In 2011, researchers published the results of the National Lung Screening Trial, comparing two ways of detecting lung cancer—low-dose helical computed tomography (CT)—often referred to as spiral CT—and standard chest X-ray.
The results were unequivocal: Individuals who underwent low-dose CT had a 20% lower risk of dying from lung cancer than those undergoing regular chest X-Ray. Despite the fact low-dose CT lung screening was not covered by Medicare or most private insurers, many providers—prompted by the apparent benefits of lung screening—began ramping up screening programs.
Atlantic Medical Imaging has 10 imaging centers in southern New Jersey and was quick off the mark when it came to offering low-dose CT screening, starting a program almost immediately after the results of the NLST were published. “We started in December of 201 and really ramped up in January,” says David Kenny, DO, medical director of Atlantic Medical’s Egg Harbor Township center. “This wasn’t a covered service, but we felt it was something we needed to offer to the community,” he continues.
“And we offered it for free from 2011, with an appropriate prescription, until 2015.”
CT lung screening is offered at eight of the Atlantic Medical Imaging’s 10 locations. From the start, one concern was whether Atlantic Medical Imaging could replicate the NLST experience and results at the community level. “Doing it in the real world as opposed to an academic setting is challenging,” he points out.
For example, Kenny says, in an academic center, a screening program will involve a multidisciplinary team that includes the radiologists who read the studies, as well as oncologists, pulmonologist and thoracic surgeons who become involved with positive results. “So the concern is how do you replicate this in a community when referring physicians have different referral patterns,” he says.
AMI has screened more than 2,000 people since the program started, and Kenny reports that the program is exceeding the expected benefits. The 2,000 screening exams have resulted in the diagnosis of 10 early-stage cancers, which translates to about 1.6 lives saved per 320 persons screened. (In the NLST, 320 individuals needed to be screened to save one life.)
Those 10 early-stage cancers (stages 1 and 2) account for 67% of the total number of cancers detected through screening, which closely mirrors the results of the NLST results, for which 70% of detected tumors were either stages 1 or 2.
“With lung cancer, most patients are diagnosed at stage 3 or stage 4,” he adds. “Diagnosing a cancer at stage 1 or stage 2 is a potential life saved because it’s a cancer that can be removed
surgically. Statistics indicate that more than 230,000 people are diagnosed with lung cancer every year and 160,000 will die. It’s a huge problem, but with lung screening, we find these cancers earlier. That will help reverse those statistics.”
While Kenny believes the benefits to lung cancer screening are clear, he acknowledges drawbacks to screening as well. “There is the theoretical risk of radiation exposure,” he notes, adding that both the dose and the risk is small. He points out that a low-dose lung cancer screening CT exposes a patient to about 1 mSv, “a fraction of the amount of background radiation a person receives living at sea level.”
Stress and anxiety also are involved when a patient gets a positive scan. “Our false positive rate is 37%, which is high,” Kenny says. “But if you follow the American College of Radiology’s algorithm on what to do with positive results and small nodules, patients aren’t being scanned or biopsied unnecessarily. In our database, we have not come across anyone who has had a negative result from an unnecessary biopsy.
“I think the emotional risks associated with false positives might be overstated. If you educate patients appropriately, they understand the context in which they are given results.”
Kenny points out that a high number of patients will have lung nodules. “We’ll tell them that lung nodules are very common—more common in some parts of the country than others. We tell them that the chances of having lung cancer from a small nodule is very, very low.”
The NLST trial determined that out of 230 detected nodules that were less than or equal to 5 mm, just three turned out to be malignant, less than 2%. “We assure them that this is common, and that we will follow up according to ACR guidelines,” he says. “To be honest, we haven’t come across anyone who has had