NcXHF

VALUE OF LUNG CANCER CT SCREENING
Less costly interventions may successfully help smokers
quit and may add value to CT screening. These include the
use of telephone quit lines and web-based smoking cessation
resources. 60,61 Additional modeling studies should evaluate
the cost-effectiveness of these interventions against traditional
one-to-one or group counseling sections and pharmacologic
interventions, respectively.
Management of Screening Incidental Findings
Incidental fındings consist of screening abnormalities other
than those suspicious for lung cancer (e.g., coronary calcifıcations,
emphysema). The impact of these fındings on
the value of CT screening is unclear. The NLST costeffectiveness
analysis suggests that the value of CT screening
decreases as the costs of managing incidental fındings increase,
but these costs were based on assumptions rather than
observed costs. 35 At least in theory, the management of incidental
fındings can either increase or decrease the value of CT
screening (Table 2). Appropriate handling of clinically relevant
incidental fındings may increase screening effectiveness
and value 62 ; work up and treatment of clinically irrelevant
fındings may increase costs and decrease value, respectively.
Data from the NELSON trial and NLST suggest a low prevalence
of clinically relevant incidental fındings (8% and 10%, respectively).
63,64 The Lahey CT screening program has reported a
similar low prevalence of clinically relevant fındings. 65 In practice,
relevant and irrelevant incidental fındings are reported frequently
enough to trigger further use of medical resources in a
large proportion of patients, without a clear benefıt. The pan-
Canadian early detection of lung cancer study revealed emphysematous
changes in 1,195 patients (58%) who underwent a fırst
CT screening exam; our registry study at the Seattle Cancer Care
Alliance showed a 73% prevalence of incidental fındings in the
fırst CT screen. 39,43 Clearly, additional research is needed to determine
the impact of incidental fındings on the value of CT
screening. Screening registries represent an excellent research
platform to address this question.
Patient anxiety and defensive medicine also can increase
screening costs and decrease value. Patients may feel anxious
when informed about the presence of incidental fındings on
screening and may request additional work up. Physicians
may order unnecessary and costly evaluations for incidental
fındings out of concern about malpractice claims. Screening
program leaders should be aware of the unintended consequences
of reporting incidental fındings and should develop
careful language in screening reports that specifıes recommendations
for follow-up visits, including a statement that
no further evaluations are necessary for clinically irrelevant
fındings. Specifıc recommendations, including those for no
follow-up care, will provide physicians and patients with the
reassurance that additional work up can be deferred safely,
thus avoiding an escalation of costs.
FINAL CONSIDERATIONS
Lung cancer CT screening may save thousands of lives and
add value to society if implemented in a manner that reproduces
the mortality benefıts seen in the NLST while minimizing
harms and costs.
Screening programs should implement practices that will
likely increase the value of CT screening, including counseling
and selecting high-risk patients for screening, monitoring
adherence to guidelines for screening-detected lung
nodules, offering smoking cessation interventions, and making
specifıc recommendations for follow-up of screening incidental
fındings.
Finally, value is only one angle to consider when implementing
CT screening. Policy makers and clinicians also need to take
into account sociodemographic disparities and other issues that
can prevent equitable access to screening. Only by taking a comprehensive
approach will we achieve the promise of CT screening:
decrease the huge burden imposed by lung cancer.
Disclosures of Potential Conflicts of Interest
Relationships are considered self-held and compensated unless otherwise noted. Relationships marked “L” indicate leadership positions. Relationships marked “I” are those held by an immediate
family member; those marked “B” are held by the author and an immediate family member. Institutional relationships are marked “Inst.” Relationships marked “U” are uncompensated.
Employment: None. Leadership Position: None. Stock or Other Ownership Interests: None. Honoraria: None. Consulting or Advisory Role: None.
Speakers’ Bureau: None. Research Funding: Bernardo H.L. Goulart, Bayer (Inst). Patents, Royalties, or Other Intellectual Property: None. Expert
Testimony: None. Travel, Accommodations, Expenses: None. Other Relationships: None.
References
1. Wood DE. The importance of lung cancer screening with low-dose
computed tomography for Medicare benefıciaries. JAMA Intern Med.
2014;174:2016-2018.
2. Woolf SH, Harris RP, Campos-Outcalt D. Low-dose computed tomography
screening for lung cancer: how strong is the evidence? JAMA Intern
Med. 2014;174:2019-2022.
3. American College of Radiology. Burwell answers Medicare lung cancer
screening coverage questions. www.acr.org/Advocacy/eNews/20140523-
Issue/Burwell-Answers-Medicare-Lung-Cancer-Screening-Coverage-
Questions. Accessed January 25, 2015.
4. Wood DE, Eapen GA, Ettinger DS, et al. Lung cancer screening. J Natl
Compr Canc Netw. 2012;10:240-265.
5. American Lung Association. American Lung Association provides
guidance on lung cancer screening. www.lung.org/lung-disease/
asco.org/edbook | 2015 ASCO EDUCATIONAL BOOK
e431