Lung Cancer Policy - Term Paper Example

Lung Cancer Policy Paper Lung Cancer Policy Paper When we speak of lung malignancy, the lungs are the ones that get affected andhence the term “lung cancer”. This type of cancer falls within the category of other dangerous cancers according to international cancer research. It is not singular to either, meaning that both sexes are susceptible to the cancer if exposed to conditions that favor this type of malignancy. In the current world “21st century”, lung cancer is one of the most prevalent cancers. For example, 29% is the representation of mortality rates related to lung cancer in the United States. Compared with a combination of other malignant cancers like colon cancer, breast cancer, and the more familiar prostate cancer, the cancer of lungs kills more people than the three mentioned cancers combined. Such is the deadly and alarming situation of cancer of the lung. The simple explanation behind this is that, prostate cancer is prone to men only, while breast cancer is more prone to women. That is a contrast with lung cancer, the malignancy is not specific to gender, and it cuts across both women and men, hence creating more deaths than other types of cancers. 2007, was the latest year that data on lung cancer was collected in the USA. The table 1.1 below displays the findings on demise and diagnostics in 2007 gender lung cancer diagnosis data Lung cancer related deaths men 109, 643 88,329 women 93,893 70,354 Table 1.1 In the entire of the nation, by the year 2007 there were roughly around 400,000 people who had survived through lung cancer. This malignancy has the lowest rates of survival compared to breast or prostate cancer which have slightly higher rates of survival. Hence since survival from the cancer is a matter of rarity, this has always resulted to lack of enough funding and even less motivation in creating awareness to the cancer. Currently in the United States the probability of developing cancer in any person’s life is such that 1 man in every 13 men will normally be diagnosed in your life time. And every 1 woman in every 16 women will be diagnosed over the same period. Research on the spending on the lung cancer carried out in 2004 show that the United States has been spending 9.6 billion dollars per year in the treatment and diagnosis of lung cancer. In men, the malignancy diagnosis of the cancer is high among the black and white men compared to Hispanic Asian or Pacific Islander men. In women there is higher statistics in white women contrary to other racial groups. When it comes to survival basing on the same ethnic or racial groups the data is as illustrated below in table 1.2, this is an overall average 5- year survival rate-: ETHNIC GROUP SURVIVAL RATE White men 13.7% White women 18.3% Black men 10.8% Black women 14.5% Table 1.2 In diagnostics over half of the diagnosis normally happens when the cancer is at advanced stages, only 16% of the diagnosis happens at earlier stages. 25% of the diagnosis happens after the cancer has spread beyond the primary sites and into lymph nodes. And lastly 51% of those diagnosed have the cancer metastasized to far regions of the body. But not all is gloomy and doom, there are tiny fragments of improvements on the lung cancer statistics. For example between the years 1991 to 2005, new cancer cases in the United States decreased by 1.8% per year among the men population. Still among the men population, there was progress in the survival rate of patients with lung cancer, related deaths decreased by 1.3% between the years 1993 to 2005, meaning there was better diagnosis timing. Women on the hand had no better news. Among them the cases of lung cancer over the period in focus 1991 to 2005, increased by a margin of 0.5% with an exception of California states. Across United States California was the only state where cases of lung cancer decreased over the same period. Between the years 2003 to 2005 according to the current statistics, there was no improvement in the survival rates of the malignancy among the women population. Between the sexes there is disparity in the survival rate and cases of new lung cancer incidences. This is because men are more synonymous with smoking than women are. Smoking accounts for most of the lung cancer incidences. Hence when more men become aware of the disease, and they cease smoking this forms a significant level of survival rates or new cases incidences. In either gender, according to the most up to date statistics collected between the years 2004 and 2008, the average age for lung cancer diagnosis is 72 years. But newer studies have deduced that, there is a slight difference in the age of lung cancer diagnosis between men and women. Studies say women develop the malignancy earlier than men by 2 years. This is better seen among the people who develop the malignancy and they are below the age of 50 years, the number of women is disproportionate to that of men at that age. The studies carried out between the year 2004 to 2008, found out that lung cancer is prevalent in almost all ages of a human life. Of note is that for every 100 cases of lung cancer 20 will be diagnosed at the age of 55 to 64 years. Table 1.3 below shows the percentage of lung cancer cases diagnosed at each age. AGE RANGE PERCENTAGE Age 20 to 34 1.0% Age 35 to 44 1.3% Age 45 to 54 7.9% Age 55 to 64 19.6% Age 65 to 74 30.5% Age 75 to 84 30.6% Table 1.3 This table reveals that majority of the cases are normally diagnosed at the age of 75 to 84 years