Dan Gorenstein: Lung cancer kills 18 Americans every hour, 130,000 people a year.

That’s more than breast, colon and prostate cancer combined.

For decades, doctors caught most lung cancers too late.

Gerard Silvestri: Half the patients were gone in less than 12 months

DG: An early detection test finally arrived around 2011.

But it comes with some real risks, and takeup has been abysmal.

Now doctors are pushing to expand the test to millions more people.

Today, balancing the promise and perils of the tool for catching America’s top cancer killer.

From the studio at the Leonard Davis Institute at the University of Pennsylvania … I’m Dan Gorenstein, and this is Tradeoffs.

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DG: Lung cancer deaths in the U.S. peaked in 1991.

Gerard Silvestri says this ‘peak,’ was really a valley.

Gerard Silvestri: It was just a horrific disease. There were a few that were cured, but not many.  

DG: In the early 90s, Gerard was finishing his training in pulmonary medicine at Dartmouth.

The New York City native says the four chemotherapy drugs available to his patients made him feel like David going after Goliath. 

GS: All of them were terrible. Everyone’s hair fell out, everybody had stomach issues.

DG: Other doctors had mammograms and pap smears to catch diseases earlier.

Some of those screens had been around since the 1920s. But still in the 1990’s, doctors like Gerard typically diagnosed lung cancer only after a patient felt something.

GS: There are no pain receptors in the lung tissue itself so the tumor had to get big enough to reach the wall of the lung, had to spread outside so go to the brain and cause headaches or the bone and cause bone pain or spread into the airway where they would then maybe cough up blood.

DG: This is what made lung cancer so lethal.

By the time patients showed up…the odds of surviving were low.

Then, around the turn of the century…

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DG: As a lot of new tech took off…

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DG: The CT scan, formally called a computed tomography scan, caught fire in medicine. All of a sudden doctors were using it to diagnose everything from pneumonia to kidney stones.

Gerard, described this magical machine to me like being rolled through a giant donut, a donut that snaps cross-sectional pictures of your body.

GS: It’s cutting you, slicing you like a loaf of bread and you’re looking up and into those slices, and so you can see really tiny changes in the lung itself.

DG: The National Cancer Institute in 2002 launched a massive randomized controlled trial enrolling 50,000 people with a history of heavy smoking, lung cancer’s biggest culprit.

The question: does a CT scan reduce lung cancer mortality more than a chest x-ray?

It took nearly a decade to gather the data. By 2011 doctors had their answer: CT scans had cut lung cancer deaths by 20 percent.

For two decades, most of Gerard Silvestri’s diagnosis conversations went like this:

GS: Look, we can hopefully control your disease but I have to tell you this: of the deck of cards you could’ve been dealt, this is serious. Really serious. 

DG: With CT scanning, more conversations could go like this:

GS: Hey, look, you know, nobody wants to hear that they have cancer but if you had to have it, this is the one we want. And why is that? Because in five years we’re going to be having a party. And I just want to put it out there now…I like top shelf vodka.

DG: Doctors finally had a new weapon in their war with Goliath.

For many of us, military metaphors come to mind when we talk about the FIGHT against cancer.

News clip: The United States has been involved in a national war

News clip: We know it will take an army to defeat this disease 

News clip: The artillery is found in the laboratory as scientists unite for a war on cancer 

Congress clip: While there have been substantial achievements since the crusade began, we are far from winning this war 

DG: And the U.S. has stacked up victories these last five decades. We’ve boosted funding, unlocked incredible treatments and turned some cancers into chronic conditions. 

But wars have casualties. In the race to deploy new cancer screening weapons, doctors, researchers and even patient advocates have made serious mistakes.

Otis Brawley: We’ve been taught ever since we were on our mother’s knee that the way to deal with cancer is find it early and cut it out. Unfortunately, many people don’t understand that there can be a downside to screening. 

DG: Johns Hopkins professor and doctor Otis Brawley was the chief medical officer at the American Cancer Society until 2018. Talking with Otis feels like skimming through a book of cautionary tales.

Some of the first screening missteps, he says, date back to the 1950s, when the American Cancer Society pushed pap smears to catch cervical cancer.

OB: The only problem was pathologists at the time didn’t know how to read pap smears. So some of these women got hysterectomies. This is 20 and 30 year old women who were rendered infertile unnecessarily. 

