You would think that if there were a way to reduce cancer deaths by thousands of lives a year, it would be implemented immediately. But apparently not -- if it is lung cancer.
More than two years ago the largest (53,000 people), most expensive ($250,000,000) cancer screening trial in National Cancer Institute's (NCI) history conclusively proved that diagnosing lung cancer early in a high risk population can change the disease from a primarily lethal cancer to a curable one. The trial compared chest X-rays to CT scans in three screening rounds with an automatic cutoff as soon as there was a 20 percent difference in death rates.
This threshold was reached earlier than anticipated -- and the trial was halted sooner than expected. Other studies and modeling analyses since then have shown that with more screening rounds and longer follow-up the actual benefit of CT screening could be as high as 64 percent.
This scientific breakthrough is a game changer, as it could save more lives than any screening method or drug developed to date for any cancer. Since lung cancer causes more deaths a year (160,340) than breast (39,920), prostate (28,170) and colon cancer (51,690) combined, even a 20 percent drop in its mortality rate, would be the largest drop in cancer history.
In addition to this breakthrough, imaging technology can already detect early heart and lung disease at the same time and is continuing to advance rapidly. Add to this ongoing refinements in risk assessment and diagnostic protocols, as well as new less-invasive surgical techniques since the trial and it becomes clear: Lung cancer screening has the potential to bring about one of the most significant, cost-effective and life-saving advances in public health ever.
This should be a slam dunk -- one would think.
But instead of a positive response and a commitment to accelerating the process for responsible implementation for those at risk, negativity and obfuscation have ruled the day. Dire warnings are raised about speculative radiation risks and over-diagnoses even though the facts dispute them. Recent papers have shown that false positives, a problem inherent to all screening methods, can be lower in lung cancer screening than in other cancer screening methods with the application of thoughtful protocols that are already in use today.
Lurking behind all these negative and inaccurate attacks are the blame and stigma long attached to lung cancer. The message being subliminally conveyed to the increasingly cost-conscious public is that public health resources would be "wasted" on those who "did it to themselves."
The collateral damage has been extensive: the underfunding of research, the continued loss of lives, the added burdens for patients and their families, the disproportionately high but ignored impact on veterans and African American men, and the increase in never-smokers being diagnosed with lung cancer, particularly younger women.
More than 50 percent of new lung cancers are being diagnosed in former smokers and another 15 percent in those who have never smoked. Current smokers are in the minority, and screening presents an unique opportunity to reach those still addicted with more personalized, effective help to quit. Yet rather than build on this potential, the naysayers make the unsubstantiated claim that a clear scan may encourage current smokers to continue to smoke. Is it sound public health policy to deny a life-saving benefit to a majority of those at risk -- former smokers -- on the off chance that some in the minority -- current smokers -- may continue to smoke?
The ultimate straw man is cost. But because CT screening for lung cancer is targeted to a readily-definable high risk population, it can potentially be deployed at a lower expense than other cancer screening tests that are population wide. At many levels, lung cancer screening may represent one of the best investments of CMS resources in terms of improving outcomes for cancer.
The timing is not auspicious. Cancer screening in general has come under concerted attack. The reality is that until there is greater progress in treating late stage and metastatic cancers of any type and in making the highly-touted biomarkers tests more accurate, screening is only way to find cancer at an early, curable stage. Restricting access by denying coverage will inevitably result in a two-tier system that will allow only those who can afford it the benefit of cancer screening.
We will not accept this for lung cancer. Committed and dedicated clinicians and doctors have already stepped forward to fill the void and developed the National Framework for Excellence in Lung Cancer Screening and Continuum of Care, which advises the public of its rights, lays out the principles of responsible screening and care and commits to a continuous improvement process through the collection of data on outcomes. The National Framework is being adopted by a growing number of leading academic medical centers and community hospitals across the country.
This is the right way forward. This is how lung cancer screening can be implemented safely, responsibly, equitably and cost-effectively -- now.
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