Lung cancer screening “decision aid”: Summary

Screening Eligibility Criteria:

If you are

1. a current smoker or

2. an ex-smoker who has quit within the past fifteen years and

3. You have smoked a total of thirty pack/years or more.
(For example, smoked an average of two packs a day for fifteen years or one pack a day for thirty years.)
And

4. You are between the ages of 55 and 80,

Medicare or Medicaid will pay for a low-dose, non-contrast, spiral CT scan for lung cancer screening, each year.

But, only after you have reviewed information in a “decision aid” – like this one- and have gone through “a shared decision making conference” with your caregiver.

This policy is based on the fact that lung cancer is the number one cancer killer in the U.S. in both men and women and has been responsible for many millions of deaths over the past century. Because of your exposure to cancer- causing chemicals in tobacco smoke, you have an increased risk of lung cancer – now – and over the next 10 years.

What is your personal risk of lung cancer?

Your increased risk is substantial and varies between
2-4% on the first scan ( odds of lung cancer between 1 in 50 And 1 in 25) and

10% over a ten year period; (odds of lung cancer 1 in 10) in high-risk patients who meet the Medicare criteria above.

In one study from the University of Toronto, Canada, 21% of high-risk individuals screened over a ten-year period developed lung cancer (odds risk of 1 in 5).

(It is widely anticipated that Medicare and Medicaid will soon extend screening coverage to smokers and ex-smokers starting at age 50 and those who have 20 or more pack/years of exposure based upon a recommendation from the U.S. Preventive Services Task Force (USPSTF).

Benefits of CT Screening:

CT screening has been shown, in multiple studies, to detect lung cancers at small size and early stage (Stage 1) in a high percentage of patients (approximately 80%)

CT screening has been determined, in multiple studies, to reduce deaths and increase the chance of survival for at least ten years, when a lung cancer is found by screening. About 80%, or 4 in 5 lung cancers found by screening can be cured, compared to less than 20% or 1 in 5 without screening.

What are the potential risks of lung cancer screening?

The National Cancer Institute (NCI) was worried that CT screening might cause more harm than benefit and performed a randomized control research trial (RCT) to study risks. Medicare requires that people considering screening must be presented with specific information on potential risks, in a “decision aid”, on the following complications that might arise from screening

1. People might not quit smoking.

2. Screening might be inconvenient

3. Screening might cause discomfort

4. Screening might cause anxiety.

5. There might be false negatives (cancer would be missed.)

6. There might be false positives (tests would be positive without cancer).

7. There might be diagnosis of many lung cancers that would never cause symptoms or kill (

8. Unnecessary tests, biopsies and surgical operations might cause complications and even deaths in patients with false positives or

9. Radiation from CT scans might cause cancers.

10. Results (early stage detection and cure) might be lower in community screening than in academic research.

Multiple research studies, as well as extensive community screening experience in Japan, have shown that the risk of the above complications is small and that benefitS far exceed harms in CT screening.

Specifically-

1. There is no evidence that people who are screened fail to quit or start smoking again.

2. Most areas of the country have screening centers available within reasonable distance.

3. CT screening causes minimal discomfort; less than other forms of screening.

4. Anxiety is relatively minor and is counterbalanced by relief when (most) CTs show no evidence of cancer.

5. False negative scans are uncommon.

6. False positive scans occur in less than 5-12% of patients – in programs using an organized plan of diagnosis and treatment ( for example, NCCN, IELCAP and Lung- RADS.

7. NLST research shows that no more than 1% of lung cancers diagnosed by CT screening are overdiagnosed.

8. Organized diagnostic plans prevent unnecessary diagnostic tests, biopsies and operations in patients with false positive scans results or overdiagnosis.

9. There is no evidence that older patients receiving annual low-dose CT scans have any increased risk of cancer.

10. Many community centers have shown results equivalent to or better than some academic centers. All centers certified by the American College of Radiology, Go2 and Medicare have gone through a rigorous process to assure high quality screening.

