Lung Cancer / Mesothelioma
(0 votes, average: 0 out of 5)
Loading ...Well, as I suspected, the topic of lung cancer cancer screening has been a bit of a minefield, but I’m going to end now by trying to pull together where we are here and now, at least in the US. The article about the very impressive results of the I-ELCAP trial that was published in the New England Journal of Medicine (NEJM) (abstract here) concludes that 80% of deaths from lung cancer could be prevented by CT screening and that such a screening program has a cost-effectiveness comparable to that of mammography for breast cancer. This conclusion has met with a range of views. The Lung Cancer Alliance, a national non-profit organization dedicated to patient support and advocacy for lung cancer, now recommends that higher-risk patients “should have a detailed discussion with a doctor knowledgeable about lung cancer screening on the potential risk and benefits of undergoing a baseline CT scan”. Those higher risk patients are defined as any smoker or former smoker over age 50 with a greater than 10 pack year history of smoking, or any adult with a significant exposure to cigarettes and a first-degree relative diagnosed with lung cancer before age 50, and there are some other groups, noted here, who they recommend should consider a screening discussion.
The fact that the I-ELCAP manuscript was published in NEJM certainly suggests that it is an important result that might potentially alter general practice. NEJM is arguably the most visible and influential medical journal in the world, and papers published there often change medical practice overnight. The editorial that accompanied the I-ELCAP paper noted that the survival in the large I-ELCAP trial of 88% was certainly superior to the general survival rate of 70% for stage I NSCLC at 5 years but also noted that this was an observational rather than a randomized trial, and that lead time and overdiagnosis bias could have been introduced in the survival analysis. Rather than saying that the study makes CT screening for high risk patients an appropriate new standard, or saying that these results are not adequate to change screening recommendations (which have been that there is not evidence sufficient to recommend screening), author Michael Unger called the I-ELCAP results “provocative” and left the rest of the world to fight about what this all means. No real help there.
The current recommendations from the American Cancer Society, National Cancer Institute, American College of Radiology, US Preventive Services Task Force, and International Association for the Study of Lung Cancer do not go so far as to recommend screening for lung cancer at this time, but that isn’t to say that people at significant risk for lung cancer shouldn’t have a discussion about screening with their doctors. Although many critics of the I-ELCAP trial consider the statement that screening could decrease lung cancer-related deaths by 80%, plenty agree that there are arguable benefits to screening. Many of those who are hesitant about recommending CT screening await the results of the National Lung Screening Trial, or NLST, which is a trial that enrolled over 50,000 current or former smokers before closing to enrollment, than randomized them to receive either chest x-rays or CT scans. It’s very large, it’s randomized, and if it demonstrates a survival benefit would probably get everyone to agree that CT screening for lung cancer should be a standard of care for people at significant risk. But it will also take another several years or so before results are available, and that leaves us in a quandary for now.
Despite the sometimes contentious debate, there is a good bit both sides can agree on. Even if not definitive, the I-ELCAP results are very encouraging. Even though official guidelines from government and medical associations are not recommending routine screening yet, people anywhere on the spectrum generally support a good discussion of the pros and cons of screening between higher-risk people and their doctors. And the I-ELCAP protocol has provided a careful, deliberate, and very evidence-based approach to lung nodules seen on CT, which includes close follow-ups for a significant minority of people who undergo screening. Many nodules will be detected. The vast majority will not be cancer, but a few will. Not every person who finds out they have a small nodule can tolerate waiting three months for another CT scan, and others may not accept a lack of change on CT as comforting enough to prevent them from wanting a needle biopsy or a wedge resection to prove a benign diagnosis. But the people running the trials and advocating lung cancer screening are highlighting that screening is a process and not just a test, which involves follow-up scans and a restraint from chasing down nodules that are designated as likely benign by the screening criteria. And pretty much everyone agrees that if a person pursues screening, it is best pursued at a center that has strong experience with CT screening for lung cancer.
In that respect, I have it easy, since my hospital is one of the 38 institutions that has participated in I-ELCAP and continues to do so. For people who are interested, the website for the study/project is here, and the list of current participating centers and contact people around the world is on this page. The study is still collecting patients and data, which we can all hope will help everyone to reach a consensus in this field.
