Curability of lung cancer

Health-policy authorities’ proclamations notwithstanding, lung cancer should now be understood to be a commonly curable disease that prevailing practices of healthcare typically fail to cure. A major change in outlook and practices is now called for.

As lung cancer is now the principal cause of cancer deaths in the USA, more common than cancers of the breast, prostate and colon combined [101], it presents the principal challenges to today’s cancer-related healthcare.

Deaths from a cancer represent failures of healthcare to the extent that cases of the cancer remain preventable but unprevented or curable but uncured. Scarcely could efforts at prevention of lung cancer, both educational and regulatory, have been much more vigorous and productive than they actually have been; thus, the current huge burden of deaths from lung cancer needs to be examined as to whether or not it reflects a major failure of the prevailing practices of healthcare to produce cures in curable cases of this disease.

To the extent that prevailing practices of healthcare are failing to cure curable cases of lung cancer, this is a matter of failing to pursue the cancer’s early, latent-stage diagnosis and thereby, its early, more commonly curative treatment. The pursuit of early diagnosis of lung cancer indeed is quite uncommon at present, as a failure in both community-level and clinical (individual-level) healthcare. In community-level, population-oriented health education there still is a policy-based failure to encourage the population’s high-risk members to seek pursuit of early diagnosis of lung cancer from clinical care; and in clinical medicine also, there is commonly a failure to recommend this pursuit to the ‘worried well’, in deference to community medicine’s health-policy agencies in their purported agnosticism regarding the usefulness of seeking lung cancer’s early diagnosis, without clinicians having any express justification for this deference.

Whereas the pursuit of early diagnosis of lung cancer, like that of any other cancer, is a matter of clinical rather than community medicine, concerned clinicians need to be clear on what community-medicine’s authorities on health policy seemingly presume to be qualified to say on this topic and thus, what it is in this aspect of clinical medicine in which clinicians now commonly yet unjustifiably defer to nonclinical authorities.

It is necessary to be clear, for a start, on what the community-medicine authorities on health policy are not saying. Given a noncalcified pulmonary nodule identified on computed tomography (CT) of the chest, whether carried out as the first test in the pursuit of early diagnosis of lung cancer or for some other reason, no agency issuing health-policy proclamations questions the justifiability of the nodule’s diagnostic work-up with a view to its possible malignancy; and if the nodule’s malignancy is pathologically diagnosed (especially upon CT demonstration of continuing growth and lack of any reversal of this by a course of antibiotic treatment), no such agency questions the justifiability of early treatment.

So, what the health-policy authorities of community medicine are actually questioning is the justifiability of only the initial, low-dose CT testing; and this testing’s justifiability they question, even though they understand that it usually is the end of the diagnostic pursuit, while exceptionally giving rise to well-justified further diagnostic work-up which, in turn, can lead to early diagnosis and, thereby, to early treatment as a superior substitute for the late treatment that would follow late diagnosis!

The remarkable basis for this remarkable policy stance appears to be, first, that those authorities view all healthcare in the absence of sickness and any abnormal result of a diagnostic test as being preventive medicine and the latter as inherently being community medicine. Then, seemingly with this presumption of singular expertise on the justification for the initial testing in the pursuit of diagnosis of latent lung cancer, they address that testing as though it were an intervention (preventive) rather than the first element in those diagnostics! Finally, while not questioning the justifiability of what clinicians do diagnostically and then, possibly, as a matter of treatment following the initial (low-dose CT) testing, they nevertheless proclaim it to be possible that the initial testing “does more harm than good” and that it may not serve to “save lives”!

Seemingly serious about ideas like this, community-medicine authorities on health policy take on the role of recommending for or against any initial testing in the pursuit of early diagnosis of lung (or any other) cancer. They recommend such testing only if evidence from randomized trials, contrasting the testing with its absence, have demonstrated that the testing reduces mortality from the cancer. In the absence of such evidence, they caution that the initial testing may do more harm than good even though they do not consider it to be materially noxious; and they insist that it may not save lives even though it leads to more commonly curative treatment! (It is of some note that while these tenets have been applied very forcefully in the context of breast and lung cancers, they have not been applied in respect to cervical cancer.)

