Lung cancer is the leading cause of cancer death in the USA, with a five-year survival of less than 20%; smoking causes at least 90% of lung-cancer deaths. In August 2000, Rudolf Giuliani, the then Mayor of New York City, announced a major health initiative—the New York Early Lung Cancer Action Program (NY-ELCAP)—to "help develop the best means for early detection and successful treatment of lung cancer". Under this initiative, 10,000 present or past heavy smokers from New York are undergoing a CT scan of the chest to try and detect lung cancer at its earliest and most treatable stage.
Steven Woloshin, Lisa Schwartz and H. Gilbert Welch (researchers at the Department of Veterans Affairs Medical Center, Dartmouth Medical School, USA) describe the history of the NY-ELCAP, and argue that New York City has not made good use of public assets in funding the study. They conclude that NY-ELCAP will be unable to determine whether screening for lung cancer with spiral CT will save lives.
Steven Woloshin comments: "Lung cancer is a major public-health concern. An effective screening programme might save thousands of lives each year. Nonetheless, it is premature, and possibly dangerous, to move forward with spiral CT screening for lung cancer before a randomised trial has confirmed its safety. Unfortunately, NY-ELCAP does just that. We believe that the underwriting of NY-ELCAP is a poor use of public funds for three reasons. First, the study cannot tell us if screening saves lives. The fundamental design flaw [the lack of a control group] is especially distressing because it could have been corrected if New York City had required a scientific review before allocation of funding. Peer reviewers would probably have insisted on a randomised design."
"Perhaps even more concerning, NY-ELCAP will harm some participants. About 2000 New Yorkers will worry about a suspicious initial scan and some will undergo painful and risky procedures before they are declared free of cancer. Others will be diagnosed with cancers that would not have caused health problems even in the absence of treatment (and never would have come to light without screening), a phenomenon known as overdiagnosis. These patients can only be harmed by treatment."
"Finally, NY-ELCAP could actually make it harder to ever learn the true effect of spiral CT screening. New York City's optimistic promotion of NY-ELCAP could increase public demand for screening, a demand that is already growing as more health institutions across the country advertise the promise of spiral CT scans. If people accept the assumption of benefit, it will be extremely difficult to recruit patients for the definitive trials needed."
He concludes: "The benefits of early detection and the value of screening are intuitively appealing ideas. It would be hard to find a more worthy target for screening efforts than lung cancer. Nonetheless, we must resist the temptation to move too fast, or our efforts could go up in smoke."
Contact: Dr Steven Woloshin, VA Outcomes Group (111B), Department of Veterans Affairs Medical Center, Dartmouth Medical School, White River Junction, VT 05009, USA; T) +1 802 296 5178; F) +1 802 296 6325; E) steven.woloshin@dartmouth.edu Evelyn Beck, Staff Assistant to the Center Director, White River Junction, VAM&ROC; T) +1 802 296 5163; F) +1 802 296 6354; E) Evelyn.Beck2@med.va.gov
Journal
The Lancet