Volume 199 - Issue 9
Should we screen for lung cancer in Australia?
Authors: Mark Hew, Robert G Stirling and Michael J Abramson
Med J Aust 2013; 199 (9): 586. || doi: 10.5694/mja13.11158
Published online: 4 November 2013
Published online: 4 November 2013
In reply: We welcome the opportunity to respond to correspondence from Marshall and colleagues and Mitchell and colleagues about the impact of the National Lung Screening Trial (NLST)1 on three distinct issues: (i) current medical practice; (ii) developing public health policy; and (iii) implementation of future screening.
Current medical practice: We do
not currently recommend community screening. In the absence of resourced, educated, and coordinated referral ...
In reply: We welcome the opportunity to respond to correspondence from Marshall and colleagues and Mitchell and colleagues about the impact of the National Lung Screening Trial (NLST)1 on three distinct issues: (i) current medical practice; (ii) developing public health policy; and (iii) implementation of future screening.
Current medical practice: We do not currently recommend community screening. In the absence of resourced, educated, and coordinated referral and management pathways (which are essential to replicate successful NLST outcomes), we advise clinicians to focus on the available method of reducing lung cancer mortality — smoking cessation. For non-smokers, we urge doctors not to embark on ad-hoc screening outside appropriate frameworks, as this may harm patients.2
Public health policy: Whether coordinated screening should proceed depends on the final balance between numerous factors, including efficacy, affordability and equity. Screening efficacy continues to evolve,3 with refinements in selecting individuals at high risk, determining screening intervals, and managing screen-detected nodules. Cost-effectiveness and risk–benefit ratios will likely improve.
Formal cost-effectiveness data for screening are still pending.4 In the interim, we estimated the relative cost-effectiveness of screening and smoking cessation in our editorial.5 These figures favoured smoking cessation, so we emphasised the importance of intensified tobacco control. We are surprised that Mitchell and colleagues view this as therapeutic nihilism, as even the NLST authors argue: “cost-effectiveness of low-dose CT screening must also be considered in the context of competing interventions, particularly smoking cessation”.1
Screening offers greatest survival benefit to a high-risk group (comprising current and recent former heavy smokers) who develop early lung cancer.1 However, effective tobacco control and smoking cessation averts even more lung cancer deaths by preventing cancer in the first place.6 We should advocate just as strongly for this far larger (but future, and, as yet, anonymous) at-risk group, as we do for our immediate and identifiable high-risk group with early cancer.
Screening implementation: Our editorial indicated that results from the Queensland Lung Cancer Screening Study would be pivotal to guide the implementation of screening.5 Preliminary data from Marshall and colleagues are therefore timely and welcome. Decisions to implement screening beyond this pilot initiative should await publication of full results. We concur that integration of screening with national tobacco control and smoking cessation programs will be vital.
Competing interests
No relevant disclosures.
References
- National Lung Screening Trial Research Team, 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. 0_CBBEJAHF
- Bach PB, Gould MK, Silvestri GA. Computed tomography screening for lung cancer. Ann Intern Med 2013; 159: 155-156. 0_i1142885
- Field JK, Oudkerk M, Pedersen JH, Duffy SW. Prospects for population screening and diagnosis of lung cancer. Lancet 2013; 382: 732-741. 0_i1142887
- Manser R, Lethaby A, Irving LB, et al. Screening for lung cancer. Cochrane Database Syst Rev 2013; (6): CD001991. 0_CBBBJCAG
- Hew M, Stirling RG, Abramson MJ. Should we screen for lung cancer in Australia [editorial]? Med J Aust 2013; 199: 82-83. 0_CBBGHGCG
- Moolgavkar SH, Holford TR, Levy DT, et al. Impact of reduced tobacco smoking on lung cancer mortality in the United States during 1975–2000. J Natl Cancer Inst 2012; 104: 541-548. 0_i1142895