Screening smokers for lung cancer might seem to some like re-arranging deck chairs on the Titanic, but a recent clinical trial has determined that annual CT scans for smokers and ex-smokers cuts their risk of dying of lung cancer by 20%.

The National Lung Screening Trial was carried out by the National Cancer Institute, a part of the National Institutes of Health, at a cost of $250 million. The trial enrolled 53,456 smokers and ex-smokers, ranging in age from 55 to 74, at 33 screening centers across the country. All participants were required to have smoked at least 30 pack-years and to have had no previous history of lung cancer. A randomized block design was used, with participants at each screening center matched for age and sex and assigned to undergo annual screening for three years, either by conventional chest X-rays or CT scans. Participants were followed for up to five years.

354 participants given CT scans died of lung cancer, as compared to 442 in the control group given conventional chest X-rays. About 25% of the study participants had false-positive diagnoses, which necessitated further scans and in some case lung biopsies.

According to this article in the Washington Post, James L. Mulshine, a research official at the Rush University Medical Center in Chicago said in a statement issued by the Lung Cancer Alliance, “With this positive trial result we have the opportunity to realize the greatest single reduction of cancer mortality in the history of the war on cancer.”

Pardon me if I’m not ready to uncork the champagne just yet.

I’d like to know how much of Mr. Mulshine’s salary is paid for by the manufacturers of CT scanning machines. And as long as we’re on the subject of money, I ought to mention that a single CT scan costs anywhere from $300 to $1,000. According to the National Lung Screening Trial website, approximately 90 million Americans are either current or former smokers, with the total number being divided about equally between the two groups. Using the low-end figure of $300 for each CT scan, annual screening for all current and former smokers would cost $27 BILLION dollars EACH YEAR. If you use the high-end figure of $1,000 per CT scan… oh, you can do the math yourself.

And that’s still not including the cost of the follow-up scans and lung biopsies for the staggering 25% false-positive rate.

We’re not paying for the medical interventions we’re getting now. Where is all this money going to come from? Are we going to take it out of Social Security? Haha, just kidding. Seriously, though – where are we going to get the money from? Education? Research and development? Infrastructure? Plant and equipment? I’d wager all of these things have vastly more potential to extend human life and improve its quality than screening smokers for lung cancer.

The data showed that, for the duration of the study, there was one fewer death due to lung cancer for every 300 smokers screened. That means that for every 300 smokers screened, 299 received no benefits at all. People talk as if being screened for cancer is in and of itself a benefit, but it’s not. It’s a benefit only if it enables you to avoid death or some other hard clinical outcome – and the vast majority of the time, it doesn’t.

Oh, and just how much longer did Mr. or Ms. One-in-Three Hundred get to live, anyway? The researchers don’t know. They don’t want to know. They’ve already got the answer they want, so they stopped the study. But middle-aged and elderly smokers, or even ex-smokers, are not a group known for their amazing longevity. There are plenty of other ways for cigarettes to kill you besides lung cancer.

But here’s the punch line: the study had no control group which did not receive any screening at all. Previous studies have already shown that screening smokers with conventional chest X-rays can increase the incidence of lung cancer. All the authors of this study have shown is that CT scans are not as bad as conventional chest X-rays. They don’t have any data that show they are better than nothing at all.

Is this their idea of a breakthrough – a preposterously expensive procedure which may or may not produce a tiny reduction in risk for a group of folks who have displayed an arrant disregard for their own health, for years and years? If they can’t come up with something better than this, we ought to admit that we have gone past the point of diminishing returns in terms of spending on medical interventions.

We already know how to end lung cancer. If people would stop smoking, that would eliminate most new cases right there. And screening homes for radon and making sure those that are contaminated with that gas are adequately ventilated would eliminate almost all remaining new cases.

People won’t stop smoking, you say? Well, I’d say that a big part of the solution to that problem is to recognize that there is no perfect solution to this or any other problem.

Oh, and please don’t tell me about smokers who started before the dangers of smoking were known. Anyone who was eighteen when the Surgeon General issued his famous report on the dangers of smoking would be 64 now. And long before that, before anyone currently alive was even born, there were plenty of people who figured out that setting fire to the leaves of a deadly poisonous plant and inhaling the fumes wasn’t such a great idea.

Fifty years ago, someone with no symptoms who was obsessing about the possibility that he might be harboring the beginnings of some horrible metastatic cancer would have been labeled a hypochondriac. We have turned into a nation of fearful hypochondriacs. That would be galling in any event, but it is especially so when you consider how many smokers and ex-smokers sneered whenever anyone who ever tried to love them questioned the wisdom of flooding their lungs with deadly poison.

“It’s my life,” smokers like to say. “Nobody lives forever.” And you know something? They’re right about that. But where is that bravado when we need it? For them to come back and demand the rest of us foot the bill for an absurdly costly screening program which produces such puny results bespeaks a puzzling lack of pride.

If there were a pill for smokers that could undo the effects of flooding your lungs with poison every day for thirty years, I would be in favor of them getting it. But there is no such pill, any more than there is a pill that can undo the effects of saturating your brain with alcohol every day for thirty years; or stuffing your body with food it doesn’t need every day for thirty years; or binging and vomiting every day for thirty years; or starving yourself for thirty years. The choices we make every day add up to a life – and it’s for precisely that reason that all these stuffy, old-fashioned, “judgmental” notions about character and virtue turn out to matter so terribly much after all.

Am I the only one who is horrified by this vision of ourselves as fragile creatures who are kept alive only by dint of fantastically expensive high-tech medical interventions? More than two thousand years ago, the author of the Book of Ecclesiastes wrote, “There is a time to be born and a time to die.” That hasn’t changed.

What this country needs is a ribbon for “Ya gotta die of something.”

Photo via Wikimedia Commons

UPDATE 17 NOVEMBER 2010: Apparently, even the figure of $1000 per CT scan may have been a lowball figure. Peter B. Bach of slate.com called fifty diagnostic centers and was quoted figures of $1,800 to $4,000 for a CT scan. At $1,800 a pop, annual screening for 90 million people would cost $162 billion; at $4,000 a pop -- oh, as I said before, you can do the math yourself.

UPDATE ADDED 14 JANUARY 2013: In a press release dated January 11 2013, The American Cancer Society recommended patients aged 55-74 with at least a thirty pack-year history of smoking, who currently smoke or have quit within the last fifteen years, discuss spiral CT scan screening for lung cancer with their doctors. The press release also noted that among smokers who were screened, 40% had an abnormal finding, usually leading to invasive procedures such as bronchoscopies or lung biopsies. 95% of these turned out to be false alarms. Of patients who received spiral CT screening, 16 died within 60 days of such an invasive diagnostic procedure. The press release noted “Some have interpreted the NLST as showing that for every 5 to 6 lives saved from lung cancer, 1 life was lost due to screening and the additional diagnostic procedures.”