The Revolutionary Test for Lung Cancer

... the medical establishment doesn’t want you to have. Yet.

Faced with the choice between changing one's mind and proving there is no need to do so, almost everyone gets busy on the proof.

-- John Kenneth Galbraith, economist

Dr. Fred Grannis, the 58-year-old chief of thoracic surgery at City of Hope National Medical Center in Duarte, Calif., kicks his slipper-shod feet up on his desk, leans back in his chair, and introduces himself as a surgeon who has spent most of his adult life taking care of people with lung cancer.

Scott Musgrove
Dr. Fred Grannis, a Southern California thoracic 
surgeon, believes mass screening for lung cancer can 
save thousands of smokers' lives.
Steven Dewall
Dr. Fred Grannis, a Southern California thoracic surgeon, believes mass screening for lung cancer can save thousands of smokers' lives.
Marie Kaplan, a 74-year-old retired nurse, has become 
an advocate for spiral CT scans after early detection 
caught cancers in both of  her lungs.
Marie Kaplan, a 74-year-old retired nurse, has become an advocate for spiral CT scans after early detection caught cancers in both of her lungs.
Retired Oregon physician Jerome Reich thinks 
screening will do more harm than good.
Retired Oregon physician Jerome Reich thinks screening will do more harm than good.
Retired Oregon physician Jerome Reich thinks 
screening will do more harm than good.
Retired Oregon physician Jerome Reich thinks screening will do more harm than good.

"And I'm fed up with the craziness," he says, dark eyes flashing under a head of wavy salt-and-pepper hair. "It's like working on an assembly line, where we work as hard as we can, but the assembly line just keeps running. It starts in North Carolina, and it just keeps running.

"And we only have a success rate of 14 percent -- 14 percent of people [with lung cancer] live five years. And that's just crazy."

His office is the kind of shrine to craziness you'd expect from a national figure in lung cancer treatment. Videos on smoking cessation are piled next to a bulletin board sporting a postcard of the Marlboro Man with a cigarette drooping out of his mouth, pointing toward the surgeon general's warning that cigarettes cause impotence.

Framed against the scorching, smoggy Southern California foothills outside, his white doctor's coat over the back of his chair, Grannis shakes his head wearily: Of course he's disgusted by the $50 billion a year this country spends on tobacco-related illnesses, and lung cancer's status as the nation's No. 2 killer, just behind heart disease. Actually, though, Grannis saves his harshest invective for those who, he thinks, should know better: fellow members of the medical community who have been quite busy refusing to change their minds about a screening test that many experts believe marks a historic advance in the early diagnosis of lung cancer.

For the past few years, Grannis has been a leading West Coast proponent of mass screening for lung cancer via a new technology called low-dose, non-contrast, spiral computerized tomogram (or spiral CT scan, for short). Whereas the traditional chest X-ray takes a two-dimensional picture of the lungs, the spiral CT scan, introduced in the early 1990s, produces a clearer, three-dimensional image. Over the past decade, studies in the United States, Japan, and Europe have shown the 20-second spiral CT scan (called low-dose because of its low level of radiation) to be much more accurate than the X-ray -- accurate enough to spot a potentially lethal lesion when it's the size of an eraser head, as opposed to when it's a much more dangerous half-dollar. The studies in Japan have been received with such excitement that the country has implemented screening programs in schools, workplaces, and health clinics.

In the United States, however, the response has been considerably less enthusiastic. Essentially all the mainstream professional medical organizations -- including the American Cancer Society, the American Lung Association, and the American Thoracic Society -- refuse to recommend routine screening of either the general population or at-risk smokers, citing the need for a large controlled study of the efficacy of CT scans -- a study that could take as long as 15 years to complete. In turn, health maintenance organizations have balked at paying for the tests, which run in the $300 to $600 range. And although more than half of the hospitals in the United States own a spiral CT machine, the vast majority use them only to determine how large and lethal a cancer is after diagnosis, not to find it in the first place.

