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Dr. Jack West is a medical oncologist and thoracic oncology specialist, and Executive Director of Employer Services at the City of Hope Comprehensive Cancer Center in Duarte, CA.

American Academy of Family Physicians Denies Utility of Chest CT Screening: A Harmful Slight to the Lung Cancer World
Fri, 01/24/2014 - 15:00
Author
Howard (Jack) West, MD, Associate Clinical Professor, Medical Oncology, Executive Director, Employer Services, Founder, President and CEO of GRACE

This week, the American Academy of Family Physicians (AAFP) elected to not follow the lead of the more influential US Preventive Services Task Force (USPSTF), which previously reviewed the information on chest CT screening for high risk patients and recommended it, and said that there is insufficient evidence to support chest CT screening.

The specific arguments were that, when the evidence from the National Lung Screening Trial is combined with some other, less definitive studies, there wasn't a clear enough signal of benefit to support chest CT screening, per Dr. Doug Campos-Outcalt, MD, MPA, the AAFP liaison to the USPSTF.

"People need to understand that their life expectancy could be extended by this, but on the other hand, their life expectancy could be shortened by it," Dr. Campos-Outcalt said in a statement. "If they're currently smoking, a better thing to do by far is to stop smoking."

I would challenge Dr. Campos-Outcalt to show us the evidence that their life expectancy could be shortened by screening, as his statement implies that the evidence is of equal strength for either concept. In fact, there is exponentially greater evidence that people can have their lives extended by screening than that it is harmful, though I am circumspect enough to recognize that there are limitations in how screening might be best applied.

At the same time, framing this issue as if there is some choice between continuing to smoke and screening for lung cancer might charitably be called asinine. Yes, smoking cessation saves lives as well, but lung cancer screening doesn't preclude this in any way and can even serve as an ideal point for initiating a new effort at smoking cessation for patients being screened who continue to smoke.

My view is that this declaration is a testament that you can interpret data selectively to support whatever preconceived biases you want. That the AAFP would say that a series of less well conducted, smaller studies that support the same conclusion to a lesser degree somehow refutes the more definitive conclusions of the NLST is befuddling, and it is telling that so many other professional societies, including the very evidence-based USPSTF, has reviewed these data and reached the opposite conclusion.

Unfortunately, I'm afraid that the AAFP stand on this complex issue likely reflects an unenlightened nihilism and a reluctance to recognize data that require changing practice. I suspect that the economic implications of screening are more of a driver here than an honest, balanced assessment of the actual evidence.

I can only hope that the USPSTF judgment outweighs the dismissal by the AAFP, or that people question the judgment of family practitioners here, who are making a unilateral decision to let potentially preventable lung cancers take the lives of people as they quibble about the lack of sufficient evidence -- similar to the arguments used by the tobacco industry that challenged the quality of the data supporting a link between smoking and lung cancer.

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