Cap Pneumologists are unanimous: lung cancer screening can save lives – insofar as the examination is conducted in good time for patients at risk. The utility of the early diagnosis programme is then guaranteed if it takes place in controlled conditions and can be shown to reduce mortality. But who should pay for this examination? This is where opinions differ: consultant Karl Klingler from the Pneumology Centre Hirslanden hopes for co-payment of medical costs by the health insurer while Professor Malcolm Kohler, Senior Consultant in Pneumology at the University Hospital Zurich, is in favour of the costs being covered by the basic insurance.
The argument for
Prof. Dr. med. Malcolm Kohler, University Hospital Zürich
"Until now in Switzerland, there has only been opportunistic early diagnosis of lung; cancer for example, for patients who undergo computed tomography due to a different suspected illness. Patients have a chance of recovery if such chance findings are discovered at a very early stage of the disease.
In the opinion of the expert commission of the five Swiss universities, the utility of this early diagnosis programme is guaranteed if such lung cancer screenings are conducted in controlled conditions and in accordance with stringent quality criteria. It is therefore important to guarantee strict compliance with the target group inclusion criteria, as defined in the American National Lung Screening Trial, and to ensure that the participants are informed of the potential benefits and risks. Only in this way can the survival benefits established in the study be transferred to the clinical practice.
Nevertheless, there is still no national screening programme in Switzerland and no related register in which tests and treatments are systematically recorded. Uniform standards for the use of low-dose computed tomography (LDCT) should also be developed. At present, practising physicians and hospital doctors should therefore send patients for lung cancer screening or they should offer such an LDCT screening themselves.
Only the creation of a national register will provide valuable insights into the implementation, quality and cost-efficiency of lung cancer screening. To be able to introduce these essential quality criteria and standards, the group of experts calls for the application of cost coverage of a lung cancer screening by the compulsory health insurance. Screenings must be available to the entire population – independent of their insurance status."
The argument against
Dr. med. Karl Klingler, Lungenzentrum Hirslanden Zürich
"If fire-fighters are standing in front of a burning house, they don’t ask themselves who will be paying for the service – they go into the house, save the people and extinguish the fire. It is reasonable to approach every life saved in the same way. Every day, almost 10 people in Switzerland are diagnosed with lung cancer - some 3,500 every year.
Most of them die from this cancer because it has been discovered too late. This doesn’t have to be the case if the people at the greatest risk of contracting lung cancer – for example, certain smokers – were offered a simple examination designed to save them. That is exactly what the Stiftung für Lungendiagnostik (Foundation for Lung Diagnosis) does with its early diagnosis programme: it makes use of undisputed scientific knowledge and the only international register – to which the Pneumology Centre Hirslanden in Zurich contributed – developed over the past 20 years to offer people at a high risk of lung cancer a low-dose computed tomography. In doing so, it satisfies the strict quality criteria necessary in this kind of programme without succumbing to the Swiss vice of requiring the same solution for everyone which is not better, only more expensive.
Of course it is preferable that all people concerned have access to this important examination at the expense of the health insurance company. Nevertheless, that does not mean that we should simply continue waiting and put human lives at risk until early lung cancer diagnosis becomes a mandatory service covered by the health insurance company. What the Foundation for Lung Diagnosis does is much more in the interests of the patients: setting up an early diagnosis programme through private initiative – and at an affordable cost too. While those concerned currently pay for the examination out of their own pockets, it doesn’t cost them more than a couple of packets of cigarettes. That is hardly too much to pay to save a person’s life."
Comment Wolfram Strüwe, Head of Health Policy
"What do smokers want? Do you remember the film “Breathless” by Jean-Luc Godard? In almost every scene, Jean-Paul Belmondo has a cigarette between his lips. In the 1950s and 60s, smoking was part of social life. This has changed dramatically. Today, smoking is frowned upon.
Everyone, even smokers, knows that smoke is life-threatening, especially over a long period of time. Yet many people continue to smoke. So what can a lung cancer early diagnosis programme do?
It can do a great deal, as the accompanying discussion shows. But before payment is discussed, it must be clarified how smokers (and ex-smokers) can be encouraged to take part in such a programme. Information is the first element. But even if this is successful, it doesn’t mean that those concerned will take part in such as screening. Despite the fact that it makes so much sense, smokers often adopt an attitude of “I’d rather not know”! In this case, special efforts are required.
The question of whether this service is a statutory benefit to be paid for by the basic social insurance or whether, as in the past, it is covered by the supplementary insurance, appears secondary. It can be covered by the basic insurance only if the criteria of efficacy, expediency and cost-effectiveness prescribed by the law are satisfied. High quality standards are involved. Apparently this clarification will take a long time."