Tinker Ready

Boston Globe: The debate over lung cancer screening

From The Boston Globe
July 11, 2000

Are lung cancer victims second class citizens? The debate over lung cancer screening

By Tinker Ready
Globe Correspondent

They are among the most unfortunate and least pitied of cancer victims.
First, they must face the fact that their diagnosis is almost always a death sentence. Then, in most cases, they have to come to terms with the reality that they brought the cancer on themselves by smoking cigarettes.
Each year, about 160,000 people die from the disease in the United States, more than any other cancer, yet, unlike other cancers, there are few groups for lung cancer patients who want to share stories and few advocates pushing for research breakthroughs.
Now, a controversial new screening test that can identify lung tumors at their earliest stages of growth is raising issues about whether doctors and scientists go after lung cancer with the same fervor they direct at other cancers.
Researchers in Japan and New York have developed a technique using state-of-the-art spiral computed tomography, or CT, that can detect lung tumors far smaller than the next best method, chest X-rays. In some parts of the country, doctors now offer the test to smokers, former smokers and anyone else who is worried about lung cancer.
But many hospitals – including some in Boston – are reluctant to offer the CT scans, arguing there is no proof they save lives. And the National Cancer Institute has refused to endorse the test until a decade-long study can demonstrate the scan’s effectiveness.
But advocates for lung cancer victims say the doubts smack of indifference to the plight of people afflicted with a terrible disease. By the time the NCI study is finished, another 1.5 million people would be expected to die from lung cancer.
“With lung cancer, there is a sentiment out there that you deserved it. You smoked. You caused it yourself,” said Beverly Ward, a Revere native and labor lawyer who has lost her brother and mother as well as one of her lungs to lung cancer. “I don’t apologize. It’s an addiction and one does the best they can.”
“If [a CT scan] had been available, my brother would be alive,” Ward added. “This is what I know. When you see a tumor with a regular X-ray, its too late. . . . You get lung cancer, you’re dead.”
In response to patient demands, the American Cancer Society has agreed to consider recommending early screening for lung cancer, which could ease the way for insurance coverage of the $150 to $200 tests. In Boston, meanwhile, Beth Israel Deaconess Medical Center already offers CT scans, and doctors at Brigham and Women’s Hospital and Massachusetts General are about to start.
But the debate over screening for lung cancer – and society’s view of its victims – is far from over.     Like most cancers, lung cancer begins quietly and without symptoms. A single cell goes awry and starts growing uncontrollably. Over time, one cell becomes many cells, which then form a tumor. Eventually, tumor cells break off, fan out into the vital organs and shut them down.
Lung cancer’s high mortality rate, many say, comes down to doctors’ inability to catch tumors before they grow and spread. Unlike cancers of the breast, colon and other organs, there is no commonly used test to pick up some lung cancers before they become deadly.
The CT scans, which essentially take a 360-degree X-ray that allow radiologists to view “slices” of organs, can find tumors at a stage where, with surgery, 70 percent of patients are alive five years after treatment, according to Claudia Henschke, a Cornell University radiologist who is championing the CT scan. Left alone, she said, such tumors will be fatal within that same time for 90 percent of patients.
Not surprisingly, after years of little improvement in the prognosis for lung cancer patients, advocates are excited.
“The Spiral CT scan is one of the most exciting things that has happened in lung cancer recently,” said Peggy McCarthy, a member of the board of the Alliance for Lung Cancer Advocacy, Support and Education, a national group based in Washington state. “It’s going to provide a major breakthrough.”
But others see problems. The test – like most screening – is less than perfect. It mistakenly identifies many benign lung problems as possible tumors. That can mean months of anxiety and, possibly, unnecessary chest surgery, before doctors can say for sure whether the patient has cancer.
It is clear that the CT scan finds cancers earlier than scans conducted once the patient starts having symptoms. It is not clear, according to current scientific theory, that screening and early detection always save lives. That sounds illogical in an era when early detection has become a battle cry in the war against cancer. But early detection does not always translate into an improved prognosis for cancer patients in general.
It will take a large, long-term study to definitively answer the question: Do CT scans for lung cancers save lives? The National Cancer Institute already is planning to look at nearly 90,000 people for at least 10 years to determine whether the CT scans improve life expectancies.
Edward Patz, a professor of radiology at Duke University Medical Center in Durham, N.C., said that, until that study is complete, he fears the test may be offering patients false hope.
Without data from a larger study, he said, no one knows whether the scans are adding years to patients lives or just getting them in for surgery a bit earlier.