The medical community has long preached that the key to fighting cancer is finding it early, but physicians and scientists who oppose the use of CT scans make a paradoxical argument that even they acknowledge as counterintuitive: The tests, they say, might detect lung lesions too early, picking up inconclusive spots that require further testing, added expense and psychological anxiety for the patient, and, perhaps, premature or unnecessary surgery. In essence, experts who oppose screening question the competence of doctors to decide on, and the ability of patients to agree to, appropriate treatment after a CT scan finds possible early-stage lung cancer -- especially when the appropriate treatment would be to simply wait and watch.

Even though spiral CT scans have not received wide publicity, burgeoning support for mass screening has pushed the National Cancer Institute to begin a randomized, controlled trial later this summer. The $200 million study will seek to enroll 50,000 people and to determine if CT scans can increase life expectancy -- but the results won't be available for at least 10 years.

Such a delay seems wrongheaded in the extreme to many on the front lines of the war on cancer, among them Dr. David Burns, a professor in pulmonary and critical care medicine at the University of California at San Diego and the man who has written or edited every U.S. surgeon general's report on smoking since 1975.

"This is the most exciting technologic advance in lung cancer -- and the ability to do something about lung cancer -- since I've been practicing medicine," Burns testified in a recent lawsuit that wanted tobacco companies to fund CT scans for smokers. "Most of the time when you deal with lung cancer, there isn't anything you can do. You make a diagnosis, and the person is going to die of it. And it's tough as a physician watching those people die, and it's tough not being able to do anything for them.

"And all of a sudden, we can now take the most common cause of [cancer] death in both men and women and do something about it. I mean, that's what I went into medicine to do, to make a difference, and now we can."

The idea of screening for lung cancer dates to the 1940s, when physicians first noticed the increasing number of men whose smoking habits resulted in premature death. By the late 1960s, after the surgeon general had declared that cigarettes do indeed cause cancer, several clinical trials had been constructed in attempts to determine whether screening tests could find lung cancer in its early stages, when surgery, radiation, and other treatments might improve survival rates. The largest such trial, the Mayo Lung Project, also became the most controversial.

As the Mayo Clinic's chief resident in the early 1970s, Fred Grannis operated on many of the patients involved in the landmark study, a randomized, controlled trial of screening with chest X-rays. Funded by the National Cancer Institute, the study was conducted between 1971 and 1983, and enrolled nearly 10,000 male smokers over the age of 45. Half received free chest X-rays and sputum tests every four months for six years; the other half received the Mayo Clinic's standard 1970 recommendation to receive the same tests, but just once a year.

"I've always thought that trial was positive, that it proved lung cancer was picked up at an earlier stage by using chest X-ray screening," Grannis says. "But the epidemiologists use the gold standard of population mortality, and there was no difference in population mortality. So they won."

Indeed, the conclusions of that study, released in 1986, have effectively prevented mass screening from becoming a reality in the United States. Although nearly everyone who has ever discussed the Mayo Lung Project admits the study was flawed -- about half of the patients in the control arm received intermittent chest X-rays, contaminating the data -- the trial found that screening with chest X-rays at frequent intervals does not decrease the death rate from lung cancer.

Ten years later, researchers at the National Cancer Institute completed a follow-up on the Mayo Lung Project and reinforced its original conclusions. At the end of 1996, after more than 20 years of tracking the study's subjects, the number of deaths from lung cancer was statistically identical for those in the screening and "usual care" arms, despite longer survival times, measured from diagnosis to death, for men who were screened. The follow-up study's lead author, Dr. Pamela Marcus, an epidemiologist in the NCI's Division of Cancer Prevention, argued that the greater survival time was simply a result of the chest X-rays picking up tumors that did not become lethal.

Seeking to provide a more definitive answer to the question of whether chest X-rays save lives, the NCI launched another large-scale study in the early 1990s, the Prostate, Lung, Colon, and Ovarian Cancer Screening Trial. Unlike the Mayo Lung Project, the PLCO trial includes women, and has enrolled nearly 150,000 participants. The results, however, are not due until at least 2015, and, because of advances in technology, they may well be meaningless by that time.

