Health Topics

Screening and Evaluating High Risk Patients

Andrew Schorr:

Right. Let’s talk about that with Dr. Chien for a second. So Barbara of course was a smoker and had been exposed to a lot including chemicals at work that may or may not have made a difference. Dr. Chien, there’s been some discussion, and I don’t know where it stands now and insurance reimbursement and all that for people who may be seen to be at higher risk to be monitored more closely and even some kinds of exams, I’ve heard of spiral CT and all this, to be used. Where do we stand with that for our listeners as to whether they should come to a clinic like yours if they have a certain history?

Dr. Chien:

Right. At the moment it is currently not recommended to screen for lung cancer using low-dose CT scans. This issue about screening for lung cancer has kind of been an ongoing discussion for the last several decades. The initial studies were with sputum, then it was chest x-ray, and now it’s CT scans. Chest x-rays are similar to CT scans but just not as sensitive, but it’s been through the randomized studies, and it’s been shown that while they can pick up lesions earlier, people who were screened with chest x-ray were not less likely to die from lung cancer than people who weren’t screened. Now the jury is still out for low-dose CT scans. The National Institute of Health, the NIH, is currently running a randomized study for low-dose CT scans, and we’re hoping the results will come out by next year so that we can get some guidance as to whether screening with low-dose CT scans will actually be beneficial for high risk patients such as Mrs. Scribner.

Currently because there are no recommendations our clinic’s approach is to take each patient individually and assess their risk in terms of lung cancer, and that would include not only their smoking history but their second hand exposure, their occupational exposure, their family history, and then work with the patient to come up with a solution that is most comfortable with them. So we won’t withhold a low-dose CT scan per se but we also educate the patient about what are the likely outcomes if we do perform a low-dose CT scan, and we also inform them that unfortunately because it’s not a recommended screening procedure their insurance companies are unlikely to pay for that CT scan.

Andrew Schorr:

All right, but if in Barbara’s case for instance, there’s something suspicious spotted on an x-ray or a CT, it’s very appropriate for them to come to a specialized clinic like yours to have the discussion.

Dr. Chien:

Absolutely.

Andrew Schorr:

That seems to be wise to me.

Dr. Chien:

That’s absolutely true. What’s special about our clinic is that this is basically all that our clinic does. We evaluate pulmonary nodules day in and day out, so we do have more experience than the standard community physician with regards to handling these issues, and the other plus is that we have access to many specialists in multiple different areas such as Dr. Wood who can help us take care of these issues very efficiently and rapidly, which is definitely key in curing lung cancer.

Andrew Schorr:

And Dr. Wood just to understand those options. So if there’s something suspicious that needs to be biopsied or if there needs to be surgery, and even in surgery you have multiple approaches, right? It’s not just a single approach. There are a lot of different procedures you do that would be again personalized to that patient’s situation and then radiation and/or chemotherapy again that’s tailored individually as well.

Dr. Wood:

Yes that’s right. I mean there are times that we can tailor a minimally-invasive type of surgery for either diagnosis or treatment or both. There are other times that we have complex tumors that require a major surgery that requires a technically very complex operation that might not be feasible in many centers. So those really get tailored to the individual aspect of the patient.

I’ll go back to the screening aspect that Dr. Chien was talking about. Lung cancer screening is a controversial topic, and we’re all familiar that breast cancer screening has recently been a controversy, and the National Comprehensive Cancer Network, NCCN, that you may be familiar with is one of the largest national bodies that creates guidelines regarding cancer, and they’ve just established a new lung cancer screening committee that I am the chair of to evaluate the data regarding lung cancer screening and to make recommendations on a national level about how to institute screening or whether to institute screening.

Dr. Chien is correct that currently there are no recommendations towards lung cancer screening by any large national or official groups. Nonetheless, many physicians and patients and lung cancer advocates feel that there should be cancer screening for lung cancer, and that’s why it’s controversial, and we have a group that is evaluating the data and will be making recommendations in the next few months similar to those that we’ve had from the U.S. Public Health Service about breast cancer screening.

Andrew Schorr:

Well I know where I come out, and I’ll validate that with Barbara in a second. Dr. Wood, then just from your point of view while the jury’s out, and you’re on the jury if you will, it sounds like for people like Barbara who proactively went to your clinic, or if someone in my family we were suspicious, that for us to make an individual decision to seek further advice that’s not unwise counsel is it? If we’re not comfortable and we have risk factors certainly the downside of not doing it is high and that we would be wise to do that wouldn’t we?