old. This is grave since lung cancer survival rate improves when diagnosed at earlier years. On that regard it is imperative that people should understand some of the symptoms if not all related to lung cancer. Among the most common symptom is a persisted cough that does not go away even after a couple of numerous treatment regimes. Other forms of supporting symptoms include-: I. Hemoptysis- coughing up blood II. Difficulty in breathing- this happens due to decreased airflow orchestrated by a tumor that is causing obstruction to the airways. Or either the tumor has spread through the lungs. III. Wheezing- this also is caused by the airflow interference by a tumor obstruction. IV. Chest, back, shoulder or arm chest pain- this occurs when a lung tumor is pressing around the lungs. V. Unrelenting infection of the lungs with conditions such as pneumonia or bronchitis. VI. Hoarseness The above mentioned symptoms do not exhibit themselves on all the lung cancer cases, 25% of all lung cancer cases do not exhibit any symptoms at all. Actually most of the tumors are normally realized by chance, when a normal chest x-ray is being carried out for other reasons unrelated to lung cancer. On normal occasions the malignancy is normally found when a procedure to screen for lung cancer on former or current smokers is being carried out. Lung cancer can be silent mainly without any viable symptoms, but when metastasis to other regions in the body starts, the victim will start experiencing the first real symptoms of the disease; lung cancer mostly metastasis to the brain, bones, adrenal glands and the liver (Health economics and policy, 2011). When this organs start getting affected they exhibit certain stress symptoms which are visible and they get to be traced to the lung cancer malignancy. The causes of lung cancer are several, but the main one is smoking. It is the mother of most of lung cancer cases. In the United States most lung cancer cases occur due to smoking, this form accounts for 87% of the lung malignancy; meaning that only 13% of the cancer victims develop it, through other means. Other major causes of lung cancer include-: a. Radon gas- this exposure is also higher on people who smoke. b. Asbestos in the workplace- this happens on certain vocations such as ship builders or pipe fitters, even more risky if the employee smokes. c. Ionizing radiation- this exposure happens when treating other cancers, the treatments can be risky to the lungs. d. Personal history- if a person has ever had lung cancer, they are normally at a risk of developing it again. e. Family history- even if a person doesn’t smoke and they have a relative or members of the family who have the cancer or a lung cancer family history, such a person is always at a risk. f. Other lung diseases- certain diseases such as TB increase the risk of lung cancer. g. Other exposures at the work place- these exposures, include exposure to, beryllium, cadmium, nickel compounds, chromium compounds, coal products, tars, and arsenic. The above mentioned causes only contribute a very minor margin to the lung cancer statistics, and even then, the risk is only higher if the person in question is a smoker. In the USA, following a general surgeon’s report on smoking and health in 1964, most of the citizens become aware of the risk that smoking pauses on a person. In the report, it said that the risk among smokers is nine times to ten times more than the risk among none smokers. Supporting those findings, it said that 90% of lung cancer instances in men occur due to smoking, while in women it accounts for 80%. Among men, those who smoke are 23 times more likely to develop the malignancy than the men who do not smoke, while women smokers are 13 times more prone to develop the malignancy than women who do not smoke. Smoking risk that lead to the cancer is calculated by something known as “pack years”; this is the number of cigarettes smoked by a person so far. With that in mind, this is the reason why 50% of the cancer cases are now occurring among former smokers who have quitted. About 10% of men with the malignancy have never smoked, and on the same, 20% of women have never smoked. Corresponding research shows that a non-smoker who leaves with a smoker has a 24% risk of developing the cancer, than a non-smoker who does not reside with a smoker. As such, it is a conclusive evidence that, the risk rises with the number of years that a victim is exposed and the number of cigarettes taken by the other person. Passive smoking according to the studies is as dangerous as direct smoking. Over 3000 lung cancer deaths in the states, occur due to passive smoking each year. Smoking statistics in the US show that, the number of smokers is very significant and hence the many cases of lung cancer. Of the people who have ever smoked, 70% of them begun smoking at the age of 18 and below, while 86% of the respondents begun smoking at 21 and below. Hence by 2009 the active smokers were around 46.6 million people, which was a representation of 20.6% of adults (18+ years). Gender wise men smoke more than women, by 2009, 23.5% of smokers were men while 17.9% were women. Even high school student’s fall within the statistics, 2009 had 19.5% of active smokers as high school students and 5% of the active high school smokers were students at the middle school level. The chain is long, and the longer it is, the more cost it presents to USA. Smoking without a break down of lung cancer or specific diseases cost the state $193 