Lung Cancer Screening: One Size Does Not Fit All

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The Costs of Screening

The most difficult time in which to demonstrate the cost-effectiveness of lung cancer screening initiatives is at the time of initiation. Initial scans, with no prior comparison, often cascade to the greatest costs, because any abnormal findings will require additional follow-up testing.

However, implementation of new screening for any disease state will lead to greater-than-average costs before its background prevalence has been altered by screening and intervention. Any newly implemented screening procedures for a condition that previously could not be detected by screening will initially result in an uptick in diagnosis, and thus an increase in the prevalence of that disease. With successive cycles of screening, the incidence (the rate of new cases) will presumably remain unchanged, but treatment of previously detected cases, and hopefully cures in these patients, results in a prevalence rate that trends down.

There may be ways in the future to offset some of these costs by tailoring the population to be screened with genetic and biomarker data. For now, though, positive screens will require correlation with other diagnostic tests and the costs associated with that follow-up.

For every patient whose cancer was not identified early, despite appropriate screening, there is another patient who wants to be screened.

Ironically, this debate over the price of lung cancer screening comes at a time when multiple forces (eg, payers, providers, healthcare systems, government) are seeking to wring costs out of the healthcare delivery system. The potential for cost savings due to earlier diagnosis of a deadly disease through screening depends on another costly, time-intensive process: shared decision-making between a trusted provider and the patient to select the most appropriate course of screening. The efficacy and ultimate success of any screening strategy depends on exactly the kind of relationship between the patient and primary care provider that has been woefully undermined in recent decades.

A study^[8] conducted in 2000 Veterans Health Administration patients confirmed the many costs associated with establishing a successful lung cancer screening program, including the development of project materials, coordination between multiple providers, patient education tools, and technology. As Linda S. Kinsinger, MD, MPH, the corresponding author, told Medscape, "[L]ung cancer screening is far more than just a scan."

Improved understanding, better communication, and continuity are the best allies of these screening efforts. Further underscoring the essential role of continuity, in the experience of one of the authors (Gregory Hood, MD), the rates of false-positives drop with subsequent scans because previously detected normal variants will not require any further evaluation.

No screening tool is ever perfect. But national data on overdiagnosis and false-positives should not be assumed to apply in areas of higher risk. For every patient whose cancer was not identified early, despite appropriate screening, there is another patient who wants to be screened. All of them would argue that efforts to kill off lung cancer screening now are premature.

Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

Cite this: Lung Cancer Screening: One Size Does Not Fit All - Medscape - Jan 17, 2019.

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