Affiliations: Syracuse, NY
Dr. Lenox is an Associate Clinical Professor of Medicine, SUNY Upstate Medical University.
Correspondence to: Robert J. Lenox, MD, SUNY Upstate Medical University, Division of Pulmonary and Critical Care Medicine, 750 E Adams St, Syracuse, NY 13210; e-mail: firstname.lastname@example.org
Lung cancer is the number-one killer among cancers. During 2002, 550,000 Americans died of cancer. Of these cancer deaths, lung cancer killed 161,400 or 29% of the total. Of those who acquire lung cancer, only 12 to 15% will be cured. Lung cancer kills more Americans than the next three most deadly cancers (breast, colon, and prostate) combined.1
Despite these sobering statistics, screening for lung cancer is not done. Three lung cancer screening studies2–4 were published in the 1980s and failed to show a decrease in the overall mortality of those screened. Since the publication of these studies, there have been advances in the detection, diagnosis, and treatment of lung cancer. Most notable, from a screening standpoint, is the availability of CT scanning for the detection of lung cancer. This has led to nonrandomized studies5designed to assess the utility of screening for lung cancer with CT scans of the chest. Nonrandomized studies6using low-dose CT scans have shown an ability to detect smaller lung cancers than those detected by chest radiographs. This has led some to advocate screening for lung cancer with low-dose CT of the chest.7
In response to those advocating screening, Patz et al8and Heyneman et al9 analyzed data from the cancer registry of their hospitals. They did not see a stage shift when smaller tumors were compared to other tumors < 3 cm in size.8–9 This led them to become advocates for the National Lung Screening Trial (NSLT). This trial is now underway. In this issue of CHEST (see page 1136), Yankelevitz et al offer a criticism of why they believe the data of these previous studies,8–9 were flawed, and conclude that the data supplied do not provide a rationale to perform a randomized controlled trial comparing CT scans of the chest to chest radiographs. If this is the case, should the NSLT continue or should screening for this deadly disease commence immediately?
This question is important for several reasons. Obviously, each year many thousands of Americans and others throughout the world are dying from lung cancer. While the issue is being studied, there is the potential for thousands more to die of this deadly malady. Screening now has the potential to save many if not thousands of lung cancer victims.
However, if lung cancer screening is to be done, how much will it cost? From where will the resources come to pay for such screening? As the current US budget deficit illustrates, there are limited resources even in a rich nation. If screening is done, will there be less for other health-care issues? Should more dollars be spent on screening and less on treatment? Should more be spent on prevention (smoking cessation) and less on screening? If billions are spent on screening, will research into the molecular mechanisms and treatment of lung cancer be cut? Will there even be fewer dollars to spend on the research of lung cancer screening? Will the expected result be realized or will some other unexpected outcome result? One need only look at the surprise outcome of the use of the cyclooxygenase-2 inhibitors to realize that what is good in theory does not always bear the expected fruit in practice.
Unfortunately, the answers to these questions are mostly unknown. Yet, even if screening is embraced, there are many questions still in need of answers before it can be done intelligently. The most obvious question is who should be screened? Should all former smokers be screened? What if one smoked only 1 year, or 10 years, or 20 years? At what age should screening begin? What is the proper interval between screening CT scans? How cost-effective is CT screening of the lung? How does the cost-effectiveness of CT screening for lung cancer compare to other health-care interventions?
Obviously, the answers to the above questions are vital if we are to screen for lung cancer in an intelligent manner. If we start without examining these questions will we ever answer these questions? How many false-positive findings occur when such screening is done? In the noncontrolled studies to date, there have been a staggering number of benign nodules discovered. In the Mayo Clinic study,6 66% of the screened individuals had noncalcified nodules found; 13% of these had indeterminate characteristics. Outside of a renowned institution, these results will be confusing and may lead to unnecessary biopsies. What will be the cost in morbidity and mortality of screening with such a high false-positive rate? Most importantly, at this time we do not know if the increased numbers of early stage lung cancers found in uncontrolled studies will lead to a decreased mortality rate, or if they are the result of lead-time or length-time bias.
The United States spends a larger percentage of its gross national product on health care than any nation in the world. Despite spending more, the US health outcomes as measured by longevity are lower than many nations. Is it wise to embark on a massive screening effort with so many unanswered questions? In the past, the United States has embraced almost any new technology without answering such questions. The result is massive health-care spending with results that are not superior to nations spending less on health care. It is time that we analyzed what we do more carefully. A more frugal use of our health-care dollars could both decrease the amount spent and improve the outcomes of health care in the United States. If we wait for the NSLT results, we should know if lung cancer screening is effective under the circumstances studied. This will provide a starting point to answer many of the questions raised by this technology. It is imperative that we be shrewd as well as compassionate. The frugal use of our health-care dollars is in the interest of the nation and in the long run the individual. Those who advocate lung cancer screening now need only to look back to the negative lung cancer screening results of the 1980s. If they do, they will realize that carefully controlled studies are needed before we embark on such a demanding journey.
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