physicians should use their specialized training to determine how well or poorly guidelines fit a given patient. Just as there are rare patients with congestive heart failure for whom b-blockers may not be appropriate, there may be rare patients at a low risk of lung cancer for whom consideration should nonetheless be given to obtaining a chest CT scan. The goal of improving the value of health care, and the essential roles of physicians in furthering this social mission, need not require cookbook approaches to clinical practice that place absolute prohibitions on clinical service use.
Acknowledgments Role of sponsors: The sponsors had no role in determining the content of this manuscript or in the decision to submit it for publication.
References 1. Simpson T. Counterpoint: are there cases in which physicians should deviate from recommendations not to order a chest CT scan? No. Chest. 2014;146(5):1147-1149.
Rebuttal From Dr Simpson Tamara Simpson, MD; San Antonio, TX
Dr Halpern1 has made several very interesting points that warrant further discussion. Physicians indeed have the responsibility to follow screening guidelines, which are established by experts in the field after reviewing all available data, weighing the risks and benefits, and taking into consideration the overall value of a given screening test.2 This patient does seem to be experiencing some psychologic stress related to the residual scar, and this must, of course, be considered when deciding how to proceed. However, the potential downstream psychologic effects and costs and the potential harm to the patient must also be considered. Assuming that this patient does have a scar by radiograph, it is not far-fetched to predict
AFFILIATIONS: From the Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center at San Antonio. FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. CORRESPONDENCE TO: Tamara Simpson, MD, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center at San Antonio, 7400 Merton Minter Blvd, 111E, San Antonio, TX 78229; e-mail: [email protected] © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-1588
1150 Point and Counterpoint
that the CT scan will also be somewhat abnormal, and this could require further potentially harmful imaging and/or procedures in an attempt to offer consolation and closure to the patient. This is a perfect opportunity for the physician to discuss with the patient the natural radiologic evolution of pneumonia, help weigh the risks and benefits of CT imaging, and offer genuine words of reassurance and encouragement for continued smoking cessation. As Dr Halpern states, the Choosing Wisely Campaign, which is endorsed by the American College of Chest Physicians and the American Thoracic Society, strongly suggests that physicians not “perform CT screening for lung cancer among patients at low risk for lung cancer.”1,3 Based on the age and smoking history criteria, this patient would not be considered at a high risk of lung cancer. If the United States truly wants to get a handle on the rising health-care costs and wants to make health care accessible to all, recommendations such as those established by the Choosing Wisely Campaign must be followed. Lastly, it is important to discuss the recent decision by the panel of the Centers for Medicare and Medicaid Services regarding the National Coverage Analysis for low-dose CT (LDCT) scan lung cancer screening. The Centers for Medicare and Medicaid Services’ advisory panel, composed mainly of physicians, voted against recommending national Medicare coverage for annual LDCT scan screening in high-risk patients, citing many of the concerns stated here, including the potential harm of radiation and subsequent procedures, as well as the difficulty in replicating the results of the National Lung Screening Trial in a community-based setting.4,5 In conclusion, the discussion of lung cancer screening with LDCT scans is far from over. Given the morbidity and mortality related to lung cancer, most agree that some sort of screening program is necessary. However, more research is needed before mass implementation of such programs. It is good to see from Dr Halpern’s comments that he certainly appreciates both sides of this controversial topic.
References 1. Halpern SD. Point: are there cases in which physicians should deviate from recommendations not to order a chest CT scan? Yes. Chest. 2014;146(5): 1145-1147. 2. Sox HC, Blank L, Cohen J, et al; ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243-246.
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3. American College of Chest Physicians and American Thoracic Society Choosing Wisely Task Force. Top 5 list in pulmonary medicine. The ABIM Foundation website. http://www.choosingwisely.org/ doctor-patient-lists/american-college-of-chest-physicians-andamerican-thoracic-society. Accessed June 1, 2014. 4. Crawford C. American Association of Family Physicians. Medicare panel recommends against covering CT screening for lung cancer.
journal.publications.chestnet.org
AAFP News. May 21, 2014. http://www.aafp.org/news/health-of-thepublic/20140521medcacctrec.html. Accessed June 1, 2014. 5. Meeting MEDCAC. 4/30/2014 – Lung cancer screening with low dose computed tomography. Centers for Medicare and Medicaid Services. http://www.cms.gov/medicare-coverage-database/details/ medcac-meeting-details.aspx?MEDCACId=68. Accessed June 1, 2014.
