Should tobacco companies pay for screening tests?

Smokers are suing to find out:

A group of heavy Marlboro smokers have filed a lawsuit in federal court in Boston, asking Philip Morris USA to pay for screenings that may detect the early stages of lung cancer, court documents showed on Friday.
The class-action lawsuit, which was filed on behalf of current and former Marlboro smokers over 50 years old who smoked a pack or more a day for 20 years, demands the tobacco company pay for an annual low-dose X-ray scan of the chest.

However, a basic flaw in their argument. There is no data that routine chest X-rays or CTs lead to a mortality improvement.

Comments

SarahW
I don’t think there can be much doubt that it will lead to earlier detection of suspicious lesions, however. And unless investigating such lesions in heavy smokers causes more harm than not finding and investigating them, it’s a clear benefit to know of disease ASAP, even if it doesn’t extend your life. In heavy smokers the lesions are far less likely to be “nothing”, and it runs counter to reason to suggest that earlier detection and earlier treatment of malignant lesions will not improve outcome, and improve survival rates. But assuming it means that the cancer is simply found earlier, that’s still a tremendous benefit to the affected person, who is likely to “live harder” and smarter, with a life-threatening diagnosis, getting more out of life and providing better for loved ones instead of just drifting along.
Anonymous
And unless investigating such lesions in heavy smokers causes more harm than not finding and investigating them, it’s a clear benefit to know of disease ASAP…
So damn the evidence? The harm is not to those who have disease, it is to those who do not. How many “healthy” people should have open lung biopsies because of false-negative exams in order to find one true-positive lesion, treatment of which has not been shown to prolong life?
Anonymous
of course tobacco companies should not pay for screening tests… people know smoking is bad, they did it knowing it will ruin their body.. that is their own problem not philip morris’s
SarahW
I never damn evidence. However, there is no evidence that screening will shorten life in that select population of heavy smokers, and it is counter-intuitive to suggest that earlier detection and treatment will have no positive effect on a population particularly at risk of malignancy related to heavy smoking.
If managed properly a screening program such as this would be a possible way to GET evidence, in a willing population.
Whether a company that actively encouraged people to minimize smoking harms should pay for such tests is obviously up for debate, and it’s reasonable to argue that foolish people should pay for their own foolish choices. But as far as the intrinsic use of screeing, it would without any doubt be of use in this select population. My argument is essentially that improved mortality is not the only measure of whether this testing is of benefit to heavy smokers. There are other benefits to be gained that are worthy of consideration.
Anonymous
Obviously you do not study medicine. There are definite cases in which screens (think Prostate Specific Antigen for example) do not decrease mortality. It is counter intuitive, but not everything in the world is intuitive.
SarahW
Anonymous 2:52 –
There are lots of reasons prostate antigen testing is of questionable usefulness, form the lack of specifictiy of the test to the natural history of prostate cancer – and CT screening of a select population of heavy (former or current) smokers is a horse of a different color. The signifigance of a lung lesion in a heavy smoker is not the same as that of an elevated PSA in the general population of males.
Kevin’s flat statement that there is no data that routine CT screening improves mortality really ought to be qualified. There is data highly suggestive that there is improvement in mortality in that subset of the population that has smoked, or smokes, heavily, and demonstates an early lung lesion detected by a screening CT.
Rich, MD
The recent study of CT screening in smokers suffers from a fatal flaw – it throws out any assessment of lead-time bias. I believe this has been discussed previously on this blog.
Lead-time bias occurs when there appears to be a decrease in mortality because of screening and “early detection”, when in fact the clock just started ticking earlier.
Take 2 identical smokers. One has a CT today which shows a lesion, he undergoes treatment, and dies in five years. The other has no CT and develops a bloody cough in 3 years, dying two years later. If lead-time bias is ignored, the CT-screened patient had a 5 year survival, while the non-screened patient had only a 2 year survival. In reality, they are identical, and died on the same day, but the CT-screened patient underwent three additional years of invasive surgery and chemotherapy.
This has been shown on several studies of radiologic screening of smokers (better called “case-finiding” since the patients are being selected).
Even though it may be counter-intuitive, it is what it is. Also, “highly suggestive” data is just that, suggestive, not conclusive or even significant. I believe there was highly suggestive data that Vioxx did not increase the risk of cardiovascular events, either.

Should tobacco companies pay for screening tests?

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