Outfoxing Lung Cancer

Call it kismet, call it luck—call it being in the right place at the right time. Two years ago, Robert Linscott just happened to see a flyer about a lung cancer early-screening clinical trial at White Plains Hospital, where he punches his card as an operating room custodian. A former smoker for 40 years who’d been exposed to asbestos in the Navy, Linscott, then 60, fell squarely into the high-risk group eligible for the trial; as a participant, he would receive a free low-dose CT scan of his chest annually. Little did he know that his first scan, in May 2013, would save his life. “I was totally asymptomatic,” says Linscott. “I had no clue that I had cancer.” Yet there it was—a walnut-size tumor in his right lung, confirmed by a follow-up PET scan that lit up the tumor like a fluorescent bulb in the center of his torso. The next step: minimally invasive, video-assisted thoracic surgery (VATS), which allowed Cynthia Chin, MD—the lead thoracic surgeon on the study—to remove the tumor through three one-centimeter incisions in his chest. The cancer gone, he was back to work in eight weeks. Says Linscott, who neatly side-stepped a very different fate, “If I had waited a year, it could have been much, much worse.”

In Preventive Medicine, a Breath of Fresh Air

It’s about time that we had some defense against lung cancer. Responsible for about 27 percent of cancer deaths, it is by far the leading cause of cancer death in both men and women. Every year, lung cancer kills more people than colon, breast, and prostate cancer combined. “The problem with lung cancer is that it’s found very late for the most part,” says Clifford Connery, MD, FACS, medical director of the Dyson Center for Cancer Care at Vassar Brothers Hospital, and the director of thoracic oncology and surgery at Health Quest hospital group. “That’s because you don’t feel pain or other symptoms when you have it. We have a phenomenal amount of lung capacity that is given to us with our original equipment. Look at Olympic athletes, cyclists in the Tour de France—we all have that kind of capacity if we’re properly trained. So you wouldn’t notice that you were getting short of breath until you lost nearly half of your lung capacity.” Because most lung cancers are found at a later stage, the cure rate is a mere 17 percent. But when they’re detected earlier, says Connery, the cure rate leaps up to 80 percent—a much sunnier statistic.

Breast cancer has its mammograms and colon cancer has its colonoscopies, but until now lung cancer has had nothing comparable to screen an individual before symptoms have developed and the disease has spread like a runaway train. Finally, that’s changing. Just last year, the US Preventive Services Task Force recommended the low-dose CT scan screening for adults aged 55 to 80 with a history of smoking comparable to a pack a day for 30 years. Thanks to the Affordable Care Act, the screening is now covered for eligible people as a basic health insurance benefit; Medicare agreed to pay for it in February of this year. It’s been a long time coming: Claudia Henschke, MD, and her pioneering team at Mount Sinai Medical Center in Manhattan have been working to standardize the low-dose CT lung scan for over 20 years, and only now has the medical establishment caught on. “It’s been hard for me to stand by knowing that there are over 150,000 people dying each year of lung cancer in the US alone,” says Henschke, professor of radiology and director of Mount Sinai’s Lung and Cardiac Screening Program. Through the International Early Lung Cancer Action Program (I-ELCAP) over the years, the I-ELCAP investigators have diagnosed more than 1,000 lung cancers through low-dose CT scans, and have cured most of them. “The recommendations aren’t perfect yet,” adds Henschke, who would like to see the screening available to a wider range of people, “but it’s a great start.”

A Ray of Hope for Long-Time Smokers

Modern medical advancements never just burst onto the scene in a dramatic debut; instead, it’s an achingly slow process of randomized control trials and peer-reviewed journal publication. Getting the low-dose CT scans in place has been decades in the making; hopefully, it won’t take too much longer before primary care doctors start prescribing them. “I think the real piece now is to educate health care providers and patients that [the low-dose CT scan] should be considered part of your annual physical exam if you’re in the high-risk category,” says Connery. Since the 1950s, doctors have prescribed chest x-rays to individuals at risk for lung cancer—but this less-precise technology falls short at detecting tumors when they’re in the small, curable stage. (Linscott himself had a chest x-ray for pneumonia just months before his screening, and it failed to reveal his growing cancer.)

The risks of the low-dose CT procedure itself are very minimal. “You do get some radiation,” says Connery, “but it’s less than one-third of the annual radiation that you get just from walking around the planet.” The key is to make sure you’re getting a low dose—and the scan can be adjusted to put out less radiation than a mammogram. “Nobody has shown that having mammograms for 30 years causes any problems,” adds Henschke. “If you get low-dose [radiation] over the years, there’s really no quantifiable risk.” Annual follow-up is essential, as many people have small, noncancerous nodules in the lung that are nothing more than souvenirs from a previous infection. Doctors can confirm their benignity when these nodules show no growth on repeat scans year after year. Beyond cancer screening, low-dose CT scans have added benefits: They can help detect evidence of emphysema, coronary calcifications (heart disease), and other health scourges.

