The rational for screening for lung cancer is that so many lung cancers present at a late stage and are thus untreatable. If it were possible to detect these cases at an earlier stage it would be easier to treat them and there would be a greater chance of increased survival.
Despite numerous attempts at implementing screening trials for lung cancer it has long been thought that such programs are not possible.
There are two major problems: There is a lack of understanding of premalignant conditions and the natural history of lung cancers. It is also difficult to easily obtain a representative sample; biopsy is too invasive, and bronchial washings or sputum samples are both unreliable. X-rays are not a useful screening tool as tumours are not generally visible until they reach an advanced stage.50
Narrowing the screening program has been attempted, in an effort to focus on those most likely to benefit. Given the strong aetiological role of smoking, trials have been conducted using only high risk smoking subjects.
In 1971 the National Cancer Institute of the USA initiated three large randomised controlled trials of periodic radiological and cytological screening of asymptomatic individuals. None of these trials demonstrated reduction in lung cancer mortality, one of the trials, carried out at the Mayo Clinic did show improvement in resectability in a sub-group of the study population. 51,52
The cost of screening programs must also be considered in relation to the increased survival, unless cancers can be detected early enough to enable successful treatment, there is no benefit from screening.
The development of Computed Tomography has lead to trials examining its use as a possible screening tool.
Interest in lung cancer screening has recently revived since publication of a report of the Early lung cancer Action Project in New York53 which screened 1000, asymptomatic volunteers aged ove 60 with a history of smoking and no previous cancer. Of the 27 cancers detected with computed tomography, 26 were resectable, the study concluded that CT scans greatly improve the likelihood of detection of small non-calcified nodules.
Dr Ian Smith, chairman of the lung cancer Group of the UK Co-ordinating Committee for Cancer Research, and leading cancer specialists have written up plans for a UK trial of screening for lung cancer, probably involving annual CT scans.54
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