Should you be screened for lung cancer?
Mammogram, check. Colonoscopy, check. PSA for prostate cancer, check. If you have regular yearly physicals, these tests are probably automatically ordered, depending on your gender. But if you are a current or former smoker, have you also had the CT test for lung cancer? If not, you should.
The U.S. Preventative Services Task Force has expanded the category for who should be screened regularly with a low-dose CT scan for lung cancer, with a goal of catching more cancers at an earlier stage.
The new guidelines update the previous guidelines, established in 2013, by lowering the age to begin screening from 55 to 50. Screening will also be an option for those who have smoked the equivalent of 20 pack years instead of 30, as the previous guidelines had recommended.
Pack years are gauged by the number of packs of cigarettes smoked per day times the number of years smoked. That means that under these guidelines, someone who smoked one pack a day for 20 years or two packs a day for 10 years (and either still smoke or have quit within the past 15 years) would qualify for screening.
If people actually follow these guidelines, more cancers will be found earlier when they can be more successfully treated, said Cape Cod Hospital thoracic surgeon Jeffrey Spillane, MD.
"One of the big problems is that we don't find a majority of lung cancers until later," he said. "Better screening means earlier detection and that has been factored into those guidelines. Those guidelines are based upon the fact that we can actually save lives."
Dr. Spillane would like this test to be a regular part of screening that every primary care doctor orders for patients who fit the criteria.
"What we would like, 'we' being people in the lung cancer business, is to get to the same place where breast cancer is or prostate cancer or colon cancer, with an easy screening tool that's not very expensive," said he said. "I don't look at it any different from a mammogram or a colonoscopy."
It is a well-known fact that the earlier a cancer is discovered, the better the recovery outcome is for the patient. Lung cancer is no exception, but historically a majority of lung cancers have been discovered when they are in the later stages. Part of the reason for that is that lung cancer doesn't have a lot of obvious symptoms in the early stages. The other factor is the lack of screening.
History of Lung Screening
An extensive study done in the 1970s by the Mayo Clinic indicated that, at that point in time, any money to prevent lung cancer would be better spent on the prevention of smoking and programs to help people quit, Dr. Spillane said. The biggest reason for that conclusion was that the only screening tool physicians had was chest X-ray, which was not very good at detecting early cancers.
"There were too many bones to get in the way, especially at the top of the lungs," Dr. Spillane said. "The ribs are very close together so when you look at a chest X-ray, you cannot see small cancers. The conclusion of the study was if you spent the money on X-rays, you would find some cancers but most of them would be more advanced and it wasn't cost-effective because you couldn't find the small ones."
Because the cancers that were detected were found at more advanced stages, X-rays had no real effect on mortality levels. When the more effective diagnostic device, CT scan, came along, the early ones were expensive, and their radiation dose was high. As the technology improved, the scans began to have better resolution and emitted much lower radiation levels. They also become more affordable.
In December of 2013, the U.S. Preventative Services Task Force began recommending that certain people at high risk for lung cancer have yearly screening with low-dose CT scans. The recommendations called for an annual screening with a low-dose CT scan for people ages 55 to 80 who had at least 30 pack years over their lifetime.
But, even with the 2013 recommendation, screening still remains too low, according to studies done by the American Cancer Society. The studies compared the proportion of people who were up to date with screening in 2010 to the proportion of people who were up to date with screening in 2015. Screening rates were just 3.3 percent in 2010, but despite the new guidelines, they had only improved to 3.9 percent by 2015.
Research supports the new, broader screening recommendations. In the NELSON trial, Europe’s largest randomized lung cancer screening trial done jointly by Dutch and Belgian researchers, participants saw a 25 percent reduction of lung cancer mortality with a volume-based low-dose CT lung cancer screening of high-risk participants after 10 years of follow-up.
The five-year survival rate for non-small cell lung cancer is 24 percent, according to the American Cancer Society. It is only 6 percent for those diagnosed with small cell lung cancer. But the figures improve depending on at what stage the cancer is caught. If a lung cancer is caught while it is still localized in the lung, the five-year survival rate is 61 percent.
"When used properly, the low-dose CAT scan is an effective screening tool that can save lives," Dr. Spillane said. "Just like breast cancer, when you find something earlier you can do a more conservative surgery. That's one of the things that I'm leaning towards, especially if you can get a really small tumor, because then you don't have to do a major lung resection. You can do a more limited lung resection or stereotactic radiation."
As part of the screening program, smoking cessation needs to be addressed, he said. For every eight lung cancers, seven are caused by smoking.
If you are interested in quitting smoking, talk to your doctor about safe nicotine replacements like gum, lozenges, patches and prescription drugs that can quell the urge to smoke. You can also visit smokefree.gov.
The website offers a quit plan, tips on the best ways to quit and smoke-free apps and text messaging that offer 24/7 support and encouragement. They also offer the chance to speak with experienced smoking cessation counselors who will help you make a plan to succeed by calling 1-800-QUIT-NOW. You can even sign up to participate in a research study that might help other people quit in the future.
Dr. Spillane said he hopes people will not hesitate to come in for screening because it has been proven to save or prolong lives. Strict COVID-19 precautions are in place at all Cape Cod Healthcare imaging locations.
"There has been more hesitancy on the part of patients to see their primary care doctor or get a screening. It's time to be taking care of these health issues again," he said.