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Spiral Computed Tomography and Lung Cancer: Science, the Media, and Public Opinion

Transdisciplinary Tobacco Use Research Center, Department of Psychiatry, and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA

Robert Hornik

Center of Excellence in Cancer Communication Research, Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA

Joan Schiller

Division of Hematology/Oncology, the Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern, Dallas, TX

Caryn Lerman

Transdisciplinary Tobacco Use Research Center, Department of Psychiatry, and Abramson Cancer Center, University of Pennsylvania; and Center of Excellence in Cancer Communication Research, Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA

The recent publication of findings from the International Early Lung Cancer Action Program (I-ELCAP) in the New England Journal of Medicine (NEJM) regarding the use of spiral computed tomography (CT) for early lung cancer detection has many in the scientific community concerned that the general population will demonstrate great interest in undergoing spiral CT for early lung cancer detection despite no evidence yet for its efficacy in reducing lung cancer mortality. This Commentary summarizes the results of a unique national survey of the general population's level of awareness and interest in the use of spiral CT for early lung cancer detection in the United States after the publication of the I-ELCAP study. The results of this survey indicate that the publication of the I-ELCAP study in the NEJM, and the ensuing media coverage of this publication, may not have increased the general public's level of awareness and interest in spiral CT for early lung cancer detection, and that most individuals in the United States do not seem to have been persuaded to undergo lung cancer screening using spiral CT, before its risks and benefits have been established.

In the United States, lung cancer is the second most prevalent cancer and remains the leading cause of cancer deaths, accounting for about one third of all cancer mortality.¹ Although the 5-year survival rate for stage IA and IB lung cancer is 73% and 58%, respectively,¹ only 16% of patients are diagnosed at this early stage.² In contrast, 16% of patients with regional disease and only 2% of patients with distant disease survive 5 years from diagnosis.³ Consequently, the development of validated methods for early lung cancer detection is an urgent priority.

Data from a recent prospective observational study of spiral computed tomography (CT) for early lung cancer detection by the International Early Lung Cancer Action Program (I-ELCAP) published in the New England Journal of Medicine (NEJM) with more than 32,000 individuals⁴ found that CT screening yielded 5,646 "positive findings," from which 484 cases of lung cancer were detected. Of these, 412 (85%) were stage I with an estimated 88% 10-year survival rate. The study authors concluded that spiral CT screening can detect lung cancers at an earlier and more curable stage, fueling a heated debate in the scientific community.⁵ A subsequent analysis of data from three screening trials using a validated risk prediction model documented that, although spiral CT yielded a three-fold increase in lung cancer diagnosis and a 10-fold increase in thoracic surgery versus no screening, there was no effect of screening on risk for advanced disease or disease-specific mortality.⁶ Skeptics of spiral CT urge the scientific community and lay public to await the results of the National Lung Screening Trial, a randomized trial comparing spiral CT to chest x-ray for decreasing disease-specific mortality,⁷ and the Dutch-Belgian lung cancer screening trial (NELSON), a randomized trial comparing spiral CT versus no screening for decreasing lung cancer mortality.⁸

Nevertheless, the media and advocacy groups publicized the results of the I-ELCAP study in the NEJM as meeting the necessary threshold of evidence to recommend CT screening. The principal investigator of the I-ELCAP study published in the NEJM was quoted in the New York Times and the International Herald Tribune as saying that spiral CT for early lung cancer detection could "prevent 80% of deaths" from lung cancer. ABC News stated that the study "...suggests that annual chest CT-scan...of people who are at high risk for lung cancer may reduce the chance of death from lung cancer", whereas CBS News stated the following: "Using computerized scans to screen for lung cancer can help save lives and should be part of a regular checkup for people who have a high risk for the disease." The Lung Cancer Alliance, a major nonprofit organization dedicated to raising public awareness about lung cancer, stated that the I-ELCAP study published in the NEJM study "...demonstrates that the number one cause of cancer death—lung cancer—can be cured." Clearly, a major gap formed between what many in the scientific community concluded about spiral CT for early lung cancer detection and what the media and advocacy groups reported to the public. Given the documented impact of media coverage of scientific research on health behavior change,⁹ critics of the I-ELCAP study published in the NEJM feared that the public could be misled into believing that the data from this study were sufficient to determine the efficacy of spiral CT for early lung cancer detection, and that individuals in the United States would begin in earnest to seek screening.