billion, which included a lost productivity of $97billion. $96 billion of the amount was in relation to direct expenditures of health care which averaged to $4260 for every smoker who is an adult. Since smoking is the leading cause, question is whether quitting the social vice will lower the risk of the cancer. There is an ongoing research and study which started in 1976, and brought together 105,000 women. The participating women were between the ages of 35 and 55, the surviving participants have been filling health questionnaires for the last 30 years. Those among this women who have given up smoking, had smoked for 15 years prior to the quitting. Studies have discovered that there were 28% of smoking related deaths from former smokers while 64% of deaths are due to current smokers. Without smoking, the risk of a quitter dying from a respiratory disease fell to the level of a life time non-smoker after a period of 20 years, with an exception of lung malignancy. 5 years after stopping smoking, the danger of dying from lung cancer decreased by 21%, but the general risk did not disappear for the 30 years of the study. Hence the study has deduced that, quitting smoking although it has proved to harbor positive end results is never efficient in reducing the incidences of lung cancer related mortalities and diagnosis. Hence if the country is to reduce lung cancer cases, this can only be tackled by viewing this from both lung cancer and smoking edges. For both a physician and a radiologist, it is normally frustrating when they are not able to detect the cancer early, and only do it, at a stage when survival rate is very low. To diagnose a patient as having lung cancer, radiology comes in handy based on a thorough history (Boyle, 2010). Chest x-ray comes in handy to look into any concerns and this might reveal a mass on the lungs or lymph nodes which are enlarged. Though important, other tests are normally needed in order to diagnose lung cancer. This is because not every mass is cancerous, and hence the requirement for further tests. Hence when faced with abnormal chest X-ray findings, the next step is carrying out a CT scan. A CT scan presents a 3-dimensional view of the organ. If the CT process still confirms the abnormality that in itself is not conclusive and further tests are needed. This will involve sampling the mass tissue and to sample the tissue, after careful history consideration the expert will use fine needle aspiration, bronchoscopy or cytology. The tests at this stage are a confirmation of an existing lung cancer, and hence enough to make a conclusive cancer of the lung diagnosis. It hence became imperative to do screening and research trial started in the 70s. In 2011 NLST- national lung screening trial, announced positive results in relation to screening. There was 20% reduction of lung cancer mortality rates from a group of 53,454 people with a 30 pack year history. This group had been assigned 3 yearly screenings with a minor dose of radiography and CT. Stratification of randomization was done by use of site, age and sex. US bureau current population surveys supplementation was used to assess the representation of the study. NLST took representatives who met the criteria of age and smoking history and specific certain demographic characteristics from the population. All of them were aged between 55 to 74years. Like all cancers, cancer of the lung starts with a lung nodule. Sequential computed tomography has the ability to diagnose small lung nodules as small as 2 mm of size. NLST used the technology to document any changes. The documentation of the nodule, looked into the following characteristics-: I. Nodule size and change type of the nodule; that is if either it is nonsolid, solid or partial solid. II. If margins were smooth or speculated III. Location of the nodule, whether in the lung or not, or presence of emphysema adjacent next to the nodule. The CT-based screening collected up to 1,089 lung cancers in a median 6.4 years of follow-up as opposed to 969 within the chest x-ray arm. This outcome led USPSTF (Preventive Services Task Force) of the U.S. to provide a positive recommendation to the CT lung cancer screening. Soon after, The ACR (American College of Radiology) and other medical Organizations as well as healthcare providers were calling for a full Medicare treatment for the low-dose CT(LDCT) screening of lung cancer. Nonetheless, by 2014, implementation of CT screening Guidelines had not been done. The United States` CMS (Centers for Medicare & Medicaid Services) has availed additional details concerning the discussion topics it intends to address in the advisory committee meeting scheduled on April 30 2014 on reimbursement for the CT lung cancer screening. The CMS noted that merely 26.6% of the participants in NLST were of 65 to 74 years of age. The extension of USPSTF suggestion to adults of 75 to 80 years was based mainly on modeling without data from NLST. Eightfold Path to a policy Analysis of Eugene Bardach outlines 8 steps which could assist an agency or an individual to assess and propose policy. Incorporating this idea into an analysis is crucial so as to better understand of the policy issues and options for a solution. I will consider how the three of Bardach’s steps can either disprove or approve that NLST suggestion for Low dose CT scan is appropriate modality of option to reduce mortality from lung cancer. The three steps are Construct the alternative, Project the Outcomes, and Select the criteria. a) Construct