In 2011, the National Lung Screening Trial (NLST) gave hope that a screening test could make a major impact on a cancer whose mortality is typically high. In 2014, the U.S. Preventive Services Task Force recommended that when patients met appropriate clinical criteria, it was reasonable to consider screening CT scans to look for cancer. The Task Force appropriately recognized that false-positives and the work ups of those false-positives can bring harms to some patients, and in what has become common in guidelines, shared decision making (SDM) was recommended. Shared decision making can help clinicians and patients negotiate these tradeoffs to make optimal choices for that patient, and Medicare went a step further, requiring documentation of SDM to allow payment of the screening CT scan.
To aid clinician’s understanding of the impact of this illness, Dr. Martin Tammemagi and others developed risk score methodologies that allow us to give individual patients their cancer risk to guide the decision. Initially, HealthDecision’s lung cancer screening tool, like all others, focused on the one choice of getting annual screening CT scans or not. While this is an important decision and our tools have helped clinicians and patients negotiate these choices, for many patients, another choice is present as well. In the NLST, 48% of subjects were current smokers and while quitting smoking has its challenges, current smokers have a second way they can substantially reduce lung cancer deaths.
At HealthDecision, we are thrilled to offer an enhancement to our lung cancer tool that demonstrates the individualized risk reduction for patients who decide to quit smoking today. Fascinatingly, the risk reduction with smoking cessation is often a little bit better than the risk improvements gained by CT scanning. There is also the big difference of what it is that gets saved. Screening CT scans don’t stop cancers from occurring, and in fact, with overdiagnosis, can identify cancers that would have been better left alone. The benefit of CT scans is that earlier and more effective treatments will be delivered, saving some patients from a cancer death and making them survivors. Quitting smoking on the other hand, saves cancer incidence, meaning the cancer is never detected. Stopping cancer before it gets started dramatically reduces cost and morbidity compared to treating cancer with surgery and other therapies.
A key element of shared decision making is reviewing the benefits and harms of different decisions. While we have had tools to facilitate the conversation about CT scans, I am thrilled that the HealthDecision tool can now bring a similar focus to the decision of quitting smoking as well.
In my practice as a cardiologist, smoking is a major risk for heart attacks and cardiac death as well. My patients who smoked knew these risks existed, but were often uncomfortable discussing the topic, concerned about being lectured, or talked down to about their addictive habit. I found, however, that having an objective way to show the risk improvements of quitting smoking, just as I would demonstrate benefits of a medication, helped normalize the conversation and get the two of us onto the same side of the problem looking for best solutions.
Screening the right people for lung cancer will save lives. Showing a smoker another way they can reduce cancer risk may save even more.