A video on the website of Wisconsin-based Gundersen Health System makes an emotional pitch for lung cancer screening.
We see a woman blowing soap bubbles with a child. A jogger exhaling after a winter run. A multi-generational family cheering at something on TV. An older woman blowing out candles on a birthday cake.
“Your lungs allow you to enjoy moments like these,” the video says. “Don’t take them for granted.”
“Love your lungs. Get screened.”
That promo was cited in a study published this week that documents overly optimistic messaging about lung cancer screening.
While screening for lung and other cancers has largely been put on hold as a result of the coronavirus pandemic, overzealous marketing remains a problem.
Lopsided information about lung cancer screening is a topic we’ve covered dozens of times on HealthNewsReview.org. The new study, published in JAMA Internal Medicine, quantifies the extent of it.
Researchers at the University of North Carolina at Chapel Hill examined 162 lung cancer screening program websites run by academic and community medical centers. Potential benefits of screening were presented 98 percent of the time while potential harms were mentioned only 48 percent of the time.
Only 10 percent mentioned the important harms of overdiagnosis (finding a condition that would never have caused a problem) and incidental findings — which can trigger a cascade of testing and treatment that may lead to anxiety and other harms.
Just 22 percent encouraged people to engage in shared decision-making with a doctor as recommended by medical guidelines.
The findings are “disappointing but not surprising,” according to an accompanying editorial by three longstanding critics of the overuse of screening tests: Steven Woloshin, MD, and William Black, MD, of The Dartmouth Institute for Health Policy and Clinical Practice and Barnett Kramer, MD, of the National Cancer Institute.
They noted that only 44 percent websites quantified a benefit, and few provided absolute numbers that would give a clear sense of that benefit.
In fact, for every 1,000 people at high risk who are screened over seven years, three lung cancer deaths would be avoided. (Of course, that means that 997 other people would need to be screened, someone would have to pay for those scans, and all would be exposed to radiation — with no chance of benefit. Going in, you wouldn’t know whether you were one of the three or one of the 997.)
Lung cancer screening with low-dose computerized tomography is considered to be a “close call” between benefits and harms, which “raises questions about the propriety of websites which are essentially advertisements for screening,” they wrote.
Strong first impressions
Those favorable first impressions may be difficult to counteract.
“Other studies have shown that the shared decision-making that is recommenced by Medicare and the (U.S. Preventive Services Task Force) is often not done or not done well in clinical practice, so the way information is presented on these websites is actually quite important,” said Linda Kinsinger, MD, who served as chief of preventive medicine at the Veterans Health Administration. She is now retired.
“These sites appear to be more focused on marketing than on actually helping patients make a difficult decision,” she said.
The study authors said developing “expert consensus and specific standards” about what information to post might encourage more balanced information. However, it’s not clear where the impetus would come from.
Richard M. Hoffman, MD, professor of internal medicine and epidemiology and director of the division of general internal medicine at the University of Iowa, said medical centers promote screening in order to “reap financial benefits from downstream testing and treatments as well as luring new patients to the practice.”
Hoffman, who has been a contributor to HealthNewsReview.org, said effective marketing “subverts meaningful and necessary-decision making,” leading to potential harms and financial costs for patients.
Going ‘cold turkey’
Lately we’ve seen hopeful speculation that the COVID-19 crisis might trigger a long-term shift away from care with small or non-existent benefits.
Since the pandemic began, the routine practice of looking for cancer in asymptomatic people has ground to a halt. That includes testing to detect lung and breast cancer.
“This recognition that breast cancer screening is non-urgent must be applauded, and the general public reassured,” UK screening mammography critic Susan Bewley, MD, wrote on a BMJ blog. “Going ‘cold-turkey’ on screening may be an unexpected, but welcome, way to wean the public off its dependence on searching for diseases that might never have harmed anyone.”
But others suggest that financial incentives need to change.
Ezekiel Emanuel, MD, and Amol Navathe, MD, directors of the Healthcare Transformation Institute at the University Pennsylvania, wrote in The New York Times that COVID-19 has “decreased the use of ineffective or low-value medications, laboratory tests, prenatal interventions, and diagnostic and surgical procedures.” However, they argue that hospitals must accept regulatory changes in order to keep themselves financially stable “without performing unnecessary procedures to generate revenue.”
Constrained resources
For a while at least, exaggerated claims about cancer screening are likely to wane. The study was performed from December 2018 to January 2019. As of this week, Gundersen still had the video on its website. Emails to the health system’s media representatives requesting comment were not returned.
Once the pandemic subsides, hospitals will face a “huge backlog of unmet medical needs” that could delay a resumption of preventive services such as screening, Hoffman said. “However, hospitals and health care systems are taking huge financial hits during the pandemic. Given that overzealous screening can make money, there may be an incentive, particularly for community hospitals, to resume screening.”
At the same time, consumers might reassess what’s worthwhile.
In an email, Woloshin said he imagines that “proponents will work hard to make screening seem essential.” He said the most important thing is for benefits, harms, and uncertainties to be communicated “so people can make wise decisions for themselves.” There are resources for people to educate themselves.
“To know if something is worth the price you have to know what you are paying for,” Woloshin said. “This may be all the more important as resources become more constrained.”
Meanwhile, if you really want to “love your lungs,” there’s a safer, cheaper, and equally effective way to do it, experts say.
Quit smoking.
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