In the Name of God, the Most Compassionate, the Most Merciful
The following article was published in the Chicago Tribune on November 19, 2006.
To screen or not to screen: A case for early detection
By Hesham A. Hassaballa
November 19, 2006
“Wasn’t there any way I could have found out sooner?”
This is one of the most common questions patients ask when I tell them they have lung cancer.
“It is very difficult to do so, because lung cancers begin as tiny spots that cause no symptoms,” I tell the patients.
Then they often ask: “Is there no way to screen for lung cancer like other cancers?”
That question ignites one of the most contentious debates in modern pulmonary medicine, and the results of a study published last month in the New England Journal of Medicine have only added to the controversy.
Researchers from more than 30 hospitals around the world, led by Weill Cornell Medical College, used CT scans to screen about 31,000 people who were at a high risk for lung cancer.
They found cancer in 484 of those participants, 412 of whom had Stage 1 disease, the earliest stage. Most had surgery, although some were treated with chemotherapy and radiation as an alternative to surgery. Eight patients received no treatment.
The researchers estimated that 88 percent of patients with Stage 1 lung cancer would survive 10 years. And if patients begin treatment within one month of their diagnosis, it is estimated that 92 percent of them would be alive 10 years later. The eight patients who received no treatment all died within five years.
These numbers are earth-shattering. Although lung cancer is not the most common cancer, it is the most deadly. It will kill an estimated 160,000 people this year.
On average, only 75 percent of patients with Stage 1 lung cancer will survive for eight years. Furthermore, previous lung cancer screening studies have failed to show a greater rate of survival in patients who received regular screenings.
In spite of the study’s findings, none of the major cancer societies has recommended routine CT scans for people at risk for lung cancer.
1 study is not enough
Dr. Robert Smith, the director of screening for the American Cancer Society, said the findings “show real promise” for cutting the leading cause of cancer death. “But,” Smith added in a statement, “health policy isn’t made on the basis of one study.”
One of the limitations of the study is that it was not a randomized trial, in which a control group of patients that had not been screened is used for comparison. That kind of study is the gold standard in research. Such a trial is under way, with results due in a few years.
But it is hard to argue with positive results. Even though a small percentage of the more than 31,000 people screened developed lung cancer, those 412 patients with Stage 1 lung cancer are more than statistics. They are real people who benefited from receiving screening CT scans of the lungs.
How can I deny such a potential benefit to my patients who are current or former smokers and are at risk for developing lung cancer?
Therein lies the rub. Not every spot on a CT scan is necessarily lung cancer. We live in an area where airborne fungi and other organisms are endemic, and infection with these organisms can cause a spot on the lung that looks like early-stage lung cancer. A biopsy is the only way to know for certain whether the spot is lung cancer.
Yet a lung biopsy is not without risks. Complications such as bleeding and the collapse of a lung can occur, and they can be painful, costly and ultimately unnecessary.
Biopsy has risks
Furthermore, many patients with spots on their lungs have other diseases, such as emphysema or heart disease. This further increases the risk of complications. Thus a lung biopsy recommendation is not made lightly.
It can be a terrible dilemma for patient and doctor. Unfortunately, definitive answers are years away, if they come at all.
So what do I do with an anxious patient in my examining room? I talk to him or her and lay out everything on the table. I explain the potential benefits and risks. The most important thing is to have my patients fully informed so they can feel comfortable about the decisions they make.
In addition, I try to counsel and comfort my patients. Many of them are scared when they are told, “You have a spot on the lung.” This is especially true if they have seen a family member with lung cancer suffer and die. Helping my patients feel a little better by saying, “I understand you’re scared, but it’s OK,” is one of the best parts of my job.
Still, despite the caveats and cautions, the results of the study are very exciting. Lung cancer is a ravenous, brutal beast that can kill its victim in a matter of weeks.
I have seen this happen, and it is devastating. I hope this study is the harbinger of a future in which this terrible disease can be detected in its early stages.
Given the results of the Cornell study, more research needs to be done, whatever the cost, because the stakes are high. For far too long, lung cancer has wreaked havoc on the lives of thousands. Perhaps one day, doctors can say the words “cure” and “lung cancer” in the same sentence.
Hesham A. Hassaballa is a Chicago pulmonologist and writer.
Copyright (c) 2006, Chicago Tribune