Screening cigarette smokers and former smokers for lung cancer seems like a no-brainer, as smoking is the biggest risk factor for lung cancer. But research on the benefits and harms of this type of screening finds that the issue is not so clear cut.
As primary care doctors Andy Lazris and Alan Roth pointed out in a commentary in American Family Physician, the evidence of benefit from lung cancer screening in the community setting is weak. The absolute reduction in lung cancer deaths from screening is only 3 in 1,000 people over 7 years.
At the same time, 250 of those people will have an abnormal scan result and will have to undergo further testing, which can be stressful and costly. While a CT scan generally costs about $300, follow-up procedures such as lung biopsies, PET scans, and lung surgeries can cost thousands of dollars; not to mention the risk and expense of possible complications. According to the US Preventive Services Task Force (USPSTF), about 10-12% of lung cancers diagnosed by screening are overdiagnosed– they would not have been found or harmed the patient within their lifetime.
Almost all of lung cancer screening websites studied (98%) included information about the benefits of screening, but fewer than half of the websites (48%) included information about the harms.
People considering lung cancer screening need to weigh these benefits and harms, to decide whether screening is right for them. However, according to a recent study in JAMA Internal Medicine, information about the benefits and harms of screening are not always available on the websites for lung screening programs.
Dr. Stephen Clark from the University of North Carolina at Chapel Hill and colleagues looked at 162 websites for lung cancer screening programs and tracked how often the websites presented the potential benefits and harms of screening. Almost all of the websites (98%) included information about the benefits of screening, but fewer than half of the websites (48%) included information about the harms. Only 44% of websites quantified the benefit of screening by sharing the reduction in risk from dying of cancer, and very few included the absolute reduction in risk. Although shared decision making is recommended for lung cancer screening, only 22% of websites recommended that individuals discuss the harms and benefits of screening with a health professional.
Many of these websites are “essentially advertisements for screening.”
In an accompanying editorial in JAMA IM, Dr. Steven Woloshin and Dr. William C. Black from the The Dartmouth Institute for Health Policy and Clinical Practice, and Dr. Barnett S. Kramer at the National Cancer Institute write that “the results of this well-done study are disappointing but not surprising.” The findings show that on the whole, screening program websites are not trying to provide the most accurate and balanced information to help viewers making an informed decision. Rather, they are choosing which information to include to persuade viewers to get screened. This pattern holds for academic medical center websites as well as community health center websites. Many of these websites “are essentially advertisements for screening,” write Woloshin et al.
What can we do about it? Woloshin et al. include a list of facts that websites should include as a basic minimum level of information. The list includes: the absolute risk of benefit of screening, both in terms of cancer-related mortality and all-cause mortality; the absolute risk of harms from screening, including false positives, unnecessary biopsies, complications from testing, and overdiagnosis; and clear criteria about who could benefit from screening, based on the criteria from existing trials. Even better would be for websites to publish their own rates of false-positives and unnecessary biopsies. And importantly, websites targeting people who smoke should make extremely clear that quitting smoking is the best way to reduce one’s risk of lung cancer.
Beyond information, it is important to acknowledge the profit motive behind screening. If we reimbursed hospitals not for the volume of procedures done, but the outcomes for patients, we would likely a much greater effort to target individuals who would most benefit from screening, rather than hospitals trying to persuade as many people as possible to get screened.