Scott Webb (Host): If I told you that for $49 you can receive a lung scan at Franciscan Health and that the scan might save your life; if you're a longtime smoker, you'd probably want to hear more. Well, you're in luck because my guest today is here to tell us about the $49 scan and the benefits of being screened for lung cancer early.

I'm joined again today by Dr. Faisal Khan. He's a Board Certified Interventional Pulmonologist and independent provider who chooses to practice at Franciscan Health.

 This is the Franciscan Health Doc Pod. I'm Scott Webb.

Doctor, it's great to have you back on the podcast. Today we're going to talk about screening and screening for survival. And that survival would be surviving lung cancer, hopefully. I know that it's the leading cause of cancer deaths worldwide. So, it's good to have you here and talk about the screening that's available for lung cancer.

And I've read about the low dose CT lung scan, so maybe we can start there. What is that?

Faisal Khan, MD, DAABIP: Basically it's a CT scan, but the reason it's called low dose is because the amount of radiation imparted doing the scan is much less than a conventional CT scan. So when you're talking about screening for lung cancer, you require a modality that will be used again and again, and radiation, by default, the more you're exposed has a high risk of causing its own radiation induced diseases of cancer. So that's why a regular CT was not the ideal option and what fortunately turned out was that if we utilize a lower dose of CT scan but get the same information that is required for screening purposes, then that would be the best.

And, I'll give you a number the radiation dose is calculated in the unit called millisievert. The low dose CT scan, is a 20 to 25 second scan, which uses 1.4 to 1.6 millisieverts of dose compared to 7.5 to 8.5 on a conventional CT scan. So it's a much, much lower dose and compared to routine chest x-ray, which is 0.1, this is 1.4, so a little more than a chest x-ray, but much less than a conventional CT scan.

Host: Yeah, Doctor and I know what Franciscan Health patients can get a lung scan, two different ways, right? Each of them has different requirements, let's say. So let's try to explain this to folks. I know the first way is a promotional lung scan for $49, which seems darn cheap to me. So maybe you can share who qualifies for the $49 option.

Faisal Khan, MD, DAABIP: I'll put it out there. Every center has their kind of a little bit own criteria, but in general, majority of the organizations across the country have adopted the lung cancer screening based off the guidelines from the NCCN, which is National Comprehensive Cancer Network.

And those are the individuals who are considered high risk, individuals who have history of 20 pack year history of smoking, meaning that on average they smoke one pack a day for 20 years and are at age of 50 and above. So those are the ones who qualify for the $49 scan, and they should have no symptoms of cancer because if you have symptoms of cancer, then of course you that by default means you're not needing screen, you need to go for a proper assessment and a diagnosis. So screening is for asymptomatic folks who fall in that category that I just mentioned.

Host: Yeah, and that's a self-pay, no doctor's order needed, you know, no insurance involved. But then there is the other option for a lung scan that can be ordered by your doctor and does go through insurance. So who would qualify for that?

Faisal Khan, MD, DAABIP: There the criteria is more or less the same. So different private insurers have adopted the same criteria that I have mentioned. But the only thing that is required there from a private insurer standpoint is that there should be a doctor order and some documentation that the screening pros and cons were discussed with the patient and that proper documentation of their smoking history and all that. There's been more and more acceptability in the private insurance world about that, and they'll cover that. In regards to Medicare, where more of the patients are getting the screening covered the criteria is a little bit different.

 There is an upper limit of age there. So Medicare criteria is anyone above the age of 50, and less than 77, more than 20 pack year history of smoking and then quit within last 15 years. If they are, ex-smokers, if they're active, then it still applies. So they have a hard cutoff of 77 years, as a top age.

Host: And, the common thread here, Doctor, is that age seems to be a factor for the scans. So there, I'm sure there probably are folks who are younger than 50 who might want to scan, especially the promo scan. Why is 50 the starting point? I'm 57, so at least I know I qualify, which I guess is a good thing.

But then also on the high end then like why is 80 the cap on the other end, especially for insurance.

Faisal Khan, MD, DAABIP: Yeah, so that's a very common and good question actually. So, when you're talking about screening a test. Screening by default means that you are going to screen a large number of patients and for an ideal screening test, it should have the characteristics of being the most effective for a disease that has a high morbidity and mortality, significant prevalence in the population, and have a known, identified risk factor.

And also is cost effective. So when you look at the data of about lung cancer prevalence, and incidence, the folks who are younger, it's very low. So if you start screening younger demographic, the outcomes in terms of detecting a significant disease is very low and you're not making a huge impact.

