Lung Cancer Screening: Who Gets To Decide?

While the U.S. Preventive Services Task Force (USPSTF) has issued recommendations on annual screening for lung cancer using low-dose computed tomography (CT), and Medicare uses similar criteria for determining coverage of lung cancer screening, a recent article in the Journal of the American Medical Association (Katki, et al.) offers a new enhanced risk-based model for determining who should undergo this type of screening.

Katki, et al., used data from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, the National Cancer Institute’s National Lung Screening Trial, and the 1997-2001 National Health Interview Survey to develop and validate statistical models to estimate lung cancer incidence and death.

In an accompanying editorial, Michael Gould, MD, MS, Kaiser Permanente Southern California, Department of Research and Evaluation, says the findings are “provocative and support the notion that an enhanced risk-based approach to screening is potentially more effective and more efficient than performing a risk assessment based only on age and smoking history.” (There are about nine million adults in the U.S. who meet USPSTF criteria for lung cancer screening.)

However, while this new lung cancer death model constitutes an “important contribution” to the discussion of who should be screened and when, the “overwhelming majority of patients who undergo low-dose CT screening will not benefit, even using enhanced risk assessment,” Gould says.  The enhanced risk-based screening “was projected to only marginally increase the number of lung cancer deaths averted from estimates of approximately 5 per 1,000 screened” to “approximately 6 per 1,000.”

In addition, the limitations of the risk-based model include the fact that the authors “did not consider the increased risk of procedure-related complications or reduced operability that would accompany screening when performed in a population at higher risk,” he says. “For lung cancer screening to be effective, patients need to be fit enough for surgery.” And while less invasive treatments exist, they “have not yet been shown effective in the context of lung cancer screening,” Gould notes. “Thus, a valid counterargument is that the net benefit of screening is highly uncertain in populations (even high-risk populations)” that differ from those that informed the risk-based model.

Other limitations include the social dimensions; for example, given that the risk-based approach “preferentially includes more African-Americans and more individuals with lower educational attainment, compared with screening using the USPSTF criteria,” implementation of enhanced risk-based screening will “require more intensive outreach to communities that have experienced limited access to screening programs,” he says.

Looking more broadly and summarizing the current state of lung cancer screening, he notes there are now “multiple statistical models of lung cancer risk—which ones are most accurate? How does risk evolve dynamically over time?”

At issue is the fundamental question of who gets to decide about lung cancer screening.

This question will be answered differently, depending on whether we examine it from a policy perspective or from an individual patient care perspective. While policymakers are likely to focus on the trade-off in costs – in both dollars and lives – between screening efficiency and avoided deaths, “in clinical practice, the decision to screen is very personal and should be individualized for each patient,” says Gould.

One idea is to let the patient decide whether to undergo testing. Gould recommends offering lung cancer screening to high risk patients who don’t meet the USPSTF or Medicare criteria and letting the patient choose whether to be tested. However, what Gould looks past is the cost to the patient when such a choice is made. Policymakers make recommendations on what insurers should pay for, and cancer screening is a great example. There is a reason for the screening recommendations to have a cut-off value – and that reason is cost.

Letting the patient decide, also means, letting the patient pay. A more nuanced view would be to pay for lung cancer screening in some instances, but not in others. If lung cancer screening to high-risk patients is cost-effective, shouldn’t insurers cover this intervention?