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Acknowledgments Role of sponsors: The sponsors had no role in determining the content of this manuscript or in the decision to submit it for publication.
References 1. Simpson T. Counterpoint: are there cases in which physicians should deviate from recommendations not to order a chest CT scan? No. Chest. 2014;146(5):1147-1149.
Rebuttal From Dr Simpson Tamara Simpson, MD; San Antonio, TX
Dr Halpern1 has made several very interesting points that warrant further discussion. Physicians indeed have the responsibility to follow screening guidelines, which are established by experts in the field after reviewing all available data, weighing the risks and benefits, and taking into consideration the overall value of a given screening test.2 This patient does seem to be experiencing some psychologic stress related to the residual scar, and this must, of course, be considered when deciding how to proceed. However, the potential downstream psychologic effects and costs and the potential harm to the patient must also be considered. Assuming that this patient does have a scar by radiograph, it is not far-fetched to predict
AFFILIATIONS: From the Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center at San Antonio. FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. CORRESPONDENCE TO: Tamara Simpson, MD, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center at San Antonio, 7400 Merton Minter Blvd, 111E, San Antonio, TX 78229; e-mail: [email protected] © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-1588
1150 Point and Counterpoint
that the CT scan will also be somewhat abnormal, and this could require further potentially harmful imaging and/or procedures in an attempt to offer consolation and closure to the patient. This is a perfect opportunity for the physician to discuss with the patient the natural radiologic evolution of pneumonia, help weigh the risks and benefits of CT imaging, and offer genuine words of reassurance and encouragement for continued smoking cessation. As Dr Halpern states, the Choosing Wisely Campaign, which is endorsed by the American College of Chest Physicians and the American Thoracic Society, strongly suggests that physicians not “perform CT screening for lung cancer among patients at low risk for lung cancer.”1,3 Based on the age and smoking history criteria, this patient would not be considered at a high risk of lung cancer. If the United States truly wants to get a handle on the rising health-care costs and wants to make health care accessible to all, recommendations such as those established by the Choosing Wisely Campaign must be followed. Lastly, it is important to discuss the recent decision by the panel of the Centers for Medicare and Medicaid Services regarding the National Coverage Analysis for low-dose CT (LDCT) scan lung cancer screening. The Centers for Medicare and Medicaid Services’ advisory panel, composed mainly of physicians, voted against recommending national Medicare coverage for annual LDCT scan screening in high-risk patients, citing many of the concerns stated here, including the potential harm of radiation and subsequent procedures, as well as the difficulty in replicating the results of the National Lung Screening Trial in a community-based setting.4,5 In conclusion, the discussion of lung cancer screening with LDCT scans is far from over. Given the morbidity and mortality related to lung cancer, most agree that some sort of screening program is necessary. However, more research is needed before mass implementation of such programs. It is good to see from Dr Halpern’s comments that he certainly appreciates both sides of this controversial topic.
References 1. Halpern SD. Point: are there cases in which physicians should deviate from recommendations not to order a chest CT scan? Yes. Chest. 2014;146(5): 1145-1147. 2. Sox HC, Blank L, Cohen J, et al; ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243-246.
[
146#5 CHEST NOVEMBER 2014
]
3. American College of Chest Physicians and American Thoracic Society Choosing Wisely Task Force. Top 5 list in pulmonary medicine. The ABIM Foundation website. http://www.choosingwisely.org/ doctor-patient-lists/american-college-of-chest-physicians-andamerican-thoracic-society. Accessed June 1, 2014. 4. Crawford C. American Association of Family Physicians. Medicare panel recommends against covering CT screening for lung cancer.
journal.publications.chestnet.org
AAFP News. May 21, 2014. http://www.aafp.org/news/health-of-thepublic/20140521medcacctrec.html. Accessed June 1, 2014. 5. Meeting MEDCAC. 4/30/2014 – Lung cancer screening with low dose computed tomography. Centers for Medicare and Medicaid Services. http://www.cms.gov/medicare-coverage-database/details/ medcac-meeting-details.aspx?MEDCACId=68. Accessed June 1, 2014.
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