In Summary:

Patients with lung cancer found by CT screening have long-term survival that is far higher than those who have not been screened.

Risks of screening are relatively minor and are preventable by good screening practice and patient compliance.

It is generally agreed by multiple screening groups and medical societies that lung cancer screening has the potential to save many lives and has a favorable benefit to risk ratio.

The results described here can be reliably anticipated in patients who return each year for their CT scans and who follow advice, based on diagnostic and treatment plans. Patients who skip scans or do not follow recommendations may experience less benefit and more risk.

Patients who quit more than 15 years earlier remain at high-risk of lung cancer and should consider screening. At the current time, you would have to pay for CT screening.

Smokers of less than 20 years, those exposed to heavy second-hand smoke, industrial chemicals, asbestos and radon have an increased risk of lung cancer and may benefit from screening, but would have to pay for the CT scan out of pocket. Depending on the center, this cost may vary between $100 -$500.

After thinking about the information above, if you decide that you wish to be screened for lung cancer, you must schedule a “shared decision making” consultation with your doctor, before Medicare/Medicaid will agree to pay for the scan.

The American College of Chest Physicians have recommended that lung cancer screening not be conducted during the COVID epidemic. There is no data to support this recommendation. Multiple screening programs (including Mount Sinai Hospital in NYC and City of Hope in Duarte, CA) are actively screening now, without evidence of COVID infections.

Your doctor must write a prescription for your scan and the CT scan must be obtained at a center approved by Medicare.

If you would like to look at more information on benefits and risks of CT screening, please continue on to visit other pages in lungcancerCTscreening.com, that provide more information on benefits and risks of CT lung cancer screening.

Potential Complications of Lung Cancer Screening:  False Positives

The basic problem in lung cancer screening is that cancers and benign nodules look the same.  With some exceptions, a radiologist cannot tell a cancer from a benign nodule just by looking at them. 

A false positive test is a positive test report in a patient who does not have lung cancer.  Such a report can cause anxiety, unnecessary testing, inconvenience, radiation exposure and/or even unnecessary biopsy or surgical removal of a lung nodule.  

Such an operation, in turn, can have no benefit, only harms such as loss of lung function, post-surgical complications or even death. 

How often do false positive results occur?

This is a difficult to answer.  Estimates of false positives in lung cancer CT screening range between 98% and 5%. 

 

How can such a wide discrepancy of results be possible?

The 98% figure – that is still being quoted today – is from a faulty interpretation of the results of the National Lung Screen Trial (NLST), a randomized control trial (RCT) conducted by the National Cancer Institute (NCI) between 2001-2011. 

NLST contained a number of major flaws in research design.

1. NLST criterion for a positive test was too loose. It included nodules with a largest diameter of 4 millimeters (for example, a nodule 4 mm. X 2 mm.) 
2. In addition, NLST considered the same nodule as positive even if it had been seen on a previous CT scan, in effect counting it as false positive twice. 
3. NLST used no diagnostic plan after a positive result was reported.
4. Many nodules that were at first considered as false positive later turned out to be lung cancers.

International Early Lung Cancer Action Program (IELCAP) researchers use a different criterion for a positive result

 – an average diameter 6 mm. or greater (for example 6×6 mm, but not 6×5 mm. in diameter).  Using this criterion, false positives fall to 12% on the first CT screen.  This standard has been adopted by most modern screening programs.

False positives are much less common on annual-repeat CT scans – approximately 5% in IELCAP.

Are all patients with false positive CT scans harmed? 

No. 

It is very important to re-emphasize that lung cancer screening is not a test; it is a process.  The process includes an organized plan (algorithm) designed to prevent complications, when a benign nodule is detected by CT screening. The IELCAP group uses a diagnostic algorithm, first introduced around 2000 that is reviewed and revised each year based on analysis of growing data on more than 80,000 individuals screened at more than 70 centers worldwide.

