GRACE :: Lung Cancer


Dr West

Lung Cancer Screening Saves Lives!

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For years and years, lung cancer advocates have often aggressively championed screening for lung cancer, while many in the medical “establishment” and policy-makers expressed reservations that, while there were encouraging indicators of benefit, there was not evidence that lung cancer screening saves lives, so we really couldn’t make a blanket statement encouraging lung cancer screening. That has now changed, as the NCI-sponsored National Lung Screening Trial (NLST) has now been reported to demonstrate a 20% improvement in lung cancer-specific survival. A preliminary but detailed manuscript describing the trial itself is published in the journal Radiology and is available at no charge.

The trial was started in 2002 and randomized over 53,000 patients who were 55-75 and had at least a 30 pack-year smoking history (pack-years being the product of average number of packs of cigarettes smoked per day x number of years smoking) to either annual low-dose spiral CT scans for three consecutive years or a chest x-ray on the same interval. These screening CT scans are done without IV contrast and are done within a single breath hold (up to 15 seconds) but can fully view the lung fields.


The Data Safety Monitoring Committee that regualrly reviews the trial results over the course of a study’s ongoing conduct recently reviewed the most current results and noted a statistically significant improvement in the lung cancer-specific survival of people were were randomized to screening CT scans. Specifically, there were 354 deaths from lung cancer on the CT arm, vs. 442 deaths from lung cancer on the arm assigned to chest x-rays, a 20.3% reduction. In addition, the CT screened patients had a 7% reduction in “all cause mortality” (not just lung cancer, but deaths for any reason), with only 25% of the deaths in the overall trial due to lung cancer. This was likely due to detection of issues such as cardiovascular disease and other incidental but significant medical problems with CT but not chest x-ray screening.

Though it remains to be seen what formal policies will be enacted, these results should be sufficient to lead to a fundamental change in screening policy in the US, and hopefully a change in how the medical community, insurers, and other policy-makers perceive the value of screening for lung cancer. The acid test is improvement in survival, and there is now clear evidence that CT screening for lung cancer saves lives, at least in this particular population.

It is important to bear in mind that these results were seen in a group of people who have been identified as being at higher risk and potential candidates for an intervention. These results don’t necessarily apply to never-smokers or much younger patients, or to people who are frail and/or very elderly and who may not be candidates for the standard curative interventions that we would pursue after detecting a lung cancer. It remains to be seen how the results of the NLST may be broadened to other groups and whether scans will routinely be covered by insurers.

We also need to remember that many lung cancer deaths were not able to be averted with screening, so we need to redouble our efforts to improve treatments once a lung cancer is detected, and to counsel people to quit smoking or to never start, since smoking remains the most significant risk factor. And sadly, some smokers feel exonerated by a clear scan and justified to continue to smoke. Screening is an ideal “teachable moment” to review the risks of smoking not just for lung cancer, but also for heart disease and other issues.

There are also some risks to consider in screening. We don’t yet know of the long term risk of screening, since these results are still the product of just a few years of follow-up. In addition to potentially detrimental radiation effects, we also know that CT scans can detect many lesions that end up not being cancer but that lead to many subsequent scans, a good deal of patient anxiety, and sometimes invasive procedures.

Nevertheless, the results just announced should settle a longstanding debate and lead to a new consensus in the value of CT screening for longtime smokers that promises to reduce the death rate from lung cancer by 20%, and that’s a great prospect as we usher in Lung Cancer Awareness Month, befitting the first exclamation point I’ve had in the title of a post.

9 Responses to Lung Cancer Screening Saves Lives!

  • JoeSperrazza says:

    As a follow-up on this topic:

    ” Today, Lung Cancer Alliance, American Legacy Foundation and Prevent Cancer Foundation urged the federal government to expedite an immediate review of its recommendations on CT screening for lung cancer.
    The letter sent by these three leading health organizations today to Carolyn M. Clancy M.D., the Director of the Agency for Healthcare Research and Quality (AHRQ), urged an immediate review of U.S. Preventive Services Task Force (USPSTF) guidelines in view of the recent announcement by the National Cancer Institute (NCI) regarding its National Lung Screening Trial (NLST) results, as well as a number of papers reporting on improvements in the clinical management of screen-detected lung cancers.
    Currently the USPSTF, which rates screening methods to help guide primary care doctors, does not recommend for or against CT screening for lung cancer.
    However, last week the NCI terminated the NLST, a large scale randomized controlled trial on lung cancer screening, when the early results indicated that lung cancer deaths in high risk individuals were dramatically lower in the group screened by CT scans than those receiving a chest x-ray.
    Laurie Fenton-Ambrose, President and CEO of Lung Cancer Alliance, said “Now that the NCI has validated low dose CT scans for those at high risk for lung cancer, we must move rapidly to revise the lung cancer screening recommendations to reflect this life-saving development.”
    Lung cancer causes more deaths a year than breast, prostate, colon and pancreatic cancers combined, and only 16% of cases are being diagnosed at an early, curable stage.
    “The year I was born about 10,000 people died of lung cancer,” said Cheryl G. Healton, DrPH, President and CEO of Legacy. “Today lung cancer is the leading cause of cancer death with 160,000 Americans losing their lives to lung cancer each year.”
    The sense of urgency was echoed by Prevent Cancer Foundation President and Founder, Carolyn R. Aldige who said: “It is critical for men and women at high risk for lung cancer to have access to the most effective screening available for early detection of lung cancer. Prompt review by the USPSTF will initiate this process and ensure that screening is provided only to those most likely to benefit. We simply cannot afford not to take advantage of this breakthrough, and the opportunity to significantly reduce mortality from the number one cancer killer worldwide.”
    AHRQ’s role is to support the USPSTF, an independent panel of non-Federal experts in prevention and evidence-based medicine which conducts scientific evidence reviews of clinical preventive health care services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems.
    Currently the USPSTF gives CT screening for lung cancer an “I” recommendation, indicating that the evidence is insufficient to recommend for or against that screening method. PSA testing of men under 75 for prostate cancer also has an “I” recommendation.
    The lung cancer recommendations were last updated by USPSTF in 2004.”

