Examining Ethics Of Lung Cancer Test
Medical ethicist Nancy Berlinger and host Jacki Lyden dig deeper into the implications of a new test that could determine a smoker's risk of lung cancer.
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JACKI LYDEN, host:
That new medical test Joanne just reported on raises as many questions as it answers. And to take on a few of those questions, we turn to medical ethics expert Nancy Berlinger, who joins me now from New York.
Welcome to the show.
Dr. NANCY BERLINGER (Medical Ethicist; Deputy Director and Research Associate, The Hastings Center): Thank you.
LYDEN: So you had to think that some people are going to get tested and find that they're in a lower risk group and perhaps use these results as an excuse to keep smoking, don't you?
Dr. BERLINGER: Absolutely. I thought in the report, the idea, the Aunt Ethel syndrome, was really helpful because when we think about, you know, a person who we probably all know who had a lifelong smoking habit and didn't develop lung cancer, we probably are not thinking about the other chronic diseases that this person probably had.
If we just think about that disease in isolation, lung cancer, we may forget the whole story of what we know about what smoking can do to people.
LYDEN: Do tests like this, Nancy Berlinger, have an effect in terms of - we also heard maybe if it's highly scary to some people, that's a good thing.
Dr. BERLINGER: Definitely understanding cancer risk through the identification of biomarkers is hugely important. But one thing that really worries me is that - let's say you had a consumer version of this test, not something that you would use in a laboratory or in a doctor's office, but something you would market to people. Where would you market this test?
You would market it in the same low income neighborhoods where the cigarette billboards are. You would market it to smokers. You wouldn't market it to people who don't smoke and say, here, you can start smoking. You would direct it to people who already have an addiction that is already impairing their health, and that raises very severe ethical consequences not just for an individual, but for an entire community.
LYDEN: Beyond that, there are some big ethical questions. Take insurance companies. If this test passes muster, could we be seeing high risk smokers paying more for their policies?
Dr. BERLINGER: That's an interesting question. It's definitely something that we're concerned about every time a test comes online that there would be some sort of way or using a test to sort people out.
LYDEN: Uh-huh. You know, stepping back from this test for just a moment, we'll soon have tests, it seems, for just about everything. What challenges does that present for ethicists?
Dr. BERLINGER: Well, there's always the idea that a test equals certainty. Any clinician, any physician, any scientist, any ethicist who looks at a test knows that the test usually looks at a range of people, a range of samples - and this test is a good example.
People who had low levels of this metabolite had lower risk of developing lung cancer. And those with high levels had much higher risk of developing lung cancer.
However, there's this always, you know, the kind of muddy middle. There aren't that many tests that are absolutely predictive. And especially, there are not that many that I know of that will tell you categorically that you won't get something.
So putting all of our faith in a test and not in the totality of what we can do to prevent health problems rather than testing once they've already taken route is the big public health challenge.
LYDEN: Nancy Berlinger is the deputy director of The Hastings Center, a bioethics research institute.
Thank you very much.
Dr. BERLINGER: Thank you.
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Test May Determine Smokers' Lung Cancer Risk
"Smoking absolutely increases your risk, but why it does so in some people but not others is a big question," Dr. Jian-Min Yuan says.
"Smoking absolutely increases your risk, but why it does so in some people but not others is a big question," Dr. Jian-Min Yuan says.
A new urine test appears to distinguish which smokers are likely to get lung cancer and which are not, by detecting whether smokers have a particular chemical in their urine that's been linked to lung cancer.
The risk of lung cancer was 8.5 times higher in those who had the highest levels of this chemical, NNAL, and the highest nicotine levels.
The test was studied in about 500 men and women in Shanghai and Singapore. The results were presented at the annual meeting of the American Association for Cancer Research.
"A history of smoking has always been thought of as a predictor of lung cancer, but it is actually not very accurate," said Dr. Jian-Min Yuan, associate professor of public health at the University of Minnesota. "Smoking absolutely increases your risk, but why it does so in some people but not others is a big question."
NNAL is created as the body metabolizes tobacco. The chemical has been shown to induce lung cancer in lab animals, but the effect in humans had not been studied until now. Researchers suspect that for genetic reasons, some people produce more NNAL than others, thereby increasing their risk of lung cancer.
Researchers say this test is no license to smoke; tobacco causes other health problems, such as emphysema, heart disease and other types of cancer.
But the test could be used as a signal that people with high levels of NNAL should be screened more frequently for lung cancer, says Tyler Jacks, the incoming head of the American Association for Cancer Research and a lung cancer researcher with MIT. That way, cancers can be detected early, when they're more treatable.
Initially, researchers collected data from 18,244 men in the Shanghai Cohort Study and 63,257 men and women in the Singapore Chinese Health Study.
To evaluate the effect of NNAL, researchers looked at 246 current smokers who later developed lung cancer and compared them with 245 smokers who did not develop lung cancer. People were followed for 10 years during the study.
Patients who had a medium-level NNAL test had a 43 percent increased risk of lung cancer, while those at the highest level had a risk that was more than twofold higher than those with the lowest levels.
This held true even after researchers considered the number of cigarettes a person smoked per day, the number of years of smoking, and urinary levels of another chemical, cotinine, on lung cancer risk.
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