To screen, or not to screen (with CT)? That is the question that is being hotly debated by lung cancer experts.
Last week the American College of Chest Physicians (ACCP; Northbrook, Illinois) issued a report recommending against the use of low-dose computed tomography (LDCT) for the general screening of lung cancer because it doesn’t appear to reduce mortality, even in high-risk patients (Medical Device Daily, Sept. 13, 2007).
In reply, the Lung Cancer Alliance (LCA; Washington) fired back with its own statement, reiterating its support for the screening test which it says can detect lung cancer at its earliest and most treatable stage for those at high risk. Its rationale is that even though some diagnostic tests fall in the grey area of efficacy, their benefits shouldn’t be ignored.
“Mammograms for breast cancer faced enormous opposition for decades and there is still heated debate over screening of women under the age of 50,” said Laurie Fenton Ambrose, president of the LCA. She added that there are “reams of papers showing no mortality benefit for PSA testing for prostate cancer,” and that scientific disagreements and debates of this type “are not new, especially when it comes to interpreting statistics about the true benefit of screening.”
And she called it “disappointing and frankly shocking that the ACCP would flatly oppose CT screening for those at high risk for lung cancer when even the government health agency responsible for setting diagnostic guidelines is more balanced.”
That balance doesn’t exactly support the ACCP’s view.
The U.S. Preventive Services Task Force neither supports nor opposes screening for lung cancer, a neutral or “sitting-on-the-fence” stance that it also takes in terms of PSA testing for prostate cancer and breast self-exams for breast cancer.
On the anti-screening side of the fence, Peter Bach, MD, a pulmonary and critical care physician at Memorial Sloan-Kettering Cancer Center (New York), and author of the screening chapter of the ACCP guidelines, told Medical Device Daily that multiple randomized trials have demonstrated there is no benefit from CT screening of lung cancer.
“You find a lot more small cancers [with CT], but you don’t find any advanced cancers that are going to kill people sooner,” Bach said.
The cancers that do show up during a CT scan grow so slowly, he said, that they don’t actually pose much threat to the patient because they would take 50 to 60 years to result in death.
LCA doesn’t agree with that reasoning either.
“How many would take that gamble?” Kay Cofrancesco, a spokesperson for the LCA, told MDD in an email. “The best option would be to remove the lung cancer and treat it early.” And she noted that The International Early Lung Cancer Action Project (I-ELCAP) demonstrates an 88% 10-year survival rate.”
Bach last week told MDD that most clinicians do not currently order CT to screen for lung cancer and that the guidelines serve to reassure them of that decision.
But the LCA disagrees.
“The fact is that hundreds of thousands of Americans have already discussed lung cancer screening options with their physicians. Many of those individuals have exercised their choice and consumed their personal resources in an informed decision to undergo spiral CT evaluation for the presence of an early lung cancer,” Fenton-Ambrose said. “Recommending against CT screening for lung cancer, as ACCP does, is an extreme position that is out of step with current realities.”
Supporting the LCA’s position is a New England Journal of Medicine study appearing in October 2006 supporting CT screening for lung cancer. According to that study, researchers report that lung cancer can be detected at its very earliest stage in 85% of patients using annual LDCT screening (Medical Device Daily, Oct. 30, 2006).
That study was launched by a team of researchers at NewYork-Presbyterian Hospital/Weill Cornell Medical Center (New York) in 1993 and has expanded into an international collaboration of 38 institutions in seven countries. That study, titled I-ELCAP is the largest, long-term study to determine the usefulness of annual screening by CT, the institutions said.
Among the 31,567 people in the study, CT screening detected 484 people who were diagnosed with lung cancer, 412 of whom were Stage I. All the patients in that group who chose not to be treated died within five years.
Instead of screening for lung cancer, the ACCP guidelines recommend mind/body modalities to reduce the anxiety, mood disturbances, and chronic pain associated with the disease. For example, massage therapy is recommended for patients who are experiencing anxiety or pain, while acupuncture is recommended for patients experiencing fatigue, dyspnea, chemo-induced neuropathy, or in cases where pain or nausea/vomiting is poorly controlled.
But Fenton-Ambrose said it is “difficult to take the ACCP guidelines seriously when they are dismissive of screening and only endorse massages and acupuncture for a disease as deadly as lung cancer.”
According to the LCA, early detection is critical in lung cancer. By the time symptoms, such as a cough or bloody sputum, appear it is usually too late and in most cases death occurs in less than a year, the organization noted.
LCA says that since last year it has raised questions and concerns about the validity of underlying assumptions and modeling being used to provide the basis for the ACCP practice guidelines.
Harvey Pass, MD, chief of thoracic surgery and thoracic oncology at NYU School of Medicine (New York), an LCA board member and chair of LCA’s Medical and Scientific Advisory Board, said that the just-issued ACCP guidelines “simply dismiss the mounting evidence which continues to mature from the largest international, protocol-driven screening effort [I-ELCAP] showing that CT screening in a high risk population has the potential to reverse the current 15% five-year survival rate.”
But Pass recommended individual patient choice as the key decider.
“[I]ndividuals at high risk for lung cancer should make it a personal choice after conferring with their doctors as to whether they want to participate in ongoing protocol-driven programs for the early detection of lung cancer using whatever means is being studied,” he said.
ACCP said that its recommendations were developed and reviewed by 100 multidisciplinary panel members, including pulmonologists, medical oncologists, radiation oncologists, thoracic surgeons, integrative medicine specialists, oncology nurses, pathologists, healthcare researchers, and epidemiologists.