So no broad national changes yet, but I’ll agree that the I-ELCAP trial is large and very provocative, and I’ll continue to stand on the fence here. I’ll update as new information comes in.
Posted in: Current Clinical Trials, Lung Cancer, Screening Issues and Controversy
email to a friend
printer friendly
Howdy Dr. West,
I enjoyed reading your posts and the comments that have followed. At the risk of sounding like a dummy, there are still a couple of things that I do not understand. First you mentioned the “NLST, which is a trial that enrolled over 50,000 current or former smokers before closing to enrollment, then randomized them to receive either chest x-rays or CT scans.” My first question is why would including a group that used x-rays make the study more defining? I thought chest x-ray was already known to be unacceptable for lung cancer screening. In my own case, I had two chest x-rays during the two weeks prior to my diagnosis to try and find the cause of my sudden onset unrelenting pain. Neither showed any of the three tumors. My second question is about the current I-ELCAP. It sounds as if it is a continuation of the study reported in the NEJM using the same perimeters. Why will that clear up the any of the controversy if they use the same set up?
My third question is a bit more personal. Since I was diagnosed at fifty-one years old, I am terrified of my adult children’s risk. I had a brother who died of Melanoma at age fifty-four and an aunt who has survived breast and lung cancer. I really want my kids to have the screening. What would you advise?
Thank you again for this forum. I found the information to be presented fairly and professionally.
Myrtle
Dr. West, you said you are going to end now and try to pull all this info together. Hope you don’t throw this “hot potato” off your plate too soon. Yours has been the only site to offer a chance to discusss this issue, making your site unique. It has to be about CHOICE.
The screening technology is there and people may want access to it. If screening would make a patient unduly anxious then I wouldn’t think they need to have it done. On the other hand some may want to know. Guess it may be up to the public to have a discussion with their doctors and insurers (IF they are lucky enough to have insurance). I feel very strongly about screening for lc as a matter of principle. After all, patients are given a choice whether to have PSA’s, mammograms, colonosopy, etc. AND they aren’t always given the opportunity for screening for these cancers b/c they are at risk.
jayc07
Myrtle,
Those questions don’t make you seem like a dummy at all, and in fact are very thoughtful and appropriate.
The truth is that chest x-rays aren’t nearly as sensitive as CT scans, but they’re not the same as doing nothing. The people who developed the trial had to test something that CT scans could beat to become the new standard recommendation, but if the people on the other half of the trial got NOTHING, those people would likely not accept participating and taking the risk of missing out on the benefit Given the energetic discussion of screening here, I believe they were right. So in truth, the chest x-ray inclusion was a compromise of doing SOMETHING, which could keep people participating on the trial, but something close to the current standard of no screening, since CXR has appeared no better than no screening (as was your unfortunate experience).
The second question is one you caught me on. The I-ELCAP is an observational study, so our comparison is really just historical experience. That’s why many people are holding out for the randomized NLST trial. The I-ELCAP trial will increase the numbers of people screened, the length of follow-up, and will give us more and more experience with what is emerging as the definitive protocol for doing CT screening, so more time and participants will certainly help us, but the design means that it will never provide the definitive answer to purists. So you’re very on the mark there.
And for your family’s plight, I don’t believe that those cancers are directly related in any identified syndrome. Cancer is very common, so I would say that the most likely situation is that your family’s multiple cancer diagnoses are not related to each other (but very unfortunate). We are rapidly picking up speed on lung cancer genetics, so I hope and expect we’ll know more in a few years, but right now, we don’t have tests to identify patients at risk for it. Some of the screening studies do include patients with less or no personal smoking history but a history of lung cancer in the immediate family. As I noted above, we’ll have only more info coming in on screening in the next few years as well. Since cancer is overall quite age-related, I would have to imagine your children are still on the young side for being at what most would consider to be at significant risk. However, larger cancer centers generally have cancer genetics specialists who might be able to review your family history and talk about these issues in greater detail with you. Even if they recommend no genetic testing or increased screening beyond current standards, it might be reassuring just to discuss your family cancer history with someone who has this as their expertise.
