From the Journals

Lung screening complications costly, more prevalent than in trial setting

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Patients need briefing on harms vs. benefits

“The conversations that are occurring about lung cancer screening are woefully inadequate and do not discuss harms,” wrote Rita F. Redberg, MD, in an editorial note. Shared decision-making visits were made mandatory prior to lung cancer screening by the Centers for Medicare & Medicaid Services. That decision was made because of an evidence review suggesting a “low likelihood” that benefits of lung cancer screening would exceed harms in the Medicare population, Dr. Redberg wrote. Despite that, most Medicare beneficiaries are not having the required visit for shared decision making before they undergo the CT scan.

Dr. Rita F. Redberg of the University of California, San Francisco

Dr. Rita F. Redberg

Of those Medicare beneficiaries who did have a shared decision-making visit, 40% opted out of screening, probably because they learned of the harms relative to the benefits during that visit, Dr. Redberg said.

“It is likely that patients’ decisions not to undergo low-dose computed tomography for lung cancer screening are driven by the high false-positive rate, high chance of incidental findings, and subsequent need for invasive procedures, and small chance of benefit,” she said in her comment.

Shared decision-making visits are also rarely happening in the privately insured population, as shown in previous research, Dr. Redberg noted.

She reported no conflicts of interest related to her Editor’s Note, which appears in JAMA Internal Medicine (2019 Jan 14).

Dr. Redberg is with the department of medicine, University of California, San Francisco.


 

FROM JAMA INTERNAL MEDICINE

The real-world rate of complications following lung cancer screening procedures is substantially higher than in clinical trials, a study suggests.

Those complications related to low-dose computed tomography (LDCT) screening are potentially costly, according to the analysis of commercial and Medicare claims data for nearly 350,000 individuals.

While tentative, these results emphasize the need to discuss the risk of adverse events and their costs as part of the shared decision-making process between physicians and patients, researchers said in a report on their study in JAMA Internal Medicine.

“As the number of individuals seeking lung cancer screening with LDCT increases, so too will the number of individuals undergoing invasive diagnostic procedures as a results of abnormal findings,” said Jinhai Huo, MD, PhD, of the department of health services research, management, and policy at the University of Florida, Gainesville.

The retrospective cohort study included 174,702 individuals who underwent an invasive diagnostic procedure related to lung cancer screening and 169,808 control subjects.

All individuals studied were between 55 and 77 years old, the targeted age range for lung cancer screening specified by the Centers for Medicare & Medicaid Services.

Complication rates were about twice as high as they were in the landmark National Lung Screening Trial (NLST), both for a younger cohort of individuals aged 55-64 years, and an older Medicare age group of individuals aged 65 to 77 years, Dr. Huo and coinvestigators reported.

The estimated rate of complications was 22.0% (95% confidence interval, 21.7%-22.7%) in the younger age group, and even higher in the older age group, at 23.8% (95% CI, 23.0%-24.6%), according to investigators. By contrast, complication rates in the NLST were 9.8% and 8.5% for younger and older age cohorts, respectively.

The cost of managing postprocedural complications was higher than the cost of the diagnostic procedures, investigators said.

Mean costs ranged from $6,320 for minor complications to $56,845 for major complications, they reported.

The most common invasive diagnostic procedure in the study cohort was cytology test or biopsy in 26.1%, followed by bronchoscopy in 25.6%, according to study data. Another 5.4% underwent thoracic surgery.

In a previous Medicare advisory committee meeting, some experts expressed concern that complication rates in settings outside of the NLST would be higher than what was reported in that study, Dr. Huo and coauthors noted in their report.

“Our findings echoed this concern,” they said in a discussion of their results.

Dr. Huo and coauthors reported no conflicts of interest related to the research, which was supported in part by grants or fellowships from the University of Texas MD Anderson Cancer Center, the University of Florida, the National Cancer Institute, and the National Institutes of Health.

SOURCE: Huo J et al. JAMA Intern Med. 2019 Jan 14.

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