Lung cancer screening reveals hope and complication

Lung cancer is especially vicious, and typically diagnosed only after a symptom -- a hard cough, shortness of breath, unaccountable weight loss -- shows up. It kills 85 percent of those whom it visits, often within five years of diagnosis.

And so it is very good news that early CT scanning can detect lung cancer in former and current cigarette smokers showing no symptoms. It means otherwise unseen, early-stage cancers may be treated with far greater effectiveness than ever -- with hundreds, even thousands, of lives saved each year.

But an immediate complication sets in. Who pays for all the testing? With tens of millions of smokers in the U.S., even the most conservative tally pushes a screening tab into the billions of dollars.

It's a cold question when so many people could potentially beat a disease that kills more than 155,000 in the U.S. every year. Independent overseers of the National Lung Screening Trial, conducted by the National Cancer Institute and the American College of Radiology Imaging Network, even halted the research on the study's 53,000 subjects after being convinced of the CT scans' effectiveness.

Most insurers do not pay for scans unless a physician, after clinical and other modest investigation, suspects the presence of disease. Hunches or statistical likelihoods don't cut it. They're typically reduced to radiologic "fishing trips" that no one wants to pay for, least of all in the current climate of cost containment. Even though the known lung cancer risk in an elderly smoker is especially high, that's all it is: a high risk factor.

The CT scan, meanwhile, doesn't come without its own complications. By taking multiple, rotating thoracic X-rays and merging them into a revealing 3-dimensional view, the scan can find things perhaps best left alone. In some cases they are benign anomalies that, by virtue of simply being known, call out for expensive, nerve-rattling follow-up.

Even so, one report this week had an unnamed Medicare official saying the federal Medicare program, which does not pay for lung cancer screening by CT scan, would reconsider its position in light of the study's compelling findings. But most folks will probably need to pay for such a scan, if they want one, out of their own pockets.

This is just the beginning, really. The math points in several directions. What may be today's high screening cost could be tomorrow's savings.

A CT scan costing hundreds of dollars may well lead to a modest fix in a patient whose otherwise unchecked lung cancer would, before killing him, saddle insurers or the public with tens of thousands of dollars' worth of cancer-fighting drugs and surgeries. That's to say nothing of pain and diminished quality of life, whose terrible costs are of another kind.

The money question also deepens the conversation about whether our health care system is configured to cure or prevent -- or both. Early screening of any high-risk crowd falls somewhere in-between. To say people shouldn't be smoking in the first place is to state the obvious while ignoring the very real question of what to do about findings that promise to save lives at a high upfront cost.

A first step is deeper analysis of the massive study's data, already planned by researchers who want to know the biologic nuances and practical implications of their discovery. Only then can medical professionals who follow patients and cancer progression set metrics for who should be screened and who should not. Only then will insurers, as well as Medicare, know when to approve an expensive test on a seemingly healthy person.

It will be imperfect, surely, but reduce complication enough to persuasively make the case that screening is no fishing trip when standards are met and lives will be saved.