Using CT scans for lung cancer triggers debate


CT scans create three-dimensional images of the lungs, instead of the two-dimensional perspectives captured by chest X-rays.
August 15, 2011

Hospitals and radiology practices around the United States have increasingly begun using high-tech CT scans to screen people for lung cancer despite intense disagreement about whether the testing should be done widely and, if so, who should undergo the exams.

The trend was triggered by a recent federal study, which found that screening certain heavy smokers and ex-smokers could slash their chances of dying from lung cancer. The finding was hailed as one of the most important advances in decades toward reducing the toll from the nation’s leading cancer killer.

Proponents of screening say the scans could save thousands of lives, and people at risk of lung cancer should be able to get the exams — and insurance companies should pay for them — in consultation with their doctors.

Critics of wide-scale testing acknowledge that CT screening represents an exciting advance but argue that it remains far from clear whether the benefits will outweigh the risks in the real world. Screening millions of Americans could do more harm than good by spawning a wave of false alarms that prompt costly, dangerous and needless follow-up testing, biopsies and surgeries, they say.

More than 222,000 Americans receive lung cancer diagnoses each year, and more than 157,000 die from the disease — more than from cancers of the breast, colon and prostate combined. Lung cancer has remained notoriously difficult to treat, in part because it is often diagnosed too late.

There are about 100 million current and former smokers in the United States, all of whom are at increased risk. Many more might be prone to the disease because of family history or exposure to substances such as radon and asbestos.

CT scans create three-dimensional images of the lungs, instead of the two-dimensional perspectives captured by chest X-rays. Scans are more likely to spot small tumors, boosting the chances of survival.

In November, the National Cancer Institute announced it was stopping the $250 million National Lung Screening Trial, which was testing the approach in 53,500 men and women in 33 sites across the United States, when it became clear the scans could slash the death rate by a stunning 20 percent compared with old-fashioned chest X-rays.

Even though many hospitals and radiology practices can do CT scans because they offer them for other purposes, officials said that more analysis was needed to answer many questions, including precisely who might benefit and under what conditions.

The scans produced false alarms in about 40 percent of cases in the study. While screening saved 88 lives among the trial participants, 16 patients died from apparent complications from follow-up procedures, including six who did not have cancer.

“Screening for lung cancer saves lives, but it is a double-edged sword,” said Otis W. Brawley, the American Cancer Society’s chief medical and scientific officer. “There’s a huge benefit, but there’s also a documented risk and a documented harm.”

Leading medical groups are urging doctors to wait until experts carefully review the findings. They also want the results of a federally funded cost-benefit analysis, which is underway. Insurers, including the government’s powerful and influential Centers for Medicare and Medicaid Services, say they will review the outcomes of those deliberations before deciding whether to pay for scans.

Health experts have been questioning the value of screening for many health problems. In recent years, intense debates have erupted over whether mammography for breast cancer, PSA testing for prostate cancer and Pap smears for cervical cancer are overused. The U.S. Preventive Services Task Force, which triggered a firestorm when it raised questions about mammography, is evaluating CT scans for lung cancer.

No one tracks how commonly CT screening is done for lung cancer, but a number of centers have announced they were starting screening programs since the findings were released, and interviews with radiologists and other experts around the country indicate the trend is accelerating.

Most major medical centers only screen people who fit the strict criteria of the study: those age 55 to 74 who have a smoking history of at least 30 “pack years.” Critics are less worried about those programs, especially because the centers have experienced interdisciplinary teams skilled at minimizing unnecessary follow-up CT scans, biopsies and surgeries.

But some centers go beyond that, testing people who are younger, older and have never smoked but may be at increased risk for many reasons, including exposure to secondhand smoke or workplace hazards.

“We’ve always said it’s a personal decision an individual needs to make,” said Claudia Henschke, a professor of radiology at Mount Sinai Medical Center in New York.

Deborah Morosini, 52, of Boston, was screened in December at Mount Sinai because her mother died of ovarian cancer and her sister, Dana Reeve — wife of the late actor Christopher Reeve — died of lung cancer at age 44 even though she never smoked.

“I really am very clear that if I am going to have lung cancer, I want it to be an early lung cancer,” Morosini said. “I do my mammographies. I do my colonoscopies and my Pap smears and all manner of screening.”

Some practices will screen anyone who comes in with a doctor’s prescription, and some are marketing the scans with radio ads and billboards.

“I think it’s valid to offer it to people,” said Jill Wilkens, a radiologist at Progressive Radiology, which offers the screening at two of its 10 offices in the Washington area. “Lung cancer is such an ominous terrible, terrible disease, and most of the time we find it when it’s too late to offer a cure.”

Matthew Bullock, 38, of McLean and his wife were screened at Washington Radiology Associates in May because both had a lot of cancer in their families. Bullock also said he smoked for about 18 years.

“We have three young boys. We just thought it was a reasonable thing to do,” Bullock said.

Peter B. Bach, a lung cancer specialist and epidemiologist at Memorial Sloan-Kettering Cancer Center, called testing people other than those who fit the criteria in the study — especially outside centers that have highly skilled interdisciplinary teams to follow-up on the results — “unconscionable.”

The false-positive rate could easily be significantly higher among a broader population, and the risks could be greater because those in the study were relatively healthy despite their smoking history. The scans can also detect other potential problems — and false alarms — near the lungs, including aneurysms, masses in the abdomen and even heart problems.

“The scans open a Pandora’s box,” Bach said.

Some question whether some hospitals and practices were offering the tests to generate revenue.

“One of the reasons health-care costs are spiraling out of control is because there is a kind of medical gluttony on the part of physicians and patients,” said Brawley, of the American Cancer Society. “Sometimes it’s out of fear on the part of the patient, and sometimes it’s for other unfortunate reasons on the part of health-care providers: profit.”

But others said people at risk for lung cancer should consider consulting with their doctor about getting screened.

“Those who would suggest that cost may be reason for delaying implementation of this benefit implies that a life saved from lung cancer is less valued than any other,” said Laurie Fenton Ambrose, president and chief executive of the Lung Cancer Alliance. “Imagine if this was the HIV community. Imagine if it were breast cancer. Why is there always a ‘but’ with lung cancer?”

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