Lung cancer is the leading cause of cancer deaths in this country. In 2012, the American Cancer Society estimates that there were about 226,000 people newly diganosed with lung cancer, and 160,000 deaths. If there is good news here-and unfortunately there isn't much good news when it comes to lung cancer-it is that deaths from this dreaded disease have been declining in men and women, since fewer people are smoking. But there is much we have to do to improve this picture.
That's one of the reasons the American Cancer Society is releasing new guidelines on screening for lung cancer. After carefully reviewing the available research, the Society has concluded that there is good evidence that lung cancer screening saves lives by reducing deaths from lung cancer (20% in largest carefully controlled study) in people at high risk when the screening is done by experienced, high-volume lung cancer screening programs.
So who should be screened? Who is at high risk?
According to the guidelines, those for whom lung cancer screening with low-dose chest CT scans are appropriate are people who are between the ages of 55 and 74 and who have smoked 30 pack years (a pack year is one pack of cigarettes a day for one year) or more or who have smoked 30 pack years in the past and quit within the last 15 years and are now within that age range. Those individuals who meet those criteria-should they choose to be screened-should have a low dose chest CT scan every year until age 74.
However, this isn't a blanket recommendation. There are other cautions in the guidelines that you should know about.
First, and very important, is the recommendation that anyone considering screening have a careful discussion with their health professional about the benefits, risks and harms of lung cancer screening.
This is not a simple or benign process. There are many folks who are screened who are found to have lesions in their lungs that are not cancer. The anxiety that can come with hearing that there is a lesion in your lung that may be cancer can not to be brushed aside easily (I know: I am not a smoker and had such lesions detected several years ago as recorded in this blog). In addition, depending on the findings on the CT scan, the doctors may suggest additional tests. Usually this is something as straightforward as a repeat CT scan, but may be more complicated such as a bronchoscopy to look down in the lung or even a biopsy through the chest wall to see if a lesion is cancerous. It may even mean chest surgery.
And we can't forget that people who smoke are frequently not in the best health. They may have underlying heart and lung disease that puts them at greater risk of medical complications. So that is another factor that has to be considered.
The guidelines also recommend that the screening be done at institutions that have experience in lung cancer screening and know the right procedures to follow if an abnormality is found. Lots of places are going to claim they have that expertise, but many actually don't. Having radiologists who understand the nuances of abnormalities on CT scans, along with other doctors including lung specialists in medicine and surgery are all part of the screening process and recommendations from the American Cancer Society.
Unfortunately, the results of screening are not perfect.
Although prior studies have suggested a high survival rate for many of the people screened, the evidence shows that even with screening many people who are found to have lung cancer through screening still succumb to the disease. So it is not a panacea, and it is should never be thought of as an excuse to continue smoking (as in, "Well, they can find it when it happens so I will be OK." Sadly, that is far from the case). That's why smoking cessation must still be emphasized as a goal even for current smokers who elect to get screened every year.
One of the issues that has concerned us is the potential (and in fact, it is more than "potential") abuse of lung cancer screening.
If history has taught us anything, it is that just because a screening test is available doesn't make it right for everyone. We need to pay attention to the science behind the test to determine whether the benefits of a screening test outweigh its risks and harms. Prostate cancer screening is a great example of this issue, and breast cancer screening continues to be debated as to when to start screening and how often to do it. Just because we want it to be so doesn't make it so.
We do believe lung cancer screening can save lives if the cautions mentioned above are taken into account. But we also recognize that there are some who will push the boundaries of lung cancer screening beyond what the science tells us. In fact, we have already seen evidence of that after the release of the initial reports of a major lung cancer screening clinical trial a couple of years ago.
To be specific:
- We don't recommend screening for non-smokers;
- We don't recommend screening for those who don't meet the criteria noted above;
- We don't recommend screening for young people who are smokers.
The bottom line: if the studies haven't been done to show benefit-and in the groups noted above they have not been done-then medically we shouldn't be recommending it. And neither should anyone else. They simply don't have the evidence that the test will save lives, and in fact it may cause more harm than good.
We do recognize that there are some people who may be on the "cusp" of the screening recommendations, such as a 52 year old person with a 40 pack year smoking history. We are going to leave that discussion to the patient and their health professional. But a non-smoker, even one who works in a smoky environment such as a bar? No, nope, nada. Shouldn't do it.
So now we have a test that hopefully will help save lives. We won't know for certain how many lives until we see how this plays out in the real world. After all, doing studies as part of a research program where everyone is paying reasonably close attention to details and there are monitors to make certain they do is different than real life.
But with careful attention to the recommendations made in these guidelines, our hope is that lives will be saved, and more birthdays will be celebrated.