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"We would never think of blaming a woman who has cervical cancer because she had had more sexual experience at a younger age," he continues, alluding to the fact that some STDs can trigger the onset of that cancer. "But we do it for lung cancer patients all the time."
Asked to clarify the American Cancer Society's position on spiral CT scans for lung cancer screening, Dr. Robert Smith, an epidemiologist and director of cancer screening for the ACS, heaves an uncomfortable-sounding sigh.
"It's really that we don't have a position," he says. "Our recommendations are based upon scientific evidence, and that kind of evidence presently doesn't exist for spiral CT. It's very hard to ask [smokers] to wait 10 and 15 years for an answer, but however powerful this technology is, it may ultimately turn out to be less effective than most people assume."
Accordingly, the American Cancer Society -- whose endorsement for early lung cancer detection would play a huge role in persuading doctors to screen and insurance companies to pay for it -- has worked closely with the National Cancer Institute to develop its upcoming National Lung Cancer Screening Trial, Smith says. And like many in the medical establishment, Smith is hopeful the study will provide a definitive answer on screening.
But if the design of the trial is any indication, it will only provide more confusion.
After arguing for decades that the Mayo Lung Project proved that screening with chest X-rays does not lower mortality, the NCI has developed a study -- the much-hailed, long-awaited "gold standard" -- that will use screening with chest X-rays as its control arm. In other words, the NCI is using, as a baseline comparison, the screening technology it has long held as potentially more dangerous than no screening at all. This stunning contradiction has caused Henschke, ELCAP's lead investigator, to label the study "fatally flawed."
"I don't know whether it's fatally flawed, but it's badly wounded, anyway," Grannis says with a chuckle. "You can't take a test that you've bad-mouthed for 20 years and now accept it as a treatment arm. You're supposed to take the old, accepted standard against a new test, and it's not realistic to do that with chest X-ray. For them to call this a gold standard is absurd."
Nevertheless, Marcus, the NCI epidemiologist who helped design the trial, defends the decision to measure CT scans against chest X-rays -- the very technique that her own Mayo Lung Project follow-up study concluded was at best ineffective and at worst life-threatening. "Even though [chest X-ray] is not recommended, people tend to go and get it, so in many ways it's a standard of care," she says. "It's a very difficult decision to make, but that's how we decided to do it."
Another potential problem for the Cancer Institute's national trial, Marcus says, is the growing public pressure to implement mass screening. Although the wishy-washy position adopted by national medical advisory organizations is hardly likely to bring droves of patients to CT scanning facilities, Marcus says widespread publication of the benefits of CT scans might undermine serious study efforts.
"Everybody's free to get it, but I would remind the person that these scans have not been shown to improve survival," Marcus says. "That doesn't mean somebody shouldn't decide to go do it, but it's not as cut and dried an issue as the people advertising it would have you believe. They're pushing this as the best thing since sliced bread."
Indeed, there seems to be a growing realization in the medical community that popular support for spiral CT scans might outpace study of the technology. Speaking at an expert-packed State of the Science convention on lung cancer last summer, Dr. John Ruckdeschel, a professor of oncology at the University of South Florida, introduced the topic by acknowledging the changing face of lung cancer screening.
"We have literally tens of millions of former smokers who are sitting out there now, many of them reasonably well-educated," Ruckdeschel said. "[They're] saying to themselves, '"You mean there is a test I can get for a couple of hundred dollars, that not only will tell me whether or not I have an early lung cancer, but just like it says here in this advertisement, tell me whether I have significant coronary disease as well? Where can I sign up for this?' And this is happening with increasing regularity, and the discussion is going on even in academic radiology departments -- not about whether they should introduce spiral CT scanning, but when and how to introduce it."
In the middle of explaining why everyone at risk for lung cancer should immediately get a spiral CT scan, Marie Kaplan, a 74-year-old resident of Rancho Palos Verdes in Southern California, explodes into a sudden coughing fit. When she regains her breath, she croaks: "I'm fine, honest."
Six years ago, things didn't look so good. Kaplan, a retired nurse, discovered she had lung cancer during a routine physical, when her family doctor happened to take a chest X-ray of her right lung. He advised her to get a spiral CT scan, which, to Kaplan's horror, also showed a small cancer blossoming in her left lung. But because she detected both of the cancers relatively early, she went to Dr. Grannis, who removed a lobe of her right lung and a wedge of the left. Now she has no greater risk of dying from lung cancer than any other ex-smoker, and she gets an annual CT scan to keep it that way.