It’s political season. The game of watching politicians perform backflips and pirouettes on a topic contradicting a previous statement now preserved forever on YouTube can be entertaining.
Some people just can’t make up their mind.
And so it is really confusing when it is a group of medical professionals changing a recommendation that seemed to be rationally thought out before. We, the primary care physicians on the front lines of medical care, then try to explain why the recommendations pivot, turn, spin, wobble and then point like a child’s toy. Evidence based data, of course.
It almost seems to be like a big game of Twister trying to keep up with the changes in recommendations and then then challenges of implementing them in real practice.
So it is with CT scan screening for lung cancer.
Back in the fall of 2013 the editor of my local paper, Jason Davis, and I had a spirited debate and negotiation concerning me writing a column for The Mountain Press. This legal and contractual drama took place on the football sidelines of Sevier County prior to a ballgame, lasted about two minutes and was interspersed with much more interesting details of a camera Mr. Davis was considering.
The basic agreement was I would write a column twice monthly on medical information and topics related the current practice of medicine. If he liked it, great. If he didn’t, no big deal. I have written on a lot of topics over the past thirty years just to clear my own thoughts on a matter with no intention of publication.
I have loved reading newspapers since my third grade teacher brought them into class on Fridays. Writers such as Sam Venable, Mike Royko, Carson Brewer, Jack Anderson, Peggy Noonan, Lewis Grizzard, Berkeley Breathed (Bloom County) and, yes, Charles Schulz (Breathed and Schulz with the gifted art of brevity and humor) have been some of my favorites. A newspaper and a sandwich is a great lunch for me.
Surely I could write about medical topics and be accurate. As accurate as one can be while driving on shifting sand, it appears.
My first column attempted to explain why CT scans of the chest are not used to screen for lung cancer. I tried to explain that it isn’t just about screening and that it has to do with false findings, unnecessary biopsies of those without cancer, worry over waiting on the next scan, radiation exposure and how it all would be paid for.
Well, nevermind. That’s all changed now.
The U.S. Preventive Services Task Force (USPSTF) is the group responsible for evaluating current data and making recommendations to Congress and the public at large on preventive medicine. They are “made up of 16 volunteer members who are nationally recognized experts in prevention, evidence-based medicine, and primary care. Their fields of practice and expertise include behavioral health, family medicine, geriatrics, internal medicine, pediatrics, obstetrics and gynecology, and nursing.”
Soon after my first column, the recommendation on lung cancer screening changed. This was based on the National Lung Screening Trial of more than 50,000 patients. Other organizations (including the American Academy of Family Physicians) disagreed with this citing the very same data did not clearly show that the benefits of a cancer diagnosis outweighed the risks of a lot of false positives (some say nearly 25%) and the additional cost.
Oh, yes, the cost. Who is going to pay for this? Well, as of mid-2015 and after a lot of discussion, Medicare is for its members. Private insurance is unclear at this time. There is still a brisk discussion about the profits this will bring in for those providing this service.
The formal recommendation states: “The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in persons age 55 through 80 years with a 30 pack year history of smoking who are currently smoking or have quit within the past 15 years. Screening should be discontinued once the individual has not smoked for 15 years or develops a health problem significantly limiting either life expectancy or ability or willingness to undergo curative lung surgery.”
If a person strictly meets the criteria above, they should then consider having a discussion with their physician about this screening. There are risks associated with this, up to and including complications of biopsying lumps that are not cancerous.
And, to put it bluntly, if a person is truly worried about lung cancer, my first question is “are you worried enough to stop smoking?” It is a solid point that should be seriously considered.
“Data changes,” said a very well respected Family Physician lecturer during a national presentation this past year.
The USPSTF is a group of highly intelligent a dedicated medical professionals with the best intentions in mind for the well being of this country. Nevertheless, not all things that are important can be calculated and not all calculations are important. Dissecting that reality is the true challenge.
Therefore, back to the basics. Talk to your physician if you meet the criteria and decide if you want to have the screening done. Some will. Some won’t. Institutionalized single payer medical care with decisions made by one group for all of us is coming, in my opinion. This is a brilliant example of how confusing it will be.
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