-Dr. West
Dr. West,
I am all for screening, early diagnosis and treatment, and increasing my odds of survival if (God forbid), I was ever likely to develop lung ca (I pray I never will) I have to admit, I am very afraid of developing lung ca. As soon as my mother was diagnosed with SCLC, I immediately quit smoking (never successful at quitting before) and ran out and had a chest x-ray. After having smoked since my early teenage years until last September (I am now 48), having a family history of SCLC (my mother- diagnosed at 67), having an aunt (my mother’s sister) who just died in June 06 with it, of course, I want to be screened before I am 50. I have been surfing the web of course about screening and found some information regarding the “Electron Beam CT” which shows images in very thin sections compared to conventional CTs, it is FDA approved technology, it is possible to detect growths as small as 2-5 mm, much smaller than what can be seen with a chest x-ray and too small for symptoms to develop, usually confined to the chest thus increasing your odds of survival. The only problem I see with that would be based on the location of the lesion/nodule and the possibility of a risky surgery just to get a pathology specimen and diagnosis, possibly as you mentioned in screening processes, maybe getting alot of negative pathology reports or just having to be stressed out by being told to wait to see if it changes or symptoms develop. I still want to have this type of CT when I decide to do my screening. I have HMO insurance,this particular insurance does cover yearly physicals, paps, mammograms, they even cover my yearly MRI of the head for my MS follow up even though I have been asymptomatic for 7 years, with my history, I think it would be interesting to see how they feel about this type of screening for lung ca. I would hate to think of waiting until I had symptoms. I will let you know what I find out. Thanks again for another informative subject to read about. Bonnie
BonnieW
Bonnie,
One other issue I didn’t bring up is some concern about risk of cumulative radiation exposure. I would say that the risk in patients with a known lung cancer is far eclipsed by the issues related to not detecting a recurrence promptly, but in someone who doesn’t have cancer, and in whom regular follow-up scans are being considered, the amount of radiation exposure from higher resolution CT scans is something to potentially factor into the equation. Plus, whatever concerns anyone has about CT scans, they aren’t related to low sensitivity. A typical spiral, low-dose CT scan used for screening is such a higher level of information than a chest x-ray provides that the incremental benefit of a super-sensitive CT is at least something to question. One thing that both the lung cancer screening advocates and detractors agree on is that the spiral CT approach is sensitive enough to do the job. The real question they’re debating is whether it’s too sensitive.
Either way, I certainly sympathize with your plight and will be very interested to hear more about how things are going for you.
-Dr. West
Dr. West
Hello-I am BonnieW sister and have a question about PET scans. I am a stage 1b melanoma survivor and have PET scans done once a year. Would this detect early LC?
Also I have a question about germctabine chemo–is this offered to most patients and have you seen success with it?
Thank You
Barbara N.
BarbaraN
Barbara,
Yes, PET scans are quite good at detecting all sorts of cancers, as long as they are metabolically active enough to pick up lots of labeled sugar (which the vast majority of lung cancers are), and it is big enough to be seen on a PET scan (1 cm is the threshold as of a few years ago, but the resolution is getting better all the time). It couldn’t reliably detect a 3-5 mm nodule that is lung cancer, unless it was very metabolically active/ growing quickly, but a PET could most likely detect many different cancers that are 1 cm or greater and growing reasonably quickly.
And gemcitabine is among the most commonly used chemo drugs for non-small cell lung cancer. Many drugs are more or less comparable to each other in activity, and gemcitabine is among the ones I commonly use and have as much success with as any. We don’t have any phenomenally active drugs in lung cancer yet, but gemcitabine is a commonly used choice because it often provides a good balance of activity vs. side effects.
-Dr. West
Posts
| Core Concepts
| Subject Archives
| Monthly Archives
| Resources
| 
Donate
| Forums
| GRACE Home
Disclaimer: The information provided at GRACE is for informational purposes only. The faculty of GRACE is not providing medical advice, diagnosis or treatment and cannot replace the medical advice of your doctor or health care provider. (Full Disclaimer)
© 2007-2008 GRACE. All rights reserved.
7 Comments
Login (Must Be Logged In To Comment)