Affiliations: Denver, CO
Dr. Petty is Professor of Medicine, University of Colorado Health Sciences Center; HealthONE, Presbyterian/St. Luke’s Medical Center.
Correspondence to: Thomas L. Petty, MD, Master FCCP, Professor of Medicine, University of Colorado Health Sciences Center, 1850 High St, Denver, CO 80218; e-mail: email@example.com
The epidemic of lung cancer continues unabated. Success in
preventing teenagers from becoming addicted to tobacco has been
effectively thwarted by the continued and unrelenting efforts of the
tobacco industry. Today, approximately 49-million people continue to
smoke in the United States. Although there are more quitters today than
ever before, many persons have been exposed to enough carcinogens from
tobacco to remain at excess risk, probably for their lifetimes. In
fact, more lung cancer is diagnosed in former smokers today than in
active smokers.1 Even if we had unexpected and miraculous
success in reducing smoking in the next few years, lung cancer would
not substantially decline for > 20 years.1
The dogma against lung cancer screening that has been promoted
for > 2 decades has led to indifference in case finding, and
essentially no efforts in screening. This policy comes from studies
conducted in the 1970s that have been questioned.2–3 Many
cancers were missed due to limitations of the screening techniques that
were employed.3We know exactly who gets lung cancer, and
where the yield of new diagnostic techniques would be high. The highest
risk is in smokers with any degree of airflow obstruction.
Approximately 2% of these individuals have lung cancer at the time of
diagnosis by sputum cytology.4 Approximately 25% of these
patients have moderate to severe dysplasia, which are probably
precancerous lesions.4Cancers that are found by sputum
cytology are mostly central squamous carcinomas. CT scans help to
identify peripheral nodules that are most often adenocarcinoma. Today,
new helical CT scans are becoming more widely available. They should be
employed today in patients at highest risk. Even a standard chest
radiograph can improve detection and survival.5
Earlier, we showed in a community-based case finding study that
both squamous and adenocarcinomas can be found when they are
roentgenographically occult. When treated by surgery or radiotherapy,
the 5-year survival is > 50%.6Most of these patients
had coexisting airflow obstruction. The Lung Health Study, which
focused on mild to moderate COPD, revealed a 1% death rate in 5 years
from unexpected cancer.7Late follow-up now reveals 2%
lung cancer in this group of middle-aged smokers with only mild degrees
of airflow obstruction (D. Miller, MD; personal communication; February
1999). The presence of airflow obstruction yields four to six
times more lung cancer than in matched patients with normal
When lung cancer is diagnosed in early stages, the survival is
excellent. This is the case for other common cancers, such as breast,
colon, uterine, and prostate cancer, all of which are aggressively
pursued by appropriate screening techniques where reimbursement is no
longer a question. We need the same for lung cancer. A very recent
study offers a pragmatic approach to lung cancer screening via
high-resolution CT scanning.10 The yield rate of diagnosis
of small noncalcified malignant lesions was increased fourfold over
standard chest radiology. When early small lesions are resected, the
survival can be ≥ 80%.10 This study was done in smokers
of > 10 pack-years who were > 60 years old.
I believe the evidence strongly indicates that smokers > 40 years old
who have smoked ≥ 30 pack-years along with airflow obstruction, as
measured by simple spirometry, should have a combination of sputum
cytology (done in a qualified laboratory) and a low-radiation helical
CT scan to identify otherwise occult lung cancer. Fiberoptic
bronchoscopy can locate many lesions, but fluorescent endoscopy is a
more sensitive technique for identifying and treating early-stage lung
cancers.11If we follow this simple approach, we will find
that we can identify and cure lung cancer in its early stages. It is
likely that together, the techniques now available to us will yield
approximately 90% of early-stage carcinoma. We can learn the cost of
early lung cancer treatment and compare it with the costs of treating
lung cancer as it is usually diagnosed based on symptoms or from chest
radiographs taken for measures other than to diagnose lung cancer.
These costs are approximately $50,000 per patient, with a survival rate
of only 22% after 2 years.12The costs of treating
early-stage lung cancer remain to be determined. A reasonable estimate
would be no more than $10,000 per patient, including diagnostic costs
and resectional surgery. Here the survival rate would be at least 80%
at 5 years.13
It could be argued that this approach will miss some lung
cancers. Certainly this is likely to be the case, but we are missing
most lung cancers now through a policy of nonscreening that has blocked
progress.14Case findings in high-risk patients will give
a high yield of lung cancer, as has been suggested
before.15 This is the low-hanging fruit that can be
readily harvested by using new lung cancer diagnostic techniques at
virtually all major hospitals in the United States today. Once we
succeed in this harvest, we can climb higher into the tree!
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