GETTYSBURG MEDICAL NEWS
The Clinical View
24 January 2007
By P. E. Hoffsten, MD

SCREENING FOR LUNG CANCER

          Recently an article appeared in The New England Journal of Medicine touting the use of “spiral CT scanning” for early detection of lung cancer.  The obvious implication of the article was that if a lung cancer was found early enough it would be curable.  This is the obvious hope of anyone who ever faces a diagnosis of any cancer, whether it be lung, colon, prostate, breast, or cervix.  The universal hope is that if the cancer can just be found early enough it can be taken out and everything will be okay.

          For cancer of the colon, that hope has been realized.  Finding polyps in the colon and removing them before they ever become cancer has clearly shown to be a lifesaving and certainly misery saving step.  The same is true for cancer of the breast.  We now recommend annual mammograms for women because breast cancers found early before they can be felt have twice the cure rate of those that are not found until they can be felt.  The same is true for cancer of the cervix.  Thus far, early detection of cancer of the prostate has not lead to better cure rates or to lives saved.  Rather, when a cancer of the prostate is found early, the man lives with the diagnosis longer than if the cancer is found at a later time, but he doesn’t die any younger because the cancer was not found early.  Thus, some cynics feel that finding cancer of the prostate early means you get to worry about it longer.

          The statistics for cancer of the lung are not favorable.  On average, seven and a half people out of every hundred who die in the United States die of lung cancer.  That amounts to 150,000 deaths per year from this disease.  Cancer of the lung comes in two types.  One is called small cell cancer, which has a six percent five year survival.  The other is called non-small cell cancer of the lung, which has a sixteen percent five year survival.  These are the worst statistics for any of the major solid tumors in the body.

          The thinking that finding a cancer early will lead to a better cure rate has been applied to lung cancer.  The article in The New England Journal of Medicine mentioned above appeared in the October 26, 2006 issue.  In that article, a large number of smokers (31,567) underwent a special kind of x-ray called a “spiral CT scan” of the chest. The plan was to look for “nodules (things)” in the chest that might represent a cancer.  Four thousand one hundred eighty-six of these patients were found to have a nodule.  On average, about one in eight patients tested.  Those patients got to start worrying right then.  Some were followed for a brief period of time and others were treated surgically to remove the “thing.”  In all, 535 individuals had their chests opened surgically to remove the nodule in their chests.  Of the 535 specimens removed, 484 of them were lung cancer.  Thus from this screening procedure, already one person in ten got their chest opened unnecessarily.

          Of the 484 cancers found, only 412 of them were surgically curable.  Thus, another fifteen out of one hundred individuals who had their chests opened to remove the tumor were not surgically cured.  On average, chest surgery has about a one percent mortality so another person is lost just from the surgical procedure.

          The article in The New England Journal of Medicine has been touted in the lay press as proving that early detection of lung cancer by screening leads to a better survival.  The statistics for that article indeed do show that the five year survival of individuals screened was about eighty-eight percent as compared to seventy percent for individuals who came to medical attention because something was wrong.  Note that in the screened population there were no symptoms and no expectation on the individual’s part that they might have a lung cancer.  Thus, the article did seem to show that five year survival was better in the screened population than it was in those who come in because something is wrong.

          But remember what we said above about prostate cancer.  Are those smokers that were screened simply individuals who were found at an earlier stage in the course of their lung cancer?  And will they eventually die of their lung cancer anyway, thus getting to worry about it for a longer period of time?  The experts are arguing about this point.

          A patient recently inquired about having a spiral CT of their chest done because they had been a smoker for many years. They heard of the article in The New England Journal and wanted to have a spiral CT of their chest done.  The question asked was, “Is it worth it?”  Screening procedures for cancer of the lung have not been shown to increase survival until this article appeared.  Medicare does not pick up on new articles quickly and is not covering a spiral CT scan as a screening procedure for smokers.  Why not?

          At the present time, a spiral CT scan of the chest at McKennan Hospital in Sioux Falls costs $1,850.  The same procedure done at St. Mary’s Hospital in Pierre is $1,628.  If one multiplies the number of CT scans done in The New England Journal times an average of $1,700 per CT scan, the cost for those 31,000 CT scans is around $53 million.  If you divide that by the number of cancers that were found to be resectable, each cancer found cost an average of $128,000 just to find it.  Medicare and insurance companies don’t really look upon that expense to find one lung cancer as “cost effective.”

          The bottom line hasn’t really been changed by the article that appeared in The New England Journal of Medicine.  With the new high tax on cigarettes and all of the disease cigarettes cause, the best way to survive lung cancer is to never get it.  If the mistake of smoking has occurred, stop now.  Anyone who still harbors the doubt that smoking cigarettes increases the risk of cancer of the lung is simply fooling themselves.  It is rather like saying that swinging a bat does not cause hits in baseball.  After all, there are a whole bunch of times when the player does not hit the ball with a swing of the bat.  Pleeease!!!!