Cancer-Free...for Now

The truth is rarely pure and never simple.

-- Oscar Wilde

I walked into the exam room and he beamed. "Thanks to the great people here, I have been cancer free for two whole years, Doc!" He could not have been happier. "You guys saved my life! I feel great!"

I smiled and congratulated him. As I moved through my examination, though, I listened to his voice. Decades of cigarettes had left his vocal folds swollen. Now his throat cancer is cured, but he remains at risk for other problems including an undetected lung cancer. Should I order more tests? And which ones?

Widespread screening for lung cancer might be on the horizon. A recent study reported the results of a large project from the International Early Lung Cancer Action Program (I-ELCAP) (The New England Journal of Medicine, Oct. 26, 2006; 355:1763-71). More than 31,000 non-symptomatic people, almost all of them smokers, underwent spiral CT scans of the chest.

More than 27,000 had annual scans. Nearly 500 of the participants were discovered to have very early, treatable cancers, and the five-year survival rate was 80% for these newly identified lung cancer patients. This is wonderful news, considering that only 15% of all US lung cancer patients will survive five years.

So why shouldn't we screen all smokers now? Patient advocates say it is time to start screening immediately. The I-ELCAP study's lead author supports screening when done very carefully in a protocol as a way to save lives. The patient advocates feel the data are strong enough to make lung screening routine.

On the other hand, there is a larger randomized National Cancer Institute-sponsored National Lung Screening Trial (NLST), but its results will not be ready for several years. NLST investigators urge caution interpreting the I-ELCAP results since poorly performed screening can lead healthy people into unnecessary "morbidity from diagnostic procedures, surgery, toxic treatments, and the psychological consequences of a cancer diagnosis." They point out that the I-ELCAP study was not randomized and did not address whether the benefits of the diagnosis outweighed its risks.

Somewhere in the middle, the American Cancer Society recommends that patients "talk with your doctor about your risk of lung cancer screening." (Cancer Letter, Nov. 6, 2006; 32 (no. 39)1-8). Needless to say, the economic consequences of a recommendation to screen would be enormous.

My patient stood to leave. I shook his hand and celebrated his cancer-free anniversary with him. I debated talking to him about lung cancer screening, but he didn't ask. I realized that there is just so much more we need to learn before we recommend routine testing. He happily headed down the hall. I made a mental note to myself that we might have a different discussion when he returns in a few months.

Bruce H. Campbell, MD, FACS
Professor of Otolaryngology and Communication Sciences
Chief, Division of Head and Neck Oncology
Interim Director, The Medical College of Wisconsin Cancer Center

"Reflections" is a collection of essays by the health professionals of the Medical College of Wisconsin.