Even as the scientific dispute over the usefulness of X-rays continued, interest in CT scanning as a way to detect lung cancer exploded.

In 1999, Claudia Henschke, chief of chest imaging at New York Weill Cornell Medical Center and a principal investigator for the International Early Lung Cancer Action Project (ELCAP), a global association of doctors and medical centers that includes Grannis and City of Hope, shook the medical community with the results of a prospective trial of CT scans. Her study, published in the British medical journal Lancet, was not of the fully randomized and controlled type often preferred for new medical tests and therapies. All 1,000 participants in this ELCAP study received CT scans. But the results showed that CT scans are far more effective at detecting early-stage cancers than X-rays, with CT scans revealing more than 80 percent of lesions in Stage I. Now, only about 7 percent of lung cancers are found this early, when they might be cured by surgery alone, and most aren't detected until a patient exhibits symptoms -- usually no sooner than Stage III, when the likelihood of surviving five years is just 10 to 15 percent .

CT scan advocates say this improved ability to find early-stage lung cancer is a historic advance that will allow faster treatment and an improved medical outlook for millions of smokers and ex-smokers. In the ELCAP study, 96 percent of the small lesions detected by the CT scans were able to be surgically removed, with a typical five-year survival rate of 67 percent.

"Low-dose CT can greatly improve the likelihood of detection of small non-calcified nodules, and thus of lung cancer, at an earlier and potentially more curable stage," Henschke wrote. What's more, she suggested a protocol -- which has been continually refined through further ELCAP studies and conferences -- for follow-up tests of any lesions too small to be declared cancerous after only one scan. "Although false-positive CT results are common," she concluded, "they can be managed with little use of invasive diagnostic procedures." Indeed, in a follow-up ELCAP study published last summer in the medical journal Cancer, Henschke reported that with repeat screenings, false positives were uncommon and usually could be corrected without resorting to the dangers of a biopsy of lung tissue.

On the East Coast, word of this exciting technology spread quickly: At long last, lung cancer seemed to have its equivalent of a mammogram. In August 2000, then-New York City Mayor Rudy Giuliani added his voice to the growing chorus advocating further tests of CT scans' effectiveness. At a City Hall news conference to announce the city's plans to contribute $4 million of its tobacco settlement money toward the funding of the New York Early Lung Cancer Action Program, a branch of the international ELCAP group, the mayor called the scan "one of the most promising new technologies for cancer screening and diagnosis."

For a variety of complex reasons, the revolutionary promise of the technology has seemed to attract particularly vehement and, sometimes, unlikely enemies.

Last year, amid growing realization that spiral CT scans had the potential to transform the biotechnology, tobacco, insurance, and health care industries, the tests themselves were put on trial. In a class action lawsuit against Phillip Morris Inc., R.J. Reynolds Tobacco Co., Brown and Williamson Tobacco Corp., Lorillard Tobacco Co., Liggett & Myers Tobacco Co., Anchor Tobacco Co., and McClure Co. Inc., a group of healthy West Virginia smokers alleged the tobacco companies had put them at a heightened risk of future disease, and should therefore be forced to pay for spiral CT scanning for the smokers.

The lawsuit was Mr. Butts' worst nightmare. A decision in favor of the healthy-seeming smokers could set a national precedent that would cost Big Tobacco almost inestimable amounts of money.

Among a series of expert witnesses favoring the scans, the court heard from Dr. Naresh Gupta, director of nuclear medicine at the West Virginia School of Medicine. Gupta told the jury that CT scans are used every day at the school, and have detected early tumors in thousands of patients. "Your best bet in saving lives with a patient with lung cancer is to detect it very early on," Gupta said. "Because only when it is picked up very early on, you can have survival of 70 or 80 percent. But if you wait and it's not picked up very early on, survival falls down to as low as 10 to 15 percent."

