Health: Test Detects Early Lung Cancer

At 76, E. Patrick Flynn believes he is alive today only because a CT scan detected a tiny tumor in his lung in 1996. "Not the slightest question in the world," says Flynn, a former smoker. The Carmel, N.Y., resident underwent surgery shortly after the tumor was found and has visited his doctor for annual CT scans ever since. They've given him peace of mind—and allowed him to enjoy "all the pleasures of life"—such as golfing, investing in real estate and spending time with his seven grandchildren.

Flynn may well be right that his life was extended by those painless diagnostic procedures. In a study published in this week's New England Journal of Medicine, researchers report that early detection of lung cancer followed by surgery within one month results in a 10-year survival rate of 92 percent. That's a big deal because lung cancer kills more Americans than any other cancer. Each year 173,000 Americans are diagnosed with the disease and 164,000 die from it. Overall, the five-year survival rate is just 15 percent—compared with 86 percent for breast cancer. Lung cancer tends to develop silently, with the classic symptoms, including chest pain and coughing, not appearing until the disease is advanced. "What this study shows is that if you find it in the early stage, we might be able to improve mortality," says Dr. Michael Unger of the Pulmonary Cancer Detection and Prevention Program at Fox Chase Cancer Center, who wrote an editorial that accompanied the findings.

In the study, called the International Early Lung Cancer Action Program, investigators using low-dose spiral computer tomography screened 31,567 asymptomatic people at risk for lung cancer from 1993 through 2005. They diagnosed lung cancer in 484 participants; 412 (including Flynn) had Stage 1, the earliest stage of lung cancer. Stage 1 lung cancer, with an estimated 10-year survival rate of 88 percent. Of the 302 patients with Stage I cancer who underwent surgery within a month after diagnosis, the survival rate was 92 percent. The eight participants with Stage I cancer who did not get treated died within five years after diagnosis.

Should people get screened now? "Unfortunately, it's very hard to give a black-and-white answer," says Dr. Norman Edelman, chief medical officer to the American Lung Association. An ALA committee is looking into whether the group should revise its position on early CT scanning. But for now, the ALA—and most doctors—are waiting for the results of a gold-standard, randomized, controlled trial by the National Cancer Institute, called the National Lung Screening Trial. This study, which began in 2002 and should be completed in 2009, is examining whether screening with CT or chest X-rays can reduce deaths from lung cancer in 53,000 current or former smokers without symptoms of the disease.

For now, the new study—performed without a control group—does not change current clinical recommendations. "Most of the policy leaders in the world will want to have evidence from randomized, controlled trials," says epidemiologist Robert Smith, director of cancer screening for the American Cancer Society. Each screen costs around $250—which would add up year after year, if they were performed on 100 million people. Researchers believe the best candidates for CT screening are current and former smokers who have smoked for at least 20 years, as well as people with environmental exposure to hazardous materials such as asbestos.

"Since it is not a randomized trial, the data cannot and do not demonstrate that screening for lung cancer with CT reduces lung-cancer mortality," says Dr. Ella A. Kazerooni, director of the cardiothoracic radiology at the University of Michigan and an investigator in the NCI study. "Without a randomization trial that also tracks a group not getting CT, it is not possible to make comments regarding prevention of lung-cancer deaths." The study "suggests, but does not prove, that CT screening should be performed and is clearly not enough to change public health-care policy," she says.

Many doctors are taking a cautious approach. "I will offer it on a case-by-case basis," says Dr. Kathy Albain, an oncologist at Loyola University of Chicago. Not everyone wants to know about every last nodule on their lungs. This week Albain saw a lung-cancer survivor who said, "'I don't want to risk finding little dots that I'll have to worry about.'"

It's a legitimate concern. Dr. Harvey I. Pass, chief of thoracic surgery at New York University School of Medicine and an investigator in this week's study, is a proponent of CT screening—"as long as the patient understands that there isn't certainty about what something may be." Rather than biopsy every last nodule, he tests the ones that subsequent CT scans show are growing. "It's a process. It's not just a CT scan," he says.

"CT is a powerful imaging tool, and when you image the lungs, you find all sorts of abnormalities, most of which are not cancer," says Smith. The lung is delicate, which means it can collapse with biopsies. "It's not the harm of the test. It's the pathway the test can put you down," says Smith.

Not every hospital is ready to interpret the results of CT scans. "Screening has to be done with quality-assurance measures, like with mammography," says lead investigator Claudia Henschke of New York Presbyterian Hospital-Weill Medical College of Cornell University.

In the future, genetic markers may help doctors identify candidates for screening. And perhaps there will be more government funding for research, as well. "Lung cancer is getting six to eight times less than breast cancer, when there are many more people dying of lung cancer," says Unger.

Ideally, the future will also bring more Americans who just say no to cigarettes. More than 85 percent of people who get lung cancer are current or former smokers—and millions of Americans fall into that category. More than one in five adult Americans still smoke. "People sometimes think we're Johnny One-Note," says the ALA's Edelman. "But the best way to deal with lung cancer is smoking prevention in kids and teenagers and smoking cessation in adults. As a society, we can do a lot more to reduce smoking rates and therefore reduce the burden of lung cancer."