Dr. Wood:

I’m going to urge caution with my answer because the kind of kneejerk response seems like it should be yes that it seems like doing more is always better, but that’s not the case, and that’s what Dr. Chien was mentioning regarding data and screening and relates to a question that you had earlier about x-rays being wrong.

The problem with indiscriminate screening is that it creates a lot of information that may actually be detrimental to a patient, and so what I would urge patients to do is that they have a very thoughtful risk assessment for lung cancer, talk about the pros and cons of cancer screening with their doctor, and if appropriate with our experts in the Lung Cancer Early Detection and Prevention Clinic and make an informed decision about whether it’s appropriate for them to have a CT scan for screening because it’s not routinely appropriate for everyone, and it’s not an easy decision and not an automatic that everybody should have a CT or benefits from it because of the potential negative findings or invasive tests that can result for patients that don’t need it.

Andrew Schorr:

All right, well I understand that. We wish there were clear answers. Dr. Chien, just to end with you from the medical point of view, so you have this clinic though and you all are well educated and with a lot of experience to have that discussion, that individual discussion we were talking about, so for the Barbara Scribner’s of the world with risk factors whether it’s your center or maybe there are a few at probably mostly university centers around the country, that’s okay. You probably see people every day who go the extra mile like that.

Dr. Chien:

Yes, that has actually been a significant portion of our clinic population, which are people who are concerned about their lung cancer risk. In those situations we give a number of recommendations that hopefully help them reduce that risk. The number one thing that any smoker can do is quit smoking immediately, and we actually have a program in house that helps them with that, the Smoke Free Life program. The second thing is that we educate them. Many people who have quit smoking believe that they’re no longer at risk for lung cancer anymore, and that’s absolutely not true. About 60% of lung cancer cases in the United States now are diagnosed among former smokers. So former smokers still need to be aware of their lung cancer risk and aware of their own body and their symptoms that might suggest early disease.

Andrew Schorr:

Right, and I just want to mention there’s a really cool program you have I know where if a cancer patient comes in I think for any cancer I know there’s a program available to them that if their spouse is a smoker you help them to quit, so I think there are some very cool options there.

I want to thank you Dr. Jason Chien and with your Lung Cancer Early Detection and Prevention clinic for being with us and the work that you do, and Dr. Doug Wood thank you so much for all you do and your leadership. I’m really curious how those recommendations are going to come out Dr. Wood, so I was going to say we’ll hold our breath, we can’t do that, but I really wish you well in your evaluation of what’s right really for people probably across the U.S. and I’m sure it will be a guiding light for other countries as well.

Dr. Wood:

Thank you for including me, and I hope we can shed some light on it and come up with recommendations that will help the greatest number of people.

Andrew Schorr:

Right. Barbara I’m going to give you the last word. There’s a team and a man who is the leader of it who helped you as an individual, and I know as you said you’re very thankful.

Barbara:

A very awesome man. That whole clinic is, and I do believe he’s right. Not everybody rushes out to get a CT scan or anything, but I think quit smoking and going and seeing your doctor and him recommending people, but I think UW and Seattle Cancer Care Alliance I think are the best. The main thing is to research. Don’t just give up. Research different things that you can do to help people and stuff like that, and yes their quit-smoking program is awesome, and it helped my family because one thing about quitting smoking is if you nag a smoker they will smoke more, but when my family went to that smoking thing they said that if they support you and help you then you’ll have a better chance, and that’s exactly what happened.

Andrew Schorr:

All right, Barbara Scribner, long, long, long life Barbara.

Barbara:

Thank you so much.

Andrew Schorr:

Thank you so much for being with us. This is what we do on Patient Power. We’ve told a story here, and I think it’s a story first of all of don’t smoke, stop smoking, if you have those risk factors you want to be on top of being evaluated, and it’s certainly in Barbara’s case but to me it seems you want to be evaluated by people who really specialize in it, and we’ve had folks like that on today from the University of Washington.

I’m Andrew Schorr. As always remember, knowledge can be the best medicine of all.

Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you’re your own doctor, that’s how you’ll get care that’s most appropriate for you.