DG: Doctors misread early mammograms in the 70’s, cut out thyroid cancers that could have just been monitored. Then there’s the prostate cancer screening in the 1990’s, where researchers quickly learned tests could lead to false alarms, unnecessary surgeries and hundreds of millions of dollars in wasteful care for some men.

And even though national experts advised doctors to stop testing men over 70, nearly 1 in 3 still get screened today. Otis says some cancer warriors just haven’t backed down.

OB: There’s even a group of folks who literally said, we understand that it’s not proven, but we have to do something because people are dying out there. You know, which is an interesting thing to say. We know what we’re doing probably doesn’t work, but we have to do something so we’re going to do what doesn’t work. 

DG: Lung cancer screening, like its predecessors, carries its own downsides and dangers. Risks some doctors rarely discuss with their patients. Gerard Silvestri thinks the most common pitfall is so important to explain, he’s come up with this analogy.

GS: Think of the lung as a two liter bottle of Coke. And in the middle of that two liter bottle Coke, there’s something a pea size right.

DG: Once the CT scan detects the pea, doctors try to confirm if it’s cancer. And that’s when patients enter risky territory.

GS: You refer the patient for surgery…the surgeon operates. After the operation the patient ends up developing respiratory failure and pneumonia. They end up in the ICU for 30 days. They end up getting a tracheostomy for complications…they eventually get transferred out to a…long term acute care facility somewhere and then they die…And…oh, by the way, it turned out that the thing that you took out was not cancer.

DG: Gerard is clear this is the absolute worst case, and it’s really rare. The point, though, is when you use a super-powered camera to look for lung spots in people who have smoked for decades they’re pretty easy to find.

Like in that big national trial, 1 in 4 people had a positive scan, but 96 percent of the time, that pea was something else — maybe scar tissue, or a harmless lump. Some got extra scans, biopsies, even surgery…a lot of worry and money…just to find out they didn’t have cancer.

Ella Kazerooni: I’m less concerned that we’re doing more harm than good.

DG: University of Michigan radiologist Ella Kazerooni heads up the National Lung Cancer Roundtable, a public-private coalition convened by the American Cancer Society.

She’s confident lung cancer is the beginning of a new chapter in screening history. One of the biggest differences: doctors have a lot more data, and they’re using it.

For example, the American College of Radiology in 2014 knew all those benign peas in the coke bottle were a problem, and set out to fix it. They analyzed screening data from around the world and realized they could safely raise the bar on what counts as a suspicious spot from four millimeters in size to six.

EK: Now that might seem like a tiny, tiny difference of two millimeters. But the majority of nodules we see are quite small. And so by raising that threshold, we decreased the number of positive screens and a lower number of follow-up tests and diagnostic procedures having to happen.

DG: The same group now tracks nearly every scan in the U.S., more than 2 million so far, on the lookout for other quality and safety issues.

EK: That’s the type of data that we have today that we didn’t have when breast cancer screening was implemented and even prostate cancer screening.

DG: Data on those scans and the number of unnecessary surgeries and complications they’ve caused have yet to be published. Until we see those stats, we can’t know for sure whether lung cancer screening is heeding the long list of cautionary tales, or becoming one.

One thing we do already know: doctors are scanning far fewer people than expected. We’ll explain why after the break.

MIDROLL

DG: Welcome back. Despite improved treatments and a decades-long decline in smoking, lung cancer still kills more than 130,000 Americans every year.

Early detection CT scans have the power to save tens of thousands lives, but like many medical interventions, they come with some rare but real dangers. 

Medical University of South Carolina pulmonologist Gerard Silvestri says the evidence is strong: Those risks are worth it — if you’re really in danger of getting the disease. 

GS: So there’s no question it works. The question is can we increase uptake in the right population?

DG: Unfortunately, the answer, so far, is no. The participation rate for common, albeit much older cancer screens, like mammograms and colonoscopies, is close to 70 percent. For lung cancer, it’s about six.

A panel of national disease experts, known as the U.S. Preventive Services Task Force, first recommended lung cancer screening in 2013 for some 8 million people.

The good news is that researchers now have a better handle on the barriers that have kept this medical breakthrough out of reach for most. The bad news: These obstacles are tough to overcome.

The first is awareness.

EK: Mammography and breast cancer screening is cocktail conversation. It’s a conversation on the sidelines of sports games. Lung cancer screening isn’t there.

