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Make an informed decision about lung cancer screening

November 05, 2014

Lung cancer causes more deaths than any other cancer. In the United States, more men and women will die from lung cancer this year than from breast, colon, and prostate cancers combined. But there is good news: Doctors now know that low-dose radiation CT scans catch lung cancers early in certain high-risk groups, and can play a key role in preventing many lung cancer deaths.

The Yale Lung Screening and Nodule Program, or Yale Lung SCAN, screens appropriate high-risk patients—and evaluates people who do not fall into that category, but are worried about their personal risk. Yale Lung Scan was launched after the landmark 2010 National Lung Screening Trial (NLST) demonstrated that a well-organized approach to low-dose radiation CT screening can prevent 1 in 5 deaths from lung cancer in certain high-risk people screened on an annual basis.

“The purpose of screening is to detect cancer early, and the purpose of detecting cancer early is to try to save lives,” said Lynn Tanoue, M.D., a pulmonologist, who cofounded the program with thoracic surgeon Frank Detterbeck, M.D. However, truly effective screening for early lung cancers was not available before the NLST. “The hope now is that carefully targeted screening will increase the number of patients who are diagnosed at an early stage where we have a good chance of curing that patient, increasing the survival rate and decreasing the mortality rate from lung cancer,” Dr. Tanoue said.

Targeting high-risk groups

Yale Lung SCAN screenings target people who meet the following criteria, based on the NLST findings:

  • They are adults aged 55 to 74 who have smoked at least 30 pack-years (a pack year is the number of years of smoking multiplied by the average number of packs per day for example, 2 packs per day times 20 years is 40 pack-years)
  • They are current smokers or have quit smoking within the past 15 years
  • They are otherwise in reasonably good health

Drs. Detterbeck and Tanoue emphasized that lung screening works best as part of a comprehensive program. Yale Lung SCAN includes a multidisciplinary team of pulmonologists, thoracic surgeons, chest radiologists, smoking cessation specialists, and nurse practitioners.

This team provides each new patient with a personal lung risk assessment, and a discussion of the individual benefits and downsides of screening. When appropriate, they refer patients to Benjamin Toll, PhD, program director of the Smoking Cessation Service at Smilow Cancer Hospital at Yale-New Haven.

Patients who do choose to undergo screening receive a low-dose screening CT scan performed in a controlled manner and read by one of three dedicated chest radiologists: Anne Curtis, M.D; Demetrius Dicks, M.D.; and Jonathan Killam, M.D. Results then go back to Drs. Detterbeck, Michaud, and Tanoue, and Polly Sather, A.P.R.N., the program coordinator, who provide each patient with an individualized recommendation that will include ongoing care and continued monitoring of any abnormalities.

To screen or not to screen?

Some people wonder if they should be screened even if they don’t fit the NLST criteria. They may have 30 pack-years under their belt, but they’re only 50 years old. Perhaps they never smoked, but grew up around secondhand smoke and have two relatives with lung cancer? Though scanning everyone for lung cancer “just to check” might seem like a good idea, it isn’t, according to Drs. Detterbeck and Tanoue. “The potential downsides of screening become magnified if the chance of developing a lung cancer is low,” said Dr. Tanoue.

For example, both doctors and patients would prefer to avoid the radiation found even in a low-dose screening CT if they don’t think the screening is necessary. However, those who fit the NLST criteria should know that CT radiation has been decreasing. Currently one low-dose CT involves only about half as much as the background radiation as an individual gets from the environment each year, and Dr. Tanoue expects the doses will continue to become safer over time. “The technology to really decrease the amount of radiation and retain the quality of the imaging is absolutely right around the corner,” she said.

Cost is another downside. Medicare does not yet cover CT-scan lung cancer screening, although it is expected to make a decision on coverage later this year. Yale Medical Group and Yale-New Haven Hospital offer screening consultations for $150; and charge an additional $150 for a low-dose CT for patients in the program. “This does not cover the overall costs of an organized screening program” said Dr. Detterbeck, “but we are doing our best to keep the cost to patients as low as we can under the present circumstances.”

Perhaps the most important downside is that CT scans are so sensitive that they pick up small nodules that are best thought of as “background noise,” Dr. Detterbeck said. The vast majority of nodules will not turn out to be cancer, but the Yale Lung Scan team must evaluate each one to determine whether it is benign or suspicious enough to call for further testing. “We have learned that careful judgment by an experienced screening team is very good at figuring out which nodules are just noise and which ones require a closer look,” he said.

“This is why it is so crucial that screening for lung cancer be done in the setting of an organized program,” added Dr. Tanoue.

Decision process is reassuring

For people who still have questions about screening, the program provides informational and educational materials, and offers patients a “shared decision-making” process that includes education and discussion of any particular fears and concerns. Gaetane Michaud, M.D., a member of the Yale Lung SCAN team, developed an educational iPad app to help provide patients gain a clear, straightforward understanding of the risks and benefits, and allow them to fully participate in any decisions.

After going through the shared decision-making process, “people whose risk is really low, but are just really worried, generally leave feeling reassured,” Dr. Tanoue said.

One-fifth of Americans are habitual smokers, so lung cancer will be around for a long time, with research is directed toward learning more about it, Dr. Tanoue said. “The whole landscape of lung cancer screening is actually really complicated, which is why really good screening requires the entire program,” she said. “We should not just screen everybody, because we have to consider emotional, physical, and economic costs—you cannot justify that. However, we really do want to screen people at high risk – that is how we will save lives.”

Yale-New Haven Hospital and Yale Lung SCAN provides periodic free screening events. The next free screening date is Saturday, Nov. 8, 2014.

For more information or to schedule a consultation, call Yale Lung SCAN at 203-200-LUNG (5864).

Submitted by Mark Santore on November 05, 2014