Your patient is a 65yo man with a 40-pack-year smoking history. He currently smokes but has cut back to 1-2 cigarettes per day. Should he be screened for lung cancer?
WHY IS THIS IMPORTANT?
- Lung cancer is the #1 cause of cancer death in US.
- Mostly preventable – smoking cessation!
- About 70% of lung cancers are diagnosed once disease is already advanced.
- Lung cancers at early stages much more likely to be successfully treated than at later stages.
A 2011 NEJM study by the National Lung Screening Trial Research Team found a significant reduction in mortality associated with CT screening.
- N = 53,454, ages 55-74yo with smoking history
- 20.0% mortality reduction from lung cancer with 3 LDCT screens
- 6.7% mortality reduction from all causes
- 26.3% of people had positive screen, BUT… 96.4% of positive screens were not lung cancer
- Number needed to screen = 320
But what if our patient is a veteran? A 2018 JAMA study on VA patients found that the number needed to screen was 687-6903 and the false positive rate was 58.2%!
WHO SHOULD WE SCREEN?
BENEFITS vs RISKS!
HOW TO TIP THE SCALES?
- Risk Stratification:
- This 2013 NEJM study showed that screening with LDCT prevented the greatest number of deaths from lung cancer among participants who were at highest risk but prevented very few deaths among those at lowest risk
- Mitigate overdiagnosis (rethink patient with many comorbidities)
- Patient has to commit (multiple screenings, follow-ups)
- Shared-Decision Making!
- Decision aids are available:
- Smoking cessation = #1 best way to prevent lung cancer, should be forefront of every conversation about lung cancer screening
- Serial low-dose CT screenings, among certain high risk groups, reduces mortality, though there are significant potential harms
- Different organizations have slightly different guidelines: ultimately, shared decision making is crucial to decide who to screen
- Use a decision aid with patients who meet CMS criteria AND who could tolerate screening/procedures
*Blog post based on Med-Peds Forum talk by Cam Ulmer, PGY1