It’s Hip to Be a Quitter

Tens of thousands of cancer deaths could be avoided every year if only people didn’t light up cigarettes. Smoking increases your risk of not only lung cancer but also about 15 other cancers as well, from cancers of the mouth and esophagus to the colon and rectum. (Of course, it’s not just cancer: A new report from the US surgeon general, released in January, found that smoking is even more harmful than previously thought and causes diseases in almost every organ in the human body.) “The number one way to prevent cancer is not to smoke,” says Sandi Cassese, vice president of oncology services at Health Quest. “Tobacco causes at least one-third of cancer deaths, and 16 percent of adults in New York still smoke, which is a huge problem.”

The new lung cancer screenings present an opportunity for health care providers to chip away at this statistic, one person at a time. “We need to give smoking cessation advice to everyone who comes in,” says Henschke. “When you tell a smoker, ‘Your lungs look okay, but you’re better off quitting,’ or ‘You have emphysema, you should quit’—these are powerful motivators. It should be part and parcel of the screening program. We’ve shown that the quit rates are very good, if you keep encouraging the person every time you see them.”

Smoking is, of course, highly addictive—more addictive than heroin, they say. The path to quitting can be circuitous and riddled with dead ends. “I probably tried to quit a thousand times,” says Linscott, who finally succeeded about four and half years before his cancer diagnosis. “I tried the patches, the nicotine gum, all that. What did it was [the prescription drug] Chantix; it took three tries, but it finally got me off the cigarettes. It takes away the pleasure. Smoking became mechanical—it became boring.” Likewise, Henschke encourages her patients to keep searching for the method that works, whether it’s a buddy, a hypnotist, acupuncture, or an Rx. “If one way doesn’t work, try another. Never stop trying.”

When Something Strange Is in the Air

Smoking is the main culprit in lung cancer, but it’s not the only culprit. Nonsmokers get lung cancer too; reasons can range from exposure to radon gas, asbestos, or secondhand smoke, to gene mutations and genetic predisposition. Two-thirds of the nonsmokers who get lung cancer are women—and the medical world hasn’t figured out why the female population is more susceptible. Other mysteries have physicians scratching their heads in wonder. “In one generation we’ve witnessed an entire turnaround in the type of lung cancer that we’re seeing,” says Connery. “It used to be that the most common type of lung cancer was squamous cell carcinoma. We much less frequently see that now. By far the most common lung cancer is adenocarcinoma. Why does that change in one generation? Humans are not going to evolve that quickly.”

Ongoing research is critical to unraveling enigmas like these. And for the wider population that gets lung cancer, we may need low-dose CT scan screenings as well to catch tumors earlier and reduce mortality. “Our program [at Vassar Brothers Medical Center] has a specific research component where we are accepting people who have different levels of smoking, different ages, than the standard group that’s been approved [for the low-dose CT scan screening],” says Connery. “We’re also looking at family history, environmental exposures, and the use of certain biomarkers on blood tests to see if we can identify a group of patients who may benefit from CT screening.” (People at risk can call to see if they qualify for a low-dose CT screening that’s covered either by health insurance or Medicare, or available at a $99 reduced rate through the clinical study at Vassar Brothers Medical Center: (845) 483-6920 or toll-free (844) 224-LUNG. Or at White Plains Hospital, call the Lung Cancer Screening Program at (914) 681-2365.)

Inhale Your Gratitude, Exhale Your Fear

For Linscott, the journey continues. Of more than 200 people enrolled in the trial at White Plains Hospital, he was the first of three to be diagnosed and treated for active cancer. Last year, his doctors found another small area of concern in his right lung; it appears to be stable, though he’s having scans every six months to be sure. The scare brought on stress and prompted him to take up smoking again; thankfully, the relapse was brief. (“It was a bad decision. I fessed up to my surgeon and quit again.”) Through it all, Linscott knows that he’s lucky: His lungs are watched over by careful, experienced eyes, and all the advances of modern medicine are on his side.

There’s no reason to fear, says Henschke. “It was hard to recruit people into our study because they were so fatalistic. They would say, ‘Once I have a diagnosis I’m dead, so what does it matter?’ That’s not the way it needs to be. So many of the ones whose lives we’ve saved, they’re so thankful, because they’ve seen their grandchildren. I tell them, don’t be afraid—early lung cancer can be cured. We’ve seen it time and again.”

This is the second of two articles about cancer. The first article appeared in the March issue.

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