lung cancer


Yes, Medicare Will Cover Lung Cancer Scans For Longtime Smokers, But…

(Source: Wikimedia Commons)

(Source: Wikimedia Commons)

…to finish the sentence in the headline: But it was not the simple no-brainer that you might think.

Lung cancer is the biggest cancer killer of all, causing 160,000 American deaths a year. But should we use lung scans to screen longtime smokers en masse for it? That question has been vigorously debated of late in medical circles, as Medicare has weighed whether to pay for the scans.

This week, Medicare announced that it did indeed propose to cover annual low-dose CT scans for smokers and former smokers, ages 55 to 74, with a smoking history equivalent to a 30-year pack-a-day habit. (More details here.)

People say ‘You deserve this because you brought it on yourself, and thus, suffer the consequences.’

– Laurie Fenton Ambrose

The draft decision now gathers public comment for a month and will still need to be finalized, but cancer activists and some doctors are already hailing it as a victory. Laurie Fenton Ambrose, president of the Lung Cancer Alliance, which had helped lead the push for the coverage, predicted that the scans would save tens of thousands of lives.

So why has screening for lung cancer sparked such hot debate? Why did it even recently trigger a rare pointcounterpoint duel in the pages of a major medical journal, JAMA Internal Medicine?

Well, first, the pendulum has been swinging lately towards greater skepticism about routine cancer screening, from mammograms to prostate tests.

(Source: FDA)

(Source: FDA)

At issue is the pivotal question of whether some forms of cancer screening do more harm than good, given that some of the tumors they pick up would never have caused any trouble. Routine blood tests for prostate cancer have fallen out of favor, for example, and the New England Journal of Medicine just published a cautionary tale from Korea about how mass ultrasound scans for thyroid cancer saved no lives.

So that’s the broader medical context. Then there’s the money. I recently heard a Medicare official say with pained realism at a public forum, “We can’t cover everything good.” Close to 5 million people on Medicare would be eligible for the screening, NPR reports, and the scans cost an estimated $241 each.

So at a time of greater emphasis on health costs and greater doubts about cancer screening, “We just found ourselves caught in that crossfire,” said Fenton Ambrose of the Lung Cancer Alliance.

With lung cancer, there’s also the question of special stigma. People say “You deserve this because you brought it on yourself, and thus, suffer the consequences,” Fenton Ambrose said. “It has always had that type of stigma, that even carried through in some of the public comments that came forth during the Medicare consideration.”

Dr. Chrisopher Lathan, a medical oncologist at the Dana-Farber Cancer Institute, similarly cited stigma as a source of “hesitation” on the coverage. “This is a cancer that’s heavily linked to a behavior,” he said. “The amount of data needed to convince everyone that this was a good screening tool — that hurdle was much higher. And also, we are in a more skeptical time, academically, when we look at screening. We know that screening is good, but it’s good in certain circumstances.”

Which circumstances, when it comes to lung scans? This is the moment for the Public Service Announcement that says, “Talk with your doctor.”

“At the end of the day, this is about the relationship between doctors and patients,” Fenton Ambrose said. And in particular, there are some gray areas that require discussion, she noted. What if, for example, you’re a bit younger, or smoked a bit less than the cut-off? Research is now under way on that “second tier” of potential scan subjects, she said. Continue reading

Pathologist: Legacy Of A 31-Year-Old Lung Cancer Patient

Microscopic image of the lung cancer that killed Kevin, a non-smoker, at just 31. (Courtesy M. Misialek, with family permission.)

Microscopic image of the lung cancer that killed Kevin, a non-smoker, at just 31. (Courtesy M. Misialek, with family permission.)

He was only 31 years old, the autopsy paperwork said.

What could have taken the life of someone just a few years younger than me? Stage 4 lung cancer, the chart said. And Kevin wasn’t a smoker.

