COMMENTARY

Lung Cancer Screening Guidelines: More Harm Than Good?

Kenneth W. Lin, MD

Disclosures

August 22, 2016

Editorial Collaboration

Medscape &

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I'm Dr Kenny Lin, a family physician at Georgetown University School of Medicine in Washington, DC, and I blog at Common Sense Family Doctor.

In a previous commentary, I discussed Medicare's decision to pay for a shared decision-making discussion with heavy smokers aged 55 to 77 years about the pros and cons of low-dose CT screening for lung cancer, and the points family physicians should be highlighting in these discussions. Since then, hospitals and medical practices across the country have implemented the US Preventive Services Task Force (USPSTF) guidelines with varying degrees of success.

A study published in the Journal of the American Board of Family Medicine described the experience of a community hospital in northern Virginia during the first year after publication of the guidelines. Nearly one-quarter of patients who received screening CT scans did not meet USPSTF criteria. In patients who did meet screening criteria, 65% of scans detected lung nodules, and half of the remaining 35% had another possibly significant finding.[1]

Another study of a University of Minnesota–affiliated health system found that counseling and shared decision making were documented in less than half of outpatient visits for those who underwent screening scans.[2] About 70% of patients had a clinically significant finding on their first scan, although only 17% required follow up sooner than 1 year. In contrast, only 27% of participants in the National Lung Screening Trial, the key study cited by the task force recommendations, had abnormalities on their first CT scan.[3]

Interviews of New Mexico primary care physicians about their beliefs and attitudes toward low-dose CT screening found that many were skeptical about the real-world applicability of the National Lung Screening Trial results, especially given its 95% false positive rate.[4] A survey of family physicians in South Carolina found that although three-quarters believed that the benefits of screening for lung cancer in patients who met Medicare criteria outweighed the harms, fewer than half had actually recommended it to more than one patient in the previous year.[5]

In my practice, I tell patients when they are eligible for lung cancer screening but emphasize that significant uncertainties remain and that many patients who undergo it will require follow up for findings that end up not being cancer. Recent studies collectively suggest that many physicians are taking a similarly cautious approach. In declining to endorse the USPSTF guidelines in 2013, the American Academy of Family Physicians expressed concern, which remains valid today, that the National Lung Screening Trial results had not been reproduced in a community setting. The harms of repeat scans, bronchoscopy, or thoracotomy for positive findings might conceivably outweigh the potential benefits if patients who aren't at high risk for lung cancer are screened inappropriately, or too many suspicious findings turn out to be harmless "incidentalomas" that would have been better left undetected. The jury is still out on whether the guidelines will end up doing more good than harm.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.

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