Whether a hospital should halt lung cancer screening during COVID-19 or any other pandemic depends on factors such as local infections and resource availability, debaters agreed at the Society of Thoracic Surgeons (STS) virtual meeting.
With no evidence for what would happen to society and health system resources if screening were to continue, and no data on the risk to patients with undetected lung cancer if screening stopped entirely, the best one can do is to “make something up,” according to Frank Detterbeck, MD, of Yale University School of Medicine.
Arguments for Pausing
Detterbeck took the position that a given center should suspend its lung screening program, arguing that such screening exposes many more patients to potential infection — from moving around or within a hospital — than the small number of lung cancer deaths that would be averted because of screening.
Since the pandemic started in 2020, COVID-related deaths account for the bulk of excess deaths in the U.S., far surpassing mortalities attributed to lung cancer, he said at the STS session.
Detterbeck was part of a CHEST task force that concluded last summer that it was reasonable to delay a surveillance CT scan by 3-6 months for a variety of situations during the COVID-19 pandemic, consistent with CDC guidance to defer non-urgent care. Those at 65%-85% risk of malignancy need PET or non-surgical biopsy to confirm a need to treat, the group decided, while those with even higher risk should skip further testing and proceed straight to treatment.
He cited the non-small cell lung carcinoma tumor doubling time of roughly 500 days on CT screening, as well as the NELSON and MILD trials that found higher-stage lung cancers not to be affected very much by the screening interval.
The guiding principle is to minimize the number of procedures but also make sure that patients are not needlessly going into the operating room, Detterbeck said.
Arguments for Continuing
Taking the position that lung cancer screening should be continued was Douglas Wood, MD, of University of Washington, Seattle.
He agreed that most screened individuals do not have cancer, but screening is important and urgent to those who do. Delayed diagnosis increases cancer stage and cancer mortality in these patients, he said, citing various randomized and observational studies.
Even if cancer treatment is temporarily delayed, he argued that diagnosis remains important as it allows clinicians to identify who the urgent cancer patients are, to prepare for resumption of care, and to avoid a backlog of delayed scans.
What’s more, the experience with COVID-19 has taught researchers that hospital transmission of SARS-CoV-2 is minimal where there are universal masking policies. One study showed that out of 9,149 people admitted to a large Boston medical center in the spring, there were only two hospital-acquired cases, according to Wood.
“Public health messaging should emphasize that avoidance or delay of needed and urgent health care is not necessary,” he told the STS audience.
“At the beginning of this, we shut down and told people not to come in. We told people a healthcare system was dangerous in March of last year, and then as we tried to restart screening programs, we struggled to get the programs back to their former levels … The message we gave last year was well-intentioned but we didn’t know what was behind it,” Wood said.
Finally, lung cancer screening is done in the outpatient setting and therefore does not divert hospital resources and personnel from inpatient acute care during a pandemic — that is, unless the hospital has reached the crisis stage and radiologists are being redeployed to acute care, according to him.
No Single Answer
Wood highlighted the principle of just resource allocation in medical ethics. On one hand, putting barriers to screening will disproportionately affect marginalized populations; on the other hand, he said, to continue screening when a health system is strained by a pandemic goes against the principle of “distributive justice.”
“Obviously, an extreme position is untenable. As with everything in life, it is a question of distinguishing shades of gray,” Detterbeck acknowledged from the start.
“Whether you suspend lung cancer screening or not depends on your situation. L.A. [Los Angeles], right now you should suspend. They are struggling with resources. We suspended our screening program but as things settled down and under control, and we have systems in place — we COVID test people and we limit how many scans we do per hour — we have restarted and been doing that for quite some time now. You have to be thoughtful how you do it,” he said.
Wood agreed that the current surge in L.A. would call for centers to “back off” on lung cancer screening.
“My point is those are small isolated parts of the pandemic, that we’ve used a blunt instrument in telling everyone to stop screening when almost everyone could still screen safely. And then have these specific circumstances, New York last year and L.A. now, where there are reasonable times to say ‘let’s pause’ by caring for those surge pandemic patients,” according to Wood.
Detterbeck agreed that throughout the pandemic, most parts of the country have probably not been hit so hard that they needed to pull back from procedures like screening.