“No way we’ll be doing it,” Patz said. “It’s medically irresponsible.”    Lung cancer is different than many other cancers in that researchers know what usually causes it – cigarette smoking. Before the 20th century, when cigarettes became popular, lung cancer was fairly rare. Today, it is the number-one cancer killer, taking the lives of three times as many people as breast cancer and five times as many as prostate cancer.
Since the 1960s, mounting evidence that cigarettes contribute to heart disease and cause lung cancer has convinced many people to quit. In 1955, about 60 percent of men and 30 percent of women in the United States smoked. That figure is now down to about 25 percent for both sexes, although it is higher internationally. And the evidence is everywhere – from sealed ashtrays on airplanes to smokers clustered outside of smoke-free office buildings. In many settings, smoking is now totally unacceptable.
Those who quit smoking lower their risk of lung cancer, but they still get the disease at a higher rate than nonsmokers. And about 15 percent of people who get the disease never smoked.
Still, many people express little sympathy for lung cancer victims. There are few support groups and, until recently, no advocates for more research.
When Beverly Ward was diagnosed with lung cancer two years ago, she looked in vain for support groups. Her mother and brother, both smokers or former smokers, had already died, and she was facing the removal of one lung.
“There was nothing,” said Ward, who is 42.
Eventually, she found the Alliance for Lung Cancer Advocacy, a five-year-old nonprofit organization set up by Washington state medical educator McCarthy after she couldn’t find good materials for her clients with lung cancer. One of the first things she discovered was that – in proportion to the number of people who die – the National Cancer Institute spends far less on lung cancer research than it does on other cancers.
In 1999, the NCI spent $146 million on lung cancer, about the same amount it spent on colon cancer, which kills about half as many people annually. Lung cancer kills more women each year than breast cancer, yet the NCI spends more than twice as much money on breast cancer.
If lung cancer is at the top of the NCI’s death rate charts, McCarthy’s group asked, why isn’t it at the top of the funding chart?
“I think they believe that lung cancer is a deadly disease and there is nothing we can do,” McCarthy said. “And after all, people caused it themselves so they deserve to die.”
She also said she believes that attitude explains why the agency is dragging its feet about endorsing the Spiral CT scans.
Not so, said Christine Berg, until recently the chief of the Lung and Upper Aerodigestive Cancer Research Group at NCI’s Division of Cancer Prevention. Comparing dollars to death rates is not a good way to measure the NCI’s commitments to a certain cancer, she said.
The agency spent a lot of time and money in the 1970s and 1980s to assess the use of chest X-rays as a screening tool for lung cancer.
While federal researchers found that annual chest X-rays – like spiral CT – detected early tumors, early screening didn’t pass the ultimate test. There were just as many lung cancer deaths among the people who were screened and the people who didn’t get X-rays. While some researchers now question the interpretation of that study – and the use of chest X-rays is being re-examined – the early findings led the American Cancer Society and the NCI to recommend against lung cancer screening.
Berg understands the frustration that some doctors feel, but she’s adamant about the need for a larger study.
“I think [CT screening] is potentially quite useful,” she said, but added, “I’d like to know how well it works and what are the potential drawbacks before we say it’s the greatest thing since sliced bread.”
But Cornell radiologist Henschke said she thinks waiting for the NCI report is research overkill, not to mention insensitive.
“It’s hard to tell the people who are at risk that they have to wait. . . . We have a lot of data from the prior studies. . . . We shouldn’t pretend that we don’t know enough about lung cancer.”
Amid the conflicting scientific advice and rising patient demand, some Boston hospitals have tried to navigate a middle course, offering CT scans, but unlike free-standing clinics in other states that promote the test, they accept only patients referred by doctors.
Theresa McLoud, the director of Thoracic Radiology at Mass. General, is almost apologetic about offering the test. But without it, she can offer nothing but a grim prognosis to lung cancer patients.
“It’s pretty solid evidence that this is a benefit,” she said. “It’s the only thing we have for such a horrible tumor.”

The Fund for Investigative Journalism  funded part of the research for this article.


2 Responses

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  1. […] Lung Cancer Screening: You read it here first. November 5, 2010 — by Tinker Ready Not exactly. But, BHN writer Tinker Ready reported on research and controversy surrounding the approach in a freelance story for the Boston Globe in 2000. […]

  2. Tinker Ready clips said, on January 10, 2011 at 8:29 pm

    […] women seem to be more likely than men to contract lung cancer. Los Angeles Times , March 26, 2001. Lung cancerscreening : hope or hype? A story about the pros and cons of a new test that promises early detection of lung cancer. The […]

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