Other methods include the clinical practice guideline for lung cancer screening of the National Comprehensive Cancer Network (NCCN) and the LungRads method of the American College of Radiology. 

It is important to stress again that the NLST study did not include a diagnostic plan.  As a result, when a study member had a positive test result, the next step was decided as an individual choice by his doctors.  This resulted in substantial harm, as many patients had diagnostic procedures, like bronchoscopy (looking into the lungs using a flexible scope and taking biopsies) that had little chance of diagnosing small cancers in the periphery of the lung.  Worse, many people had surgical resection of lung nodules that were benign. 

The lesson learned from the NLST experience is that a diagnostic plan (algorithm) is necessary to prevent unnecessary invasive tests, while at the same time not allowing a delay that will allow lung cancers to progress and reach higher stages where cure is less likely.  

How do diagnostic algorithms prevent unnecessary invasive tests and operations? 

The plan currently used is not complicated or difficult to understand. 

First, nodules are put into one of four categories

1. Calcified nodules

2. Solid nodules

3. Non-solid nodules

4. Part-solid nodules.

and then size is carefully measured. 

A 1. calcified nodule is very rarely cancer and no further action is required until the next annual CT scan.

A 3. Non-solid nodule may be a cancer, but is typically non-invasive (in-situ) and so slowly-growing, that no action is required until the next annual CT scan. The risk that such a cancer will become incurable in a year is close to zero. 

A 2. Or 4. Solid or part solid nodules have a risk of being a faster growing, invasive cancer.  

If the solid nodule is less than 6 mm. in average diameter, it is safe to wait 12 months until the next annual CT scan to re-measure the size of the nodule. 

If the solid nodule is larger than 6 mm. Then it is not safe to wait a year.

  

If the nodule is between 6-8 mm. A CT scan is done again in 3 months.  If significant growth is seen, the nodule is probably a cancer and further investigation is required.

If the nodule is larger than 8 mm. A PET scan is recommended.  

If the PET scan is negative, the nodule is probably not a cancer and a repeat CT is ordered to check for growth in a few months.

If the PET scan is positive, the nodule is probably a cancer or an infection.  Biopsy is indicated.  This is preferably by trans thoracic needle biopsy, done under CT scan control.  Alternatively, the nodule can be surgically removed.

If the nodule is 1.5 cm. or larger, immediate action is necessary.  Lung cancers of this size are dangerous and may spread.  Delay to observe for possible growth is not safe.  Biopsy is indicated.

Non-solid nodules can be observed at one year intervals by CT scan.  If a solid nodular component arises within the non-solid nodule, it probably represents development of an invasive cancer.

 If these basic rules are followed, false positive test results seldom result in unnecessary needle biopsy, bronchoscopy or surgical resection.  

On the flip side of the coin, if the rules are followed, it is uncommon for a lung cancer to reach higher stage or become incurable. 

The bottom line is that when lung cancer screening is carried out in an organized and responsible manner, patients with benign nodules in their lungs are seldom harmed.  

Despite careful guideline based management, a small percentage of screened patients will undergo biopsy or resection of benign nodules.

A recent report from the NELSON study from Scandinavia, which used a carefully organized diagnostic plan, shows a false positive rate of only 5%. 

Complications of lung cancer screening: Unnecessary operations, complications, deaths

Potential Complications of Lung Cancer Screening: Overdiagnosis

What is cancer overdiagnosis? 

William Black defines an overdiagnosed cancer as one which “will never cause symptoms or kill”.  

This idea is hard for most people to grasp.  Popular understanding is that lung cancer is a relentless disease that will rapidly kill unless it is treated.

If doctors treat a patient with a cancer that will never cause symptoms or kill, with surgery, radiation therapy or chemotherapy, the patient derives no benefit, only harm.  Such treatment is called overtreatment.

How many patients experience harm from overtreatment of overdiagnosed lung cancers?

Patients participating in screening in certified lung cancer screening programs have a very low risk of overdiagnosis and/or overtreatment. 

