Lynn T. Tanoue

Disclosures

Curr Opin Pulm Med. 2016;22(4):327-335. 

In This Article

Implementation

A comprehensive policy statement by the American College of Chest Physicians and the American Thoracic Society provides a basic guide to the program components necessary to achieve high-quality lung cancer screening (Table 2).[39] Adherence to these principles should maximize benefit and minimize harm. Clearly, a programmatic approach will most reliably accomplish these goals. The components include performing screening in the population for whom it has proven beneficial; screening that population in a structured timeframe; ensuring LDCT quality; defining the characteristics of a positive result; reporting LDCT results in a structured fashion, using a system such as the American College of Radiology LungRADS;[40] ensuring that positive findings are managed by clinicians with appropriate expertise; integrating a tobacco treatment program; providing education to patients and providers, including use of decision support tools; and collecting data relating to the above components, that will be reportable to a national registry and used for quality measurements.

Whether the benefit of lung cancer screening as observed in the NLST can be recapitulated as screening is adopted into clinical practice remains to be determined. Several predictable challenges may influence outcomes, and periodic re-evaluation will be crucial over the coming years. First, participants in NLST were not completely typical of the estimated 8 million Americans who meet USPSTF screening criteria; the study population was younger, more educated, and less likely to be currently smoking.[16] Second, the majority of NLST study sites were tertiary centers, presumably with ready access to multidisciplinary specialty care. The low rate of interventions may reflect this expertise, as well as the ability to commit both time and effort to focused evaluation. This expertise also impacts a third issue, that of surgical complications. In the NLST, surgical mortality for lung cancer resection was only 1%, compared with national data reporting 2–5% mortality.[32,41,42] Surgical mortality in the DANTE study, performed in two large community hospitals in Italy, was 3.3%.[18] It is important to appreciate that access to thoracic surgical specialty care is not uniform. In a national US inpatient database of over 500 000 thoracic surgeries performed on adults of all ages and insurance types between 1996 and 2005, the majority were performed by surgeons whose primary focus was not thoracic surgery.[32] The distribution of lobectomies performed by general thoracic surgeons, cardiac surgeons, and general surgeons were 8.5, 38.4, and 53.1%, respectively, whereas the associated surgical mortality rates were 2.3, 3.0, and 4.1%, respectively. It should be noted that mortality rates reflect factors other than surgeon specialty, including the volume of procedures and the expertise of the performing institution. This highlights the important issue of healthcare access, which is unequal across the country, and presents a formidable challenge to ensuring quality of care.

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