Will the chest CT soon be part of the routine physical?

A recent NEJM study suggests that it may save lives, but there are downsides to routine chest CTs:

“Everyone knows we can pick up things better with screening,” said Dr. Elliott Fishman, a professor of radiology and oncology at Johns Hopkins Hospital in Baltimore. “But is picking up the same thing as curing? If I pick up a tumor that is one centimeter today and you live five years or I pick it up four years later and you live one year, it’s the same thing.”
Even evaluating patients with suspicious CT results can be risky, more dangerous, say, than evaluating women with suspicious lumps on a mammogram, said Dr. David Johnson, deputy director of the cancer center at Vanderbilt University and a past president of the American Society of Clinical Oncology.
In Dr. Henschke’s study, doctors investigated more than 4,000 nodules in patients, finding about 400 early-stage cancers.
“This is not sticking a needle in a breast,” Dr. Johnson said. “It is sticking a needle in the chest, where it can collapse a lung.” In some cases, that is followed by surgery to further evaluate a lump. “How many people do we subject to needless evaluations?” Dr. Johnson asked.

Comments

Anonymous
Great. Annual CTs for “high risk people”, meainng all 46 million adult smokers, their spouses, and others. That’s nearly 100,000,000 scans yearly. As if the radiologists don’t make enough money.
You know, as someone in primary care, this is getting more and more frustrating. I do all the interlectual work – including deciding who to screen, help them quit smoking, deal with insurers, manage rising overhead, quel unsatisfied patients, etc… yet I lose money. While the technician, reaps even more procedual benefits. Just like the SEC, Medicare should investigate why radiologists and their oncology buddies make over $500,000 each. The system is tilted in their favor.
I haven’t even open the doors to my internal medicine practice and I already feel like it’s not worth it. And if I even mention doing concierge medicine, I get the evil eye from the establishment. You know, maybe this country doesn’t deserve my services as a community physician. Frustrating…just frustrating
Anonymous
Hey pal:
The fact is medicare adjusted the oncology practice of billing due to markup of chemo by oncologist’s (and rightfully so). BUT they have still yet to fully compensate for chemo nursing while, if you have not noticed is very specialized. I understand your plight. But don’t blame the subspecialist for insurance company’s and mediciare’s inability to pay primary care doc’s what they are worth. Frankly why should an insurance company be expected to pay for regular CT scans for smokers. Maybe they should take responsibility for their behavior and pay for the scans themselves (if the studies eventually show benefit which they HAVE NOT YET). If someone can pay 5-20 dollars a day for their nicotine habit why can’t they pay for their CT scans?
PS: I was a general internist before going back to fellowship. Why do you think I went back?
Diora
from the NEJM article:
We estimated the 10-year lung-cancer–specific survival rate
Have these guys ever heard of lead-time bias?
Annual spiral CT screening can detect lung cancer that is curable.
Can it also detect the one that would’ve never progressed? Because it is sure easy to cure a non-progressive cancer. I haven’t seen estimates of overdiagnosis in the article.
Not that I care about smokers. Hey if a false positive causes scares someone into stopping smoking this could be an extra benefit. But what is to prevent some doctors to start sending everyone for this test and not just smokers?
Anonymous
The short answer Diora: Nohting.
Anonymous
” But what is to prevent some doctors to start sending everyone for this test and not just smokers?”
Not waking up every morning scared shitless that I’m going to end up spending 6 months being sodomized in court just for clocking in at work. Being able to get off the psych meds me and my colleagues have to take because it’s just gotten too hard to deal with the daily stress of another frivolous lawsuit for just doing our job. It’s called tort reform, but since Politicians don’t give a shit, I will keep ordering millions of dollars in useless tests. I don’t have a high powered legal team. Test ordering is my ONLY protection and defense.
slugger
Diora:
The issue of overdiagnosis was looked at by Marcus in J Nat Cancer Inst 98:724 using data for the old Mayo Clinic chest X-ray study that ended in 1983. They found 85 overdx out of 585 cases detected. There were 6100 study participants.
Diora
Slugger, thanks.
But if chest CT is able to detect cancer even earlier, wouldn’t there be more overdiagnosis?
Also, haven’t there been studies of chest X-ray that failed to find any mortality benefit?
Just asking — too much work nowadays to look stuff up myself.
Anonymous
“I haven’t even open the doors to my internal medicine practice and I already feel like it’s not worth it. ….. You know, maybe this country doesn’t deserve my services as a community physician”
With this attitude I can assure you to get out now. Nobody will want to see you. Forget even being a concierge at a hotel, they won’t want you either. BTW do you know how many taxpayer dollars subsidized your training?
Anonymous
“How many people do we subject to needless evaluations?”
How many people have plaintiff’s attorneys subjected to needless evaluations in cahoots with slimeball physicians in asbestos litigation screenings? How about cardiac evaluations for fen-phen? I’m sure we could get the trial bar to fund these screening CT’s; no need to get health insurers involved.
