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Lung Cancer Screening

Lung Cancer Screening To the Editor: I concur with Dr Petty1 regarding lung cancer screening. Epidemiology is important, but it can sometimes obscure variations in individual disease. Survival is not only related to tumor size but also to tumor biology and behavior and individual immune responses. In my own practice, I have had the opportunity to observe individual variations in the progression of malignant disease. I discovered a solitary 3-cm pulmonary nodule in 1 of my patients when she had a chest radiograph for suspected pneumonia. Needle biopsy was twice unsuccessful, and the patient refused open biopsy and removal. The mass remained stable for 6 years; we congratulated ourselves that this was a benign process. Then the nodule began to grow. In the seventh year after discovery of the nodule, the patient died of lung cancer. Screening policies by governments or other third parties must be circumspect and based on strong evidence because, when bills are paid collectively, only aggregate outcomes seem justified. A danger is that individual decisions by thoughtful physicians may be hamstrung by those policies, either formally or by peer pressure. Any high-risk patient (smoker or former smoker) could be harboring a pulmonary mass detectable by chest radiograph. Advising a high-risk patient to undergo a chest radiograph is common sense, even without definitive trials to prove efficacy in large populations. The survival benefit in the Mayo Clinic, Czechoslovakian, and Memorial Sloan Kettering studies2 convinced me years ago to offer chest radiographs to all of my high-risk patients. Helical computed tomography (CT) may be more sensitive, but it is too expensive for routine screening. Studies that show its efficacy also show chest radiography to be useful, only less so. If physicians are worried about doing harm in the case of pseudodisease, they are better off with the chest radiograph because, in addition to detecting less cancer, it also will detect less pseudodisease. Dr Frame3 believes that screening with chest radiographs for high-risk patients is wrong and should not be done. I submit that no one really knows yet, so clinicians must be free to use all evidence as they see fit, with enlightened assent from patients. References 1. Petty TL Screening strategies for early detection of lung cancer: the time is now. JAMA. 2000;284:1977-1980.Google Scholar 2. Strauss GMGleason RESugarbaker DJ Chest X-ray screening improves outcome in lung cancer: a reappraisal of randomized trials on lung cancer screening. Chest. 1995;107(suppl 6):2705-2795.Google Scholar 3. Frame PS Routine screening for lung cancer? maybe someday, but not yet. JAMA. 2000;284:1980-1983.Google Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Lung Cancer Screening

JAMA , Volume 285 (2) – Jan 10, 2001

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Publisher
American Medical Association
Copyright
Copyright © 2001 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.285.2.163
Publisher site
See Article on Publisher Site

Abstract

To the Editor: I concur with Dr Petty1 regarding lung cancer screening. Epidemiology is important, but it can sometimes obscure variations in individual disease. Survival is not only related to tumor size but also to tumor biology and behavior and individual immune responses. In my own practice, I have had the opportunity to observe individual variations in the progression of malignant disease. I discovered a solitary 3-cm pulmonary nodule in 1 of my patients when she had a chest radiograph for suspected pneumonia. Needle biopsy was twice unsuccessful, and the patient refused open biopsy and removal. The mass remained stable for 6 years; we congratulated ourselves that this was a benign process. Then the nodule began to grow. In the seventh year after discovery of the nodule, the patient died of lung cancer. Screening policies by governments or other third parties must be circumspect and based on strong evidence because, when bills are paid collectively, only aggregate outcomes seem justified. A danger is that individual decisions by thoughtful physicians may be hamstrung by those policies, either formally or by peer pressure. Any high-risk patient (smoker or former smoker) could be harboring a pulmonary mass detectable by chest radiograph. Advising a high-risk patient to undergo a chest radiograph is common sense, even without definitive trials to prove efficacy in large populations. The survival benefit in the Mayo Clinic, Czechoslovakian, and Memorial Sloan Kettering studies2 convinced me years ago to offer chest radiographs to all of my high-risk patients. Helical computed tomography (CT) may be more sensitive, but it is too expensive for routine screening. Studies that show its efficacy also show chest radiography to be useful, only less so. If physicians are worried about doing harm in the case of pseudodisease, they are better off with the chest radiograph because, in addition to detecting less cancer, it also will detect less pseudodisease. Dr Frame3 believes that screening with chest radiographs for high-risk patients is wrong and should not be done. I submit that no one really knows yet, so clinicians must be free to use all evidence as they see fit, with enlightened assent from patients. References 1. Petty TL Screening strategies for early detection of lung cancer: the time is now. JAMA. 2000;284:1977-1980.Google Scholar 2. Strauss GMGleason RESugarbaker DJ Chest X-ray screening improves outcome in lung cancer: a reappraisal of randomized trials on lung cancer screening. Chest. 1995;107(suppl 6):2705-2795.Google Scholar 3. Frame PS Routine screening for lung cancer? maybe someday, but not yet. JAMA. 2000;284:1980-1983.Google Scholar

Journal

JAMAAmerican Medical Association

Published: Jan 10, 2001

References