So, has the widespread media coverage of the I-ELCAP study published in the NEJM affected awareness of, and interest in, undergoing CT screening to detect lung cancer? To address this question, and to identify individual and contextual factors that may serve as barriers and facilitators of awareness and interest, the authors included items about lung cancer CT screening in the Annenberg National Health Communication Survey conducted in November and December of 2006. Annenberg National Health Communication Survey data are collected by Knowledge Networks, which maintains a panel of respondents identified using random-digit dialing procedures (listed and unlisted phone numbers). If needed, this panel is provided with free hardware (Web TV) and Internet access to complete surveys online. For the present survey, a random sample of participants was selected from this panel. Thirty percent of those contacted through random-digit dialing agreed to join the panel and 72% of those respondents completed the survey (n = 514). Characteristics of the sample converged well with 2000 Census data¹⁰: 51% of the sample were male, 20% of the sample had less than a high school education, 75% of the sample were white, 54% of the sample were married, 29% of the sample earned less than $25,000 per year, 22% of the sample were current smokers, and 25% of the sample were former smokers. Respondents were given a brief introduction to spiral CT ["A lung cancer spiral or helical CT scan (or ‘CAT’ scan) is a new screening test for lung cancer. It was developed recently to provide a clearer picture of growths in the chest than is possible with traditional X-ray."] and then responded to the following questions: (1) In the past month or two, how often have you seen or heard any news about the use of spiral CT to detect lung cancer? (from 1 = not at all, to 5 = almost every day); and (2) If you could get a spiral CT scan, how likely would you be to get one in the next 12 months? (from 1 = very unlikely, to 5 = very likely). [For ease of interpretation and because certain levels of each variable had small numbers of respondents, the variables were dichotomized as (1) not at all aware versus once in the past month, once per week, more than once per week, or almost every day; and (2) very unlikely, somewhat unlikely, or neither unlikely or likely versus somewhat likely or very likely.] The national survey also included questions about respondent's primary sources of medical and health information (ie, television, radio, newspaper, internet, and magazines), perceived risk of getting lung cancer, and beliefs about the role of genes versus behavior in determining health.

A paucity of relevant studies makes it difficult to establish a baseline for awareness of, and interest in, spiral CT for early lung cancer detection before the publication of the I-ELCAP study in the NEJM. One study found that interest in lung cancer screening exceeded 75% among a sample of more than 500 current or former smokers, although this study did not specifically address spiral CT as the screening modality and awareness of spiral CT screening was not assessed.¹¹ A second study, which focused specifically on spiral CT, reported that 23% of respondents were aware of this technology for early lung cancer detection and 44% of respondents expressed a high level of interest in undergoing spiral CT screening.¹² In our present survey, only 16% (n = 81) of respondents indicated that they had seen or heard any news about the use of spiral CT to detect lung cancer. Among all respondents, 21% (n = 109) indicated that they were somewhat or very likely to get a scan. Among only those respondents who had seen or heard any news about the use of spiral CT to detect lung cancer, 30% (24 of 81) indicated that they were somewhat or very likely to get a scan. However, contrasting this subgroup to the entire sample to identify the specific effect of media coverage on interest, only 5% (24 of 514) had heard or seen media coverage of spiral CT for early lung cancer detection and were somewhat or very likely to get a scan. It should be noted, however, that because comparative data¹² were collected from a nonrepresentative sample, primarily from a Comprehensive Cancer Center, previous estimates of awareness of, and interest in, CT screening may be higher than one would expect. As such, our present data may not reflect a lack of effect from media coverage of the I-ELCAP study published in the NEJM but, rather, more accurate (and lower) population estimates of awareness of, and interest in, CT screening for early lung cancer detection.

Furthermore, respondents who indicated receiving their health news primarily from magazines and respondents who indicated greater agreement with the statement that genes influence health to a greater extent than behavior indicated greater awareness of spiral CT for early lung cancer detection (Table 1). Of note, smokers were no more aware of spiral CT for early lung cancer detection than nonsmokers. Lastly, with regard to interest in undergoing screening, survey respondents who were smokers and who perceived themselves to be at greater risk for developing lung cancer cited greater interest in undergoing spiral CT screening (Table 1).

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

AUTHOR CONTRIBUTIONS

Conception and design: Robert A. Schnoll, Robert Hornik, Joan Schiller, Caryn Lerman

Collection and assembly of data: Robert Hornik, Caryn Lerman

Data analysis and interpretation: Robert A. Schnoll, Robert Hornik, E. Paul Wileyto, Caryn Lerman

Manuscript writing: Robert A. Schnoll, Robert Hornik, Joan Schiller, Caryn Lerman

Final approval of manuscript: Robert A. Schnoll, Robert Hornik, Joan Schiller, Caryn Lerman

ACKNOWLEDGMENTS

Support for this article was provided by the Center of Excellence in Cancer Communication Research (Grant No. P50 CA101404; R.H.) and the Transdisciplinary Tobacco Use Research Center (Grant No. P50 CA/DA 84,718; C.L.). The data were collected through the Annenberg National Health Communication Survey, supported by the Annenberg School for Communication at the University of Pennsylvania and the Annenberg Trust at Sunnylands, Philadelphia, PA.

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