Drs. Steven Woloshin, Lisa Schwartz and H. Gilbert Welch, Dartmouth Medical School, White River Junction Veterans Affairs Medical Center, and Norris Cotton Cancer Center, describe the history of the the New York Early Lung Cancer Action Program (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.
Lung cancer is the leading cause of cancer death in the US, with a five-year survival of less than 20 percent; smoking causes at least 90 percent of lung cancer deaths. In August 2000, Rudolf Giuliani, then Mayor of New York City, announced a major health initiative--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.
The authors comment, "Lung cancer is a major public-health concern. An effective screening program 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 randomized 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 randomized 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."
They conclude, "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."
For more information, contact Steve Woloshin, MD, at email@example.com.
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