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"Now, more than one hundred years later, epidemiologists have emerged from behind the curtain of their big tent and announced, in a spate of publications, that '"the lung cancer overdiagnosis bias am loose,'" Grannis writes. "But physicians are not rubes, and hopefully, specialists in radiology, pulmonary medicine and thoracic surgery are not benighted yokels. We must not be induced to flee in terror of phantoms.
"No one has ever actually seen a Gyanousa, and precious few cases of overdiagnosed lung cancer have ever been observed or reported."
Gilles Monarque, a 59-year-old survivor of lung cancer who credits screening with saving his life, is unequivocal in his support for spiral CT scans. "If you're over 40, you should go," he says. "I hadn't been to the doctor since I was in high school, and I was never a believer that smoking causes cancer. But to tell you the truth, now I don't care whether you smoke or not -- I think you should have it done."
The screening process Monarque underwent is simple and painless. The patient lies down on a gurney, which is wheeled slowly into a 3-foot-wide tunnel that looks like an upright doughnut. For the next 20 seconds, the patient is instructed to lie still and hold his breath while the machine takes a series of cross-sectional pictures, millimeters apart, throughout the lungs.
"Then you go to lunch, have a martini, and hope to God everything's fine," Monarque says.
In Monarque's case, everything was not fine. The scan detected a 2-centimeter dot on his lung -- a Stage IA lesion that was too small to be accompanied by any symptoms. If Monarque hadn't had the scan, he might still not know he had cancer. So two years after a lobectomy to yank out the tumor, Monarque makes a habit of visiting the doctor, getting occasional CT scans, and telling anyone who'll listen about the value of lung cancer screening.
"We're not happy [the insurance companies] don't pay for it," Monarque says. "But the money is immaterial."
Estimates of potential costs vary widely, but Grannis has crunched the numbers -- and his math makes sense.
"You can either pay $300 now or $43,000 later, which is the current cost of the best chemotherapy regimen," he says. "With that, you get five-year survival that approaches zero. With the screening, you get five-year survival at 80 percent. To me, it's a no-brainer. HMOs pay lip service to preventative medicine, but when it comes to actually paying for preventative medicine -- like helping someone quit smoking -- they won't pay a penny. It's blatant hypocrisy."
Equally noxious, Grannis says, is the argument that "average" physicians are too unskilled to handle the early detection provided by CT scans, and would recommend unnecessary surgery to patients with high comorbidities (that is, having more than one serious diagnosable condition at the same time). In fact, lung surgery is serious business -- which is why thoracic surgeons go through a minimum of seven years of special training after medical school before they are allowed to crack a chest.
"Physicians who take care of lung cancer are acutely aware of the problem of comorbidity and factor it in when they make decisions about what tests and what treatments will be tolerable to their patients," Grannis says. "There are also some patients with such severe comorbidity that they will obviously not be candidates for screening, because no reasonable treatment could be offered if disease were found. The average family practitioner in the U.S. is perfectly competent to advise his patients in this area."
Indeed, Dr. Paul Brunetta, a member of the thoracic oncology and tobacco control programs at the University of California at San Francisco, says he makes a full disclosure to his patients about the risks and benefits of early lung cancer detection. Brunetta launched a small study two years ago to examine the effectiveness of CT scanning, but funding ran out before he could enroll more than 50 patients. Part of the reason he didn't seek to continue the trial, Brunetta says, is because UCSF is strongly considering opening a full CT scanning center in the near future. When the center opens, Brunetta says, he will be honest with smokers who desire the scans. "I tell my patients that we still don't have a study that has demonstrated reduced mortality," Brunetta says. "So I can't recommend it one way or another. Then they look at that data, understanding that they do have risks, but that if they got cancers without screening, it's often more advanced."
Before changing the medical community's mind-set about lung cancer screening, advocates like Grannis will have to change the medical community's mind-set about lung cancer patients. Because 90 percent of lung cancer is caused by smoking, the more than 150,000 people who die from it annually are victims of a largely preventable disease. In turn, funding for lung cancer research has always lagged behind the money funneled toward AIDS, breast cancer, and other more sympathetic killers.
"I've taken care of lung cancer patients for years, and they're very, very nice people," says Grannis, whose face visibly reddens when this topic comes up. "They're not bad people, they're ordinary people like anyone else. And almost all of them were addicted to nicotine since they were children, which is exactly how the tobacco industry planned it. It's just cruel and heartless and callous to blame lung cancer patients for their disease.