Wednesday was a significant day for lung cancer screening, as it was the day investigators published long-awaited results from the National Lung Screening Trial (NLST). Nine years ago, I was a new staffer at the American Cancer Society, sitting in a room with Denise Aberle, M.D., of UCLA Medical Center, co-Principal Investigator for NLST, as we planned efforts to promote what we hoped would be a landmark trial comparing low-dose CT scans to x-ray to detect lung cancer in current and former smokers. It was a critical question, potentially lifesaving for thousands of current and former smokers. Eventually, with the support of the ACS, more than 53,000 people selflessly volunteered for the trial.
On Wednesday, there was reason to celebrate –albeit very cautiously– as the trial showed screening a high risk population using low-dose CT reduces the risk of death from lung cancer. There are still many questions to be answered. A high rate of false positives, the potential for significant harm, and how to deliver quality care without breaking the bank are among the challenges that face public health experts as they consider implementing the technology in real life. Still, Otis Brawley, M.D., the American Cancer Society’s chief medical officer summed it up when he told Medscape Medical News: “We’ve been looking for this kind of good news in lung cancer for a long time.”
Some of you may know we take heat from critics who say we’re not doing enough in lung cancer, and even that our efforts to prevent tobacco-related deaths have contributed to the stigma surrounding lung cancer. They are criticisms that hit us like a punch to the stomach, especially for those of us, including me, who have lost friends and loved ones to this disease, some of whom smoked, and some of whom, like my dear friend Curt, did not. We must lift this stigma. We must also continue to fund the most promising research on this disease. The ACS currently funds 92 multi-year grants totaling more than $51 million on lung cancer research, most of that basic science that will help smokers and non-smokers alike. And while the news from NLST is big, it must not diminish the efforts in tobacco control that are largely responsible for the drop in lung cancer mortality rates we have seen among men for years, and now for the first time, are seeing among women.
But today is a day to celebrate. And again, we do so with caution, because while these findings are potentially lifesaving, they come with plenty of caveats. Here is Dr. Brawley‘s full statement:
“This is a momentous time in the history of public health research, and the NCI investigators are to be congratulated. We also owe a great debt of gratitude to the more than 53,000 men and women who agreed to participate in this trial. The NLST study is the best designed and best performed lung cancer screening study in history. These are very important findings, and they will be considered as major groups including the American Cancer Society create recommendations for the early detection of lung cancer. The process for creating these guidelines requires an examination of these and other data as well as assessing reviews from others over several weeks after the current study’s publication. Other lung cancer screening trials are underway in Europe, and they also likely will influence recommendations in the future.
“Until then, it is important that we keep in mind that the implementation of lung cancer screening in the population faces challenging hurdles. Guidelines groups have yet to carefully evaluate these and other data to determine who should and should not consider undergoing screening for early lung cancer detection and how often. Best practices have yet to be defined and in place in all clinical settings that will offer screening and diagnostic procedures, nor are we prepared to articulate the details that high risk individuals should hear before making a decision to undergo screening.
“As this study demonstrates, the rate of findings suspicious for lung cancer was high in each screening round (over 27% in the first two rounds), but low-dose CT exams also can identify other non-lung related abnormalities, and this positivity rate also was high. So managing abnormal findings and avoiding doing harm in individuals with false positive findings are among the major challenges we will confront.
“A very sobering observation in this report is that there were 26 deaths associated with invasive diagnostic procedures. We are reminded of the period right after the results of the first mammography screening trial were published in the late 1970s. Our country did not rush into screening, but rather the ACS and the NCI rushed to implement the Breast Cancer Detection Demonstration Project as a strategy to gain experience in the community based implementation of breast cancer screening. We must prepare to implement lung cancer screening in an even more deliberate and organized manner to ensure steady progress towards maximizing benefits, minimizing harms, and insuring that appropriate screening takes place based on risk.
“While the study showed that screening can reduce the risk of lung cancer death in current and former smokers, we must always emphasize that screening is a secondary risk reduction strategy to smoking cessation. Proven smoking cessation strategies and the policies that promote them, including strong smoke-free laws, higher tobacco taxes, and fully funded smoking cessation programs, remain critical in the fight against cancer. The findings of this study do not diminish their importance, nor do they suggest that resources could be shifted from prevention to early detection. We estimate that quitting smoking will in ten years time reduce a smoker’s risk of death from lung cancer as much as CT screening did in this study.
“Finally, if and when major groups do make a recommendation for screening, it will be important that those considering screening be made aware of the significant number of false positive findings and potential other harms associated with downstream testing that can occur with spiral CT scanning.”