Although critics of lung cancer screening warned early that the risk of overdiagnosis was as high as 80%, and later estimated that the early results of the NLST study showed an excess of (overdiagnosed) lung cancers in the CT-screened arm of 26%.    After 11 years of follow-up in NLST, however, this excess fell to 1%.  

The bottom line is that overdiagnosed lung cancer is very uncommon in lung cancer screening.

More important, the diagnostic plans (IELCAP, NCCN, LungRADS) used in lung cancer screening prevent overtreatment of overdiagnosed lung cancer. 

We know now that an unknown percentage of patients with non-solid lung nodules may never develop symptoms or die of lung cancer. Non-solid nodules make up about 5% of nodules on the first CT scan; very few are seen on later annual repeat CT scans.

 Biopsy or surgical removal of non-solid nodules is prevented by adherence to the diagnostic plan.  No intervention is recommended – no PET scan, no needle biopsy, no bronchoscopy, no surgical resection – only another CT scan in one year is advised. 

If you are interested in the sordid history of overdiagnosis and the tobacco industry, continue reading below. Otherwise, move on to the next segment.

Complications of lung cancer screening: Unnecessary operations, complications, deaths

Where did the concept of overdiagnosed cancer arise? 

Pathologists performing autopsies have found cancer of the lung, thyroid and breast after patients died of other causes.  These findings aroused no particular interest, until cervical cancer screening by PAP smear and mammographic screening became common medical practice in the 1940s and 1950s.  PAP smears and mammograms began to detect small, pre-invasive carcinomas “in situ” (CIS and DCIS).  Doctors assumed that these in-situ cancers would become invasive and kill the patient.  They recommended that in-situ, non-invasive cancers should be surgically removed.  Although this practice has resulted in major reduction in the number of women dying from cervical and breast cancers, some doctors began to criticize this practice.  They argued that we did not know for sure that these in-situ cancers would invade and kill, many of them might be overdiagnosed.  If that were true, many women might be having unnecessary hysterectomy or partial or total mastectomy.

Some extreme examples of this movement include Fiona Godlee MD, the editor of the British Medical Journal, who tells audiences that she will not have mammographic screening and Peter Goetsche who advises his daughters not to get mammograms. 

In any event, no one in medicine ever believed that there was such an entity as overdiagnosed lung cancer during my medical school and residency training or the early years of my thoracic surgical training up to 1986.

In that year however, a group of doctors at Yale University headed by Alvan Feinstein MD PhD, the “father of American epidemiology and one of the “three pillars of evidence based medicine (EBM) wrote a series of articles describing lung cancers on autopsy that had not been diagnosed previously.  They called these “post-mortem surprise” lung cancers.  They did not use the word overdiagnosed, but when the Mayo Lung Project results were published in the late 1980s, the Feinstein publications were cited as evidence that many of the lung cancers found by chest roentgenograms (chest x-rays) were probably overdiagnosed.  In the interval between then and now, the large majority, including many prominent individuals, have unflinchingly accepted this seemingly outlandish idea as true.  Yet only a few individuals, including the author, challenged this idea as unwarranted.

It is worthwhile to stop and consider how this idea might be proved or disproven.  Most of the proponents are also strong believers in the primacy of evidence based medicine (EBM) and, accordingly, only prospective randomized control studies could provide the needed proof.  Would a reasonable adult agree to sign up for a research study that would leave their CT diagnosed lung cancer untreated, to see if it would kill them?  Of course not.  That would be insane as well as highly unethical.  Remember that that is precisely what was done in the notorious experiment in Tuskegee, Alabama that allowed black patients with syphillis to go untreated for many years.

We now know, however, from long experience in the U.S. and Japan, that it is safe to not remove and to closely follow individuals with in-situ, non-invasive lung cancers, at yearly intervals, with CT scans.  Although some patients do develop invasive cancers – as evidenced by development of solid components in non-solid nodules, most such patients are cured by surgical resection.  With longer follow-up we will learn whether any and if, how many of these in-situ cancers are truly overdiagnosed.  It is likely that the percentage of overdiagnosis will be lower in younger I n comparison to older patients.

