If you are a smoker or a former smoker—even if you quit 15 years ago—it’s understandable if you have nagging thoughts about lung cancer. It’s the second most common cancer in men and women in the United States, causing more cancer deaths than breast, colon, and prostate cancers combined. What’s more, the vast majority of lung cancer deaths are caused by smoking.
“Quitting smoking is the most powerful intervention there is for decreasing lung cancer mortality,” says Lynn Tanoue, MD, MBA, a Yale Medicine pulmonologist.
Regular screenings for lung cancer could be the next step, depending on your background, smoking history, and other factors. But unlike mammography or prostate cancer screening, lung cancer screening is not built into most people’s health care regimens. That’s why Dr. Tanoue and her colleagues want people to know about their options.
The Yale Lung Screening and Nodule Program at Smilow Cancer Hospital (also called Yale Lung SCAN) launched after the landmark 2011 National Lung Screening Trial (NLST) demonstrated that a well-organized approach to low-radiation dose chest CT (LDCT) screening can prevent 1 in 5 deaths from lung cancer in certain high-risk people screened on an annual basis. Yale Lung SCAN recommends lung screening for people who meet the criteria of the United States Preventive Services Task Force (USPSTF)—an independent, volunteer panel of national experts in disease prevention and evidence-based medicine:
- Your age is between 55 to 80 (Medicare provides coverage up to age 77)
- You have a smoking history of at least 30 pack-years (for example, one pack of cigarettes/day for 30 years or two packs of cigarettes/day for 15 years)
- You are asymptomatic (no signs or symptoms of lung cancer)
- You are a current smoker or have quit smoking within the last 15 years
- Your health is good enough to withstand and recover from surgery or other oncology treatment
“The purpose of screening is to detect cancer early, and the purpose of detecting cancer early is to try to save lives,” says Dr. Tanoue, who co-founded Yale Lung SCAN with Frank Detterbeck, MD, chief of Yale Medicine Thoracic Surgery.
Truly effective screening for early lung cancer was not available before the NLST demonstrated benefit with LDCT screening. While regular chest X-rays may show some abnormal masses or nodules on the lungs, large studies showed they were not effective in reducing lung cancer deaths. “The hope now is that carefully targeted screening will increase the number of patients who are diagnosed at an early stage where we have a good chance of curing those patients and decreasing the mortality rate from lung cancer,” Dr. Tanoue says.
Anyone who fits the NLST criteria and is concerned about radiation from CT scan screening should know that efforts have been made to minimize exposure. Currently one LDCT results in exposure that is less than the background radiation one gets from the environment each year, and Dr. Tanoue expects the doses will continue to become even lower over time. “The technology to really decrease the amount of radiation and retain the quality of the imaging is right around the corner,” she says.
About half of the patients diagnosed by Yale Lung SCAN are diagnosed with Stage I cancer—when the tumor is small, hasn’t spread to the lymph nodes or distant organs, and can be cured, she says.
Can you be screened if you don’t fit the criteria?
Some people wonder if they should be screened even though they don’t fit the USPSTF criteria. Maybe they have been smoking for 30 years, but they’re only 50 years old, or they are concerned because a parent died from lung cancer. Lung cancer occurs in nonsmokers, too. Other risk factors for lung cancer include the following:
- Hereditary factors (e.g., having a close relative who has had lung cancer)
- Exposure to carcinogens such as asbestos or radon
- Other lung problems such as chronic obstructive pulmonary disease (COPD) or interstitial lung disease
- Exposure to secondhand smoke (which carries a small risk)
Those who don’t fit the USPSTF criteria but feel they have reason to be concerned about lung cancer should discuss the possibility of screening with their primary care doctor, Dr. Tanoue says. Scanning “just to check” isn’t necessarily a good idea, she says. “The potential downsides of screening become magnified if the chance of developing lung cancer is low.” Both doctors and patients would prefer to avoid the radiation found even in a low-dose screening CT if they don’t think screening is necessary.
Perhaps the most important downside is that CT scans are so sensitive—they can pick up small nodules that are best thought of as background noise, Dr. Detterbeck says. The vast majority of nodules will not turn out to be cancer, and the American College of Radiology has endorsed a structured reporting system called LungRADS to minimize unnecessary evaluation of very small nodules. For nodules large enough to warrant more evaluation, “careful judgment by an experienced screening and nodule team will be used to figure out which nodules are just noise and which ones require a closer look,” he says.
Why lung cancer lags behind other cancers in diagnosis
Most people who have early-stage lung cancer have no symptoms, so it is important to talk to your doctor about chest pain, persistent cough, shortness of breath, hoarseness, coughing up blood or rust-colored sputum, or recurrent illnesses including bronchitis or pneumonia. Persistent symptoms, when related to lung cancer, are more likely to be associated with more advanced disease.
