Note to our followers: Our nearly 13-year run of daily publication of new content on came to a close at the end of 2018. Publisher Gary Schwitzer and other contributors may post new articles periodically. But all of the 6,000+ articles we have published contain lessons to help you improve your critical thinking about health care interventions. And those will be still be alive on the site for a couple of years.
Read Original Story

The Times offers informative breakdown on the value of lung cancer screening

You smoked for years. Maybe you still do. Now that Medicare promises to begin covering lung cancer screening, should you sign up?

That’s a difficult question.

The eligibility requirements seem fairly clear-cut: You can receive an annual low-dose CT scan if youare 55 to 77 years old, have a smoking history of at least 30 “pack years” — meaning that you smoked a pack a day for 30 years, or two packs a day for 15, and so on — and still smoke or quit only within the past 15 years.

More than 10 million Americans will be eligible for screening, the United States Preventive Services Task Force, an independent, volunteer panel of national experts, has estimated, though many of those millions aren’t yet Medicare recipients.

But screening will not help everyone who is eligible, experts warn. Like any medical test or procedure, it will subject some patients to harm.

“How do you make a blanket coverage decision about something that’s a good idea for some people and not so good for others?” said Dr. Michael Gould, a pulmonologist and senior research scientist at Kaiser Permanente Southern California, and a nonvoting member of Medicare’s coverage advisory committee.

That committee voted last year against covering the procedure, saying it found insufficient evidence of benefit. A few months earlier, the preventive services task force had come to precisely the opposite conclusion and recommended annual screening, which made coverage mandatory for private insurers but not for Medicare.

Overriding its own advisory committee, Medicare approved coverage but decided to require — a first — a “counseling and shared decision-making visit” with a physician or other medical professional before reimbursement for a scan.

“Because the follow-up testing is invasive, biopsies and such, and lung cancer has such serious mortality and morbidity risks, we wanted to ensure that Medicare beneficiaries were informed,” said Dr. Patrick Conway, chief medical officer at the Centers for Medicare and Medicaid Services.

Lung cancer, overwhelmingly caused by smoking, still causes more deaths than any other cancer, in part because it is hard to detect at more curable stages.

Unlike lumps in breasts, for example, “nothing in your lungs allows you to sense the presence of a nodule or mass,” said Dr. Douglas Arenberg, director of the lung cancer screening program at the University of Michigan Medical School.

With treatment, usually surgery, 70 percent to 80 percent of patients with Stage 1 lung cancer, and half of those with Stage 2, survive for at least five years. But most lung cancer is diagnosed when the disease is more advanced, leading to lousy overall mortality rates: Just 18 percent of all lung cancer patients survive for five years.

Pulmonologists have tried for years to find ways to detect lung cancer earlier. Experiments using ordinary chest X-rays proved disappointing. Then in 2011, researchers running the National Lung Screening Trial, involving 53,454 smokers and former smokers ages 55 to 74, reported encouraging findings: Patients who received a low-dose CT scan annually for three years were 20 percent less likely to die of lung cancer over an average of 6.5 years than those tested with X-rays.

Those results led to the preventive services task force’s endorsement and, eventually, to Medicare’s approval. “We’re covering evidence-based preventive services for beneficiaries, which will save lives,” Dr. Conway said.

How many lives? While the overwhelming number of people with lung cancer are or were smokers, most smokers don’t develop lung cancer. So although a 20 percent reduction in mortality sounds impressive, it represents a small number of people.

In the national trial, those screened with chest X-rays had about a 1.7 percent chance of dying from lung cancer during the study period; in the CT scan group, it was about 1.4 percent.

For every thousand people screened with a low-dose CT, three fewer died of lung cancer.

Lay people struggle to grasp these kinds of numbers. “They look at me and say, ‘Doc, just tell me what to do,’ ” Dr. Arenberg said. Or they give a how-can-it-hurt shrug and opt in: Maybe they’ll be among the three in 1,000 saved.

The problem is, testing can cause harm, too.

First, a high proportion of those tests will trigger a false alarm. CT scans can’t distinguish well between small nodules that aren’t dangerous and those that become lethal.

In the national trial, close to 40 percent of participants got positive results from at least one of their three CT scans, but more than 96 percent of these nodules weren’t cancerous.

False positives usually require additional scans, over several years, to determine whether nodules are malignant. Meanwhile, “you have to be willing to live with that uncertainty,” Dr. Gould said.

Worse, some positive results require more invasive follow-up, particularly biopsies, which also have risks, though low ones. Twenty to 25 percent of the time, a biopsy causes a pneumothorax, or collapsed lung, which usually heals on its own but occasionally requires hospitalization. Biopsies can also produce false negatives or dangerous bleeding.

