Exploring rare potential harms from low-dose CT lung cancer screening to aid decision making

Several recent studies have explored the potential benefits of screening for lung cancer with low-dose CT. But what about the potential harms, particularly among minority populations treated at safety-net hospitals?

Philadelphia physicians recently set out to explore these questions, conducting a prospective study including nearly 1,000 patients screened for the disease. They found rare instances of harm, highlighting five example patients whose cases can help inform future discussions, according to a study published Sept. 9 in the Annals of Thoracic Surgery.

In one instance, CT of a 74-year-old Black female patient revealed an 8 mm nodule in the right upper lobe that further imaging confirmed was lung cancer. However, the woman declined treatment until two years later when she experienced discomfort breathing, leading to a biopsy and radiation therapy.

“In-depth discussions about willingness to undergo treatment must be done before screening to avoid scenarios like this,” Lynde Lutzow, MD, with the Department of Surgery at Temple University Health Systems, and colleagues advised. “Levels of mistrust are higher in underserved and minority patients given instances of racism, implicit bias, and microaggressions experienced by these patients in the healthcare system,” they added later. “Specifically, African American lung cancer patients are more likely to decline surgery compared to their White counterparts. Our patient illustrates how clinical care experiences must facilitate trust between clinician and patient to successfully deliver [shared decision making] for [lung cancer screening].”

Scientists conducted the study between 2014-2019 at an urban safety-net institution, including a two-year follow-up period. Out of 995 individuals who received LDCT testing, nearly 55% were Black, 11% Hispanic, and doctors diagnosed 2.9% with lung cancer (higher than other previous trials), with nearly 86% at a treatable stage. Lutzow et al. noted a 9.4% false-positive rate resulting in unnecessary procedures in seven patients (0.7%) but zero major complications or deaths.

Lutzow and colleauges highlighted other cases including an 80-year-old Black male smoker who received a false positive but later turned out to have granuloma. In another instance, a false negative in a 59-year-old Black man with a history of smoking later led to dyspnea, a stage 3 diagnosis, and his death from the disease three months after lobectomy. The authors noted additional challenges facing this patient group but see screening as feasible.

“Multiple factors impact the delivery of high-quality LCS to this underserved population including incorporation of comorbidities into treatment plans and effective communication in cases of low health literacy,” Lutzow and authors advised. “Our study demonstrates successful implementation of LCS in a safety-net institution with a predominantly African American population. However, scaling this successful model to larger populations will be challenging. We estimate 12,000 patients are potential candidates for LCS, and our annual uptake of screening in this study population is approximately two percent.”

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