In her “Smoke Alarm! Is It Now OK to Smoke?” blog from September 6, Rebecca Bechhold, MD, asked a number of questions, and expressed a hope that her blog would stimulate discussion and elicit comments. Here goes:
Dr. Bechhold accurately quotes estimates of potential lives saved by screening and the number of individuals who will need to be screened. But unfortunately, the primary source of the quotes is highly inaccurate and grossly underestimates both the number of lives that can be salvaged by CT screening and the number of individuals who are at sufficiently high risk to warrant screening. The basis for these underestimates lies partly in the fact that the National Lung Screening Trial (NLST) did not utilize a diagnostic algorithm to guide clinicians in the next step in the workup following detection of a nodule, with the result being that the percentage of stage I diagnoses and long-term survivors were substantially lower in the NLST than in multiple screening studies utilizing such an algorithm. More important was that NLST investigators’ research design incorporated only three screens—one at baseline and the others at 1 and 2 years later. Despite not screening annually beyond year 2, the NLST counted deaths from lung cancer that occurred after screening had ceased as deaths attributable to screening. There were more than 1,000 such deaths in the trial. This allows Peter Bach, MD, (in the Journal of the National Cancer Institute) and others to state that only 1 of 5 individuals with lung cancer diagnosed by CT screening was a survivor and that 4 of 5 died. In reality, in screening trials with annual CT scans, in the context of a strong, validated diagnostic algorithm, survival at 5 and 10 years is greater than 80% in screened patients diagnosed with lung cancer. Accordingly, the number of estimated lives saved by screening is approximately four times as high.
A second problem with the quoted information is that it reflects the screening of only a small portion of the individuals at risk. If screening is extended to all those at increased risk, the potential for lives saved is much greater. Such individuals would include patients surviving after treatment of a prior tobacco-caused neoplasm of the lung, individuals above age 74 (and above age 79) in good general medical condition, individuals with substantial exposure to industrial carcinogens (radon, asbestos, chromates, arsenic, etc.), individuals with a family history of lung cancer, and individuals with heavy tobacco exposure who quit more than 15 years earlier. And this list is still incomplete.
The question of whether there are enough CT scanners in the United States to perform these scans is a good one. Andrea McKee, MD, of the Lahey Clinic, estimates that her center has the ability to accommodate at least 100 screening CT scans each week, ie, 5,000 annually. There are now approximately 70 centers participating in the International Early Lung and Cardiac Action Program (I-ELCAP) and another 125 who have signed on to an agreement to screen responsibly via the Lung Cancer Alliance (LCA).[1,2] The I-ELCAP experience has already demonstrated that community medical centers not associated with university academic programs can provide high-quality screening. Undoubtedly, the number of centers participating will increase rapidly in the next few years. It is important that such centers endorse and follow the principles established by the LCA.
With regard to people at risk paying for their own scans, there is an important issue of social justice in play. It is well-known that “smoking follows underprivilege like a cloud.” Those at highest risk, ie, smokers, are more often in lower educational and socioeconomic groups, and their ability to pay for screening is compromised. The question of stigma also arises in this context. The tobacco companies have cynically and dishonestly portrayed smoking as “an adult choice” and accordingly, some blame the smoker for causing his/her own problems. But this is neither accurate nor humane. In a very real sense, lung cancer is a pediatric disease. In the large majority of cases, the choice to initiate smoking is made during childhood and adolescence, two periods of life not characterized by wise decision-making. Initiation is quickly followed by addiction to nicotine.
An unfortunate victim of this lethal cascade was Marie Evans, an African-American child in Roxbury, Massachusetts, who was given samples of mentholated cigarettes by tobacco company representatives. She became addicted to cigarettes, developed lung cancer, and died in her early 50s.
The topic of intolerance of obesity (the newly minted term is “overweight stigma”) and tobacco is highly relevant. It is important to remember that smoking among American women, African-American women, and Latinas in particular, has historically been relatively low. This presented a business opportunity for the tobacco industry. In the 1970s—after they already knew that their products were addictive and caused cancer—they actively marketed cigarettes to women, specifically to young women. The most notorious of such ad campaigns was the Virginia Slims campaign, featuring feminist heroine Billie Jean King (a long-term Philip Morris board of directors member), that sought to convince young women that they could stay slender by smoking Virginia Slims. The bitter harvest of this murderous marketing is evident in the lung cancer carnage we currently see among American women smokers and ex-smokers, as well as among American women who have never smoked but have involuntarily inhaled carcinogens in the form of secondhand smoke.