DG: University of Michigan radiologist Ella Kazerooni calls this test the toddler of the cancer screening world, still really new to both patients and providers, especially in primary care.

But both breast and colon cancer screening had uptake rates around 30% in their early years, according to the American Cancer Society. Ella chalks some of the problem up to lung cancer’s conspicuous absence from the national stage.

EK: We still talk about the Katie Couric effect today in colon cancer screening. 

TV clip: Katie Couric: Hi everyone, here we are 18 hours plus before I get my first colonoscopy

TV clip: Jimmy Kimmel: And before my birthday, Katie asked if she could accompany me for my first colonoscopy

TV clip: Harry is having a colonoscopy and with him throughout the morning is CBS evening news anchor Katie Couric 

EK: When you look at lung cancer and try and find your Katie Couric, it’s really challenging. People don’t want to have their legacy associated with something that they feel is stigmatizing.

DG: Stigma dogs the world of lung cancer. 

Lisa Carter-Harris: It’s not just a name. It’s almost like a scarlet letter.

DG: Lisa Carter-Harris, a nurse practitioner and behavioral scientist at Memorial Sloan Kettering, says the disease suffers from a double standard. 

LCH: If someone tells you that they had a heart attack. Do you look at them and say, “Oh, you’re not vegan and you don’t run three days a week?” we don’t do that. But if someone tells you they have lung cancer, what’s the first thing people say? “Oh, I didn’t know you smoked.”

DG: Lisa says stigma doesn’t just get in the way of celebrity endorsements and ad campaigns.

LCH: I was actually doing research on people who were diagnosed with lung cancer and having them tell their story…

DG: She found stigma affects people who smoke so much they’re delaying important care.

LCH: You know, I had one patient say I just feel like I’m taking up resources. You know, I did this to myself. 

DG: Lisa hopes the more forgiving attitudes towards opioid use spill over to people who smoke…shifting from a moral failing towards suffering from a hard to beat addiction.

The other big drag on screening growth: there’s a lotta hoops to jump through. Talking with your doc about smoking, finding a hospital with a CT scanner, coming back year after year…the list goes on.

Those tasks may be easy enough for some, but Gerard Silvestri points out, smoking is much more common among the uninsured and people with low incomes — the kind of people who might not have primary care or time off from work.

GS: So all these other social determinants come into effect. And I think people are completely underestimating this, like wildly underestimating for all of lung cancer screening because of that demographic of where smokers lie: education, insurance, socioeconomic status.

DG: There’s a third and final lesson researchers have learned over the decade screening’s been around, and there’s a much easier fix. In fact, it’s already happened. 

News clip: A federal task force is rewriting the rulebook when it comes to the #1 cancer killer 

News clip: New recommendations out today lower the screening age from 55 to 50

News clip: …and the smoking years from 30 years to 20 years

DG: The original 2013 screening criteria missed some high risk groups, including younger Black people. Black men have by far the highest lung cancer mortality rate of any group. 

In March, the same panel of disease experts updated their guidelines, doubling the number of Americans eligible for lung cancer screening, from about 8 to 15 million.

Private insurers are required to cover screenings for the newly eligible…but Medicare and Medicaid are still deciding whether to follow suit.

Gerard says simply making the pie bigger doesn’t guarantee more people get a piece.

GS: We have the potential to make many more African-Americans eligible based on these new criteria, taking that potential and realizing it is a completely different story.

DG: It’s a recurring theme in medicine, that we put far more money and effort into discovering incredible new advances than we do into ensuring they are accessible to all who could benefit.

We’re seeing this play out right now with COVID vaccines, and Otis Brawley says cancer’s been plagued by the exact same problems.

OB: The most important paper of my entire career, by the way, estimated that of 600,000 people dying per year of cancer, 132,000 could be prevented if every body got every thing that’s available from screening to diagnosis, treatment and prevention. Who are the ones who don’t get everything? Poor people, people who traditionally suffer from health disparities.

DG: Without larger systemic solutions, whittling away at the twin barriers of awareness and access means some people will continue to die even though we have the technology to keep them alive.

Some lung cancer screening programs are going after those barriers more aggressively than others.

Until COVID hit, staff at the program at Temple University Hospital in North Philadelphia swarmed every health fair, church, mosque and primary care office that they could find. 

