MedPage Today: Lung Cancer Screening Proves Challenging in Real-Practice Setting

by Salynn Boyles on January 30, 2017

Implementing a comprehensive lung cancer screening program proved to be both more complex and more challenging than expected in the first evaluation of a large pilot screening program administered by the Department of Veterans Affairs health system.

Just 58% of eligible veterans invited for screening agreed to participate, and researchers reported that the rate of positive findings after one round of screening was more than twice that seen in the National Lung Screening Trial (NLST) (59.7% versus 27.9%).

The false positive rate among the screened cohort was also higher than in the NLST, wrote Linda S. Kinsinger, MD, of the VA Administration National Center for Health Promotion and Disease Prevention in Durham, N.C., and colleagues in JAMA Internal Medicine.

Of 2,106 patients screened, 1,257 (59.7%) had nodules, 1,184 (56.2%) required tracking, 42 (2.0%) required further evaluation but did not have lung cancer, and 31 (1.5%) had lung cancer.

Incidental findings, including emphysema, other pulmonary abnormalities, and coronary artery calcifications were recorded in 41% of screened participants.

Based on findings from the NLST showing a modest reduction in lung cancer associated with screening, the U.S. Preventive Services Task Forces moved to recommend lung screening for current and former smokers between the ages of 55 and 80 with low dose CT. In 2014, Medicare coverage was granted for lung cancer screening to smokers and former smokers between the ages of 55 and 77, based on shared decision making.

But citing concerns about the reproducibility of the NLST experience in community practice, the American Academy of Family Physicians recently concluded that the evidence is insufficient to recommend for or against screening.

The newly reported findings from a lung cancer screening program offered at eight academic VA hospitals represents some of the first real-practice analysis of screening.

In an interview with MedPage Today, Kinsinger said it is not yet clear if the harms of screening outweigh the benefits in real-world practice.

"There is definitely a mortality reduction, but I think it is a close call at this point," she said. "There certainly does seem to be some benefit, but at the expense of a lot of false positives, a lot of anxiety, and a lot of work to coordinate it all."

Kinsinger said it took a great deal of effort to coordinate screening efforts among primary care, pulmonology, and radiology clinicians and staff. This effort involved full-time lung cancer screening coordinators, electronic tools, tracking databases, patient education materials, and radiographic and nodule follow-up guidelines.

"This was a challenge, but our experience may represent the best case scenario for screening," she said. "The advantage that the VA has is that we do have central organization and we were able to develop resources and provide support for facilities. I would think it would be much harder in smaller practice settings without these dedicated resources."

A total of 93,033 VA patients were originally assessed for screening eligibility in the demonstration project, but 39.3% had inadequate information about their smoking status and history. Of the remaining 56,478 patients, 18,083 (32%) met the smoking history criteria for eligibility for screening.

Across the eight VA sites, 2,452 of 4,246 patients offered lung cancer screening agreed to be screened and 85.9% completed their first low dose CT scan by July of 2015.

Among the findings:

  • Most nodules were small (<5 cm; 710 of 1,293 [54.9%]) and solid (1,079 of 1,293 [83.4%]).
  • A total of 73 patients (3.5% of all patients screened) had findings suspicious for possible lung cancer and underwent further diagnostic evaluation
  • Lung cancer was confirmed for 31 of those patients within the 330-day follow-up period; 20 (64.5%) of the cancers were stage I
  • The rate of false-positive test results for lung cancer was 97.5% (1,226 of 1,257) during the 330-day follow-up period

 

In an editorial published with the study, JAMA Internal Medicine editor Rita. F. Redberg, MD, of the University of California San Francisco, and colleagues wrote that the early real-world screening findings highlight the importance of limiting screening to fully informed patients who are most likely to benefit, following shared decision making.

However, a research letter published in the same issue of the journal suggests that this may not be the norm in the clinical practice setting.

An analysis of data from the 2010 and 2015 National Health Interview Survey revealed a significant but slow uptake of screening in eligible patients and an increase in screening among never smokers and low-risk smokers who did not meet screening eligibility criteria.

"To what extent the increasing use of CT for lung cancer screening was driven by recently released guidelines or simply reflects a rising trend of CT use in general needs to be explored in future research," wrote Jinhai Huo, MD, PhD, of the University of Texas MD Anderson Cancer Center in Houston, and colleagues.

The researchers also found that the use of chest x-rays remained stable despite their lack of effectiveness in lung cancer screening, and they noted that this "may reflect primary care physicians' knowledge gap regarding the latest scientific discovery in lung cancer screening."

This research was funded by the Veterans Health Administration.
Researcher Linda S. Kinsinger reported no relevant relationships with industry related to this study.

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