Dr. Bechhold is not the only medical oncologist to voice the concern that we cannot afford to screen for lung cancer, that we need the money for treatment. The problem is that curative treatment of lung cancers presenting with symptoms has only increased from 12% in the 1970s to 16% today; not a very cost-effective strategy, particularly since newer targeted and personalized treatments are astonishingly expensive, and societal costs of cancer treatment are skyrocketing.[5,6]
I agree with Dr. Bechhold that increasing taxes on tobacco products, as well as earmarking the receipts for lung cancer prevention, smoking cessation, screening, treatment, and palliation is sensible, but this solution ignores political realities. Unfortunately, it is almost impossible to successfully enact a new tobacco tax. Our elected officials, a large majority of whom accept tobacco industry campaign contributions, almost always violate the public interest by voting against such legislation.
Barnett Kramer, MD, director of the division of cancer prevention at the National Cancer Institute and one of the most prominent opponents of population screening for lung cancer, has indeed frequently stated that smoking cessation is more effective than screening, but this ignores a simple observation that both Dr. Bechhold and I are aware of, and which the editor of the Journal of the National Cancer Institute should definitely be cognizant of: The majority of patients who present in our clinics with lung cancer have already stopped smoking. The problem of the epidemiology of lung cancer is more complex than that of cholera. In the case of cholera, all one has to do is turn off the contaminated water tap and the disease disappears within weeks. But even if we were able to completely turn off the source of cigarettes in the United States, there would still be cases of lung cancer in our clinics 20, 30, 40, and 50 years later.
With regard to “legions of young smokers,” that is certainly not the case in California or other states like Minnesota and Massachusetts, where strong efforts at funding primary prevention have been deployed, and smoking among young people is much reduced.
In the final paragraphs, Dr. Bechhold appears to have bought into the concern that lung cancer screening will provide a “license to smoke.” This is one of the many bugaboos that opponents of screening have stressed. The limited amount of research that has been performed, however, does not show that screened individuals resume or continue smoking. Instead, the evidence suggests that initiation of screening presents a teachable moment in smoking cessation that can and should be exploited. The I-ELCAP consortium has always emphasized the importance of combining smoking cessation in tandem with screening. The Guiding Principles in the National Framework for Excellence in Lung Cancer Screening and Continuum of Care specifically “includes a comprehensive smoking cessation program in its screening and continuum of care program based on best practices evidence.”
At the September 10 Warner Lecture Series on Lung Cancer Screening, Cheryl Healton, the director of the American Legacy Foundation, talked about the “three-legged stool” to be utilized to reduce lung cancer deaths, ie, tobacco control public policy, smoking cessation, and lung cancer screening.
With regard to the final question of who should pay for lung cancer screening, I believe that the answer here is obvious. When Exxon and British Petroleum created enormous toxic spills, our society and courts required that they pay for the cleanup. In similar fashion, the tobacco industry has, in effect, caused the biggest toxic spill in history, one that has very literally killed millions of Americans. It is time that the courts compel the industry to clean up their mess, including payment for provision of lung cancer medical monitoring programs.
1. International Early Lung and Cardiac Action Program. Screening Sites. Available at: http://www.ielcap.org/screening-sites/all/list
2. Lung Cancer Alliance. Lung Cancer Screening Centers. Available at: http://www.lungcanceralliance.org/get-information/am-i-at-risk/where-should-i-be-screened/lung-cancer-screening-centers/
3. Lung Cancer Alliance. National Framework for Excellence in Lung Cancer Screening and Continuum of Care. Available at: http://www.lungcanceralliance.org/get-information/am-i-at-risk/national-framework-for-lung-screening-excellence.html
4. Supreme Judicial Court. For the Commonwealth of Massachusetts. No. SJC-11179. Suffolk County. Willie Evans, as Executor of the Estate of Marie R. Evans. Plaintiff-Appellee v. Lorillard Tobacco Company.
5. Fojo T, Grady C. How much is life worth: cetuximab, non-small cell lung cancer, and the $440 billion question. J Natl Cancer Inst. 2009;101:1044-8.
6. Institute of Medicine. Delivering high-quality cancer care: charting a new course for a system in crisis. Available at: http://www.iom.edu/Reports/2013/Delivering-High-Quality-Cancer-Care-Charting-a-New-Course-for-a-System-in-Crisis.aspx
7. Lum KL, Barnes RL, Glantz SA. Enacting tobacco taxes by direct popular vote in the United States: lessons from 20 years of experience. Tob Control. 2009;18:377-86.
8. California Department of Public Health. California Tobacco Control Program. Available at: http://www.cdph.ca.gov/programs/Tobacco
9. International Early Lung and Cardiac Action Program. Protocol Documents. Available at: http://www.ielcap.org/protocols