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Dr. Marcus is an Epidemiologist, Division of Cancer Prevention, National Cancer Institute.
Correspondence to: Pamela Marcus, MS, PhD, 6130 Executive Blvd, Suite 3131, Bethesda, MD 20892-7354; e-mail: pm145q{at}nih.gov
Lung cancer screening is a frequent visitor to the pages of CHEST, and this issue is no exception. The article by Jerome Reich (see page 329), "Improved Survival and Higher Mortality: The Conundrum of Lung Cancer Screening," helps to remove some of the mystery behind the theoretical underpinnings of lung cancer screening. In doing so, the article provides a compelling case against the establishment of mass lung cancer screening programs at this point in time, be they with chest radiographs or helical CT scanning.
Randomized controlled trials of lung cancer screening have produced seemingly conflicting findings. These trials have demonstrated increased patient survival but, at the same time, have shown no reduction in lung cancer mortality.1 2 3 In his article, Dr. Reich addresses how these conditions can legitimately occur at the same time. He also reviews other important issues in lung cancer screening that tend to be overlooked.
The topics discussed by Dr. Reich are not new. The lung cancer literature is replete with articles and editorials positing that it is too soon to establish mass lung cancer screening programs.4 5 6 7 So why publish another manuscript? Why did I, a reviewer of Dr. Reich’s article, recommend that it be accepted?
Simply put, there is too much at stake to establish a program of mass lung cancer screening without solid evidence of its benefits. Sadly, the available data8 9 10 11 12 cannot provide irrefutable evidence of a reduction in lung cancer mortality, or even an extension of life, with screening by either chest radiograph or CT scanning. Lung cancer detection, as intuitively appealing as it is, is limited in what it can tell us.
Why is lung cancer detection not enough? The problem with cancer screening, as Dr. Reich points out, is that there is harm that is inherent in the process. There is the very likely possibility of overdiagnosis.4 5 If, by some chance, overdiagnosis did not exist in lung cancer screening, risks would still exist.13 Although the imaging examination itself poses a small immediate threat, the sequelae of a positive screening finding (ie, diagnostic evaluation and, if necessary, cancer treatment) can cause trouble. Smoking-related comorbidities (such as heart disease and compromised pulmonary function) make follow-up and treatment even riskier.
Ignoring the financial costs and the strains on the health-care system, it seems, from an ethical perspective, that it would be acceptable to implement mass screening programs at this point in time only if lung cancer screening were, at worst, innocuous. What must be acknowledged is that no mass cancer screening program is ever innocuous; even in the presence of a benefit, there is a guarantee of harm.14 Of course, there is a wide range of harmful effects. At one end, there may be small inconveniences and wasted resources, but on the other end, there may be premature deaths due to complications from undergoing a thoracotomy.
Lung cancer is a horrific disease. Screening proponents and opponents alike agree that something must be done to reduce the burden. It would be unforgivable, however, if a prematurely established lung cancer-screening program resulted in more harm than benefit. Some would contend that such a result is impossible, but Dr. Reich shows us that it could very well happen.
References
This article has been cited by other articles:
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  H. Esteva Surgery in Lung Cancer Patients Chest, August 1, 2004; 126(2): 656 - 656. [Full Text] [PDF]
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