the Alternatives: the two alternatives which can be considered regarding reducing lung cancer mortality. i. LDCT ii. Chest X-ray/sputum analysis iii. No screening b) Select the Criteria: i. Patient safety or radiation induced malignancy: The doctors have forever assumed that the benefits outdo the risks. X-rays that revolve around the chest, head, or another body part, assist to make a three-dimensional image which is much more comprehensive than pictures from the standard x-ray machine. However, a single CT scan expose the human body to about 150 to 1,100 times radiation of the conventional chest x-ray, which is about year of exposure to a radiation from artificial and natural sources in the environment. Researchers at National Cancer Institute approximate that 29,000 future cases of cancer could be associated to 72 million CT scans done in 2007. That increase is equals to 2% of 1.7 million cancers diagnosed countrywide each year. Medical centers in San Francisco Bay Area did a study in 2009 and found the same risk: one additional case of cancer in every 400 to 2,000 regular chest CT exams. Because LDCTs distribute less radiation to patients, it`s anticipated to cause low radiation malignancy , but a research by Anderson Cancer Center fulfilled that the data reveal a small but legitimate risk of a radiation-induced malignancy from the LDCT scans. NLST revealed a 20% decline in mortality when chain smokers were screened with CT. Effective dose of NLST was around 1.5 mSv for the lung scan, however, the risk of a low dose like that is not negligible. A single low-dose of CT scan would cause a lifetime risk of cancer of 0.01% to 0.06%, depending on the sex, smoking status, and age. An annual CT scans of ages 50 to 75 could cause a risk of up to 0.2% to 0.85%.Given the generally poor prognosis of the lung cancer, incidence is robustly correlated to the mortality and radiation risk might be on a similar order of magnitude as the gain observed in NLST. In contrast, a chest x-ray delivers only 0.16 mSv to any patient. It is considered to be the modality that delivers the minimum dose of radiation. Sputum analysis is a non-radiological diagnostic tool therefore no risk of radiation is present ii. Cost Effectiveness of Screening: Despite the NLST outcome revealing a 20% decline on lung cancer mortality, anxiety still exists concerning the financial demands which lung cancer screening might place on an already stressed health care structure. The cost of low-dose CT may vary among facilities but presently is around $300 a study. Thus, it is essential to compare CT screening for lung cancer with some other more economical modalities such as a chest X-ray that does not exceed $50. For Sputum analysis its price estimate is around $75. Medical intervention can be evaluated in form of quality as well as quantity of life generated by the particular intervention, defined as a quality-adjusted life year (QALY). Cost per QALY is defined as a cost-effectiveness ratio for a particular medical intervention. However, a more economical modality of lung cancer prevention may be smoking cessation, which can have a cost-effectiveness ratio of around $11,400 per QALY. If screening participation is found to increase smoking cessation, then lung cancer screening could be considered cost effective. Until then, lung cancer screening is more expensive than other current screening programs in the United States iii. Over diagnosis and False-positive Results: An examination of NLST data from 2002 to 2010 reveal 18% of lung cancers captured by low-dose CT scan were actually slow-growing tumors which wouldnt have bothered patients in their lifetime. Over diagnosis were also spotted in persons with true-positive results. Most of these positive outcomes would have never been realized if these persons were not screened with low-dose CT. Part of these positive outcomes were finally found to be malignant but perhaps would not been detected or transformed into a complex illness or even warrant treatment. Consequently, over diagnosis was realized with low-dose CT scan that exposed individuals to invasive processes and aggressive treatments which they otherwise would have not undergone. For sputum analysis, the closer the cancer to central airways, the higher is specificity. However once cancer detected it is highly unlikely that it is false positive. iv. Universality: Across the Atlantic, there have been multiple trails simulating the NLST including Danish Lung Screening Trial (DLST), Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON), Multicentric Italian Lung Detection (MILD), and U.K. Lung Cancer Screening (UKLS) trial. Their early outcomes, although these trials have not finished are conflicting outcomes to NLST. In summary their preliminary conclusion has revealed the following; the DANTE trial compares low-dose CT with sputum and chest radiography in high-risk patients. Preliminary data appear to show higher detection rates with the low-dose CT group than with sputum and chest radiography, with early results suggesting no differences in mortality rates. However, the study is small (2,500 participants). The NELSON trial was specifically designed to find a 25% reduction in mortality rates with low-dose CT screening. Unlike the NLST or the DANTE trial, the NELSON trial is comparing low-dose CT screening with no screening. Researchers enrolled 7,500 participants to determine the impact of CT screening effects on smoking cessation and cost. v. Ease of reading the