Linda S. Kinsinger, MD, MPH; David Atkins, MD, MPH; Dawn Provenzale, MD, MS; Charles Anderson, MD, PhD; Robert Petzel, MD
This article was published online first at www.annals.org on 12 August 2014.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1070.
Requests for Single Reprints: Linda S. Kinsinger, MD, MPH, National Center for Health Promotion and Disease Prevention, Veterans Health Administration, 3022 Croasdaile Drive, Suite 200, Durham, NC 27705; e-mail, Linda.Kinsinger@va.gov.
Current Author Addresses: Dr. Kinsinger: National Center for Health Promotion and Disease Prevention, Veterans Health Administration, 3022 Croasdaile Drive, Suite 200, Durham, NC 27705.
Dr. Atkins: Office of Research and Development, 810 Vermont Avenue Northwest (10P9H), Washington, DC 20420.
Dr. Provenzale: Durham Veterans Affairs Medical Center, 508 Fulton Street (152), Durham, NC 27705.
Dr. Anderson: Diagnostic Services, Office of Patient Care Services, Veterans Health Administration, 3022 Croasdaile Drive, Suite 100, Durham, NC 27705.
Dr. Petzel: 4621 East Lake Harriet Parkway Minneapolis, MN 55419.
Author Contributions: Conception and design: L.S. Kinsinger, D. Atkins, D. Provenzale.
Drafting of the article: L.S. Kinsinger, D. Atkins.
Critical revision of the article for important intellectual content: L.S. Kinsinger, D. Atkins, D. Provenzale, C. Anderson.
Final approval of the article: L.S. Kinsinger, D. Atkins, D. Provenzale, C. Anderson, R. Petzel.
Administrative, technical, or logistic support: L.S. Kinsinger.
Collection and assembly of data: D. Provenzale.
Kinsinger L., Atkins D., Provenzale D., Anderson C., Petzel R.; Implementation of a New Screening Recommendation in Health Care: The Veterans Health Administration's Approach to Lung Cancer Screening. Ann Intern Med. 2014;161:597-598. doi: 10.7326/M14-1070
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Published: Ann Intern Med. 2014;161(8):597-598.
Last winter, the U.S. Preventive Services Task Force (USPSTF) gave a positive recommendation (B grade) for lung cancer screening with low-dose computed tomography. The recommendation applies to high-risk adults aged 55 to 80 years with a smoking history of at least 30 pack-years who are still smoking or have quit within the past 15 years (1). The USPSTF based its recommendation on the landmark National Lung Screening Trial (NLST) (2), which provided evidence about the efficacy of screening but did not answer questions about effectiveness when implemented in everyday clinical practice. The recommendation, as noted in an accompanying editorial, leaves many of these critical issues unaddressed (3). Indeed, the Medicare Evidence Development & Coverage Advisory Committee recently concluded that there was inadequate evidence to recommend national coverage for lung cancer screening (4). This conclusion highlights the controversy over what constitutes sufficient evidence to support widespread implementation of a new technology. It has also heightened the tension between advocates who are eager to see wide deployment of screening quickly and others who are concerned about the ability of health care systems to provide a low-dose computed tomography screening program to the potentially large number of patients meeting criteria while still minimizing harms (4). That a new intervention can work in randomized trials does not guarantee that it will work as well when delivered in real-world practice, nor that the benefits in the community will justify the possible harms and costs (including opportunity costs). Should these unanswered questions delay implementation of screening pending further study, or do the potential benefits compel their early adoption?
Xin-Zu Chen; Rui Wang; Jian-Kun Hu
Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
September 8, 2014
Low-dose computed tomography is considerable for lung cancer screening in China
To the editor: Kinsinger and et al. discussed the new recommendation by Veterans Health Administration, U.S. on low-dose computed tomography (LDCT) for lung cancer screening, and accept LDCT as an exciting opportunity to reduce mortality from lung cancer (1). Lung cancer is always the leading cause of cancer death in China and induces heavy healthcare burden. Compared with U.S. and Germany, 5-year prevalence of colorectal cancer in China (55.2/100,000 persons) is lower than those in U.S. (106.4/100,000 persons) and Germany (78.5/100,000 persons) (2). Nevertheless, mortality-to-prevalence ratio of lung cancer is as high as 0.59 in China, compared to only 0.27 and 0.28 in U.S. and Germany, respectively (2). It indicates the overall survival outcome of lung cancer is apparently worse in China, despite of the lower prevalence. This unfavorable situation has to attribute to that most Chinese patients with lung cancer are diagnosed at symptomatic stage, but few at early stage (16%–22%). In 2003, Ministry of Health (MOH), China issued governmental outlines of China Cancer Prevention and Control Program (2004–2010). Thus, lung cancer has been defined as one out of eight key malignancies requiring intensive prevention and control in China, due to substantial healthcare burden from increasing mortality. However, screening and surveillance programs for lung cancer are merely implemented with loose organization in few major cities in China. In 2009, the government developed an affordable and accessible national healthcare insurance system covering both urban and rural residents, and including those eight key malignancies. In 2012, MOH launched an organized community-based screening project in 9 urban areas for 5 key malignancies. Despite of previous efforts of cancer prevention and control, mortality-to-incidence ratios of lung cancer were not decreased (0.91 in 2004 and 0.90 in 2012, respectively) (2). Commonly, the screening examination for lung cancer is based on chest X-ray for many years in China. According to NLST trial, LDCT shows better performance for detecting early-stage lung cancer and is associated with decreased mortality from lung cancer (4). By now, many Chinese hospitals attempt to practise LDCT for lung cancer screening during health-checkup instead of traditional chest X-ray test. Regarding the poor survival outcome, it’s possibly cost-effective to establish organized nationwide screening and surveillance programs based on LDCT among high-risk population to improve overall survival outcome of lung cancer in China.Conflicts of interest: None declared.References1. Kinsinger LS, Atkins D, Provenzale D, Anderson C, Petzel R. Implementation of a new screening recommendation in health care: The VHA's approach to lung cancer screening. Ann Intern Med. 2014. doi: 10.7326/M14-1070 [PMID: 25111673]2. Ferlay J, Soerjomataram I, Ervik M, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://globocan.iarc.fr3. National Lung Screening Trial Research Team, Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011 Aug 4;365(5):395-409. [PMID: 21714641]
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Hematology/Oncology, Pulmonary/Critical Care, Lung Cancer, Cancer Screening/Prevention, Prevention/Screening.
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