They’ll screen and screen until I’m sick

Copperfield on the impending workload dump that awaits GPs with Targeted Lung Health Checks

Oh dear. That 25/day patient contact limit we’re, ahem, all collectively working to isn’t going to stretch very far. Because pretty soon it’s going to be filled with fallout from the NHS’s latest Big Clinical Idea, which is the Targeted (also ahem) Lung Health Check aka lung cancer screening.

This is being rolled out across England. But it has nothing to do with us, does it? As per most screening programmes, all we contribute is some headed notepaper, right?

And, yes, not even NHSE would seriously expect us to manage screen-detected lung cancer in our lunch break. But lung cancer isn’t the issue. The actual problem is that the lung cancer screening programme is a de facto coronary disease screening programme.

Here are the stats – and you might want to sit down at this point. The ballpark figure for percentage of CT screen detected lung cancers is 2-3%. The ballpark figure for percentage of coincidental CT screen detected coronary calcification is 40-50%. So, spotting a potential cardiac issue is 17 times more likely than finding the pathology that is actually being screened for. Is this the first ever screening programme for incidentalomas?

No prizes for guessing that these chalky-arteried screenees are going to be directed to their GP. Anyone else feel a dump coming on, both from on high and from stress-related IBS? Never mind. GPs are used to creating order from chaos. We’d assume that all this would have been covered in the original consenting process, and that we can follow authoritative guidance on what to do with screen-detected coronary calcification in asymptomatic individuals.

Except that, in order, it isn’t and you can’t. Targeted Lung Health Check Protocols do not specifically mention coronary calcification, even though the odds of it being detected are 50/50. And precisely no one knows what to do about the finding of coronary calcification on these scans, so there is no guidance. Believe me, I’ve checked.

Screening tub-thumpers would say there’s always collateral damage, but I’d counter that this is the point; we don’t really know if those collaterals are damaged. The only silver lining is that many cardiologists I’ve spoken to reckon we should just QRisk these patients in the usual way, though they had a strangely terrified look in their eyes as they said it. That, of course, is mediated through our glorious NHS Health Checks, which means one non-evidence based activity is cancelling out another. Which is a coincidentaloma.

Dr Tony Copperfield is a GP in Essex. Read more of his blogs here