  • Laya D. says:


  • myrtle says:

    I have been a bit surprised by the lukewarm and sometimes negative reporting about this. The ACS’s statement seemed to say that screening will give a free pass for people to continue smoking and the NYT article was certainly not a ringing endorsement. Too bad we are always fighting the stigma…..even with proof that CT screening saves lives.

    Hopefully there will be enough momentum in the medical community and those affected by lung cancer to overcome the discrimination against those at high risk for lung cancer.


  • JoeSperrazza says:
    I have been a bit surprised by the lukewarm and sometimes negative reporting about this. The ACS’s statement seemed to say that screening will give a free pass for people to continue smoking and the NYT article was certainly not a ringing endorsement. Too bad we are always fighting the stigma…..even with proof that CT screening saves lives.


    This article provides some insight into the conflict on this issue between some anti-tobacco advocacy and lung cancer treatment advocacy:

    “The pessimism surrounding Dr. Henschke’s work started from anti-tobacco activists two years ago who believed that lung cancer management might be misinterpreted to encourage smoking. These worries, were expanded by reporters who have learned that they can “generate a buzz by identifying corporate sponsorship of academic research and eliciting outraged soundbites from the pharmascolds, who are always ready to castigate the sinner in their midst while extolling their own implied virtue.”

    Absent from all these stories is objective, careful reporting, which would have shown that corporate sponsorship of research has proved highly beneficial for medical innovation. Industry-sponsored research enabled the introduction of cholesterol-lowering statin drugs, for example, contributing to spectacular declines in deaths due to heart attacks and strokes.

    We agree with Dr. Varmus, director of NCI, that “No one should come away from this thinking that it’s now safe to continue to smoke.” But as Dr. Henscke noted to MSNBC, this research has “now taken 10 years. “If you think about it, in the United States we have 160,000 deaths each year from lung cancer. That’s 1.6 million.”

    Think about all the lives that could have been saved or improved between Dr. Henscke’s initial report and the research published this week, and then tell that to those families who lost someone to lung cancer between 2006 and the present. Could industry funding have helped these people, or was it the way media portrayed industry funding that prevented industry from helping them?”

  • JoeSperrazza says:

    The International Early Lung Cancer Action Program (I-ELCAP uses the same low-dose helical chest CT scanning technique as this study did. I-ELCAP, funded by the Department of Energy (DOE), and co-sponsored by the United Steel Workers, Queens College (City University of New York), and the Atomic Trades & Labor Council, has screened over 10,000 nuclear weapons workers in three states between 2000 and 2010, detecting 70 lung cancers, three-quarters of which are at an early stage. Additionally, free screening for smokers and flight attendants is available (

    Here are two interesting bits of information from them:
    “Due to advances in the technology of CT screening, it is now possible to detect lung cancer at its earliest stage, possibly improving the cure rate of a staggering amount of lung cancer patients as well as lowering the costs associated with lung cancer treatment. The cost of a low dose CT scan usually ranges from $200 to $300, and treatment for Stage I lung cancer is less than half the cost of the late-stage treatments which most often have grave outcomes. In fact, compared to the cost of routine mammogram screening, the long term savings could be similar or even better.

    A study by I-ELCAP researchers found that women were twice as likely as men to develop lung cancer when comparing similar smoking histories. The study was published in the July 2006 issue of the Journal of the American Medical Association and involved 17,000 subjects from CT screening sites across North America. In the study, women were found to have 1.9 times the risk of developing lung cancer as men when the results were analyzed to control for age and smoking histories.”

    The 24th International Conference on Screening for Lung Cancer will take place in Scottsdale, Arizona on February 25, 2011 to February 26, 2011 (

  • JoeSperrazza says:

    The “Indy” (Britain’s The Independent, my favorite newspaper whilst I was in the UK) has an excellent article on this topic – the author really seems to “get it”.

    Thousands of lives could be saved by screening for early signs of lung cancer, a groundbreaking new study has found. Deaths from the disease fell by 20 per cent among former or current smokers who were checked with CT scans, according to the US National Cancer Institute (NCI) study of more than 50,000 people.

