New recommendation encourages more activist approach to lung cancer screening

04/07/05

PROVIDENCE, RI Physicians caring for people at high risk for lung cancer should assume responsibility of informing their patients about options for screening for lung cancer, according to a group of international physicians. This is the central recommendation of the "Como International Conference Position Statement," published in the April issue of Chest. The recommendation goes beyond existing public policy recommendations.

The position statement strongly encourages asymptomatic men and women over 45 to 50 years of age, who are current or former cigarette smokers, to enroll in clinical trials that offer screening for lung cancer. However, if such clinical trials are not available, patients should be informed about options for lung cancer screening, which currently include chest X-ray (or chest radiography) and computed tomography (CT).

High-risk individuals should be informed that when lung cancer is diagnosed because of the presence of symptoms, the disease is usually in advanced stage and incurable. On the other hand, they should also be told that surgical treatment of asymptomatic early stage lung cancer offers a reasonably high chance of cure. While acknowledging uncertainties and controversies regarding the value of screening for lung cancer, the position statement asserts that "it is wrong for these discussions not to take place." The position statement concludes that "after discussion of the current state of knowledge, it is reasonable for an individual at risk to choose to undergo testing for lung cancer."

The paper is authored by physicians from Rhode Island Hospital, Georgetown University, Mayo Clinic, City of Hope National Medical Center and the University of Insubria in Varese, Italy.

Currently, the American Cancer Society (ACS) and other public policy organizations do not recommend testing for early lung cancer detection. Instead, policy organizations have advised cigarette smokers to quit smoking, and they recommend that people check with their physician if they develop symptoms.

"The problem with this approach is that it requires many years for lung cancer risk to be substantially reduced following smoking cessation," says lead author Gary Strauss, MD, MPH, an oncologist and epidemiologist at Rhode Island Hospital and Brown Medical School. "For this reason, lung cancer is increasing in frequency among former cigarette smokers. Current and former smokers should be made aware of this continuing risk." Current public policy is largely based upon the results of randomized trials from the 1970s and early 1980s, which have been widely interpreted as showing that screening for lung cancer is ineffective. In fact, these studies have been interpreted as indicating that screening frequently results in the overdiagnosis of lung cancer, which leads to unnecessary procedures. However, more recent analyses of the data from those clinical trials show that overdiagnosis of lung cancer was minimal. Moreover, the data demonstrate that virtually all long-term survivors following the diagnosis of lung cancer were those who had undergone complete surgical removal of the tumor.

In addition, the authors noted that innovations in imaging technologies in the past decade, such as CT scanning and more advanced chest X-rays (which utilize such methods as digital radiography and computer-aided detection) provide the opportunity to detect smaller lung cancers than before. Although false positives might still occur, particularly with CT scans, the medical community has developed effective protocols in order to minimize surgeries on patients with benign tumors, the paper notes.

"There have been major improvements in the methods used for finding lung cancer over the past 10 years. Both CT scanning and improved methods of chest radiographs enhance lung cancer detection, but they were not used in earlier studies. The best current methods can help radiologists detect smaller lung cancers," says Matthew Freedman, MD, MBA, a radiologist and associate professor of oncology at Georgetown University Medical Center.

The Como International Conference was held in 2003. It built upon the 1998 "International Conference on Prevention and Early Diagnosis of Lung Cancer," held in Varese, Italy. While the Varese Conference helped revitalize interest in screening for lung cancer, it made no recommendation that high-risk individuals should consider screening outside the context of a clinical trial. The Como Conference was held to address whether, five years later, sufficient evidence exists to advise high-risk individuals to consider screening for lung cancer.

Lung cancer is the most common and the most deadly cancer in the world, killing an estimated 1.1 million people around the globe each year. More people will die of lung cancer this year in the United States than will die from breast, prostate, colon and pancreatic cancers combined. Lung cancer is usually detected in advanced stages, when long-term survival is unlikely. Overall survival is 11 percent worldwide and 15 percent in the United States. On the other hand, when lung cancer is detected in the earliest stage, the survival rate is 70 to 85 percent.

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