November marks lung cancer awareness month. Most people are already painfully aware that lung cancer kills more Americans every year than breast, colon and prostate cancers combined and, despite improvements in treatment options for advanced lung cancers, patients with all but the earliest stages at presentation rarely are cured.
This is particularly tragic because, over the past decade, several large trials have demonstrated that for people with a significant smoking history, a simple low-dose radiation chest CT scan can save lives. In one large, government-sponsored study in the U.S., more than 50,000 current and former smokers who participated in an annual CT scan saw a 20% reduction in lung cancer mortality. Put another way: screening 100 eligible patients will diagnose three to four patients with curable lung cancers who otherwise would present later with more advanced disease and a far grimmer outlook.
The possibility of earlier detection and saving lives is thrilling. Until recently, detecting early-stage lung cancer has been accomplished primarily by chance, as small lung tumors are most frequently silent and asymptomatic. The possibility that a regular, outpatient scan can detect lung cancers well before they spread makes a more-optimistic outlook for lung cancer patients going forward.
Yet, as exciting as the breakthroughs have been to those of us immersed in lung cancer care, less than 5% of eligible patients elect to undergo this potentially lifesaving screening.
Not everyone is eligible for the screening. Currently, the Center for Medicare and Medicaid Services (CMS) has determined only asymptomatic current or former smokers between 55 and 77 years old are covered for the annual screening. The smoking history is, on average, a pack a day for at least 30 years; smokers who have quit must have done so within the last 15 years, and those who have not quit must undertake mandatory smoking cessation counseling..
These criteria are rather strict. Lung cancer risk increases in smokers well before 30 years of a pack a day habit, but the CMS limits the screening to the highest risk population to mirror the government trial criteria. And insurance coverage is guaranteed only if the primary care physician has a shared decision making conversation with the patient regarding the possible harms of screening, including radiation exposure (negligible) and additional diagnostic testing (far better than identifying lung cancer later at an incurable stage).
These logistical hoops have led to scarce and inconsistent referrals for the potential lifesaving lung cancer screening CT scans.
Complicating matters is the fact that some smokers, well aware of the dangers of smoking, feel that they brought their suffering on themselves. That feeling, combined with the fact that many patients have historically presented late in their course of disease, have led to outcomes were predictably poor. As a result, lung cancer engenders a nihilistic attitude on many potential patients and caregivers alike. The belief that one is doomed does not lend itself to a desire to be proactive in getting a yearly screening, even if the scan could identify a small tumor in its earliest stages. The truth is, if a stage I lung cancer is completely removed, a patient can be cured up to 90% of the time.
Lung cancer screening programs, including the one at my institution, Rush University Medical Center in Chicago, have tried to address some of these issues with education of caregivers and patients. Nurse navigators guide patients through the process of obtaining their scans assist primary physicians in identifying eligible patients and following up on their results.
And there is reason for hope. Concentrated education of the general public and primary care providers has begun to move the needle. These efforts need to be intensified. In addition, the government and private insurance companies are beginning to notice data from recent studies demonstrating treatment of earlier-stage lung cancer is not only more effective but more cost effective as well. Liberalizing the criteria for those with less but still significant smoking histories and eventually addressing patients with a family history of lung cancer would be moving in a positive direction. Scientists are hard at work to develop molecular testing to better identify cancers and address the 20% of lung cancers that present in non-smokers who to date don’t qualify for screening.
This November, we should raise awareness, not of the danger of the disease, but of the hope for early detection. Just as mammograms and colonoscopies have helped identify early-stage breast and colon cancers, lung cancer screening can dramatically reduce mortalities. The numbers don’t lie. If we flipped the current statistics and 95% eligible patients received a screening CT scan, we would turn lung cancer into a largely curable disease instead of the death sentence it often is now.