For older people, the odds shift somewhat. Their cancer risk rises with age, so the scan will detect more lung cancer, according to an analysis of the national trial participants over age 65. But their rate of false positives rose, too, making invasive diagnostic procedures more likely.

At older ages, these procedures may not be trivial.

Elayne Green, a retiree in Boca Raton, Fla., learned this in 2013, when she was 76. Because she’d smoked for 30 years, before hypnosis helped her stop at 43, her health care provider recommended lung cancer screening. She agreed and paid $95 out of pocket. (She wouldn’t meet Medicare eligibility requirements now.)

The CT scan found a “hot spot,” she was told. Regular follow-up screenings “felt like a guillotine over my head,” she said. So Mrs. Green had diagnostic surgery called wedge resection, which found no cancer but caused considerable pain.

“I couldn’t wear a brassiere for three months,” she recalled.

Among the 65- to 74-year-olds getting CT scans in the national trial, moreover, many had other serious health problems — heart disease, diabetes, hypertension, pulmonary disease — which probably contributed to only 55 percent surviving five years, compared with 64 percent among those under age 65.

Researchers call it “competing mortality.” Finding lung cancer is a hollow victory if patients endure testing and treatment, then die of another illness before the cancer would have killed them.

Most older adults, especially smokers, have multiple chronic diseases. “If I find a teensy lung cancer in a 77-year-old with heart disease, I may not have done him any favor,” Dr. Arenberg said.

In fact, if screening finds cancer, some seniors won’t withstand the surgery, usually a lobectomy, that may cure it. The post-surgical death rate in the national trial was just 1 percent, but that involved major medical centers with specialized radiologists and surgeons — the ideal setting.

Nationally, deaths from this operation run two to four times higher, and they increase with the patient’s age. And the trial provides no information on screening results for those older than 77.

So those required “shared decision-making visits” with doctors will involve lots of very individual questions and judgments. Researchers are developing decision aids to guide physicians and consumers beginning to struggle with lung cancer screening. (A University of Michigan team has put a helpful one online at And Medicare has established a registry to see how well large-scale screening works.

But it is worth remembering that however effective it is, screening can’t ward off disease. It only finds the damage already done.

“The only way to prevent lung cancer or reduce your risk,” Dr. Gould said, “is to stop smoking.”

On Medicare and Assessing the Value of Lung Cancer Screening

Our Review Summary

Doctor looks back at the camera with a serious face as he examines a chest x-ray on a lightbox. Camera: Canon EOS 1Ds Mark III.

Is the opportunity for Medicare recipients who are heavy smokers to receive yearly low-dose CT scans a boon or a problem? This New York Times analysis not only provides a little history about the recent Medicare decision to fund the procedure, which seeks to find lung cancer in its earlier stages, but also shares plenty of detail and context as to the likely benefits and harms of getting screened. Cost was the only one of our 10 criteria that wasn’t satisfactorily addressed. Excellent reporting on a complicated issue.


Why This Matters

Among the illnesses caused by smoking, lung cancer is a big one. It is the number one cause of cancer death in the U.S. and most lung cancers occur in smokers. So short of stopping smoking, what can be done to decrease the risk of dying from lung cancer? Before the National Lung Screening Trial (NLST), the answer was nothing. This trial demonstrated that compared with a chest x-ray, a yearly low dose computed tomography (CT) scan for three years reduced the likelihood of dying from lung cancer by about 20%, or by 5 in 1000 people (0.5% absolute reduction). Depending on one’s perspective, a 20% relative reduction or 0.5% absolute reduction, may or may not be important. And that is the focus of this article. How do you educate individuals who are eligible for this test so they can make a personal choice that’s right for them? Traditionally, doctors have simply told patients what to do. “I think that screening for colon cancer with a colonoscopy is a good idea for you.” However, this article points out that in addition to a small potential for benefit, there is also a real potential for harm or at least inconvenience. Almost 1 in 3 will have an abnormality seen on the CT scan that will require special follow-up. Of those abnormalities, only 6 in 100 will actually turn out to be something serious enough to require a biopsy or treatment. So patients and doctors are going to need to find ways to communicate these potential risks and benefits and help individuals assess preferences and other health or life issues that may influence the choice to screen. How well we do this will determine whether translating the results of a research study done under strict controls by experienced investigators translates into the same benefits in the broader population.


Does the story adequately discuss the costs of the intervention?

Not Satisfactory

The story describes the case of one patient who paid $95 out of pocket for a lung cancer screen in 2013. But while the story does attempt to at least provide some cost perspective with the coverage, we’d note that under the Affordable Care Act, approved preventive tests do not carry copayments, so the cost of the initial scan is not really an issue for eligible patients. And in any case, the real costs to individuals and society are not really addressed by the cost of one scan. The story notes high up that the number of Americans who would be eligible for Medicare-funded scans would be in the millions. So the cost to Medicare and private insurers to fund this program will be, well, gargantuan at that scale. There is the cost of the initial test, annual testing if negative, and potentially more testing if an abnormality is found. This is not going to be a cheap program.