That’s why screening to catch lung cancer early is so important, Dr. Tanoue says. “When we talk about tumors, we have to talk about staging [which describes the size of the tumor and if it has spread], which is fundamentally how we talk about survival,” Dr. Tanoue says. More than two-thirds of breast cancers are diagnosed at Stage I or II, and many of these diagnoses result from screening mammography, she says. Because of this high rate of early detection, overall breast cancer survival rates are very high. “It’s the opposite with lung cancer—half of patients are diagnosed at Stage IV, and three-quarters at Stage III or IV. We need to find these patients before their cancers spread. So, it’s really clear that we need early detection for lung cancer.”
Drs. Tanoue and Detterbeck emphasize that lung screening works best as part of a comprehensive program. The Yale Lung SCAN team includes pulmonologists, thoracic surgeons, chest radiologists, smoking cessation specialists, and nurse practitioners, who coordinate care. This team provides each patient with a personal lung risk assessment and a discussion of the expected individual benefits and possible downsides of screening. When appropriate, immediate access to the Smoking Cessation Service at Smilow Cancer Hospital at Yale New Haven Hospital is available.
Lung cancer screening LDCTs are read by dedicated chest radiologists. Results then go back to the Yale Lung SCAN team, who ensures that the patient’s primary care provider receives the results, including recommendations for any appropriate next steps. Patients with lung nodules warranting further assessment can be referred for evaluation back to Yale Lung SCAN.
Decision process can be reassuring
For people who still have questions about screening, the program provides educational materials. Every patient undergoing lung cancer screening through Yale Lung SCAN receives an individual “shared decision-making” visit with the program APRN that includes a calculation of his or her own risk of lung cancer and an opportunity to discuss any particular concerns he or she may have. The visit includes an interactive educational module using an iPad app to help patients gain a clear, straightforward understanding of the benefits and possible risks of screening, and to allow them to fully participate in the decision to undergo screening.
After going through the shared decision-making process, people whose risk is really low, but who are just really worried, generally leave feeling very reassured, Dr. Tanoue says.
“The whole landscape of lung cancer screening is complicated, which is why really good screening requires a comprehensive program that includes the capability of evaluating patients with abnormal findings and treating those with lung cancer effectively with modern, precision therapies,” she says. “We should not just screen everybody regardless of risk or even really low-risk individuals, because we have to consider emotional, physical, and economic costs. Instead, we want to screen people at high risk—that is how we will save lives.”
The most important thing you can do is quit smoking
Fourteen out of every 100 U.S. adults ages 18 years or older (34.3 million people) were still smoking cigarettes in 2017, according to data from the Centers for Disease Control and Prevention (CDC). This is despite widespread efforts to educate people about the risks of smoking. According to the National Cancer Institute:
- Cigarette, cigar, and pipe smoking all increase the risk of lung cancer.
- Smoking tobacco products causes 9 out of 10 cases of lung cancer in men and 8 out of 10 cases in women.
- Choosing low-tar or low-nicotine cigarettes does not change the risk of lung cancer.
- The risk of lung cancer for people who smoke is about 20 times greater than the risk for people who do not smoke.
- Studies show that the risk of lung cancer from smoking cigarettes increases with the number of cigarettes smoked per day and the number of years smoked.
- Women may be at higher risk of developing lung cancer at lower levels of smoking than men.
Doctors have yet to learn about the impact on health that will come from vaping, a cigarette alternative that involves inhaling vapor that can include nicotine and a range of other chemicals created from a liquid heated up inside a device. While the vaping industry has presented e-cigarettes as a healthier alternative to tobacco cigarettes, the CDC recently advised people to avoid e-cigarettes while federal and state officials investigate a nationwide outbreak of severe, sometimes fatal respiratory illnesses that may be associated with the use of e-cigarette, or vaping, products. “Along with the rest of the nation, we have been seeing concerning cases of severe lung injury related to vaping, particularly in younger people,” Dr. Tanoue says. “We did not understand that cigarette smoking caused lung cancer until decades of smoking had passed,” she says, “and the medical community is incredibly concerned that the same could happen with vaping.”
Never smoking to begin with—or quitting if you do smoke—can help address many concerns. “I think lung cancer screening is a teachable moment for smoking cessation,” says Dr. Tanoue. “When an individual comes in for screening, we have that opportunity to talk to them about smoking at a time when they may be ready to try to quit. Sometimes patients say, ‘I’m too old, I’ve been smoking so long it won’t make a difference,’ but that’s not true. Smoking cessation at any age results in benefit, not just from decreasing lung cancer risk, but also in decreasing risk of heart attack and stroke. Screening is important and saves lives, but quitting smoking saves even more lives.”
For more information or to schedule a consultation, call Yale Lung SCAN at 203-200-LUNG (5864).