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In other words, Reich is suggesting that the average (or "community") doctor might be too dumb, uninformed, or ill-equipped to handle CT scans responsibly.
"If you find cancer on mammography, you can go ahead and biopsy it and there's no significant risk," Reich says in an interview from Portland. "But if you find a nodule in somebody's lung, that's a different matter. If you biopsy it, in Cornell's hands, the results are superb. In less skillful hands, the risk of internal bleeding is 2 percent, collapse of the lung is 10 percent. Finding lesions that may or may not be malignant is far more dangerous in the lung than in the breast. My thesis is that the acceleration of comorbidity as a result of major surgery offsets what might have been gained by earlier detection."
There are three ways to perform a lung biopsy: through a scope fed down the windpipe, with a needle inserted through the chest wall, or via open-chest surgery on the lung. Possible complications, while infrequent, include partial collapse of the lung, bleeding, infection, and other pain. If surgery is necessary, doctors perform either a thoracoscopy, in which the surgeon inserts a thin tube with a camera through a small incision in the patient's side and works on the lungs while watching a video monitor, or a thoracotomy, which begins with a long incision between two ribs, from front to back, on one side of the chest. After opening the chest wall, the surgeon can remove all or part of a damaged lung. These procedures can be more dangerous in smokers because of their accompanying heart conditions.
"Most patients who develop lung cancers have comorbidities of cardiovascular disease and emphysema," Reich says. "So if you do the standard operation -- a lobectomy, which removes about a fifth of the lung -- you bring on manifestations of cardiovascular diseases earlier than they would have appeared. The lungs are a vital organ. The breast, the colon, the uterus -- you can live as long, if not as well, without those organs. But you can't without part of your lung."
Too many patients, Reich argues, might get CT scans that show inconclusive abnormalities -- such as smoking scars, inflamed areas, or other noncancerous conditions -- and unwisely demand treatment, or even surgery, on the spot. How many, Reich asks, will be willing to settle into the ELCAP protocol of follow-up screening to monitor the growth of potential trouble spots?
"In a situation like Cornell, where you have a sense that the physicians are speaking with a high reputation, patients may be comfortable with [waiting]," Reich says. "But with a local physician or local pulmonologist, a lot of these people are going to end up going to a surgeon and having these indeterminate lesions whacked out."
There are other fronts on which screening opponents attack spiral CT scans.
Some suggest lung cancer screening could result in a so-called "license to smoke," enabling smokers to continue their habit until a scan comes back positive.
Others argue that mass screening would place too great a financial strain on the country's medical centers, Medicare programs, and insurance companies.
As it stands, most health maintenance organizations flatly refuse to pay for the tests, citing the need for a recommendation from the American Cancer Society and the National Institutes of Health. The policy of Oakland-based Kaiser Permanente, the nation's largest HMO, says there is not sufficient data to recommend population-based screening for patients who aren't exhibiting symptoms. This doesn't necessarily preclude physicians from recommending the scans, says Robin Cisneros, Kaiser's director of medical technology assessment. But she adds, "We would hope individual physicians would have good evidence for making that decision."
"At this point, most of our physicians would say, '"There's not a good solid basis for screening people with CT,'" Cisneros says. "We have a very evidence-based concept in how we approach things, and there's a lot of concern about false positives and overdiagnosis right now."
Indeed, overdiagnosis bias is the primary reason the National Institutes of Health are recommending caution with the tests.
"Not every cancer is clinically relevant," says the Cancer Institute's Marcus in an interview from Bethesda, Md. "The concept of overdiagnosis is that you're picking up tumors that would never kill a person. Let's say Joe gets screened on January 1st, and they find something. In the absence of screening, he would never have been diagnosed until March. But in February, he has a heart attack and dies. So his tumor had little or no clinical relevance."
That's an argument that doesn't sit well with Grannis, who has encountered a steady stream of average Joes with all-too-real, all-too-lethal lung cancers. Grannis has developed a literary metaphor to explain this sky-is-falling viewpoint espoused by opponents of screening. In an article for Chestcheekily headlined "Lung Cancer Overdiagnosis Bias: '"The Gyanousa Am Loose!'" Grannis rails against the "arm-chair epidemiologists" -- with a little help from legendary journalist H.L. Mencken. Mencken recounted that 19th-century traveling carnival shows often featured a tent where local farmers could peek, for a price, at a mysterious and ferocious creature, the Gyanousa. But after the rubes had paid their entry fee, just as they approached the curtain, a terrified child would bolt from behind it, screaming, "The Gyanousa am loose!" Everyone would flee, oblivious to the fact that the monster had never been glimpsed.