Each week, as part of “Power Friday,” The Examiner profiles researchers, scientists and health care professionals who are making a difference in the everyday lives of Marylanders.
Dr. Enser Cole, chief of medical oncology at Saint Agnes Hospital, leads the International Early Lung Cancer Action Program at the hospital, which uses computed tomography scans to screen for early stages of lung cancer, the No. 1 cancer killer in America. The technology has allowed Cole and his team to find very early Stage 1 lung cancers, which hold much greater chances of being cured.
Tell me about the program and how you got into lung cancer.
For me this really started back in the mid-’70s when I was a fellow in oncology at Hopkins. At that time, people were trying to find out whether chest X-rays were an effective screening tool for lung cancer [and discovering they] are not.
It became a mantra in every textbook and every teaching session that there was no effective screening for lung cancer.
Dr. Claudia Henschke at [Weill Medical College of Cornell University] really asked the question when CT scanning became available: We have a tool that is 1,000 times more sensitive than a chest X-ray. Maybe this is the answer.
In that time period there was no screening for lung cancer?
No, and really the way we screen for lung cancer would be as though you as a patient came to me to be screened for breast cancer and I told you when you see blood on your bra or your breast is so big it won’t fit in your bra then you should come to me and we will see if you have a breast cancer.
Nowadays if I told you that, you would tell me I was woefully out of date.
The way we currently screen for lung cancer is we wait until you start coughing up blood or got short of breath or have pain in your chest or start losing weight. Most patients who present with [these] symptoms have stages three and four, which many times are not curable.
What Claudia Henschke did was to start screening smokers with CT scans. …
The problem with any screening trial is picking out the cancer from all the noise.
Is there more noise with the CT scan?
Yes in some ways. If you look at breast cancer mammography for example, in the United States if 100 women go in and get a mammogram routinely, 14 percent of them will be called back for some sort of extra studies. Most of those people don’t have breast cancer, but something is seen on the scan that requires additional views.
Mammography is like finding black dots on gray sheets, and CT is more like finding black dots on white sheets — but we find an awful lot of black dots that are not all tumors.
The beauty of what [the Lung Cancer Action Program] has done is to develop a treatment algorithm that gives you a set of rules to say how do we deal with these nodules.
Will the technology get more accurate?
The simplest but most brilliant way to sort out nodules that are cancers from nodules that aren’t is growth over time. So we look at how quickly is it doubling in size. If it’s doubling quickly, it has a high chance of being a cancer.
One thing that has changed in the technology is we now have [positron emission tomography] scanning, which is a way of looking at whether the tissue there is metabolizing sugar at a higher rate, [which indicates it is a tumor].
How much does it cost?
Scans are about $300 to $400 apiece. Initially we subsidized it and charged only $75. We had a provision that patients that couldn’t afford that could get the scan for free.
More recently we have upped our charge to $150, and that was purely because this is a product of success. … The hospital was running out of funds to do this.
You mentioned some physicians don’t support this program. Why?
As other great philosophers of science have said, “Leading physicians is like herding cats.” New ideas, even new ideas that are pretty well backed up, aren’t going to be backed readily, especially if insurance companies aren’t pushing for them and there is no financial incentive.
The trial we did, a big deficiency in many people’s mind was it wasn’t a randomized controlled trial. They argue that since we haven’t done that, we haven’t proved a survival difference between the group who was screened and the group who wasn’t.
Can CT scans be used for other cancers?
No; as of yet we don’t know the answers to those. Those are tougher situations. Because of the nature of where they are, they don’t show up as well.
How do you handle working with patients with such a deadly disease?
Someone once taught me the frustration ratio. He was an engineer. He said your frustration in life is equal to your expectation divided by the reality.
You have to manage your expectations. You also have to reframe your expectations. If your expectation as a cancer doctor is that you are going to cure everybody, you are going to fail and you are going to be frustrated.
If it’s that this is a patient with potentially curable lung cancer but the chances are only 20 percent, so this may evolve into a case where I can help them but not cure them.
The other secret is never do it by yourself, always do it as a team.
Knowing what we know about lung cancer and smoking, why are people still smoking?
Considering how addictive this is, you know, I am avid anti-smoker but I have become much more forgiving to people for being smokers. I know how difficult it is for some of them to quit.
Smoking does a lot of good things for you, and that is an odd thing to hear. It really is a way of self-medicating if you have anxiety, depression, boredom. If it were benign, I would actually prescribe it for some people for psychiatric reasons.
But it isn’t. It is responsible for a third of all the cancers we see.
