Lung cancer is not the most common of all cancers. Prostate cancer occurs more often in men, and breast cancer more often in women. And skin cancer is the most common type across both genders. But lung cancer has the unfortunate distinction of being the most deadly cancer—for both sexes. In 2018, more than 150,000 Americans were expected to die from the disease.
The death toll reflects a grim truth: By the time most people experience symptoms, the disease has spread and cannot be cured. The good news is that there is a test—a low-dose computed tomography (CT) scan of the chest—that can screen for lung cancer when the disease is still in its early stages. In 2011, the results from a large study called the National Lung Screening Trial showed that this specialized screening test in high-risk people reduced deaths from lung cancer by 20 percent compared with those who did not receive this screening.
That would make a big difference, except that very few people are actually getting the test.
How did we get here?
In 2013, the U.S. Preventive Services Task Force (USPSTF), an independent panel of national experts, recommended that Americans at high risk for lung cancer get an annual low-dose CT scan (an update is currently being prepared). “High-risk” includes:
- Being between the ages of 55 and 80 (or 55 and 74, as the American Cancer Society [ACS] recommends)
- Being a current cigarette smoker with a 30 pack-year history (pack-years are the number of years you have smoked multiplied by the number of packs per day)
- Being a former smoker who quit smoking within the past 15 years.
But the percentage of people in the high-risk group who got the scan in the previous year was only 3.3 percent in 2010 and 3.9 percent in 2015. That’s according to the National Health Interview Survey, a large U.S. Census Bureau tracking of the nation’s health.
What’s behind the low numbers?
If the screening is recommended, why aren’t more people getting the test?
There are a few theories. One is that many patients and their doctors don’t know about the USPSTF recommendation—or do not know about available reimbursements for the test. For example, in a 2015 survey of family physicians in South Carolina—described in the August 1, 2016, issue of the journal Cancer—only 36 percent of the doctors correctly said that the scan should be given each year to high-risk patients. (The majority said it should be done every two or three years.) Only 18 percent said they “always” or “frequently” discuss the benefits and risks of the screening with their high-risk patients. Most did not know that Medicare covers the test for people up to age 77 with a written doctor’s order.
Even providers at a major center were not as knowledgeable as they should have been. Researchers surveyed more than 200 primary-care providers at a large academic medical center in 2013. Their study, published in the journal Cancer Epidemiology, Biomarkers & Prevention, found that providers were much more likely to order a chest X-ray for lung cancer screening than a CT scan. But chest X-rays are not recommended for lung cancer screening. Another potential reason that so few high-risk individuals get the scan is that some don’t have a high-quality imaging center near their home.
What to expect
If you are or were a heavy smoker, and your doctor does not raise the issue, ask whether you should be screened for lung cancer.
Your doctor may decide not to screen you if you have other serious health problems. That’s because you need to be well enough to handle a potential surgery in the event that the screening finds signs of cancer. Also, you may not be considered a good candidate for the CT scan if you have metal implants in your chest or spine, as these can interfere with the quality of the images.
Some people who already have symptoms of lung cancer may get a chest X-ray first. But for a screening—the kind of test used when there are no symptoms—the low-dose CT scan is recommended over a chest X-ray for lung cancer detection. Chest X-rays used for screening have not been shown to improve lung cancer survival. The low-dose CT scan provides a more detailed view of the lungs, potentially finding things that are not normal.
During a CT scan, you lie on a table while the scanner rotates around you taking pictures. About 1 in 4 tests will find something out of the ordinary. But in most cases, such a finding will be a false-positive result—not cancer.
Why not test everyone?
You have probably heard of people who developed lung cancer even though they never picked up a cigarette. As many as 20 percent of people who die each year of the disease have not used tobacco in any form, according to the ACS. There are other known risk factors for lung cancer: Secondhand smoke is a risk factor, as are air pollution and exposure to materials such as asbestos and diesel exhaust at workplaces. Exposure to high levels of radon—an invisible radioactive gas—in the home is perhaps the leading cause of lung cancer in nonsmokers.
You may wonder, then, if it would be a good idea for you or a loved one to be screened for lung cancer, even if you don’t have a history of heavy smoking. The answer is generally no. There isn’t enough evidence to determine whether the benefits of screening outweigh the risks for nonsmokers or light smokers, according to the ACS and the American Lung Association.
Risks of the screening include false-positives, or results that aren’t cancer but need to be checked out with other, possibly invasive, tests. Those include using a needle to biopsy the lung or even lung surgery. False alarms can also make people worry about their health when there actually was no cause for concern.
In addition, screening chest CT scans emit a low dose of radiation, and it is known that the cumulative amount of radiation an individual is exposed to can increase the risk of cancer.
Will I have to pay?
As long as you fit the high-risk profile for getting tested, your first screening will be covered without a co-pay if you are 55 to 80 and have private insurance, or if you are 55 to 77 and have Medicare.
Be aware, though, that if you go to a provider or health facility that is out of network for your insurance plan or that does not accept Medicare, you may be charged a co-pay.
If you haven’t quit already, keep trying
The most important thing to know about lung cancer screening is that it is no substitute for kicking the tobacco habit. Even if you have smoked for years, quitting now will reduce your risk of lung cancer and other diseases. New research suggests that within five years of quitting your risk of developing lung cancer will be 39 percent lower than that of someone who still smokes. Within 10 years of quitting, your risk of dying of lung cancer will be half that of a current smoker.
Smoking cessation has additional benefits. Within just two weeks to three months of quitting, your risk of a heart attack will begin to decrease. Within a year, your risk of heart disease will be half that of someone who still smokes. In addition to reducing your lung cancer risk, you will also reduce your risk of cancers of the esophagus, larynx, mouth, throat, kidney, bladder, liver, pancreas, stomach, cervix, colon, and rectum, as well as acute myeloid leukemia. What’s more, you will feel better; within just one to nine months, your shortness of breath and coughing will subside.
If you’re still unsure, the American Lung Association has an online quiz to help you decide whether testing is right for you. Find it at www.lung.org/our-initiatives/saved-by-the-scan. And raise the issue with your doctor or other provider if you have questions.