Screening for Lung Cancer: An Important Opportunity to Advocate for Our Patients
Douglas E. Wood, MD
STS News, Summer 2013 -- The STS mission is “to enhance the ability of cardiothoracic surgeons to provide the highest quality patient care through education, research, and advocacy.” We accomplish this mission in innumerable ways: leading research through our new Research Center, enhancing quality through our STS National Database, educating surgeons during our annual meeting and multiple freestanding courses, collaborating with like-minded specialty societies in education and guidelines, and advocating for health care policy that is important in the delivery of thoracic and cardiovascular care. Increasingly our mission leads us into initiatives and engagement that directly impact our most important constituency, our patients. Last year we successfully supported a National Coverage Determination for TAVR, assuring our patients equal access to consistent high-quality care related to this new technology. This year, opportunities may arise related to new therapies for mitral and pulmonic valves; however, perhaps no issue has more urgency or imperative than the emergence of lung cancer screening. Herein lies the prospect for STS members, individually and as a Society, to substantially lower lung cancer mortality by serving as patient advocates and facilitating access to lung cancer screening for patients at risk.
The National Lung Screening Trial (NLST) randomized more than 53,000 patients to screening with low-dose computed tomography (LDCT) versus chest x-ray, and, in October 2010, the NLST was halted due to a 20% mortality reduction identified in the study population (LDCT). A 20% mortality reduction is, by far, the most profound finding that benefits our patients at risk for lung cancer, overshadowing improvements in surgical care, new chemotherapy drugs, and evolution in radiation combined. This immediately led to a reassessment of lung cancer screening by specialty physician groups and patient advocates. The first, and probably the most comprehensive, new guideline supporting lung cancer screening was published by the National Comprehensive Cancer Network (NCCN) in October 2011. The multidisciplinary NCCN guidelines group considered not only the complex issue of patients at risk for lung cancer who are screening candidates, but also the conduct of the screening program itself and management of abnormal findings. Several US societies have already published guidelines or statements recommending lung cancer screening, including STS, the American Cancer Society, the American Lung Association, the American College of Chest Physicians, the American Society of Clinical Oncology, and the American Association for Thoracic Surgery. (Read STS’s statement at www.sts.org/LungCancerStatement.) The NCCN has completed its third annual update of lung cancer screening guidelines, refining and revising them each year as new data are published.
What is remarkable is that the primary body responsible for recommendations that direct national health policy, the United States Preventive Services Task Force (USPSTF), has yet to make any recommendations about lung cancer screening, even though the NLST results were announced nearly 3 years ago. This is in spite of assurances from AHRQ, which oversees the USPSTF, that screening recommendations would be forthcoming in 2012. This past May, I joined other physicians and government officials in a Senate briefing to educate policymakers about the major opportunity to save lives from our most common cause of cancer death and shine a light on the long delay in action by the USPSTF.
It is easy to understand caution on the part of the USPSTF. Cancer screening is not the same as treatment of a disease. Legitimate potential harms of screening may outweigh the benefits, particularly if the population selected for screening is too broad, leading to fruitless workups, unnecessary testing, and perhaps even risky procedures being performed on individuals at low risk for cancer. And the USPSTF has recent experience in the consequences of overreach in breast and prostate screening programs, as well as the political backlash of trying to pull back from screening guidelines precedent. But there are also harms of delay or too narrow interpretation of the patient population at risk. The evidence supporting lung cancer screening is compelling. The benefits far outweigh the risks of screening in the NLST population, meaning that delay in recommendations and coverage decisions denies the chance of cancer cure for some of the 160,000 people who die of lung cancer each year. Further, it is naïve and narrow-minded to argue that only patients with the NLST inclusion criteria should be eligible for screening given decades of research that have outlined additional risk factors other than smoking. I believe our patients who are at risk of developing and dying of lung cancer deserve thoughtful and timely access to lung cancer screening. This is a time when we can support and advocate for our patients. Write to your Congressional representatives and/or HHS Secretary Kathleen Sebelius, urge action by the USPSTF, and do not let politics or finances interfere with clear evidence of benefit from lung cancer screening for our patients.