One of the cornerstones that define the primary care physician who takes care of adults is the emphasis on screening and preventive care. Cancer screening at this time is limited to cervical, breast, prostate and colorectal cancer. A recent article indicates the potential to reduce the mortality for lung cancer by using low dose helical computed tomography.1 While this is an exciting advance, it raises issues for those of us whom are most likely to incorporate this technology in our screening repertoire.
Physicians will undoubtedly embrace the potential to screen for lung cancer but that enthusiasm will be tempered by several factors:
Cost. If this procedure is mandated and supported by private and/or federally funded agencies, the main barrier to utilization will be overcome. With our current economy, even the most routine cancer screening programs have to be “sold” to our patients as being worth the cost.
Safety. We should have little problem in convincing our patients that the low dose of radiation involved will not jeopardize their health.
False positivity. Approximately 95% of CT and radiographic positive studies were shown be false positive for cancer. Such patients may be subjected to an invasive procedure which could result in a number of serious side effects, pneumothorax and bleeding being the most obvious. Once again, the cost of the procedure and its morbidity will have to be considered by the referring primary care physician. Selecting the appropriate patient will be our responsibility, and explaining the risks and benefits will be part of the counseling process.
There will need to be a multiple level approach to inform and educate primary care physicians about the proposed new guidelines for lung cancer screening. These will need to include among others, those who are eligible by clinical parameters and the availability and acceptance of screening procedures in the particular community across the country. In the same way that currently well established screening procedures had to be introduced into the “standard menu” of preventive measures (e.g. mammography, colonoscopy and PAP smears), so will the lung cancer screening program with all its permutations need to be introduced into current preventative screening parameters. There are numerous strategies for education of all levels of healthcare providers, starting in medical school and progressing into the curricula of all primary care provides including physicians, nurse practitioners and physician assistants. Many women regard their gynecologist as their primary source of care and they need to be included in educational programs for the screening of lung cancer.
Screening for lung cancer will probably be initiated by the patient's primary health care provider. The initial screening procedure will be performed, according to an agreed protocol, at approved screening facilities. The results and further action will be directed by the responsible primary care provider, who will have been educated in the screening and follow up protocol. Freestanding imaging facilities may perform the procedure but the question then remains as to whom or how the follow up will be delegated. Given that so many eligible patients do not have an identifiable personal primary healthcare provider, lung cancer screening as well as the other available screening protocols will be incomplete. This could change if all patients are required and funded to select their own personal primary healthcare provider under the new healthcare proposals.
The question of responsibility for informing the patient rests on the shoulders of the entire medical community. Using different multimedia sources will also be very effective in bringing the new screening capability to the attention of the public, bearing in mind that different ethnic groups have different preferences as to how they might need to be approached in introducing this new technique to screen for lung cancer.
However, once the patient is informed and arrangements made for the screening, it is the patient's responsibility to follow through. In primary care, we are only too aware of patient's failures to complete the recommended screening procedures including PAP smears and colonoscopies. In these cases, it is incumbent for the referring healthcare provider to document that the patient was informed, appointments made and whether or not the screening procedure was completed. This is not only important to encourage patient adherence but also to protect the referring provider should the patient opt to decline screening and subsequently develop an advanced and potentially treatable diagnosis.
While the advent of improved screening techniques will raise interest in both patients and practitioners, the sobering results of even the most current therapeutic options (surgery, chemotherapy and radiation therapy) have to be considered when patients question us as to what the ultimate benefit of this new protocol might be.2
1. Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395–409
2. Woolf SH, Harris R. The harms of screening: new attention to an old concern. JAMA. 2012;307:565–566