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Is lung-cancer screening worthwhile?

Consumer Reports News: November 12, 2010 12:53 PM

When it comes to lung-cancer screening, heavy
smokers have a difficult decision to make.

The National Cancer Institute released initial study results last week of lung-cancer screening in people 55 to 74 who have smoked at least 219,000 cigarettes in their lives. That's right: 219,000 cigarettes, the equivalent of a pack a day for 30 years or two packs a day for 15 years. That's a lot of cigarettes. Well, all those cigarettes cause a lot of problems, but until now, medical science didn’t offer much help in the way of detecting the disease early.

Multiple studies had failed to show that the easiest test to look for early lung cancer, a chest X-ray, made any difference. For the last several years a fancier and more expensive test, spiral CT, was studied in various ways. Some showed promising results, others didn’t. The NCI study, the best of the bunch, appears to support spiral CT as a somewhat effective though by no means perfect screening test.

After three years of annual screening, folks who were screened with CT scans had about a 20 percent reduction in death from lung cancer compared with those who had X-rays. If the results hold up to further analysis, that means spiral CT could be a better screening test for lung cancer than mammography is for breast cancer in women in their 40s and prostate-specific antigen (PSA) testing is for prostate cancer in men of any age.

It also means doctors need to do a lot of soul searching. When I was a younger physician I struggled to take care of smokers. How could they continue such a dangerous habit? For a while it made it easier on me when I told them that their cough was the first sign of lung cancer and they would likely pay for their weakness with their life.

But it didn’t take long to realize that most smokers want to quit, are frustrated that they can’t, and have difficult adjustments to make as they die of a “preventable” disease. I also learned how tobacco companies marketed tobacco and made it addictive. When I took care of veterans, I discovered that the U.S. military made it easy for GIs to get cigarettes. And I watched big tobacco companies successfully oppose efforts to reduce smoking in children and adolescents.

So we now have some hard decisions to make. Yearly spiral CT scans of long-term smokers means that about one out of five smokers who are destined to die of lung cancer will survive instead. But that benefit comes with a price: unnecessary tests and treatments in many people. That’s because for every life saved, about 300 smokers will have multiple CT scans, 100 will have an abnormal finding that requires follow-up testing, seven will have an invasive test to confirm the results, and two will have surgery for what turns out to be a false alarm. And everyone who has a CT scan will be exposed to a substantial dose of radiation, which could pose health problems down the line.

And, of course, it will cost a lot of money: about $90,000 a year to save one life. And that doesn't count all the additional tests needed on those 100 who have a false positive, or the seven who get an invasive test, or the couple of folks who have surgery for a benign tumor.

Now, you may be thinking as I once did: make smokers pay themselves. We should all be responsible for our behavior. Easy to say, but quite a few of us have habits that could do us in. Have you weighed yourself recently?

No, it has been too easy for too long to ignore smokers. Now we have more reason than ever to help them understand and fight their addiction, and to hold tobacco companies accountable. We have a lot of reasons—219,000 of them for each of those smokers.

BOTTOM LINE: Long-term, heavy smokers 55 to 74 have a difficult decision to make. They need to weigh the modest possibility that CT lung-cancer screening will detect an early-stage cancer and end up saving their life against the much greater chance that it will lead to unnecessary and invasive tests and treatments, and expose them to potentially dangerous doses of radiation. The benefits of the test for other smokers are unknown, though almost certainly even smaller, making the usefulness of the test for them far more dubious.

No smoker, even those who opt for the test, should see it as an excuse for continuing the habit. Their best bet, by far, remains stopping as soon as possible: Research shows that those who successfully kick the habit, even after many years of smoking, dramatically lower their risk of premature death. And while stopping is hard, it’s not impossible. See our advice on how to quit smoking and our treatment ratings of smoking-cessation strategies.

John Santa, M.D., M.P.H., director, Consumer Reports Health Ratings Center

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