Volume 199 - Issue 9
Should we screen for lung cancer in Australia?
Authors: Henry M Marshall, Kwun M Fong and Rayleen V Bowman
Med J Aust 2013; 199 (9): 585-586. || doi: 10.5694/mja13.11110
Published online: 4 November 2013
Published online: 4 November 2013
Smoking cessation measures and tobacco control are cost-effective means of reducing deaths from lung cancer, and more progress is needed before national lung cancer screening can proceed.
To the Editor: Lung cancer screening is a controversial issue, as clearly discussed by Hew and colleagues, who focus on the high false-positive rate, generalisability and cost.1
Nonetheless, the United States Preventive Services Task Force concludes that screening is beneficial, awarding a Grade B draft recommendation, meaning that, if approved, screening will qualify for US Medicare coverage.2 Preliminary data from the National Lung Screening Trial (NLST) suggest an incremental cost-effectiveness ratio of US$67 000 (cost per quality-adjusted life-year; Christine Berg, member of the NLST Executive Committee and Research Team, personal communication). Beyond the NLST, potential improvements to screening efficacy are emerging. For example, Kovalchik shows that using lung cancer risk factors in addition to age and smoking to select patients for screening substantially improves efficacy.3 Our Australian data (from the Queensland Lung Cancer Screening Study4) support this strategy. We used NLST eligibility criteria except for an age range of 60–74 years instead of 55–74 years, and detected lung cancer in 5% (13 of 256 patients) with three annual scans. All cancers clustered in the two highest quintiles when stratified by a published risk model,5 while false-positive scan results were evenly distributed.
We agree that smoking prevention remains the cornerstone of lung cancer control. However, most lung cancer in Australia now occurs in former smokers. Thus, the best overall strategy to reduce lung cancer mortality might be a combined approach of continued tobacco control together with risk-stratified screening and an embedded smoking cessation program.
The NLST has proven the value of screening in principle, and emerging data could help translate this to real-world settings. We must evaluate these findings in the context of our national Population Based Screening Framework,6 while being mindful of the stigma and nihilism often associated with lung cancer.
Competing interests
No relevant disclosures.
References
- Hew M, Stirling RG, Abramson MJ. Should we screen for lung cancer in Australia? Med J Aust 2013; 199: 82-83. 0_CBBDCDDD
- United States Preventive Services Task Force. Screening for lung cancer. Draft recommendation statement. Agency for Healthcare Research and Quality publication no. 13-05196-EF-3. http://www. uspreventiveservices taskforce.org/uspstf13/lungcan/lung candraftrec.htm (accessed Aug 2013).
- Kovalchik SA, Tammemagi M, Berg CD, et al. Targeting of low-dose CT screening according to the risk of lung-cancer death. N Engl J Med 2013; 369: 245-254. 0_i1142883
- Marshall HM, Bowman RV, Crossin J, et al. Queensland Lung Cancer Screening Study: rationale, design and methods. Intern Med J 2013; 43: 174-182. 0_CBBHAHEE
- Tammemägi MC, Katki HA, Hocking WG, et al. Selection criteria for lung-cancer screening. N Engl J Med 2013; 368: 728-736. 0_i1142889
- Australian Population Health Development Principal Committee Screening Subcommittee. Population based screening framework. Canberra: Australian Government Department of Health and Ageing, 2008. 0_i1142891