Cherie Erkmen: The stigma of lung cancer as lethal and there’s nothing that you can do about it, that’s a large part of what we’re trying to change.

DG: Thoracic surgeon Cherie Erkmen started the program in 2014 just after the first guidelines came out. Since then Cherie has consistently driven her team towards one goal: get people in the door.

Temple sits in a predominately Black, low-income neighborhood. Community members ranked ‘convenience’ as a top priority in a survey the program put out several years back. 

Inconvenience was one lung cancer screening problem Cherie could get her arms around. 

CE: So there are many different steps to lung cancer screening. And navigating all of those steps is quite a challenge, especially when resources may be limited, time may be limited.

DG: Cherie’s team created a kind of one-stop cancer screening shop.

CE: So they would come in, get the scan, get the results and know what the next steps were with a single visit.

DG: Cherie knows the plan to make screening more visible and easier to access has begun paying off. Their screening rate in Temple’s zip code is about 10 percent, nearly double the national average. About 60% of the 2,000 patients screened so far are Black…in a city that’s 43% Black. And more than eight out of ten cancers they’ve caught have been at an early stage.

Nobody at the hospital is satisfied with the program’s scale yet. But even with modest numbers there’s a hint of something remarkable starting to happen.  

It happened for Ida Pittman and her family. 

When the 60 year old north Philly native found out she had stage one lung cancer late last year, she worried first about her health. A very close second: how her family would react

Ida Pittman: I wasn’t real scared. I was a little scared. I had family family members more scared than I was [laughs].

DG: Ida’s cousin, Helena Price understood why. 

Helena Price: When they hear cancer, they automatically think death. They don’t look at it as something that you can recover from.

DG: Helena and Ida are close — so close, they call each other “sister cousins.” The pair grew up in the same house, have almost identical birthdays and watched together, the disease sweep through their home. 

HP: Her mother passed away from cancer. My mother passed away from cancer.

DG: Ida knew, given their history, breaking the news would be hard. So she tapped her “sister cousin” to play her special role in the family: medical translator. Having worked as a hospital registrar for decades, Helena was comfortable navigating the medical system, the jargon and the white coats.

IP: I wanted them to hear it straight, the straight story of what I was going through.

DG: 25 relatives crowded into Ida’s house one evening…wondering and worried. Helena started with the good part, first.  

HP: It’s just a spot. She’s in the beginning stage, which is good. And I explained to them exactly what the doctor told me, that after the surgery, as long as they got everything, she may not need the chemo, she may not need the radiation because they caught it in an early stage.

DG: But the fear of cancer ran so deep, Ida says her granddaughter and her son in particular missed what Helena actually said. 

IP: My son took it so bad, like, cause my mom died of cancer. He feel as though my mom is gonna go and get this operation and my mom’s gonna die. They was crying. And all of this, you know, they thought they were going to lose me.

DG: Cherie’s team removed Ida’s cancer with a single procedure on November 12th last year.

CE: And she returned to work within six weeks of her surgery.

IP: January 4th, 2021. And I’ve been working since.  

DG: It’s easy to understand why cancer has held such a tight grip on Ida and Helena’s family, and so many other families, given lung cancer was diagnosed so late for so long.

But Ida’s success and the other screening success stories are piercing the deeply held conviction that the disease is invincible. And that…is the remarkable thing starting to happen.

IP: I’m living proof. So they know you go to the doctor, you find out what’s going on with yourself, do what you got to do, get it over with and just take care of yourself.

DG: It’s a new chapter for the family, a story Helena knows she’s going to keep telling.

HP: I have the family gatherings at Christmas, so this Christmas, unfortunately, due to COVID, we didn’t have a family gathering. But it doesn’t matter if it’s five years from now, ten years from now. When get together again, it will be brought up again about her having cancer and how she came through her cancer by early detection. If you don’t talk about it, then how can you help anybody else? 

DG: For doctors like Cherie Erkmen and Gerard Silvestri, the new more inclusive screening guidelines put out this spring could accelerate a new era when doctors look patients in the eye and say ‘You. Will. Be Fine.’

After decades of doling out death sentences, it would be a gratifying change.

But without more awareness and better access, that change promises to arrive slowly…one family rewriting the story of lung cancer at a time. 

I’m Dan Gorenstein. This is Tradeoffs.