Andrew Holtz is an independent health care journalist based in Portland, Oregon and a long-time contributor to HealthNewsReview.org. He has been a medical correspondent for CNN and is past president of the Association of Health Care Journalists.
Everyone who has ever smoked cigarettes should take this quiz because “Lung cancer screening could save your life,” according to the American Lung Association’s (ALA) new “Saved by the Scan” campaign.
But after taking that quiz, almost all current or former smokers (roughly 9 out of 10) will learn that they’re not good candidates for screening.
Why isn’t screening for everyone? The campaign materials don’t say. They also don’t say why even those considered “eligible” might not rush to be screened… or why many health care experts aren’t jumping on the lung cancer screening bandwagon.
The ALA campaign emphatically and colorfully proclaims that low-dose CT scans save lives. There is a heartwarming video of a woman portraying a former smoker conquering both the addiction and its legacy of lung cancer risk. (Watch for it on TV soon.) There are “screening success stories” that hit you right in the gut with tales of how “Frank was saved by the scan,” how Kathy is often told “my guardian angels were working overtime,” how Eva-Marie now gets a lung scan every year “like getting a mammogram” and so on.
It all sounds so wonderful. The “Saved by the Scan” materials don’t include any specific downsides to getting CT scans. Sure, if you dig deep enough, pass the quiz and then download, open and read a guide to talking with your doctor, at the bottom, under “Key points I want to cover” is “Risks vs. benefits” and a prompt to ask about the cost. But really, after reading, hearing, and seeing — again and again and again — that screening “saves lives” (and in the testimonials “saved MY life”), how could any unnamed risks possibly outweigh saving your life!?
Well, apparently the American Lung Association campaign leaders thought that even after seeing the TV and online pitches, some malingerers wouldn’t get with the program, so on a “resources” page they include tips for friends and family, to help them quash resistance. The tips include “focus on the potential benefits” (no mention of risks) and a note about how screening is free for high-risk patients (without noting possible bills for follow-up testing) and a suggestion that you remind the person “you are having this conversation because you care” (emphasis added). And then if all that still hasn’t done the job, the final tip includes a link to the American Lung Association’s Lung HelpLine. Presumably the pros will close the deal.
Why doesn’t the “Saved by the Scan” campaign explain why screening is not recommended for 90 percent of current and former smokers? Why does it trumpet potential benefits of screening, while failing to whisper even the slightest hint of potential harms? Because the purpose of campaigns like “Saved by the Scan” is not to educate, it is not to provide an objective summary of the evidence… oh, no… it has one purpose and only one purpose: to motivate action. If you want someone to act, don’t mention anything that would give them a reason to hesitate! And the reality is that with lung cancer screening, there are plenty of reasons why a reasonable person might say, “Thanks, but no thanks”.
The ALA campaign is based on results from the National Lung Screening Trial which followed more than 53,000 current and former smokers as they went through up to three annual CT scans. After seven years of follow-up, the results indicated that fewer people in the CT scan group died of lung cancer (18 lung cancer deaths per thousand people in the CT group vs. 21 per thousand in the control group), but almost all of the scans that found “something” were false positives. Implementing such screening would be difficult and costly, the researchers concluded. The Agency for Healthcare Research and Quality (AHRQ) summarized the pros and cons in a decision aid for patients.
Richard M. Hoffman, MD, MPH, director of the Division of General Internal Medicine at the University of Iowa Carver College of Medicine and the Iowa City VA Medical Center wrote in an email that he has so many concerns about this pitch for lung cancer screening that he wasn’t sure where to start with his comments, which include questions about equity (since there are no accredited screening centers in many areas, including those with some of the highest smoking rates), out of pocket costs for follow-up testing and treatment, and doubts about the safety and effectiveness of screening in the real world compared to the idealized environment of the National Lung Screening Trial (NLST).
“Compared to the general population, NLST participants were more likely to be white and had higher socioeconomic status than the general population—and they had extraordinary levels of adherence with testing and treatment. Complications rates related to invasive diagnostic procedures and operative mortality rates in the study were far lower than observed in Medicare data. Given the small absolute lung cancer mortality benefit (3/1000 in 7 years) and the many potential harms, screening is considered a complex decision,” Hoffman wrote.
Vinay Prasad, MD, an oncologist at the Oregon Health & Science University, has pointed to the “sobering” picture of lung cancer screening painted by AHRQ’s decision aid (see graphic), which shows that 356 out of 1,000 people screened will receive a false alarm. He also noted that the NLST results may not actually prove that screening saves lives. One clinician replied with a tweet saying that she’d never had a patient agree to be screened at her Veterans Affairs clinic after giving them an evidence-based decision-making aid.
A formal evaluation of an attempt to do lung cancer screening in the VA concluded, “Implementation of a comprehensive lung cancer screening program requires significant clinical effort for as-yet uncertain patient benefit.” (HealthNewsReview.org’s Joy Victory used NPR reporting on this study to introduce advice for journalists who write about cancer screening, including its potential to do harm.) An editorial comment that accompanied the VA study article also questioned whether widespread lung cancer screening pays off in the real world, noting another study found that in actual practice lung cancer screening outreach tends to send a lot of lower risk people in for screening, while missing the people who are most likely to benefit.
A recent case report serves as a counterpoint to the “survivor” stories provided by the ALA campaign. Physicians wrote about a woman who was referred for lung cancer surgery after getting screened. But the surgeons decided to wait, and the “tumor” went away, indicating it wasn’t cancer after all. The authors call the case a teachable moment… but not the lesson the ALA is preaching.
Since campaigns such as “Saved by the Scan” are designed to persuade, not merely inform, the job of telling patients about all these off-message facts is dumped in the laps of frontline physicians. They would have to divert scarce moments with their patients to cover even the basics. My guess is that very few are at all prepared to provide personalized advice. And with a lot of other patients waiting in exam rooms, if insurance will pay for a scan, why not just order it… and let the specialists sort it all out later?
So allow me to revise my opening questions. Why did the American Lung Association decide to try to persuade millions of people to sign up for lung cancer screening, despite widespread doubts about its effectiveness? Why did they choose to put resources into this battle, instead of bolstering other campaigns? Why do they want TV stations to bump other PSAs in order to run the “Saved by the Scan” spot?
I reached out the ALA. A spokesperson emailed she would be “happy to put [me] in touch with an expert or patient storyteller regarding lung cancer screening.” I wrote back that “I’d like to speak to someone who can talk about how and why the ALA decided to go forward with this campaign at this time, and the way you and partners at the Ad council & Hill Holliday decided to shape the message.”
A few more emails were traded over several days. I’m still waiting.
This media push by the American Lung Association appears to have generated few news stories. A Google News search on August 13, 2017 returned only a few hits, including some that were business notes about the ad campaign or mere reprints of the ALA news release. The CBS TV affiliate in Philadelphia ran a story that parroted the key points of the campaign. The only interviewed source was a surgeon with a local hospital group. The surgeon’s quotes only promoted promised benefits, without any mention of unnecessary biopsies or other harms.
TIME produced a more nuanced story. While it led off with a pitch for the ALA quiz and potential benefits of screening, the story eventually pivoted to comments from Gil Welch, MD MPH at Dartmouth who has written extensively about the need to assess claims of screening benefits in light of the potential harms and the limitations of medical evidence.