Editor’s note:
In the era of personalized medicine, a critical appraisal new developments and controversies are essential in order to derived tailored approaches. In addition to its educative aspect, we expect these discussions to help younger researchers to refine their own research strategies.
Rebuttal from Dr van Meerbeeck
We agree that CT-scan is currently the most sensitive tool to screen for early stage lung cancer and that the population of radically treated patients has the highest risk of developing another lung cancer. We however have the following serious concerns about the immediate and widespread implementation of yearly CT-scan surveillance as advocated by WC Hanna (1):
- With more than 50% of radically treated non-small-cell lung cancer (NSCLC) patients succumbing within 5 years, most of them because of either metastatic spread, comorbidity or complications of the treatment, the number needed to screen in order to cure one patient will become unduly large, in case this surveillance program is installed from the first year after resection in all patients.
- The National Lung Cancer Screening Trial (NLST) and NEderlands Leuvens Screening ONderzoek (NELSON) have settled for 3 yearly scans and the (cost-) effectiveness of longer screening has not been reported
- Screening is only done in participants who are candidate and fit for a radical treatment. A considerable fraction of radically treated patients might not be eligible for a second treatment for functional or personal reasons and will be needlessly troubled by routine scanning
- Conventional contrast enhanced and low-dose spiral CT-scan are two different types of imaging the chest each with its particular strengths and weaknesses. The latter may miss mediastinal recurrences, the former may miss non-calcified nodules (NCN). Changing from one to the other modality after 5 years may result in an increase in false positive and false negative findings
- The prevalence of NCN’s after a first resection is unknown. This could influence the metrics of the effect of screening
Recommendations and guidelines of the scientific societies have a moderate grade IIB-IIIC, reflecting not the highest evidence but merely the consolidated expert’s opinion. In the absence of further randomised evidence, this should not be presented as unequivocal and that ‘there should be no doubt in anybody’s mind that CT surveillance is the standard of care (. .)’.
Acknowledgements
None.
Footnote
Conflicts of Interest: The author has no conflicts of interest to declare.
References
- Hanna WC. Pros: long-term CT scan follow-up should be the standard of care in patients who are curatively treated for an early-stage non-small cell lung cancer. Transl Lung Cancer Res 2015;4:476-8.