    With more than 1.3 million new cases worldwide every year, lung cancer is Britain’s biggest cancer killer and 80 per cent of patients die within a year of being diagnosed. Smoking is the biggest risk factor, but around 4,000 new patients every year have never smoked a cigarette in their lives, according to Cancer Research UK; as many as half of new cases are former smokers. The number and rapidity of patient deaths is largely due to late diagnosis, as symptoms usually appear only after it is too late for surgery.

    UK experts last night said they were “incredibly excited” about the US research, which for the first time shows how relatively harmless CT scans can save thousand of lives. They hope the results will provide much-needed impetus for the UK’s own lung cancer screening study, which has languished after its announcement almost two years ago.

    Dr Michael Peake, the national clinical lead for lung cancer at NHS Cancer Improvement, said: “This is the first time that lung cancer screening has shown a positive impact on survival rates. If this was breast cancer, the results would be all over the front pages, but the public still see lung cancer as self-inflicted. It isn’t sexy and few survive, so there aren’t many people banging their fists on TV, and it’s hard to find a young attractive female lung cancer patient, I’m afraid, yet it kills more people than any other cancer. Targeted screening, together with increased awareness among the public and primary care professionals about the symptoms, and improved standards of hospital care could save 10,000 lives a year.”

    Currently, only 7 per cent of lung cancer patients in the UK are alive after five years (the vast majority, –80 per cent – are beyond curative surgery by the time they see a specialist). This compares with survival rates of 82 per cent for breast and 76 per cent for prostate cancer. While a small pea-sized lump in the breast can be detected through vigilant self-examination, a lung tumour must be 50 times as big before any symptoms such as a persistent cough appear.

    To make matters worse, the chances of having an operation depend on your postcode, as more than two-fifths of hospitals have no specialist thoracic surgeon, said Dr Peake.

    The NCI study compared annual CT scans with X-rays on current or former heavy smokers from across the US. Survival rates increased with CT scans, as malignant cells were detected earlier. Research shows that 70 per cent of lung cancer sufferers can survive for at least five years if surgeons operate before disease spreads within the lung or to other organs.

    Researchers in the US are now analysing the data to see if CT scans would benefit high-risk non-smokers, such as those who inhale smoke passively over many years. Dr Christine Berg from the NCI said: “The study cost $250m, but given the huge worldwide burden of this disease, this was an extraordinarily important question to answer. The public health message is to never smoke, but for all those who make the mistake but then quit, they should know we are trying to do as much as possible to help them, too.”

    The long-awaited UK pilot study is likely to investigate whether one-off scans produce similar results, as this would be much cheaper for the NHS. Economic analysis shows that catching cancer early saves money on expensive drugs, hospital admissions, lost earnings and benefits.

    Dr Jesme Fox, medical director of the Royal Castle Lung Cancer Foundation, said: “We’ve seen the massive difference screening has made to breast, bowel and cervical cancer, so I hope there will now be a big step forward for lung cancer screening.”

  • Pingback: Lung Cancer CT Screening Saves Man's Life | Lung Cancer

  • shorrall says:

    Many wonderful comments, the trial seems to be a “win” for the hard-hit cancer screening community.

    One major issue, the same issue with all cancer screening, it would appear (save cervical)…there is, at this point, no evidence that this form of cancer screening saves lives. Yes, if you have early lung cancer detected on CT, you might get early enough treatment to change when you will die to a later date.

    However, overall mortality is what matters, not disease-specific mortality rates. The reason is, that while you can help those from dying earlier who have the actual disease, people without the disease (so-called “false positives”) will be harmed and will die from the testing that they will undergo to rule-out the disease. Not to mention those that will die from renal failure from the contrast from the CT, severe allergic reaction to the contrast dye, as well as those that will develop a deadly cancer from the radiation from the CT itself (there is a 1/125 risk of developing cancer if a young woman in her 20s receives a similar CT scan…per each CT and these are cumulative!).

  • Dr West
    Dr West says:

    Thanks for your comment, which really underscores that the conclusion that lung cancer screening saves lives applies to those in the high risk population — namely those who are in age range 55-74, significant smoking history (30 pack-years or more), and still smoke or quit in last 15 years. There was a demonstrated improvement in overall survival, and this is with low-dose, non-contrast screening CT scans. The hope is that we’ll be able to use less and less radiation with a screening CT and still be able to see things pretty well. It’s definitely true that harm could potentially exceed benefit if annual scans are with a “diagnostic” CT with contrast, which entails far more radiation, over many years and potentially over a decade.

    It’s also definitely true that ambiguous nodules lead to additional scans, a lot of anxiety, and some invasive procedures for things that turn out to be nothing. The ratio of benign findings vs. true cancer is only going to be more of an issue if lower risk patients, such as younger people or those with little or no smoking history, are included. Accordingly, the conclusions we can make about benefits of screening only apply to the higher risk population that was included in the NLST study, and not a broader population than that.

    -Dr. West

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