I made the first incision. As I worked, it became clear that cancer had overtaken Kevin’s body. Tumor had encased his lungs, growing into the rib cage and heart, blurring the normal anatomical landmarks.

As a pathologist, I have learned that cancer knows no boundaries. It can strike anyone regardless of age, sex, race or class. I’ve also witnessed a disheartening trend over the past few years: many of the patients I see with cancer are younger and younger.

When I began my training, it was eye-opening to diagnose breast cancer in a 40-year-old. Over time, that yardstick has dropped a decade, then more. Once, my colleagues and I would stand in amazement having diagnosed the disease in 30-year-old patients. Now, unfortunately, that bar is set at more like age 20.

Kevin (Courtesy M. Misialek, courtesy of the family.)

Kevin (via M. Misialek, courtesy of the family.)

What is cancer? Cancer can be microscopic, only a few cells under my microscope, or it can be large and disfiguring. It can be indolent or aggressive. Some cancers may never cause harm while others will be relentless and deadly. This is something I have yet to understand. Many pathologists and other researchers are working on this exact question.

To me, everyone who battles cancer is a hero. Each patient is unique. It might be tumor characteristics seen on a pathologist’s slide or data collected from a clinical trial, but all patients teach us important lessons. They add to our growing understanding of cancer and search for a cure.

Kevin’s oncologist, Dr. Daniel Costa of Beth Israel Deaconess Medical Center, came over to collect some tumor tissue. It turned out that Kevin was one special patient. His tumor harbored a rare mutation in the ALK gene which made him eligible for the then still-experimental inhibitor PF-02341066. Being one of the first patients treated with the drug, he was a pioneer, blazing a path where no one had been before.

Kevin was also an outspoken advocate for lung cancer, working to erase the stigma that it is a patient’s fault because they smoked. Continue reading

Annual CT Scans Urged For Smokers At Risk For Lung Cancer

An influential government panel recommends that millions of smokers and ex-smokers at high-risk of developing lung cancer get annual CT scans to determine if they have early signs of the disease.

thirdhand smoke

The U.S. Preventive Services Task Force released draft recommendations that will likely be approved, experts say, paving the way for insurers to pay for such screening. Currently, most patients must pay out-of-pocket for the scans, which cost about $300-$400. The full set of recommendations was published today in the Annals of Internal Medicine. The bottom line: “Strong evidence shows that [low-dose] CT screening can reduce lung cancer and all-cause mortality.”

Lung cancer is the leading cause of cancer-related death in the United States, and “because early-stage lung cancer is associated with lower mortality than late-stage disease, early detection and treatment may be beneficial,” the report said. But such early detection and treatment has been elusive, according to experts.

In making the new recommendations, the 16-member government panel said that screening should target older patients at highest risk:

After reviewing the evidence, the Task Force determined that you can reach a reasonable balance of benefits and harms by screening people who are 55 to 80 years old and have a 30-pack-year or greater history of smoking, who are either current smokers or have quit in the past fifteen years. A “pack year” means that someone has smoked an average of one pack of cigarettes per day for a year. For example, a person reaches 30 pack years of smoking history by smoking a pack a day for 30 years or two packs a day for 15 years.

Continue reading

Opinion: Mass. Should Follow Bloomberg, Ban Cigarette Displays

(State Archives of North Carolina/Flickr CC)

(State Archives of North Carolina/Flickr CC)

Last month, New York City Mayor Michael Bloomberg announced a new public health initiative: He called for legislation that would require stores to keep cigarettes and other tobacco products out of sight, so they’d present less of a temptation. Here, Ilana Knopf, director of the Center for Public Health and Tobacco Policy at New England Law | Boston, argues that Massachusetts should follow his lead.

Ilana Knopf (Courtesy)

Ilana Knopf (Courtesy)

By Ilana Knopf
Guest contributor

Walk into virtually any convenience store in your town and you will have trouble avoiding colorful, prominent cigarette displays. They’re almost always located at eye-level, behind the registers, formed into a power wall of cigarettes that resemble an in-store billboard. It’s not an accident that these tobacco product displays are so visible. Tobacco companies spend billions of dollars on point-of-sale advertising. The reason is simple: it works.

