James R. Jett, MD; David E. Midthun, MD
Screening for lung cancer is not currently recommended, even in persons at high risk for this condition. Most patients with lung cancer present with symptomatic disease that is usually at an incurable, advanced stage. The recently reported NLST (National Lung Screening Trial) showed a 20% decrease in deaths from lung cancer in high-risk persons undergoing screening with low-dose computed tomography of the chest compared with chest radiography.
The high-risk group included in the trial comprised asymptomatic persons aged 55 to 74 years, with smoking history of at least 30 pack-years. Screening with low-dose computed tomography detected more cases of early-stage lung cancer and fewer cases of advanced-stage cancer, confirming that screening has shifted the stage of cancer at diagnosis and provides more persons with the opportunity for curative treatment. Although computed tomography screening has risks and limitations, the 20% decrease in deaths is the single most dramatic decrease ever reported for deaths from lung cancer, with the possible exception of smoking cessation. Physicians should offer computed tomography screening for lung cancer to patients who fit the high-risk profile defined in the NLST.
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Steven, Walerstein, MD, President of the New York chapter of the American College of Physicians, Dr. Alan Multz, Dr. Vladimir Gotlieb, Nassau University Medical Center, Department of Medicine, Division of Hematology and Oncology.
October 25, 2011
Financial Logistics Still Loom Large
Articles "Screening for Lung cancer: for patients at increased risk for lung cancer, it works" and Screening for lung cancer: it works, but does it really work?" published in the journal recently 4,5 , is a commendable effort, though the question about financial logistics still looms large pending "official" recommendations. Financial consequences of such screening modality would stimulate extensive debates within medical and non-medical communities, before it becomes a standard of care.
We at Nassau University Medical Center conducted a study which found that hospitals with poor catchment areas diagnose significantly more people with Stage 4 lung cancer and less people in Stage 1 as compared to national average and to the hospitals with richer catchment areas 1 ,2 .
NUMC vs. NSR
NUMC vs. LIJ
NUMC vs. US
NUMC- Nassau University Medical center, NSR- North Shore University Hospital, Long Island
Numbers in parenthesis are the number patients in the series.
We are currently looking into how to address this disparity.
The National Lung Screening Trial 3 as well as the articles published in Annals 4 ,5 are interesting because of what we found. If there is a question about making this screening into a universal recommendation due to financial reasons, it would be prudent to include hospitals caring for a larger percentage of lower socioeconomic patients as well as those of a more "insured" payer mix.
There are currently about 150,000 deaths recorded in the United States related to Lung cancer. High proportion of them are diagnosed in advanced stages and started on the treatment with knowingly low expected survival at 5 year mark. These numbers have been unchanged for the last 10 years. Advances in chemotherapy for lung cancer have lead to very small survival benefits. These facts clearly justify more aggressive approach to screening for this deadly condition with the goal of detecting it in the lower stages especially in the higher risk categories.
We think this would go a long way in mitigating the disparity in the stages of lung cancer found in our study.
Dr. Steven Walerstein, President of the New York chapter of the American College of Physicians
Dr. Alan Multz, Dr. Vladimir Gotlieb, Nassau University Medical Center, Department of Medicine, Division of Hematology and Oncology.
1. Gotlieb V., Verma V, Fogel J., Multz A, Gralla R. Poster presentation. Abstract #6037 2011 Annual ASCO meeting. Comparative analysis of lung cancer in a public hospital versus private hospitals in New York City metropolitan area.
2. The International Early Cancer Action Program Investigators: Survival of Patients with Stage I Lung Cancer Detected on CT Screening. N Eng J Med 2006; 355(17):1763-1771
3. Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening. NEJM, June 29, 2011.
