This is a major advance as American healthcare evolves from reactive to preventive.
But a key to success in this lung cancer screening program is keeping the radiation dose of each exam as low as possible – certainly well below one mSv. Ideally, a low dose approach would involve model based or some other form of iterative reconstruction. All the other techniques to minimize dose should be employed together. Fortunately, this is an application where very low kVp will work well (70-100).
Next – and possibly even more impactful: coverage for screening CT colonography.
We already know that low-dose CT is a valuable tool for reducing mortality rates, but now there’s evidence that it might reduce financial costs as well. A new analysis of the 2010 National Lung Screening Trial (NLST) shows that low-dose CT is a cost-effective diagnostic tool for patients at high-risk of lung cancer, according to AuntMinnie.com.
The Medical Imaging and Technology Alliance (MITA) released a statement saying the organization welcomes the analysis and “looks forward to ongoing collaboration with patient advocates and others in the imaging community to ensure access to this lifesaving technology.”
In my opinion, though, the key question in whether low-dose screening for lung cancer is cost effective is: what is the cost of working up the false positives? That cost needs to be subtracted from the cost benefit of the lives saved. This new analysis suggests that low-dose screening is indeed cost effective. One thing no cost analysis considers: the value of a negative exam to a very worried patient.
Further new twist: we now can do ultra-low-dose lung cancer screening using fully model-based iterative reconstruction techniques. This technique enables a 60 percent radiation dose reduction (down to the sub-0.5 mSv range) below that of even recent low-dose CT – further substantially decreasing any downside from lung cancer screening in high-risk patients.
That there are strong associations between smoking and emphysema and smoking and lung cancer is well established. Therefore, it’s of little surprise that a report from Lung Cancer finds emphysema that is visible to radiologists from CT scans is correlated with an increased risk of lung cancer.
However, these results were only discovered when the emphysema was read by radiologists— and not by computer interpretation. Researchers point out that radiologists and automated computer software likely detect different types of emphysema- with only doctors appearing to detect the type of emphysema associated with lung cancer. This clearly highlights the “intuition” factor in scan interpretation by experienced radiologists—a factor not yet evident in intelligent computers!
Patients that are found to have emphysema detected by CT scans are already at an increased risk of developing lung cancer and should quit smoking as soon as possible. It is interesting to remember that before cigarette smoking became widespread, both lung cancer and emphysema were exceedingly rare diseases. Those high risk patients should explore the benefits of lung cancer screening and lung cancer screening programs.
For more information on the benefits of lung cancer screening, please see here.
Is low-cost an added benefit to widespread lung cancer screening? According to this article, from April’s Health Affairs—yes! The study on this much debated about topic asserts that routine CT lung cancer screening of high-risk individuals would save thousands of lives annually for less than one dollar a month per patient, if implemented throughout the US. According to these figures, the cost of low-dose lung cancer screening could be less than that for both breast cancer screening and colorectal cancer screening.
As we’ve pointed out, lung cancer screening is effective and life saving. For high- risk patients, those who are multiple pack year smokers for 25 years or more, screening provides significant benefits. For these individuals, low-dose CT screening reduces the number of lung cancer deaths by 20 percent!
Despite this, widespread lung cancer screening has yet to be implemented nationwide, largely due to cost. This study reports interesting and encouraging data about widespread implementation of the procedure, though. However, we must remember that there are also reputable articles which report much higher cost numbers when adjusted for quality-life-years saved. It is necessary to take these studies into account, too.
I recently came across a study that questioned the cost- effectiveness of low-dose CT scans for lung cancer screening. As I’ve discussed before, there is sufficient and sound research validating that among high- risk individuals, low-dose lung cancer screening is a life saving process. However, this article claims that the medical imaging procedures may be too costly for the United States, “a nation struggling to control growing health care costs, even though some lives would be saved.”
This article clearly shows how charges relate to the execution of healthcare. At standard charges, screening CT of patient’s at high risk for lung cancer may not be cost effective. But, if these are regarded as add-on incremental cases and are priced at marginal cost (approximately $200), the screening equation may change and become financially viable from society’s prospective.
As with any screening program, the first caveat is to “do no harm” – hence an ultra-low dose CT technique would be advantageous. Similarly, figuring out how to keep the cost way down will be critical. I think we can….
Research published in this month’s American Journal of Roentgenology reported excellent results on a protocol for working up patients with nodules found in CT lung screening. Ever since the National Lung Screening Trial showed a 20% mortality reduction among high-risk patients screened for the disease, criticism has been vocalized due to the potentially large number of false-positive results following diagnostic imaging investigations. Though the possibility of finding cancer outweighs the risk of false positives, the researchers argued that false-positive results could potentially increase the risks and costs of screening, diminishing the benefit of early cancer detection.
This study, which required participants without a history of cancer to have smoked a minimum of 10 pack-years, concluded with positive results. According to the research, the algorithm produced low false-positive rates, and could make the establishment of large-scale CT screening programs more feasible.
Follow-up CT protocols in lung cancer screening – once a finding is discovered and needs to be evaluated over time or even just routinely on a schedule – is one area ripe for ultra low-dose CT technique. With this technique, we really can see doses reduced by 40 – 80% among these applications! Accepting higher noise in images, very low-dose kVp (in the 80-100 range), and aggressive application of iterative reconstruction techniques can produce diagnostic CT results at breathtakingly low doses.
As the war on cancer continues, a group of U.S. oncologists picked its “Top Five” most essential advances in cancer care, as reported by HealthDay news. I’m pleased to announce that CT-based lung cancer screening is listed as one of the major advances for 2011.
The report, published in the Journal of Clinical Oncology, placed only targeted drug therapy above CT-based lung cancer screening. Both advancements will be major game changers for cancer care. The report confirms that the U.S. National Cancer Institute found that screening smokers and former smokers with a CT chest scan was “dramatically better than the chest X-ray.”
There now is no question about this! In high risk heavy smoker populations, low dose CT- lung cancer screening saves lives… and quite a few. The challenge now is getting our healthcare delivery systems to incorporate this approach into routine preventative medical practices….but only for high risk individuals. We need to make these scans easy to obtain, fast to perform, very low in radiation, covered in health plans, and inexpensive.
The good news is that all of these things are possible. Turning CT-lung cancer screening into a regular practice for in-need individuals is very do-able!