Unnecessary surgery in lung cancer screening could happen in two circumstances.
An invasive procedure could be advised based upon a false-positive test result – a result that is positive even though the lung nodule reported is not a cancer.
An invasive procedure could be advised for a positive test result that is a cancer, but a cancer that is in-situ (not invading), very slow-growing, and unlikely to spread or kill in the future (an overdiagnosed lung cancer).
What are invasive procedures?
Biopsy by a needle inserted between the ribs under CT scan control (trans-thoracic needle biopsy).
2. Biopsy carried out through a bronchoscope (a flexible tube inserted through the mouth and voice box into the lungs. In some cases this biopsy is “directed”, that is guided by CT scan images.
3. Surgical biopsy. Today this is typically done under general anaesthesia, using video-assisted technology (VATS) with small incisions between the ribs, long tubular instruments and a stapler guided by a video camera.
4. Surgical resection can be carried out using VATS methods, robotic surgery or older open methods (make a longer incision and spread the ribs open).
Each of these methods can have complications.
1. Needle biopsy can result in air leak into the chest cavity (pneumothorax) that may collapse the lung and require placement of a drainage tube. Less frequently, a patient can experience coughing up blood. A small percentage will require hospitalization. Rarely air can embolise into (spread through) major blood vessels. Death is very uncommon.
Needle biopsy can also have false negative results. The radiologist or pathologist may miss the cancer. For this reason a follow up CT scan is done in 3 months to see if the nodule has grown and should be re-biopsied or removed.
Results of needle biopsy vary with the skill and experience of the radiologist.
2. Bronchoscopy and Biopsy of small peripheral nodules in the lung is technically difficult, with a high false negative rate. More modern “guided” systems show better results, but are highly dependent on the skill and experience of the operator.
Pneumothorax and coughing blood are complications. Death is uncommon.
3, Surgical biopsy is more invasive, requires general anaesthesia and surgical incisions, and is much more expensive. Diagnostic rate is generally high and if a cancer is found on frozen section, curative surgery may immediately follow. If a benign condition is found, the surgery generally has not helped the patient. In some cases, for example a diagnosis of tuberculosis, the patient benefits from appropriate treatment with antibiotics.
4. Surgical resection: the situation is the same as in 3., but if the operation is open, hospitalization and recovery to full activities is longer. If a lobectomy is performed, the patient will experience approximately a 12% reduction in total lung function. Major complications can occur as often as 20% or higher and mortality typically less than 1% in modern programs.
I believe that it is wise for the patient to be proactive when an invasive procedure is recommended. He/she should ask whether the biopsy is advised under the guideline used? Would the guideline also recommend a PET scan first, or a repeat CT scan in 3 months. If the doctor is making a recommendation different from the guideline, for example “I don’t care what the guideline says; it looks like a cancer to me.” A second opinion is in order, in my opinion.
In the specific circumstance of a completely non-solid nodule detected by CT, a recommendation for biopsy or surgery should prompt a second opinion. Current guidelines do not recommend any action other than a follow-up CT scan in one year.
Strict adherence to the IELCAP diagnostic algorithm or the NCCN Lung Cancer Screening guideline, should prevent most unnecessary invasive procedures or operations, but even following guideline recommendations, invasive interventions will occur in a small percentage of patients screened, who do not have lung cancer.
If the local screening program has a radiologist with skill and experience in needle biopsy, I believe that this is the best option in most circumstances. In situations where needle biopsy is not feasible it may be necessary to move to surgical biopsy and/or resection.
If the guidelines are complied with, the number of patients who benefit from early stage lung resection will far outnumber those who are harmed by biopsy or removal of benign nodules.
Dr. Otis Bradley has written that there were 16 deaths following invasive procedures among the 50,000 research subjects in the NLST trial, but has produced no data to indicate that any death was caused by the procedure.
NLST study doctors also performed large numbers of bronchoscopic studies. They have not published what percentage of these exams were diagnostic of cancer.
The author would guess that the large majority were non-diagnostic and would not advise any patient to have a bronchoscopic exam in the diagnosis of a small, screen-detected nodule, unless the operator uses a guidance system and has a large experience and can demonstrate good results.
Potential Complications of Lung Cancer Screening: Radiation Carcinogenesis: