-- 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.
"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.