Anonymous
The only logical response to this article is to buy stock in Siemens and GE. Siemens medical imaging division is a larger part of their income stream then GI, so a bump in their CT scanner deman will result in more profit per dollar invested. They are trading at a PE of 27. Just document you suggested to each smoker they get this and pay for it out of pocket. Do not fight the system. Be the stream.
b
Anonymous
“The only logical response to this article is to buy stock in Siemens and GE.”
I beg to differ. GE is a huge company, some extra CT scans won’t bump it’s bottom line. I would buy the radiology outsourcers, ie Nighthawk radiology (NWHK) all they do is read films. On the same theme, there’s a company in San Diego called Biosite (BSTE) that makes alot of the defensive tests we order in the ER, like Troponin and BNP.
I have no postions in any of these stocks, though my mutual funds own GE.
SarahW
“If I pick up a tumor that is one centimeter today and you live five years or I pick it up four years later and you live one year, it’s the same thing.”“
The date of death may be the same.
Why does this physician not realize that knowlege of what is happening in one’s own body has value?
A known life-threatening illness changes, in most cases, a person’s priorities. It allows estate planning and adjustments to expenditure and investment of resources. Events otherwise postponed by the person move to the front burner ( a marriage, a trip, a task, a purchase, etc….) – to get things done while on’es state of health allows it to be accomplished.
It can explain nagging symptoms that frustrate a patient and the patient’s family – ending denial and dismissal or suspicion of the patient as malingerer – sometimes even by the patients physician.
KNowing has value, even if it doesn’t alter the actual date of death.
Diora
If I pick up a tumor that is one centimeter today and you live five years or I pick it up four years later and you live one year, it’s the same thing.”"
A known life-threatening illness changes, in most cases, a person’s priorities. It allows estate planning and adjustments to expenditure and investment of resources.
Yes, but think about quality of life implications. Keep in mind, they are not talking about people who have “nagging” symptoms – anyone with symptoms should go to the doctor who is likely to order diagnostic tests. Screening is by definition for symptomless people. So if a symptomless person finds out about it 4 years from now, and dies within a year, he lives 4 years as a healthy person and one year as a dying person. Finding out 5 years (without change in the ultimate outcome) means that one lives for 5 years as a cancer patient – with corresponding morbidity from the treatment. So yes, you gain advance knowledge, but you loose what could be last 4 good years of your life. So the benefit of it is not as obvious as it seems.
Also, for every person who gets this “advance knowldedge”, many healthy people will get false positive results – which in case of this particular test carry significant risks; and some people will get converted into cancer patients even if their “cancer” would never have spread and suffer from side effects, sometimes for lifetime, and can get their life shortened as the result. A poster above listed an estimate, but this is from only one study and from an X-rays. The numbers from a test that is able to pick up even earlier cancers are likely to be higher.
This why some evidence that CT saves lives is really important; otherwise, more people can get hurt than are helped.
Diora
If I pick up a tumor that is one centimeter today and you live five years or I pick it up four years later and you live one year, it’s the same thing.”"
A known life-threatening illness changes, in most cases, a person’s priorities. It allows estate planning and adjustments to expenditure and investment of resources.
Yes, but think about quality of life implications. Keep in mind, they are not talking about people who have “nagging” symptoms – anyone with symptoms should go to the doctor who is likely to order diagnostic tests. Screening is by definition for symptomless people. So if a symptomless person finds out about it 4 years from now, and dies within a year, he lives 4 years as a healthy person and one year as a dying person. Finding out 5 years (without change in the ultimate outcome) means that one lives for 5 years as a cancer patient – with corresponding morbidity from the treatment. So yes, you gain advance knowledge, but you loose what could be last 4 good years of your life. So the benefit of it is not as obvious as it seems.
Also, for every person who gets this “advance knowldedge”, many healthy people will get false positive results – which in case of this particular test carry significant risks; and some people will get converted into cancer patients even if their “cancer” would never have spread and suffer from side effects, sometimes for lifetime, and can get their life shortened as the result. A poster above listed an estimate, but this is from only one study and from an X-rays. The numbers from a test that is able to pick up even earlier cancers are likely to be higher.
This why some evidence that CT saves lives is really important; otherwise, more people can get hurt than are helped.

Will the chest CT soon be part of the routine physical?

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