CT scans offer lung cancer hope Survival rates up sharply, study finds By Ronald Kotulak Chicago Tribune science reporter Published October 26, 2006 A new generation of CT scanners that can detect lung cancer as small as a grain of rice--when the tumor is still highly curable--is raising hopes that screening may dramatically reverse the grim outlook for lung cancer, just as mammography did for breast cancer. A large, long-term study reported in Wednesday's issue of the New England Journal of Medicine estimated that at least 88 percent of patients whose early-stage lung cancer was detected through CT screening would survive for 10 years after the tumor was surgically removed. The 10-year survival rate for people diagnosed with early lung cancer is usually about 70 percent. But 85 percent of tumors are not detected until they are more advanced and difficult to treat. Many experts applauded the findings and said doctors would now look more closely at using CT scans on patients at risk for the nation's top cancer killer. The scans are currently used to diagnose cancer once symptoms appear, not for routine screening. But experts also cautioned that the results of even larger studies now under way are needed before CT scanning is broadly recommended for people at risk. Among the concerns about the new study is that because all participants were screened, the findings do not definitively show that scanning reduces the death rate from lung cancer when compared with a similar group of people not screened. CT screening also picks up small lesions, such as tiny scars, that may be confused with cancer, putting a person through additional testing and anxiety. Nevertheless, experts agreed that the results of the International Early Lung Cancer Action Project are encouraging and cause for hope. "This is a huge deal," said Dr. Ravi Salgia, director of the University of Chicago's thoracic oncology research program, who was not involved in the study. "Mammography has revolutionized how we detect breast cancer early, and we believe CT screening can do the same for lung cancer. "It's going to spark a big movement from all of us physicians and health-care providers, as well as patients and those who potentially may develop lung cancer, to really think very seriously about screening," Salgia said. The study, headed by Dr. Claudia Henschke of the New York-Presbyterian Hospital/Weill Cornell Medical Center, followed 31,567 people at risk of developing the disease as they were screened yearly between 1993 and 2005. They were 40 or older and considered at risk for lung cancer because of a history of smoking, occupational exposure to asbestos, beryllium, uranium or radon, or exposure to second-hand smoke. The screening turned up 484 lung cancer cases, 412 of which were Stage 1 cancer--when it has not spread and can be cured by surgery. These patients' estimated 10-year survival rate after surgery was 88 percent. Of the 302 patients who had surgery within a month after diagnosis, the rate rose to 92 percent. Eight patients were diagnosed with Stage 1 lung cancer but refused treatment for personal reasons. All died within five years. Low chance of cure "Lung cancer is a very fatal disease," said Dr. David Yankelevitz, a member of the study group and professor of radiology and cardiothoracic surgery at Weill Cornell Medical College. "Once a person has symptoms [such as coughing, chest pain, shortness of breath, hoarseness, spitting up blood] the chances are enormously high that it's in an advanced stage and the chance for cure is less than 5 percent. "This study turns it all around," he said. "This basically takes it from being a highly fatal cancer to one that if you're in a screening program and it's caught early, your chances of really being cured are very high." CT, which stands for computed tomography, has since the early '90s greatly improved the detail it can reveal, going from only 30 images per scan to 600 and showing tiny lesions beyond the ability of X-rays to detect. A detailed scan delivering a low radiation dose can now be taken in one breath-hold lasting 15 to 20 seconds. Screening to detect early cancers has helped to reduce the death rates from cancers of the breast, colon, cervix and prostate. But early detection of lung cancer has lagged, primarily because earlier studies using chest X-rays showed no benefit and because of the perception that cigarette smoking, the major cause of lung cancer, was a matter of choice. "For over 20 years, nothing was really done for lung cancer, which is killer No. 1 of all the cancers in the U.S.," said Dr. Michael Unger, director of lung cancer prevention and detection at Fox Chase Cancer Center in Philadelphia. "Unfortunately, we have not left behind the idea that lung cancer is a punishment, not a disease," Unger wrote in an editorial in the New England Journal. "The legacy of the stigma that has been associated with lung cancer may have delayed the launching of vigorous research on early detection of the disease." Lung cancer deaths have been climbing steadily. An estimated 173,000 Americans are diagnosed with lung cancer each year, and 95 percent die of it, more than die from breast, prostate and colon cancer combined. "This paper could be the dawn of a transition from a very frustrating, expensive and unsatisfying management of late-stage lung cancer to a much more systematic focus on early-stage lung cancer management," said medical oncologist Dr. James Mulshine, vice president for research at Rush University Medical Center. The study is promising and shows that very small cancers can be found and cured, said U. of C. radiologist Dr. Heber MacMahon, but further studies are needed to determine the value of routine CT screening for the whole population. Some cancers slow-growing "One of the issues is that there are many very small cancers that are indolent, that are very slow-growing," he said. "We can discover these with CT screening, but many of these cancers may never kill the patient. ... Many people die with lung cancer that they apparently never knew about." To help answer these questions, the National Cancer Institute four years ago launched a massive study involving 50,000 people at 30 U.S. medical centers. They are randomly assigned to have a CT scan or a chest X-ray and will be followed to 2009 to see if the CT group has a higher survival rate. "We hope our results are borne out in the other studies that are ongoing both in the U.S. and in Europe," said Dr. Daniel Ray, head of pulmonary and critical care medicine at Evanston Northwestern Healthcare. The hospital, which is participating in the international lung screening program, has scanned 300 participants so far, primarily current or former smokers of at least a pack of cigarettes a day for 20 years. Scheduled for 2nd scan Between 1 and 2 percent of those screened have been diagnosed with lung cancer and 85 percent are in the Stage 1 category, Ray said. When a very small lesion is found, the person is scheduled for another CT scan anywhere from three months to a year later to determine if the lesion has grown--a sign that it probably is cancer. "The results of the study are very compelling as to this being an effective way to reduce lung cancer mortality," Ray said. "Lung cancer has a terrible mortality rate, and we haven't been able to make a dent in it. This gives us a new hope that we can make a difference in these people's lives." ARE YOU A CANDIDATE FOR CT SCREENING? CT screening for lung cancer is not yet routine, so people in high-risk groups may want to consult their physician to see if they're a candidate. Most lung cancer is caused by smoking, but other risk factors include exposure to second-hand smoke, asbestos, beryllium, uranium or radon. The procedure costs $200 to $300 and is not covered by health insurance for routine screening. More information is online at ielcap.org.