Does the story adequately quantify the benefits of the treatment/test/product/procedure?


The story does an admirable job of explaining the modest benefit of these scans. The story’s effort to explain the statistics in several ways, including the use of absolute numbers, could serve as a model for other journalists. Example: “In the national trial, those screened with chest X-rays had about a 1.7 percent chance of dying from lung cancer during the study period; in the CT scan group, it was about 1.4 percent. For every thousand people screened with a low-dose CT, three fewer died of lung cancer.”

Another way to express this benefit would be the number need to treat (NNT) — the number of patients screened to prevent one lung cancer death. In this case, the NNT appears to be around 1 in 400. This is considerably better than other screening programs such as breast or prostate cancer.

Does the story adequately explain/quantify the harms of the intervention?


This story devotes considerable space to explaining the potential problems invoked by false positives, again with facile use of numbers. The one narrative offered in the story elaborates on this element by focusing on an elderly retiree whose scan unearths a “hot spot” on her lung that, after considerable angst and pain caused by diagnostic procedures, was found to contain no cancer.

Another harm that could have been added is that the screening x-ray involves radiation, which may cause cancer itself. Though the scan is “low dose”, it isn’t “no dose,” and we know that screening not only will prevent death from cancer, but it will in fact be the cause of some of the cancers.

Does the story seem to grasp the quality of the evidence?


The story references a large screening trial involving more than 53,000 smokers and former smokers. It could have provided the reader with more information about how the study was carried out — for instance, emphasizing that to achieve the benefit seen in the trial, you need a yearly CT scan until either you age out or, if you’ve stopped smoking, you reach 15 years since quitting. But the story contains plenty of context about the study, especially with respect to the types of patients enrolled and the harms observed in the study. It also noted that treatment for those found to have cancer “involved major medical centers with specialized radiologists and surgeons — the ideal setting” — suggesting that the same results may be difficult to achieve at less specialized centers. We’ll rule this Satisfactory.

Does the story commit disease-mongering?


In some ways, this story is an example of a way to avoid disease-mongering. Because any Medicare-approved procedure will, by definition, be carried out on elderly individuals, the story’s reflections on “competing mortality”—the tendency for older folk to be saddled with multiple chronic diseases—emphasizes the importance of situating lung cancer among the elderly in a larger matrix of health issues. Lung cancer is clearly an important disease, but, as one physician/researcher noted in the story, “If I find a teensy lung cancer in a 77-year-old with heart disease, I may not have done him any favor.”

Does the story use independent sources and identify conflicts of interest?


The sources in this story are clearly identified, but no effort is made to articulate the presence—or absence—of conflicts of interest. However, a quick search of these individuals does not reveal any major conflicts, so we’ll rule this Satisfactory.

Does the story compare the new approach with existing alternatives?


The single study discussed in this story—the National Lung Screening Trial—compared low-dose CT scans with more traditional X-ray diagnoses. But in reality, the comparison is between low- dose CT and not doing one at all. No one is recommending a regular x-ray of the chest.

Does the story establish the availability of the treatment/test/product/procedure?


The issue of interest here is whether low-dose CT scans are available for older, heavy smokers to screen for lung cancer. While this is satisfactorily addressed (it’s the main topic of the story), it isn’t entirely clear from the story if screening has actually begun or when it will. Programs to do the shared decision-making for Medicare patients haven’t been established and Medicare hasn’t yet released codes for billing for the initial visit where the issue is reviewed. It’s also unclear if commercial insurers are covering and for whom.

Does the story establish the true novelty of the approach?


The story makes it clear that low-dose CT scans are now in use. What is novel here  is a recent decision by Medicare to cover the cost of such scans for current or former heavy smokers who meet specific criteria.

Does the story appear to rely solely or largely on a news release?


We see no evidence that this analytical narrative relied on a news release.

Total Score: 9 of 10 Satisfactory

Comments (3)

Please note, comments are no longer published through this website. All previously made comments are still archived and available for viewing through select posts.

Sam LaMonte

May 18, 2015 at 10:00 am

You fail to point out that smoking cessation is an aspect of this program. These patients are motivated to be assured they are clear of cancer. That is a great relief, and once they know they are clear, they may actually quit.


    Gary Schwitzer

    May 18, 2015 at 10:33 am


    Thanks for your note.

    To whom were you referring when you wrote, “You fail to point out….” ? The New York Times published the story. Did you mean they failed to point this out?

    We didn’t publish the story; we reviewed it.



May 18, 2015 at 5:20 pm

Good review of this complicated subject. V.P.