Rather than permitting that kind of extraclinical authoritarianism to constrain their autonomy of thought on matters clinical, clinicians concerned to promote cures from lung cancer should pay heed to these words of a genuine authority, Kant [1]:

“There is in human nature an unworthy propensity ... to conceal our real sentiments, and to give expression only to certain received opinions, which are regarded as at once safe and promotive of the common good. ... But when principles have been developed, and have obtained a sure foundation in our thought, this conventionalism must be attacked with earnest vigor, otherwise it corrupts the heart, and checks the growth of good dispositions with the mischievous weed of fair appearances.”

Kant added [2]: “[Individual freedom, constrained by law in the interest of the common good] will, among other things, permit our openly stating the difficulties and doubts which we are ourselves are unable to solve, without being decried on that account as turbulent and dangerous citizens. This privilege forms part of the native rights of human reason, which recognizes no other judge than the universal reason of humanity; and as this reason is the source of all progress and improvement, such a privilege is to be held as sacred and inviolable. It is unwise, moreover, to denounce as dangerous, any bold assertions against, or rash attacks upon, an opinion which is held by the largest and most moral class of the community; for that would be giving them an importance which they do not deserve.”

Putting this sagesse into application, it may be noted that if clinicians were not so prone to seek “fair appearances” by concealing their “real sentiments” and, to this end, “to give expression only to certain received opinions” on the (un)justifiability of pursuing latent-stage diagnosis of lung cancer, they would pursue “progress and improvement” in healthcare by exercising “the native rights of human reason” rather than accord policy-promulgating authorities “importance which they do not deserve”.

In the framework of endogenous, unadulterated clinical thought, given the relevant and unquestionably correct premises that latent-stage diagnosis of lung cancer is now possible and that its associated early treatment is more commonly curative than treatment following late, sickness-prompted diagnosis, it can be (and commonly is) securely deduced that the modern pursuit of lung cancer’s early diagnosis, rare though it remains, serves the purpose of saving lives that otherwise would be lost to this cancer.

While clinicians see this conclusion to be correct, materially as well as formally, justification of the pursuit of lung cancer’s early diagnosis requires clinicians to understand, among other inputs, knowledge regarding the extent to which each of those two premises is true. The curability gain deduced from these quantitative understandings must be large enough to justify the cost, monetary and other, of the process, especially if the indication for the pursuit (mainly a matter of smoking history and age) is less than compelling for the person to be one of the ‘worried well’ with respect to lung cancer.

Recently, both of those premises have been addressed quantitatively in a very large program pursuing early diagnosis and, thereby, early treatment of lung cancer. The evidence from this program indicates that by means of a suitable regimen for the early diagnostic pursuit and timely treatment upon early diagnosis, lung cancer now is commonly curable, perhaps as commonly as 80% of cases [3].

In any quantitative interpretation of this evidence it is necessary to consider the possibility of overdiagnosis in the meaning of the investigators possibly having classified as malignant neoplasm (cancer) some cases that were actually benign or so slowly progressing as being practically benign. All of the diagnoses were confirmed by an expert panel on pulmonary pathology; 95% of the resected stage I cases were classified by this panel as already showing invasion in the surgical specimens; and all eight of the untreated patients with stage I disease died of lung cancer (within 5 years). Nevertheless, some overdiagnosis bias as a boost to the quantitatively very dramatic result must be allowed for.

On the other hand, major productivity of that program’s regimen in pursuing latent-stage diagnosis of (screening for) lung cancer is undeniable. The fact that its application usually achieves the cancer’s diagnosis before detectable spread (i.e., in stage I) and thereby provides for its curability in most cases, should be recognized, resolutely dismissing attempted detractions by unsubstantiated and false claims of ‘lead time bias’ and ‘length bias’ and equally unjustifiable claims of need for ‘control group’ for the diagnostic part of that program which, as a first in cancer-screening research, distinguishes between diagnostic and therapeutic studies [4].

Those attempted distractions by uncritical followers of community medicine’s health-policy authorities do have the meaning of unfortunately suggesting that the thus far nihilistic policies regarding screening for lung cancer are not about to be changed. So, the professional calling of pulmonologists and other members of lung cancer screening teams, concerned with helping thoracic surgeons and other interventionists to cure curable cases of lung cancer, is to ignore those policies, especially when understanding their true basis. It cannot be that health-policy authorities and their followers are as irrational as they appear to be. Rather, their claims must be disingenuous. To them, a priority higher than upholding truth in scientific proclamations, and also higher than saving lives in the practice of healthcare, must be pandering to the pecuniary interests of governments and other third-party payers of healthcare.