Friday, June 23, 2000

Center to add lung scans

By Tim Bonfield
The Cincinnati Enquirer

        The Barrett Cancer Center plans to begin offering helical CT scans sometime this year in hopes that earlier detection of tumors will help reduce deaths from lung cancer — the Tristate's No. 1 cancer killer.

        While no date has been set for the Barrett Center service, the move would represent a significant local expansion of a screening test that has become the focus of increasing national debate.

        The screening test issue has special relevance in Greater Cincinnati because local smoking rates and lung cancer death rates have exceeded national averages for years.

        “Just like prostate cancer, breast cancer and colon cancer, the earlier we pick it up, the more lives we will save. There's no question about it,” said Dr. Kenneth Foon, Barrett Center director.

        Nationally, several medical centers and radiology groups already offer helical CT scanning for longtime smokers (current or former), people with family history of lung cancer and those who had workplace chemical exposures that put tham at risk. Among them:

        „Memorial Sloan-Kettering Cancer Center in New York.

        „New York Presbyterian Hospital.

        „The Arizona Heart Institute in Phoenix.

        „Epic Imaging in Portland, Ore.

        „The University Radiology group in New Brunswick, N.J.

        In Greater Cincinnati, at least two private groups and one hospital offer lung cancer screening with helical CT scanners:

        „ProScan International in Kennedy Heights.

        „Healthsouth Diagnostic Center in Montgomery.

        „Dearborn County Hospital in Lawrenceburg, Ind.

        Prices vary from $150 to about $400; fees typically are not covered by insurance. At some centers, patients can make their own appointments. Others require a physician referral.

        The potential value of CT scanning is immense. According to the American Cancer Society, lung cancer kills about 157,000 people a year — far more than the No. 2 killer, colon cancer, at nearly 48,000 deaths per year. Unlike mammograms for breast cancer or PSA blood tests for prostate cancer, there is no early detection test for lung cancer.

        Even worse, most treatments for lung cancer have proven ineffective — especially when the disease is caught in advanced stages.

        The five-year survival rate for lung cancer is 14 percent for all stages combined, far lower than breast cancer (85 percent) and prostate cancer (92 percent).

        When patients are detected with early-stage lung can cer, they can get surgery to remove portions of their lungs. For them, five-year survival rates run about 42 percent.

        But without a useful screening test, more than half of lung cancers are detected only after they have spread beyond the initial tumor. Those patients get chemotherapy and radiation that can extend life and reduce pain, but rarely lead to cure.

        The five-year survival rate for lung cancer detected at the “regional” stage is about 20 percent; for “distant” stage cancer, survival dips to 2 percent.

        The disparity in survival rates between lung cancer and other common cancers is what makes finding a useful screening test so important, Dr. Foon said.

        “The only ones cured from lung cancer are those detected early enough for surgery to be of benefit. Everyone else dies,” Dr. Foon said.

        The debate about CT scanning at the national level focuses on costs, concerns about people getting unneeded treatment based on “false positive” test results and the unknown question of how much impact on death rates widespread screening might have.

        In essence, if people expect government or employer-based insurers to pay for the test, those organizations want proof screening will make enough difference to justify costs.

        The National Cancer Institute has estimated it would cost $39 billion to provide CT scans to all current and former smokers.

        But it has not accounted for the potential value to society of reduced hospital and nursing home stays, reduced disability payments, increased workplace productivity and the hard-to-quantify benefit of more people living into their 70s and 80s.

        Dr. Barnett Kramer of the National Institutes of Health told the New York Times this week he is worried about the rapid spread of CT scanning for lung cancer. He hopes to avoid the dashed hopes that followed promising talk in the 1960s and 1970s about chest X-rays and sputum analysis serving as screening tests for lung cancer.

        He supports a controlled, randomized trial to look at CT scanning, a study that could involve up to 20,000 patients and take at least three years to complete.

        But some doctors who offer CT scanning say hundreds of thousands of lung cancer patients will die waiting for the results.

        “This is the same argument they had about mammography,” said Dr. William Drew, a radiologist at Dearborn County Hospital, who watched his mother die of lung cancer when she was 42 and he was 13.

        “All you have to do is see it once and anybody at high risk will know it's worthwhile doing,” Dr. Drew said. “Lung cancer tends to be excruciatingly painful. And you end up in a wasted state. My mother weighed about 80 pounds when she died. She looked so bad my father wouldn't let me attend the funeral.”

        At Dearborn County, the hospital has performed 80 screening tests (for $150 each) since September. They found 17 suspicious nodules that required further testing. Of those, three were confirmed to be malignant.

        All three were found at Stage I, which means they had not spread to any lymph nodes. Two cases were smaller than 2 centimeters. At stage IA (less than 2 cm.) five-year survival from lung cancer is about 80 percent, Dr. Drew said. At stage IB (more than 2 cm.) the survival rate dips to 60 percent.

        The American Lung Association, a leading consumer and research support group, has been reluctant to endorse CT scanning for lung cancer.

        “It is premature for the ALA to endorse screening of all at-risk patients with this method. The technique is not widely available yet, and its use requires specialized knowledge. Further, patients and control groups have not yet been followed up to determine whether in fact the CT technique will lead to higher cure rates,” according to a national policy statement provided by local ALA spokesman Chuck Sikorski. “The expense may well be considerable and thus may make regular widespread screening impractical.”

        In addition, Elizabeth Hlinko, ALA director of media relations said, “We don't want to promote something that is not widely available or that could potentially encourage smokers to continue to smoke because they mistakenly think that this test is a cure-all.”

        The New York Times contributed to this report.


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