Summary: When I heard the drumbeat of lung cancer screening at the most recent
RSNA meeting, the words were déjà vu from the last decade of whole-body
CT screening. We all recall how whole-body CT screening formed a big
bubble to the extent it was marketed directly to the consumer1
and was offered as a winning prize or gift certificate raffled by
charitable organizations. Then its allure burst and faded away.
Dr. Tehranzadeh is Chief of Radiology at Long Beach VA, and
Professor Emeritus and Vice Chair of Radiology, Department of
Radiological Sciences, University of California, Irvine Medical Center,
Orange, CA. He is also a member of the Applied Radiology Editorial Advisory Board.
I heard the drumbeat of lung cancer screening at the most recent RSNA
meeting, the words were déjà vu from the last decade of whole-body CT
screening. We all recall how whole-body CT screening formed a big bubble
to the extent it was marketed directly to the consumer1 and
was offered as a winning prize or gift certificate raffled by charitable
organizations. Then its allure burst and faded away.
So is lung cancer screening another bubble that will inflate and burst?
remains the second-leading cause of death in the United States (U.S.).
Although the third-most common cancer (after prostate and breast), lung
cancer is the most common cause of cancer death. It accounts for 28% of
such deaths in the U.S., and its annual burden is greater than that of
any other neoplasm.2
The recent report from the
National Cancer Institute’s (NCI) National Lung Screening Trial (NLST)
and the American Cancer Society’s (ACS) lung cancer screening guidance
concluded that lung cancer mortality can be reduced in specific
high-risk groups by annual screening with low-dose computed tomography
(LDCT) with the caveat that the potential harm-to-benefit ratio should
be considered.2,3 The ACS does not recommend lung cancer screening for everyone.
link between lung cancer and tobacco use, previously denied for so many
years by tobacco companies, is now indisputably proven. The epidemic of
lung cancer death is now receding in some countries where tobacco
control has reduced smoking, but it is rapidly increasing among current
and former smokers in others.4 Age-specific lung cancer incidence increases with age and the number of cigarettes smoked per day.5
the high rate of tobacco use among veterans, the NLST team’s report,
and the ACS guidance, the U.S. Department of Veterans Affairs (VA) has
decided to take an active role in the early detection and treatment of
lung cancer in this population. The VA is now embarking on a “phased
implementation” of CT lung screening at 6 to 8 VA hospitals. These
trials will help the department plan a system-wide program in the coming
Eligibility criteria for the NLST include
being an active or former smoker, age 55 to 74, with no signs or
symptoms of lung cancer,
and having a 30-pack-year smoking history (a pack year is the equivalent
of 1 pack of cigarettes per day per year; 1 pack per day for
30 years or 2 packs per day for 15 years would both be a 30-pack-year).
Active smokers should be urged to enter a smoking cessation program, and
former smokers must have quit within the past 15 years.2
NLST showed a statistically significant 20% reduction in mortality in a
group of high-risk adults randomized to receive 3 consecutive annual
LDCT lung cancer screening examinations (at baseline, year 1, and year
2), compared to an equivalent risk group of adults randomized to receive
3 consecutive annual chest radiographs.2 In all 3 rounds,
there was a substantially higher rate of positive screening tests in the
LDCT group than in the radiography group at baseline (27.3% vs. 9.2%),
at year 1 (27.9% vs. 6.2%), and at year 2 (16.8% vs. 5%).3
requires a variety of health practitioners to work together. The
importance of a multidisciplinary team composed of a primary care
physician, radiologist, surgeon, pulmonologist, prevention physician,
oncologist, and radiation therapist was emphasized by Dr. Reginald
Munden, of the MD Anderson Cancer Center, at the 2012 RSNA.7
economists have a more sinister view of these issues than do most
physicians. They remind us that U.S. healthcare costs represented 17.9%
of the gross domestic product (GDP) in 2010 and are continuing to grow.
It is projected that the U.S. will spend 20% of GDP on healthcare in
2020. Economists also warn that we already have the highest healthcare
costs as a percentage of total budget compared to any other nation.
with tobacco control, smoking cessation, and lung screening, we are
increasing healthcare expenditures and contributing to decreasing
mortality by increasing the longevity of our seniors. People are living
longer, which translates to more healthcare costs for senior citizens
and a higher financial burden on such resources as pensions and Social
Security. We physicians are rightfully arguing that we cannot put a
price on human life.
Nevertheless, the reality is that > 95% of CT-detected pulmonary nodules are ultimately found to be benign.8
To complicate this, studies that have evaluated the outcomes of benign
biopsies have found false-negative rates varying widely, from 6% to 54%.8
False-positive results (eg, benign noncalcified nodules or premalignant
lesions that would not evolve into malignancy) invite potential
burdens. Intervention (biopsy) may lead to pneumothorax and other
complications. Costly investigation of incidental findings discovered
outside the lungs may also lead to unnecessary studies. Yet another
concern: If we embark on these trials, are we sufficiently equipped to
handle the required high CT volume? Do we have enough support from
facility leadership to provide the primary care, interventional
radiologists, pulmonary physicians, pathologists, oncologists,
cardiothoracic surgeons, radiation therapists, and clinical coordinators
or case managers to care for the lung cancer patients we discover?
light of the promising NLST report and the advent of ultrafast low-dose
CT scanners that can image the entire chest in 0.3 sec, the ACS and the
VA see a silver lining in screening smokers over age 55. We at the VA
medical center in Long Beach, CA, are applying to participate in this
phased implementation trial. Hopefully, by collecting more data, we can
set a road map to wisely guide wider implementation of CT lung cancer
- Modic MT, Obuchowski N. Whole-body CT screening for cancer and coronary disease: Does it pass the test? Cleve Clin J Med. 2004;71:47-56.
- Wender R, Fontham ETH, Barrera E, et al. American Cancer Society lung cancer screening guidelines. CA. Cancer J. Clin. 2013; Epub ahead of print
- Aberle DR, Adams AM, Berg CD, et al. Reduced lung cancer mortality with low dose computed tomographic screening. N Engl J Med. 2011;365:395-409.
- World Health Organization: WHO report on the global tobacco
epidemic, 2011: Warning about the dangers of tobacco. World Health
Accessed February 6, 2013.
- Bain C, Feskanich D, Speizer FE, et al. Lung cancer rates in men and women with comparable histories of smoking. J. Natl Cancer Inst. 2004; 96:826-834.
- Karr D. VA set to begin CT screening in Veterans after Success in
Medical Trial: The Mesothelioma Cancer Alliance Blog at
Mesothelioma.com: Aug. 29, 2012. Accessed February 13, 2013.
- Fratt L.RSNA: Lung cancer screening: Where hope and fear converge. Health Imaging.
Posted November 26, 2012. Accessed February 6, 2013.
- Gelbman BD, Cham MD, Kim W, et al. Radiographic and clinical
characterization of false negative results from CT-guided needle
biopsies of lung nodules. J Thorac Oncol. 2012;7:815-820.