studies: Comparisons need to be made between chest x-ray and LDCT as they are read by radiologists whereas pathologists read sputum analysis. Both European and American experience with over 100 screenings per day for years, confirmed that screening is a difficult task that may wear out radiographers and radiologists. Both radiographers and radiologists do the reading in Europe while in USA the board certified radiologists do the reading. Radiologists are comfortable with reading 100 to 150 chest X-rays within 9 hours. A chest X-ray investigation is 2 images whereas LDCT chest CT is about 50 images. A radiologist may read up to 50 days on average. Computer-aided detection (CAD) may assist as the first reader of choice. CAD may soon be capable of estimating risk of malignancy based on the nodule density and morphology. vi. Availability and cost of equipment: The cost of a CT machine can be as high as $450,000 with an annually maintenance of approximately $75,000. In the contrary, the cost of a CR machine and sputum analysis machine can be lower than $75,000 with an annually maintenance of approximately $10,000 and they are also abundantly available in every health care outlets. CT machines can only be found in hospitals and amongst private radiology groups. vii. Application of Screening: Even if the NLST outcome did show a decline in lung cancer mortality with screening with low-dose CT, the concern is whether these outcomes can be replicated in usual practice. The participants in the NLST were selected based on age, access to a multidisciplinary medical center, a minimum pack per year smoking history, and they had close follow-up for the period of the study, but the concern of most practitioners is that the conditions cannot be duplicated in a huge portion of the population. Since patients are uninsured or underinsured or they live in an area where a large multidisciplinary medical center is not easily accessible, access to health care as well as affordability issues still pose potential barriers to the screening for lung cancer with low-dose CT. Moreover, many patients in normal practice are lost to follow-up, which would cause screening with low-dose CT to be less beneficial (Haas, 2010). The effect screening can have on smoking cessation rates is also a concern. Some think that CT screening serve as a teachable moment to motivate individuals to stop smoking, but others disagree since if screening fail to detect lung cancer, then patients can think they will never develop cancer and keep on smoking. c) Consider and Project the outcome: This step is the best in constructing a Criteria Alternative Matrix. I will use the weight/scores of 0-3 where 0 implying no effect, 1 implying mildly positive, 2 implying moderately positive and 3 implying highly positive. Alternatives:  LDCT Chest x-ray/sputum analysis No screening Criteria Decrease in Mortality 3 0 0 Patient and Radiation Induced safety 1 2 3 Cost effectiveness of screening 1 2 3 Over diagnosis& false positive Results 1 2 3 Universality 1 1 0 Ease of Read 2 3 0 Availability and cost of equipment 1 3 0 Application of Screening 1 1 0 Total Sum 11 14 9 Think about the tradeoff Since smoking is the leading cause of lung cancer with a statistic of 95 % and 85 % of lung cancers in men and women respectively, in my opinion, policies about cutting down smoking are more significant than a CT scan for the lung cancer screening. According to (Courtney & Thomas, 2005), the methods to slow down smoking particularly among the young populations ought to comprise: Change packaging style by putting pictures of blind persons or wheelchair oxygen in order to make smoking less attractive particularly for children. Increasing the smoking age from 18 to 21 as was the case with alcohol. Just like alcohol, Nicotine is also an addictive chemical which when inhaled via a cigarette cause pleasant feelings to smokers yet it speeds up their heart rate and raises their blood pressure. Raise taxes on cigarettes and channel the extra revenue into conducting more research so as to perfect early screening of the lung cancers. Ban cigarette smoking in cars indoor, workplaces, and areas of licensed premises. Decide and tell the story Going by the projected result, it appears there is slightly more benefits to Chest-X-ray and sputum analysis combined than LDCT and Non screening. I think more clinical researches and studies needs to be carried out to confirm that sputum analysis and chest X-ray combined may be a superior screening tool than LDCT. Further analysis of NLST trail requires to be conducted so as to eradicate the relative disadvantage which LDCT had in my own paper. The only test ever revealed as reducing mortality among high-risk smokers is the screening of Lung cancer using low-dose CT. As a chest radiologist, I believe that eligible candidates go through screening at the centers of excellence, like NLST study locations. Our present policies together with the already implemented polices ought to further decrease the smoking rate. In the United States, between 2009 and 2012, the smoking rate amongst adults has declined from 20.6 % to 18%, a trend which experts on smoking cessation associate to public policies such as smoke-free air rules, cigarette taxes, media campaigns, and reduced exposure to smoking habit in movies. This was the first statistically significant recorded change over several years since 1997 to 2005, when that rate only fell from 24.7 % to 20.9 %. 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