tack tests, and these can add up fast, not to mention they can heighten patient risks by inaccurately prompting yet more unnecessary, painful, costly, and invasive procedures.
Even as the health care system needs to expunge low value test and treatments, it is important at this time to add a few other points: Patients should not postpone important screenings and medical care due to excessive fears of Covid-19 infection. Fast spreading and growing cancers will not wait for patient worries to subside, and many medical practices and clinics and hospitals need to resume seeing those in need for economic reasons, too.
Your own doctor can best advise you about lung-cancer screening, its necessity, effectiveness, and urgency. But if you don’t smoke (or vape) now, please don’t start. If you do, please stop. If you have a history of tobacco use, don’t forget as you grow older to remind your doctors about your history.
We’ve got a lot of work to ensure lung cancer no longer will be as debilitating as deadly as it is now.