No easy answers to questions about early lung cancer screenings for heavy smokers

[Thomas3.20.2010]

Many smokers wish there was a way to detect lung cancer in its early stages -- a test that would do for the No. 1 cancer killer what mammograms did for breast cancer.

But studies of X-rays and early CT scans found screening with these tests didn't reduce the number of people who eventually died from the disease.

Then in June came the results of a trial of more than 50,000 patients, all heavy smokers with no symptoms of lung cancer. Deaths among those screened with low-dose helical CT scans were 20 percent lower than among those screened with chest X-rays.

Because of the finding, WellPoint now covers screening scans for smokers who fit the profile of those in the study. A major local hospital offers $99 screening scans.

Lung cancer is a major killer in the U.S. and Indiana. Each year, lung cancer claims the lives of 160,340 people, the American Cancer Society says.

In Indiana, where about 21 percent of people smoke, lung cancer kills about 4,140 people each year, and about 5,460 people are diagnosed yearly.

Early lung cancers don't cause symptoms, making them hard to detect. The majority of lung cancers are found only after the disease has spread.

So doctors have yearned for a test to find lung cancer early.

But the American Cancer Society and most physician groups still don't recommend blanket screening for heavy smokers. Many experts say it's not clear that screening, which carries risks, is for everyone.

WellPoint doesn't agree. In November, the insurer's policy committee deemed the tests medically necessary for an estimated 250,000 of their policy-holders.

"In this high-risk group, there was a survival benefit. I think that's notable," said John Whitney, WellPoint's medical director for policy. "It's a very important consideration in screening. If you're going to screen and find things that you can't do anything about, there's not much point in that."

The study looked at asymptomatic people ages 55 to 74 who had a history of smoking about one pack a day for a year. Participants did not have to currently smoke, but if they were former smokers, they could not have quit more than 15 years before.

Just as the study did, WellPoint's policy allows for an annual screen every year for three years. After that, it's not clear what the insurer will recommend; that will depend on what subsequent studies find, Whitney said.

Depending on policy specifics and where the scan is performed, the cost to the policy-holder ranges from $150 to $300, WellPoint says.

The study compared the outcomes of 26,000 heavy smokers who underwent annual CT screening for three years with those of 26,000 people who had screening X-rays. Ten years later, 354 people in the first group had succumbed to lung cancer, compared with 442 in the second group.

But there was a flip side. Forty percent of those who had CT screenings had an abnormal result that led to additional testing, and 16 premature deaths occurred because of interventions prompted by the screening, such as needle biopsies of the lung. Six of those people didn't have lung cancer.

"It saves lives, but it also costs lives," said Dr. Otis Webb Brawley, chief medical officer and executive vice president of the American Cancer Society.

Compare this scenario with mammography, Brawley suggested. That test, which the cancer society recommends, can produce false positives, leading to additional testing. But a false positive on a mammogram will seldom cause complications.

About a quarter of all lung screens find something abnormal, said Dr. Nasser Hanna, an associate professor of medicine at the Indiana University Simon Cancer Center. In Indiana, where the lung disease histoplasmosis is common, the percentage of people with problem spots may be even higher, Hanna said. And for about 95 percent of these people, the abnormality will be benign.

But it's impossible to know unless a biopsy or second scan is done.

For that reason, it's critical that patients who undergo screening discuss it with their doctors or a screening counselor to help them understand what the scan reveals, Hanna said.

"The decision to get screened is not simple," Brawley said.

The American Cancer Society stopped short of recommending screening for all heavy smokers. The group said smokers should be aware of the trial and discuss screening with their doctors.

For some, screening is a no-brainer. Sue Caudill heard about the $99 scan while going through St. Francis' smoking cessation program.

A few months earlier, the Elizabethtown resident had a chest X-ray after she started coughing up "this black stuff." Nothing scary was detected, but she wanted to be sure.

At 52, Caudill, who smoked for more than 30 years, is a few years shy of the lower age limit, but she persuaded St. Francis to allow her to have the scan.

"I said, 'I'm here to get this done, because for one, I want to know if there is anything wrong, and if there is, I'm hoping to catch whatever it is early,' " she said. "I was afraid because I had smoked a long time."

Since August, about 70 patients have had scans at St. Francis.

So far, doctors haven't picked up any early cancers or found any lesions that have gone to biopsy.

The doctors counsel the patients on the significance of potential results, said Dr. Raj Gupta, a St. Francis radiologist. And they urge those still smoking to quit.

"Prevention is the key," Gupta said.

Many hospitals offer low-cost CT screening as a "loss leader," Brawley said. Because about 40 percent of screenings result in an abnormal finding, hospitals profit from the follow-up testing.

"There's lots of money to be made in screening," he said.

More understanding is necessary when it comes to people choosing whether to have the scan, he said.

"The most important thing for people to realize is it's not an open-and-closed book. . . . It's important because there are so many people who think if people get screened, they won't die," Brawley said. "It is not 'don't get screened'; it's not 'do get screened.' It's a real decision to make."