Is lung cancer overdiagnosis a manufactured product of the tobacco industry? 

Only after tobacco industry internal documents were leaked to University of California, San Francisco researcher Stanton Glantz and published on a University website, was it possible to learn what had gone on behind the scenes at Yale.  Documents show that Alvan Feinstein began received grants as well as money from the notorious Council for Tobacco Research (CTR) for consulting and public testimony for the tobacco industry for more than thirty years between the 1960s and his death in 1997.  The documented total was more than two million dollars and specifically paid for the “post-mortem surprise” research and publications.  Why would the tobacco industry be interested in lung cancer overdiagnosis?  

That answer became clear in the early 2000s as lawyers sought, in medical monitoring lawsuits, to compel the tobacco companies to pay for lung cancer screening that might save the lives of customers who would develop lung cancer caused by their products.  Testimony from prominent medical experts in these trials cited the Yale articles as evidence that people screened for lung cancer would be harmed when overdiagnosed lung cancers were treated with surgery.  A number of these expert witnesses, who had previously published articles critical of screening, had received tobacco company money and failed to disclose this information in conflict of interest reports to journal editors and readers.

These include Denise Aberle MD of UCLS, co-principal investigator of the NLST trial, William Black MD of Dartmouth University, Philip Goodman MD of Duke University and R.J. McCunney MD of Harvard University.

The tobacco industry, with the assistance of this testimony, was successful in winning in courtrooms in Louisiana, West Virginia and Massachusetts.  The author testified against Philip Morris Corp in New York, California and Massachusetts. 

The industry prevailed in all three actions.

This would appear to provide strong evidence to support a hypothesis that lung cancer overdiagnosis is a manufactured product of the tobacco industry. 

If this were true, it would mean that not only is the tobacco industry responsible for causing the large majority of lung cancers in the twentieth and twenty-first centuries, for deliberately marketing its products to children and adolescents and for deliberately marketing its products to women = even though it was known that cigarettes cause lung cancer; in addition, they were also working behind the scenes to cast doubt upon and delay acceptance and implementation of the best opportunity to save the lives of those who made the tragic mistake of believing that it was safe to smoke their products.

Complications of lung cancer screening: Unnecessary operations, complications, deaths

Potential Complications of Lung Cancer Screening:  False Positives

The basic problem in lung cancer screening is that cancers and benign nodules look the same.  With some exceptions, a radiologist cannot tell a cancer from a benign nodule just by looking at them. 

A false positive test is a positive test report in a patient who does not have lung cancer.  Such a report can cause anxiety, unnecessary testing, inconvenience, radiation exposure and/or even unnecessary biopsy or surgical removal of a lung nodule.  

Such an operation, in turn, can have no benefit, only harms such as loss of lung function, post-surgical complications or even death. 

How often do false positive results occur?

This is a difficult to answer.  Estimates of false positives in lung cancer CT screening range between 98% and 5%. 

Using best practices from currently available lung cancer screening guideline recommendations, false positives should be no more than 5-12%.

For more information on this topic, read below or move on to the next section.

Potential Complications of Lung Cancer Screening: Overdiagnosis and Overtreatment

 

How can such a wide discrepancy of results be possible?

The 98% figure – that is still – irresponsibly – being quoted today is from a faulty interpretation of the results of the National Lung Screen Trial (NLST), a randomized control trial (RCT) conducted by the National Cancer Institute (NCI) between 2001-2011. 

NLST contained a number of major flaws in research design.

1. NLST criterion for a positive test was too loose. It included nodules with a largest diameter of 4 millimeters (for example, a nodule 4 mm. X 2 mm.) 
2. In addition, NLST considered the same nodule as positive even if it had been seen on a previous CT scan, in effect counting it as false positive twice. 
3. NLST used no diagnostic plan after a positive result was reported.
4. Many nodules that were at first considered as false positive later turned out to be lung cancers.

