Counseling Patients on Lung Cancer Screening Concerns
Philippa Cheetham, MD: Do you find that some patients are reluctant to have a CT scan because of the radiation?
Kim L. Sandler, MD: I do, and I think there’s misinformation about the amount of radiation and also the effect that an amount of radiation can have on a patient. Patients who are younger are much more susceptible to radiation-induced cancers than we are as we get older. So, the patients who we’re screening based on their age group, it’s very, very unlikely that we would induce any abnormality based on the radiation from these scans.
Philippa Cheetham, MD: Now, we know that trying to get CT scans or MRI scans in the medical profession, they’re not cheap and insurance companies will do anything to avoid paying for these. Chest X-rays are cheaper. Because this is a screening program, is it fair to say that if a patient meets the screening criteria of 55 to 75 years old, there’s not going to be any issue with getting the CT scan approved by insurance? Is that pretty much a done deal that it will be approved? There’s no issue of the doctor having to get on the phone and go through the patient’s risk factors? Because for many doctors, that’s a huge amount of time and often an obstacle to patients getting the test they need in the first place.
Kim L. Sandler, MD: Absolutely. And based on the USPSTF (United States Preventive Services Task Force) guideline recommendation of falling under this class B categorization, this exam is covered in full by Medicare. And then typically what happens is the private insurers will then follow suit and adopt the Medicare policies. So, as long as the patient has some form of insurance, the exam is covered in full without a co-pay.
Philippa Cheetham, MD: And what happens for patients who may have no insurance, is there any support for those patients?
Kim L. Sandler, MD: I think that’s also institution specific. So, we offer the exam. We have to offer it at the same price that Medicare pays because of healthcare regulations, but we will help patients pay for those exams. We have them pay one-third of the cost initially and then can arrange payment plans for them. We’re also working very hard to raise funds through other means to help patients pay for the exams if they don’t qualify.
Philippa Cheetham, MD: We’ve heard about the screening for patients. Two points I wanted to bring up. If you are a lifelong non-smoker but you’ve lived with a lifelong heavy smoker, does that bring you into the screening criteria? And where do we bring patients like Chris’s wife into the equation who didn’t meet any of the screening criteria? Should we have exceptions to the rule for screening? Do you think the screening program needs to change to accommodate other patients like Chris’ wife?
Kim L. Sandler, MD: I think, with the first question about second-hand smoke, that screening is not approved for those who have been exposed to second-hand smoke and there have not enough data available yet to say that the benefit of screening would outweigh the risks. In terms of Chris’ wife, I believe that screening should change to more of a risk prediction model. I think we’re going to have more and more evidence that shows us that someone who’s currently smoking two packs a day but maybe slightly younger is at higher risk than someone who quit smoking 10 years ago. I don’t think that this type of screening will ever be applicable, unfortunately, to younger patients who take very good care of themselves, they’re very healthy, they’re non-smokers. I think once we move to things like blood tests, like we’ve seen with BRCA mutations in breast cancer, I think there will be other means to help detect those cancers earlier in patients.
Philippa Cheetham, MD: If someone has been involved in meeting Chris, hearing about Team Draft, going on the American Lung Association and says, “Well, I don’t really have any risk factors, but I’m aware, I’m educated, I’m concerned, and I want to have a non-contrast CT scan anyway and if need be, I’ll pay out of pocket,” is that something that you would recommend for a patient who may just want to know they have the disease or not?
Kim L. Sandler, MD: We are absolutely happy to have that discussion with anyone who thinks that they may need a screening exam, and we will sit down and have a consultation with them, discuss their individualized risk factors. Every time a patient comes to our program, we give them their personalized risk of developing lung cancer in the next six years. So, your risk of developing lung cancer in six years is this percent based on your history. Someone who hasn’t smoked and is younger, their risk is going to be so incredibly small that I think that may change their mind. They may then say, “Well, here’s all of the evidence, my risk is really negligible. There are probably other things I could be doing to take care of myself and my health, and my screening, and this isn’t necessarily the test for me.” But we will always have that conversation with patients who are interested.
Philippa Cheetham, MD: So, I guess when a patient turns up for screening, they’re focused on, “Wow, this result may not turn out to be good news.” That’s a great opportunity to educate people about smoking cessation and awareness. How do you strike while the iron is hot?
Kim L. Sandler, MD: We talk about things in their lives that would be made better if they were able to quit smoking. How much more time could you spend with your family? What are some of the activities that you may want to do if you’re able to quit smoking? How ready are you right now to quit? And if they say, “You know what, it’s just not the right time, I’m not going to be able to do it,” we don’t push anyone by saying, “You absolutely need to stop now.” We say, “Well, maybe we’ll revisit this conversation in six weeks. We’re happy to call you. Maybe if you want to wait longer, we’ll contact you then. And also, here’s some information for our quit line. Here are some people you can contact if you have questions.” If you want to talk about different medications that are available to help you quit smoking, we can talk about that as well, but we really try to focus on all of the benefits that would come by being able to quit smoking.