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    Sunday, March 11, 2007

    Searching for Lung Cancer: Several months ago, there was a flurry of news reports that purported that the previous conventional wisdom about lung cancer screening - that we have no meaningful and effective screening method - was wrong. Based on this study, the reporting claimed that CT scans for high risk people could detect lung cancer early, and implied that doing so would save lives. However, the news this week is that although routine CT scans detect lung cancer early, they doesn't save lives. In fact, screening doesn't even change the number of lung cancers that go on to advanced stages. What it does change, is the number of people who had surgery for lung cancer. It increased that number by 10-fold, from 10.9 to 109. That's a lot of surgery for no benefit, and potential harm. In the pro-CT study, two patients died as a result of their surgery.

    The studies looked at different populations, but they also approached the question of whether or not routine CT scans save lives in different ways. The pro-CT study lumped all of the patients with cancer together and estimated their 10-year survival rate as a group, regardless of cancer type. As you can see, a lot of people had to have biopsies (thousands) to detect a small number of cancers.

    The less-than-enthusiastic-about-CT scans study compared the number of cancers found by routine CT scanning, and their actual survival rates, with the number of cancers and their survival rates that one would expect based on past experience for their given populations. They also broke their cancers down into advanced and early. There were more cancers and more surgeries than predicted, but the number of deaths and the numbers of advanced cancers detected were what one would expect without screening.

    This is a particularly difficult point to communicate to patients. Most people believe intuitively that doing a periodic chest x-ray has the potential to save them from lung cancer. The worst scenario is when a patient is diagnosed with advanced lung cancer and then blames their physician for never doing a chest x-ray or CT scan, even if they didn't have any symptoms. In fact, you could have a chest x-ray every month and still die of advanced lung cancer. Lung cancer is one of those cancers that has many faces. There are some that are so aggressive, finding them early makes no difference. By the time they've shown up, they've already spread. There are others that are slow and passive and easily treated, even if we only find them once they become symptomatic. But try telling an angry cancer patient that. Especially one who read the first set of news stories touting the benefits of routine CT scans, but missed this weeks's news.
     

    posted by Sydney on 3/11/2007 03:09:00 PM 2 comments

    2 Comments:

    I'm a practicing radiologist in Texas, and the results of this study do not surprise me in the least. IIRC, the original study for low-dose CT screening came out of NYC, and when it was repeated at Mayo the results were not so rosy. The midwest is the histoplasmosis belt, nearly everyone here has one or more tiny masses in their lungs, some calcfiied and some not. The calcified ones we know what they are, the non-calcified are overwhelmingly non-calcified and benign granulomas, but only a couple years of observation will establish that. The SPNs that stand out so well in NYC are masked by many more pulmonary masses in the remainder of the lung fields in the midwest and south.

    Many CT cycles are expended to chase benign findings, but to your point -- it's due in part to unreasonable expectations. It's hard for people to believe they can be killed by a small cell carcinoma smaller than a dime, but it happens pretty much every day. PET helps, but only for lesions 7mm or larger, and it's sometimes iffy at that size.

    Thanks for posting about this.

    By Blogger Darren Duvall, at 2:58 PM  

    Ovarian cancer is the same way. By the time it is detected by "screening" methods, it's too late. It's a disease that does not lend itself to screening because there is no precancerous stage, no preclinical stage during which it can be reliably detected, and all tests have a high false-positive rate and/or high cost.

    There is no evidence that regular screening with US or CA125 will make a difference, even in high risk populations, but, as you say, try telling that to a patient with cancer.

    It's really difficult for both patients and doctors to accept, but pouring money down the drain in the name of "doing something," is not only falsely reassuring, it's potentially harmful. The problem is, it's a whole lot easier to do so than it is to try to explain why such tactics won't work.

    By Anonymous danie, at 1:11 AM  

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