Gupta added that the radiation level in the test itself is not dangerous -- roughly equivalent to the amount absorbed during a plane flight from New York to San Francisco.

Differing strongly with that opinion was Dr. Philip Goodman, chief of thoracic imaging at Duke University, who testified for the tobacco industry. ELCAP's follow-up protocols, in a worst-case scenario, could result in a patient receiving the radiation equivalent of about 2,000 chest X-rays in one year, said Goodman. Grannis dismisses Goodman's testimony as "obscene," and even Goodman added that his calculations had not appeared in any peer-reviewed publications.

"Unless it's really medically indicated, no amount of radiation is good for you," Goodman testified. "There is no lower threshold that may or may not cause harm to you. So it's always best, if you don't need radiation, don't get radiation."

Asked if he would recommend the test to his patients, Goodman said: "I would try my hardest to talk them out of it unless they wanted to join up in one of the randomized, controlled trials that might investigate the true validity and value of that test. But certainly not recommend it."

And in the end, neither did jurors, who decided unanimously in favor of the tobacco industry. Although the jury agreed the smokers were at a heightened risk for disease, they said medical screening for the entire class was unreasonable, and blamed smokers for deciding to take up a harmful habit in the first place.

"It came down to, "If you smoke, stop. If you don't smoke, don't start,'" jury foreman Mark Burris said after the trial. "The only way to stop latent disease is stop smoking. That was the bottom line for all the jurors."

In a sign of how contentious and consuming the topic of spiral CT scans has become, the July issue of Chest, the cardiopulmonary and critical care journal, carries no fewer than four articles about lung cancer screening. Grannis weighs in, along with Japanese scientists who report that "low-dose spiral CT seems to be a promising method for screening early lung cancer as a part of annual health examinations."

In the opposite corner, however, the National Cancer Institute's Pamela Marcus reiterates her concerns about the technology in an editorial called "Lung Cancer Screening, Once Again," which says it would be "unforgivable ... if a prematurely established lung cancer-screening program resulted in more harm than benefit." And Dr. Jerome Reich, a retired Kaiser physician in Portland, Ore., backs up Marcus' position with a lengthy article titled "Improved Survival and Higher Mortality: The Conundrum of Lung Cancer Screening."

In his article, Reich posits the usual arguments against CT scans: They've never been tested in a fully randomized trial; they've never shown decreased mortality; and because biopsy or surgery on the lung is especially dangerous, finding tumors early might actually result in more patient deaths.

But Reich goes a step further, making explicit the underlying argument that has driven screening opponents' concerns about false positives (i.e., scans that suggest cancer where none exists). He writes: "Whether community physicians employing [spiral CT scans] would reproduce the notable sensitivity, specificity, low morbidity, and minimization of invasive procedures (including resection) displayed by the ELCAP investigators is open to question."

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.

"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.

"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.

In the wake of her experience, she has become a fierce, if cheery, advocate for mass screening. When she realized most people didn't know spiral CT scans even exist, Kaplan wrote an article for NurseWeek, a Sunnyvale-based trade magazine for nurses, urging wider implementation -- and acceptance -- of the tests.

"I was very lucky, and I'd like to spread that luck around," Kaplan says. "I believe very, very firmly in people doing screening. There are so many people dying of lung cancer, and if people are screened the number who are cured would go up. You have to find ways to pay for it, but the [cost] is going down, and the CT scans are getting better."

The surgery is difficult, Kaplan admits, but because she lived through it twice -- a month apart -- she doesn't put much stock in the gloom-and-doom arguments advanced by those opposed to early detection. Asked whether she was scared by the threat of possible complications -- internal bleeding or a collapsed lung -- she just scoffs.

"I was much more concerned about what would happen if the cancer spread. That's the scary thing. There's always a danger when you do major surgery, but look at the alternative," Kaplan says, pausing for effect.

"There is no alternative, is there?"

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