4. Jett J and Midthun D. Screening for Lung Cancer: For Patients at increased Risk for Lung Cancer, It Works. Annals of Internal Medicine, October 18, 2011:540-542. 5. Silvestri G. Screening for Lung Cancer: it works, but does it really work? Annals of Internal Medicine, October 18, 2011:537-540. Conflict of Interest:
Frederic W., Grannis, Jr., MD
October 28, 2011
Disagree With Author's Advice
The pro/con debate in the pages of the Annals of Internal Medicine between Gerard Silvestri and James Jett on whether an otherwise healthy, high-risk individual should be offered computerized tomographic screening for lung cancer (LCS) is of particular interest because both individuals were authors on the Second American College of Chest Physicians (ACCP) Guideline which recommended against such screening. I have commented elsewhere on what I perceived as major problems with this guideline.
Dr. Jett has now revised his stance on LCS and answers "Yes" that he would recommend screening, with appropriate discussion of potential benefits and risks. This change is presumably in response to his analysis of the randomized controlled trial evidence of a minimum 20% mortality reduction in the National Lung Screen Trial as well as the estimated 28% reduction in mortality in his own Mayo LCS study.
Dr. Silvestri, however, has not altered his "No" recommendation, despite the availability of a wealth of data published since release of the ACCP guideline. He appears to base his advice partly upon risks of needle biopsies recently published by the White River Junction VA Hospital epidemiologists, in which multiple deaths were reported following SEER registry transthoracic needle biopsies. What Silvestri fails to inform his readers is that none of these needle biopsy deaths were in the context of LCS and that most deaths were in patients who were already sufficiently ill to be hospitalized before diagnostic biopsies had been performed. To the best of my knowledge, there is not a single published report of a fatal complication following a needle biopsy of a benign nodule found in LCS studies reporting on more than one hundred thousand individuals.
With the understanding that there are approximately 500,000 individuals with lung cancers 2 mm. and larger, detectable by CT scan in the U.S. at this moment in time, that a minimum of 85% will die in the absence of screening that a minimum of 20% of these deaths would be prevented following CT detection, and that the NLST study found no unanticipated risks, I disagree with Silvestri's advice that the patient to "run as far and as fast away from a CT scanner as she can get". It was irresponsible for the editors of the Annals to have published this recommendation.
1. Silvestri GA. Screening for lung cancer: it works, but does it really work? Ann Intern Med. 2011;155:537-9. [PMID: 21893614]
2. Jett JR, Midthun DE. Screening for lung cancer: for patients at increased risk for lung cancer, it works. Ann Intern Med. 2011;155:540-2. [PMID: 21893615]
3. Bach PB, Silvestri GA, Hanger M, Jett JR; American College of Chest Physicians. Screening for lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132:69S-77S. [PMID: 17873161]
4. Grannis FW Jr. There are major problems with the American College of Chest Physicians Second Lung Cancer Guidelines [Letter]. Chest. 2008;133:1049; author reply 1050-1. [PMID: 18398132]
5. Jett JR, Midthun DE, Swensen SJ. Screening for lung cancer with low-dose spiral CT scan of the chest and sputum cytology. Pulm Perspect 1999;16:1-3.
6. McMahon PM, Kong CY, Johnson BE, Weinstein MC, Weeks JC, Kuntz KM, et al. Estimating long-term effectiveness of lung cancer screening in the Mayo CT screening study. Radiology. 2008;248:278-87. [PMID: 18458247]
7. McMahon PM, Kong CY, Weinstein MC, Tramontano AC, Cipriano LE, Johnson BE, et al. Adopting helical CT screening for lung cancer: potential health consequences during a 15-year period. Cancer. 2008;113:3440-9. [PMID: 18988293]
8.Wiener RS, Schwartz LM, Woloshin S, Welch HG. Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records. Ann Intern Med. 2011;155:137-44. [PMID: 21810706]
9. Greenlee RT, Hill-Harmon MB, Murray T, Thun M. Cancer statistics, 2001. CA Cancer J Clin. 2001;51:15-36. [PMID: 11577478]
Jett JR, Midthun DE. Screening for Lung Cancer: For Patients at Increased Risk for Lung Cancer, It Works. Ann Intern Med. ;155:540–542. doi: 10.7326/0003-4819-155-8-201110180-00367
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Published: Ann Intern Med. 2011;155(8):540-542.
Hematology/Oncology, Lung Cancer, Prevention/Screening, Pulmonary/Critical Care.
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