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INTRODUCTION

A 67-year-old man with past medical history of hypertension and chronic obstructive pulmonary disease (COPD) presents for an annual physical. He has no symptoms. He smoked 1 pack a day for 30 years but quit 5 years ago when he was diagnosed with COPD. He is asking about his risk of lung cancer. What screening modality, if any, you can offer this patient?

Learning Objectives

  1. What are the guideline recommendations for lung cancer screening?

  2. What are the harms and benefits of lung cancer screening?

  3. Is lung cancer screening cost-effective?

Lung cancer is the leading cause of cancer-related mortality worldwide. The 5-year survival rate of lung cancer is only 18% because most cases of lung cancer are diagnosed at an advance stage.1 Clinical outcomes of lung cancer are related to the stage at diagnosis, ranging from 56% five-year survival rate for stage I to 4% five-year survival rate at stage VI. Therefore, early detection of lung cancer is an important opportunity to decrease mortality.

SCREENING MODALITIES

Chest X-ray and Sputum Cytology

Screening for lung cancer by chest radiograph (CXR) and/or sputum cytology is not recommended. There have been at least six large randomized controlled trials,2-5 beginning as early as the 1960s, but none of the trials has demonstrated a mortality benefit for CXR screening. However, only the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial5 compared screening with no screening.

In the Memorial Sloan-Kettering2 and the Johns Hopkins studies,4 a combined total of 20,427 men were randomized to either an annual CXR alone or a CXR in combination with sputum cytology. No difference was noted in lung cancer incidence or mortality between the 2 groups. In the Mayo Lung Project,3 10,993 male smokers underwent a baseline screening with CXR and sputum cytology. If results were negative for cancer, the men were randomized to receive CXR and sputum cytology every 4 months or usual care, which was a recommendation for an annual CXR. After 6 years, the lung cancer mortality rate was not statistically different between the screened and control groups.

The PLCO Cancer Screening Trial5 is a population-based study of men and women aged 55 to 74 years for several cancers, including lung cancer. A total 154,901 participants were randomly assigned to receive either annual CXR for 4 years or standard of care (no CXR) and were followed up for 12 years. At the end of the study, the two groups demonstrated similar cumulative lung cancer incidences, lung cancer mortality, and stage and histologic findings of detected lung cancers.

Computed Tomographic Screening

Refinement of computed tomographic (CT) scan techniques with evaluation of low-dose CT (LDCT) scan developed interest in CT as screening modality. LDCT refers to a non-contrast study obtained with a multidetector CT scanner ...

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