RE: Results of Lung Cancer Screening in the Community AND Lung Cancer Screening Guidelines Implementation in Primary Care: A Call to Action.

Kudos to Handy et al. for their excellent report on their remarkable work.(1) They successfully marshaled the multidisciplinary resources of a large health system and created a rigorous, high-performing lung cancer screening (LCS) program. This included reviews by a multidisciplinary thoracic disease conference and deployment of a full-time LCS coordinator, who facilitated 99.9% follow-up of the 3,402 study participants.
Their aim was to address the concern that outside of the rigorously-conducted NLST, LCS performed in typical community sites could fail to achieve similar outcomes. While they have demonstrated similar results in their system, they did so by committing significant resources and leveraging a well-designed program with high levels of engagement and follow-through. Unfortunately, the question remains: Are these results generalizable to typical community practice?
The authors also describe the “eager participation” of their primary care clinicians, leading one to wonder if perhaps it was too eager, promoting LCS without adequate shared decision-making (SDM). This has been demonstrated previously.(2,3)
Meanwhile, the “Call to Action” put forth in the same issue by Doubeni et al. concludes that “engagement of primary care clinicians and support from payers and funding agencies are needed to catalyze the adoption of LCS.”(4) In doing so, they seem to presume that the benefits of LCS uniformly exceed the harms. As the authors note, every organization which supports LCS recommends SDM before proceeding with screening; CMS requires it. Not everyone agrees that the benefits demonstrated in NLST (decreased lung cancer mortality of 3 per 1000) exceed the harms (4 overdiagnosed lung cancers and 365 false positives per 1000 people screened). More recently, the NELSON trial of LCS reported zero all-cause mortality benefit and an even higher rate of overdiagnosis.(5)
While I agree with Doubeni et al. that LCS has likely been underutilized and that family medicine clinicians are ideally positioned to improve this, it is important that we strive to promote the right thing: proactively offering LCS to eligible people with appropriate SDM and subsequent honoring of the values and preferences of our patients -- not unconsidered screening.
1. Handy JR, Skokan M, Rauch E et al. Results of Lung Cancer Screening in the Community. Ann Fam Med. 2020; 18(3):243-249; DOI: https://doi.org/10.1370/afm.2519
2. Brenner AT, Malo TI, Margolis M, et al. Evaluating shared decision making for lung cancer screening [published online August 13, 2018]. JAMA Intern Med. doi:10.1001/jamainternmed.2018.3054
3. Redberg RF. Failing Grade for Shared Decision Making for Lung Cancer Screening. JAMA Intern Med. 2018;178(10):1295–1296. doi:10.1001/jamainternmed.2018.3527
4. Doubeni CA, Wilkinson JM, Korsen N, Midthun DE. Lung Cancer Screening Guidelines Implementation in Primary Care: A Call to Action. Ann Fam Med 2020; 18(3):196-201; DOI: https://doi.org/10.1370/afm.2541
5. De Koning HJ, van der Aalst CM, de Jong PA, et al. Reduced Lung-Cancer Mortality with Volume CT Screening in a Randomized Trial. N Engl J Med 2020; 382:503-513. DOI: 10.1056/NEJMoa1911793