To the Editor: In the February 2012 issue of JNCCN, Goulart et al1 performed a careful cost-effectiveness analysis of low-dose computed tomography (LDCT) screening for lung cancer. They relied predominantly on data from the National Lung Cancer Screening Trial (NLST),2 accounting for multiple factors, including the screening CT, the incidence of additional imaging and interventions, and the cost of complications as noted in NLST. They included an estimate of overdiagnosis in their calculations and assumed that LDCT screening for lung cancer would be applied only to patients similar to those enrolled in the NLST.
Despite the detailed nature of their model, we believe that Dr. Goulart and colleagues are still missing several critical components of CT screening that add cost: namely, the infrastructure needed to perform screening in a responsible way, data collection pertaining to quality metrics, and the cost of clinician counseling.
Organization and structure are required to perform lung cancer screening.3,4 Screening is not just the scan, but a process; the outcome is determined by a complex interplay of the inherent risk and selection of the patient, scan quality and interpretation, judicious management of detected lesions, quality of interventions, and compliance with follow-up. The NLST provided infrastructure for most of these components as part of the study, and the costs of the study were much higher than the cost of the LDCT scan itself. There is much evidence to suggest that without such structure, the process (selection, screening, interpretation, management and follow-up) is unlikely to be similar to that in the NLST.5,6
One could argue that the cost of administering the NLST included the costs of data management specifically for the study. This is true, but some data collection and attention to quality metrics should be part of a screening program. We have many unanswered questions, and experience with other large scale screening programs (eg, mammography) has taught us that quality metrics and tracking thereof are important. Most major societies that have issued position statements or guidelines for CT screening have recommended research participation, data collection, and implementation in an organized fashion.4,7–9
Finally, NLST data collection and the Goulart et al analysis focus on procedures almost exclusively. Neither accounts for clinician time to discuss whether screening is right for a particular patient or the meaning of finding small nodules, or to provide follow-up or smoking cessation intervention. To think that screening (a new intervention) for lung cancer (a disease that engenders tremendous fear) using a test with a high rate of false-positive findings can be done without significant discussion and time investment with the patient is unrealistic.
We think that screening has a huge potential for benefit if implemented in a careful structured manner. Studies such as the one by Goulart et al help us understand the implications and highlight that the benefit will come at a cost. Recognizing all of the implications is important, however. Ignoring the costs of the necessary infrastructure is likely to lead to results very different from the NLST, and ignoring the costs of data collection and quality assessment is likely to hamper refinement of the process over time and thwart cost-effectiveness. Ignoring the need for clinician involvement is unrealistic. If we create the impression that implementation will proceed just like in the NLST, but without several key pieces of the process of conducting the NLST, we will have set an expectation that is impossible to achieve.
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Goulart BHL, Bensink ME, Mummy DG. Lung cancer screening with low-dose computed tomography: costs, national expenditures, and cost-effectiveness. J Natl Compr Canc Netw 2012;10:267–275.
Aberle D, Adams A, Berg C. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365:395–409.
Wiener RS, Schwartz LM, Woloshin S. Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records. Ann Intern Med 2011;155:137–144.
Bach P, Gould MK. When the average applies to no one: personalized decision making about potential benefits of lung cancer screening. Ann Intern Med 2012.
Field J, Smith R, Aberle D. International Association for the Study of lung Cancer Computed Tomography Screening Workshop 2011 Report. J Thorac Oncol 2012;7:10–19.
Jaklitsch MT, Jacobson FL, Austin JHM. The American Association for Thoracic Surgery guidelines for lung cancer screening using low-dose computed tomography scans for lung cancer survivors and other high-risk groups. J Thorac Cardiovasc Surg 2012;144:33–38.