Lung cancer generally starts after the age of 50, very rarely in, in a younger demographic. On the flip side, when you're talking about why the eighties, the upper limit, now some societies like NCCN does not have an upper cutoff because they recognize that as the society is evolving, we are seeing more and more, quote unquote, healthier 80-year-old or 85-year-old. So, and the treatment options are evolving where you have minimally invasive treatment options for early stage cancer. But traditionally, the concern was that because the idea is that going to do the screening to have a positive impact on the survival, the life expectancy after the age of 80 is low because generally in that demographic, there are comorbidities. And even if you detect the cancer, the treatment options or applicability of the treatment options may be low because of the other medical factors in that individual.

That was the mindset. The second is lung cancer, majority of the time will present itself in the earlier years of 50 to 80 range. So most of people would have presented by, by that age, time, or that limit. So that's why from a larger population standpoint, the data did not show that there was much impact if you start screening older individuals, both in terms of detection and in terms of outcomes because the treatment modalities were not as, widely applicable as in a younger demographic. So that's, again, going back to the philosophy of the screening, the concept of screening itself, as a recommendation, on a mass population. And those were the reasons that the age limits were set.

Host: Sure. Yeah. And after someone's had that first scan Doctor, how often, especially if they had a clear scan, how often should they be getting future scans, let's say?

Faisal Khan, MD, DAABIP: That's the fundamental, important point I want to make. So, compared to other screenings where there may be a gap of a few years; lung cancer screening, it's imperative that the benefit that has been documented in the literature and shown in the literature is only if you qualify for a screening, you get screening every year because you may have a normal scan one year. But the way the lung cancer pathophysiology evolves, it may show up within a year still in an early stage, but if you wait more than that, then you may not get the same impact and benefit as you would if you're doing a yearly scan.

It's a quick 20 - 25 second scan with a low radiation. So the overall a positive impact is much more than any perceived harm that people may associate with it.

Host: Not like a colonoscopy. There's no real prep involved. And you're in and you're out. And it makes me wonder, Doctor then if there is a finding on a scan, what are the next steps?

Faisal Khan, MD, DAABIP: Majority of the patients would not have a finding. One of the main trials that led to the approval of this modality as a screening and adoption for a screening; if I quote that, about 27% of folks who got the screening had some abnormality, and out of that 27%, 95, 96% did not have cancer.

So the actual incidence is really low. So the chances are 75% that you're going to have a normal scan and you should do once a year scan. Should you have an abnormal, the chances are majority of the time, it'll be just something that may require a yearly follow up, and not something more interventional or invasive and then a smaller risk. So if some, if there is an abnormality, there is a method of categorizing from a medical standpoint how we categorize that abnormality. And we rate the significance of the abnormality. So majority will fall in one what we call, Lung-RADS 1 and 2, which means just a follow up scan in a year just to keep an eye on that abnormality.

And then there's a smaller subset which falls in the category 3 and 4. Category 4 is the more concerning, which then every hospital has a setup of how to expedite the workup of those individuals. And category 3 generally means a follow up in six months. But those are much lesser in terms of overall prevalence there when you go through a screening than the 1 and So 1 and 2s get just get a routine annual scan, and 3 and 4 need a, like a second eye on them.

Host: Really appreciate your time. I know we've done a couple of these together and I'm sure we'll speak again in the future, but just want to touch here at the end.

There may be folks who hear this and they qualify for a scan but maybe they're afraid or they're unsure about getting one. So what would you say to them, Doctor, to encourage them to take that next step? Either opt for the $49 option or make an appointment if they have to, to get that lung scan?

Faisal Khan, MD, DAABIP: So what I want them to recognize is that if you're a smoker and you're falling in the high risk category, don't wait for the symptoms. Just recognize that the lung is a very large organ. And a potential cancer has to grow to a certain size to give symptoms, but when it grows to that size, it's already, majority of the time in a late stage where you can maybe control the disease but not cure it.

Even now, 70% of the cancers, approximately present in late stage, what we call stage three and four, by the time they give symptoms, that's when people present. So it's imperative that we detect the cancer in the earlier stages, ideally stage one but even in stage two, the treatment is done with the intention to cure.

Those one and two stages are not going to give you any symptoms for years. So, if you're not having symptoms and you're a smoker for many years, that may be a false assurance that you don't have a cancer because it may be brewing in your body and you just don't know about it. And by the time you know, it's too late. I know there's anxiety of going through the scan and the what if, if, if something is found. But keep in mind that if, even if something is found and it's bad, the chances are it's found early stage and we can do something to cure it, and not late stage. So that's what would be my key message for those individuals.

Host: Well, that's great advice from an expert. I appreciated your time for these two podcasts that we've done. As I said, we'll probably speak again in the future, but for today, thanks so much.

Faisal Khan, MD, DAABIP: Thank you so much.

Host: To learn more about $49 promotional lung scans at Franciscan Health, visit franciscanhealth.org/screeningbundles.

 And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.