International Early Lung Cancer Action Program (IELCAP) researchers use a different criterion for a positive result

 – an average diameter 6 mm. or greater (for example 6×6 mm, but not 6×5 mm. in diameter).  Using this criterion, false positives fall to 12% on the first CT screen.  This standard has been adopted by most modern screening programs.

False positives are much less common on annual-repeat CT scans – approximately 5% in IELCAP.

Are all patients with false positive CT scans harmed? 

No. 

It is very important to re-emphasize that lung cancer screening is not a test; it is a process.  The process includes an organized plan (algorithm) designed to prevent complications, when a benign nodule is detected by CT screening.

The IELCAP group uses a diagnostic algorithm, first introduced around 2000, that is reviewed and revised each year based on analysis of growing data on more than 80,000 individuals, screened at more than 70 centers worldwide.

Other methods include the clinical practice guideline for lung cancer screening of the National Comprehensive Cancer Network (NCCN) and the LungRads method of the American College of Radiology. 

It is important to stress again that the NLST study did not include a diagnostic plan.  As a result, when a study member had a positive test result, the next step was decided as an individual choice by his doctors.  This resulted in substantial harm, as many patients had diagnostic procedures, like bronchoscopy (looking into the lungs using a flexible scope and taking biopsies) that had little chance of diagnosing small cancers in the periphery of the lung.  Worse, many people had surgical resection of lung nodules that were benign. 

The lesson learned from the NLST experience is that a diagnostic plan (algorithm) is necessary to prevent unnecessary invasive tests, while at the same time not allowing a delay that will allow lung cancers to progress and reach higher stages, where cure is less likely.  

How do diagnostic algorithms prevent unnecessary invasive tests and operations? 

The plan currently used is not complicated or difficult to understand. 

First, nodules are put into one of four categories

1. Calcified nodules

2. Solid nodules

3. Non-solid nodules

4. Part-solid nodules.

and then size is carefully measured. 

A 1. calcified nodule is very rarely cancer; no further action is required until the next annual CT scan.

A 3. Non-solid nodule may be a cancer, but is typically non-invasive (in-situ) and so slowly-growing, that no action is required until the next annual CT scan. The risk that such a cancer will become incurable in a year is close to zero. 

A 2. Or 4. Solid or part solid nodules have a risk of being a faster growing, invasive cancer.  

If the solid nodule is less than 6 mm. in average diameter, it is safe to wait 12 months until the next annual CT scan to re-measure the size of the nodule. 

If the solid nodule is larger than 6 mm. Then it is not safe to wait a year.

  

If the nodule is between 6-8 mm. A CT scan is done again in 3 months.  If significant growth is seen, the nodule is probably a cancer and further investigation is required.

If the nodule is larger than 8 mm. A PET scan is recommended.  

If the PET scan is negative, the nodule is probably not a cancer and a repeat CT is ordered to check for growth in a few months.

If the PET scan is positive, the nodule is probably a cancer or an infection.  Biopsy is indicated.  This is preferably by trans thoracic needle biopsy, done under CT scan control.  ( A slender needle is passed between the ribs and guided into the lung nodule.) Alternatively, the nodule can be surgically removed.

If the nodule is 1.5 cm. or larger, immediate action is necessary.  Lung cancers of this size are dangerous and may spread.  Delay to observe for possible growth is not safe.  Biopsy is indicated.

Non-solid nodules can be observed at one year intervals by CT scan.  If a solid nodular component arises within the non-solid nodule, it probably represents development of an invasive cancer.

 If these basic rules are followed, false positive test results seldom result in unnecessary needle biopsy, bronchoscopy or surgical resection.  

On the flip side of the coin, if the rules are followed, it is uncommon for a lung cancer to reach higher stage or become incurable. 