If you have never noticed these displays or don’t think they’re a big deal, it’s probably because you’re more than 18 years old and outside of the tobacco industry’s true target audience: teenagers. In its quest to preserve and grow market share, tobacco companies are heavily invested in recruiting new users, and these new users are overwhelmingly (90 percent) our teenage sons and daughters.

Don’t take my word for it; take it from the tobacco companies themselves. As one Philip Morris report put it, “[t]he ability to attract new smokers and develop them into a young adult franchise is key to brand development.”

Tobacco companies are extensively invested in the point-of-sale strategy. They spend nearly $8 billion each year on this type of marketing (93 percent of their marketing budget), which is five times more than junk food, soda and alcohol manufacturers spend combined.

The tobacco industry already focuses on influencing youth decisions about tobacco use. Isn’t it time we caught up?

Point-of-sale displays are particularly effective in attracting young people. Tobacco companies rely upon the fact that teenagers are open to experimentation and move from experimenting to addiction far more quickly than for adults. The companies’ goal is to get young people to try tobacco with the intent of converting them into lifelong users. Research has found that adolescents are more influenced by tobacco marketing than peer pressure in their decision to start smoking.

In New York City, Mayor Bloomberg has proposed significantly restricting tobacco displays. Under his proposal, retail stores will still be permitted to sell cigarettes and other tobacco products — and advertise that such products are available for sale — but would have to do away with the large display of cigarette packs and other tobacco products that customers see behind the checkout counter in many convenience stores, pharmacies, and other retail establishments. Tobacco products would remain out of sight until a customer has asked for them and the salesclerk has verified that the customer is at least eighteen years old.

The mayor’s proposal makes sense. Continue reading

Lahey Radiologist On Lung Cancer CT: Good News And Hard Questions

Big news today on lung cancer, the number one cancer killer. A federal study of more than 50,000 current or former smokers found that low-dose “spiral CT” scans cut the death rate by 20 percent compared to screening with regular chest X-rays.

The Associated Press reports: The difference was significant enough that the researchers ended the study early, but the National Cancer Institute said that “it’s not clear that all smokers should get the scans, which aren’t risk-free.”

We asked Dr. Christoph Wald, of the Lahey Clinic, for his take on the findings. What do they mean for the public?

It’s early days yet, he said, and it will likely take months for the full data to be published. But for people who fit the high-risk profile of the subjects of the study — ages 55 to 74, and with a smoking history amounting to the equivalent of a pack a day for 30 years — “We can say that if you do what they did in the trial, get three consecutive low-dose CT scans, you have a very significant mortality benefit over the next five ensuing years.”

Dr. Christoph Wald of the Lahey Clinic

Dr. Wald expects clinicians to take a look at which patients in their practice fit the high-risk profile of the patients in the federal trial, and the doctors may well recommend CT screening to those patients. “At this time, since there are no national guidelines, it’s between the physician and the patient to decide how they want to incorporate this good new information into their physician-patient relationship,” he said.

Now for the hard parts:

-What if you’re at lower risk than the older, 30-pack-year patients in the trial? Younger, or less of a smoker? The trial offers no guidance on whether to do spiral CT screening, Dr. Wald said.

-Cost: A spiral CT costs several hundred dollars, compared to a typical chest X-ray, which generally costs $50-$100.

-And here’s the really hard part: Currently, insurance does not generally cover CT for screening purposes, only if you have symptoms or a chest X-ray abnormality. That is likely to change with this excellent new data, but for now, Dr. Wald said, “There’s going to be a bit of a confict potential for the time being. If patients walk into our office on Monday wanting this screening CT, we’re going to have an issue because we can’t get paid for it. It will put the providers in a bad spot initially.”