The bottom line is that when lung cancer screening is carried out in an organized and responsible manner, patients with benign nodules in their lungs are seldom harmed.  

Despite careful guideline based management, a small percentage of screened patients will undergo biopsy or resection of benign nodules.

A recent report from the NELSON study from Scandinavia, which used a carefully organized diagnostic plan, shows a false positive rate of only 5%. 

Potential Complications of Lung Cancer Screening: Overdiagnosis and Overtreatment

Potential Complications of Lung Cancer Screening:  False Negatives

A false negative exam occurs when a person has a lung cancer, but the CT scan fails to report a positive test result.  

Are there false negatives in CT lung cancer screening? 

Yes.

False negative screening tests are possible if the lung cancer is very small or is in the center of the lung where cancers are harder to see.  It is also possible that a small cancer can be visible, but be missed by the radiologist.

Fortunately,` false negatives are uncommon in CT lung screening.

Because the lung is mostly air-filled (seen as black on a CT image), it is relatively easy to see tiny white spots as small as 2 mm That may represent cancer.

What harm does a false negative cause?  

False negative tests result in delay in diagnosis and treatment.  Because false negative lung cancers are typically very small and because CT scans are performed at yearly intervals, when the lung cancer is found one year later it will hopefully still be at a small size and early stage and amenable to potentially curative treatment. 

A potential false negative scan report is one reason why it is important for a person to continue to go for screening every year and not discontinue screening.

Potential Complications of Lung Cancer Screening: False Positives

Potential Complications of Lung Cancer Screening: “License to Smoke”

Multiple prospective and retrospective research studies have looked at the question of whether people who smoke decide not to quit smoking, because CT screening will prevent them from dying from lung cancer.  There is general agreement that there is no evidence that quit rates are lower in individuals participating in CT screening.

There is no evidence that screened individuals who have quit resume smoking after beginning screening.

There is some evidence that CT screening represents a window of opportunity to initiate smoking cessation efforts.

It is generally agreed, that centers of excellence in lung cancer screening will 

ASK and record the smoking history of CT screening participants and evaluate willingness to try to quit

ADVISE them to quit

ASSIST them by offering participation in a smoking cessation program in conjunction with screening

AUDIT smoking cessation status at the next screening appointment

If a person undergoing screening is able to quit smoking, he or she will derive a further benefit i.e. that further damage to lungs, heart and blood vessels will stop immediately and that risk of progressive disease in these body organs as well as risk of cancer in the mouth and throat, lungs, esophagus and bladder will diminish progressively over time, compared with those who continue to smoke.

Potential complications of lung cancer screening: Inconvenience

Potential Complications of Lung Cancer Screening:  Expense

Is CT screening expensive? 

It depends on your medical insurance coverage.

If you have insurance coverage with Medicare, Medicaid or a private company and meet Medicare eligibility requirements,

-age between 55-80

– smoked 30 or more pack/years. (For example one pack/day for 30 years or 2 packs/day for 15 years)

– currently smoke or quit less than 15-years earlier

– have no symptoms of lung cancer

You should be eligible for first-dollar coverage for CT screening.

That is, you can be screened at no personal cost.

It is probable that in the near future, eligibility  for first-dollar coverage will extend to those

-age 50-80

-20 pack/years of smoking.

Persons who do not meet eligibility criteria may have to pay out of pocket.  Prices vary widely among centers.  You will have to discuss with the nurse coordinator in your local center to get this information.  In the author’s experience, the price for a CT screening exam varies between $100-500.

If a scan result is positive, further tests, including 

repeat CT scan

PET scan

Needle biopsy

may be recommended.  The cost of such exams and/or treatment costs would depend on the specific features of your personal medical insurance coverage. 

Potential Complications of Lung Cancer Screening: False Negatives

Potential complications of Lung Cancer Screening: Inconvenience

The first step in getting a screening CT scan is to get a prescription from your healthcare primary provider (doctor, nurse practitioner or physician assistant).  Medicare requires that you review a decision aid document or other media and then discuss potential benefits and risks of screening with your caregiver, before approval can be given to proceed with the test. 

Most people who are at increased risk of lung cancer and wish to participate in a lung cancer CT-screening program live near a center of excellence.  

A national list of centers of excellence in CT screening can be obtained from the websites of the American College of Radiology and the Lung Cancer Alliance.

Individuals who live in rural areas, particularly in Western states, may live far from the closest screening center.  These people will experience inconvenient travel to distant centers to obtain screening.

At the current time, due to the COVID pandemic, radiology centers are experiencing delays that may make it difficult for persons to obtain a prompt appointment to be screened by CT scan. 

Potential Complications of Lung Cancer Screening: Discomfort

Potential Complications of Lung Cancer Screening:

Discomfort:

Is a CT scan for lung cancer screening uncomfortable?

No.

 

When you get to the clinic or hospital where the CT scan will be done, you will have to register and provide medical insurance information.

When you are taken to the CT scanning room, 

You will not have to undress.

No intravenous needle or injection is needed.

You will be asked to lie down flat on your back on a padded platform and asked to breathe in, then breathe out and hold your breath for a few seconds while the platform moves into and out of a donut shaped scanner.

The scanner is “open” and does not trigger claustrophobia anxiety in most people. 

 You will be asked to remain lying down for a few minutes, until it is confirmed that the scan was obtained, then helped up and leave the room.  

In some centers, you may wait until after the radiologist reads the scan and gives you a report before leaving. 

Most persons agree that CT screening has less discomfort than screening tests for cancer of the breast, cervix, colon and prostate. 

Potential complications of lung cancer screening: Expense

What is “screening” in medicine?

Screening is based upon the simple idea that results of treatment of a disease are better – i.e. lower chance of death, faster recovery, fewer complications, less disability, less expense – when disease has been diagnosed at an early stage, before it has caused permanent damage.

There are many ways to screen.

COVID screening is a recent example of how this process works.  COVID screening is not one single test, but rather represents a process, relying on multiple steps.

The first step is to ask questions.  A person is asked about risk factors, for example have they recently traveled to another country? Have they been in contact with a person infected with COVID?

The next step is to screen for fever with a thermometer.

If the patient has a fever, or has had contact with a sick patient, then the risk of COVID is higher and the next step in the process is to test for COVID virus by nasopharyngeal swab. 

If the COVID infection diagnosis can be made at this stage, before pneumonia and sepsis force hospitalization, treatment can be begun with antiviral drugs and or convalescent serum.  Both of these treatments lower chance of hospitalization, complications and death. 

If these treatments are given only after the patient has become so sick that hospitalization in an ICU is required or ventilator support is needed, then medical treatments have less effectiveness and the chance of death or major complications is much higher. 

Everyone is familiar with many other forms of medical screening.  

When the doctor feels your pulse they are screening for cardiac arrhythmia.  

A blood pressure measurement is a screen for hypertension. 

A weight measurement screens for obesity. 

You are asked to read an eye chart to screen for vision loss.

A tonometer placed on your eyeball screens for glaucoma.

There are literally hundreds of other screens that a patient goes through in the course of medical care. There is nothing exotic or intrusive about screening in medicine.

Screening can also take place in laboratory testing.

A urine specimen can be used to screen for diabetes, kidney disease, pregnancy and other conditions.

“Routine” blood tests screen for anemia, diabetes, hyper cholesterolemia, hepatitis, kidney disease, AIDS and other diseases.  

Screening can also be carried out using x-rays and other imaging tests.  Chest x-rays were used extensively for tuberculosis in past years, when that disease was more common in the U.S. .  Pregnant women undergo ultrasound examinations to ensure that the fetus is safe. 

The reason that I give so many examples of screening is that, in recent years, some doctors have attacked screening, pushing forward the idea that there are major harms to screening, particularly in the case of cancer screening.

The potential risks of medical screening will be discussed further in future blogs.