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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: tlpdoc{at}aol.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.3 We 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.4 Cancers 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%.6 Most 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.7 Late 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 airflow.8 9
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.11
If 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.12
The 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.14 Case 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!
References
This article has been cited by other articles:
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  C. Esteban, J.M. Quintana, M. Aburto, J. Moraza, and A. Capelastegui A simple score for assessing stable chronic obstructive pulmonary disease QJM, November 1, 2006; 99(11): 751 - 759. [Abstract] [Full Text] [PDF]
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 N.C. Thomson, R. Chaudhuri, and E. Livingston Asthma and cigarette smoking Eur. Respir. J., November 1, 2004; 24(5): 822 - 833. [Abstract] [Full Text] [PDF]
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 T. L. Petty Screening for Lung Cancer Ann Intern Med, October 19, 2004; 141(8): 649 - 650. [Full Text] [PDF]
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N. Jakeways, T. McKeever, S.A. Lewis, S.T. Weiss, and J. Britton Relationship between FEV1 reduction and respiratory symptoms in the general population Eur. Respir. J., April 1, 2003; 21(4): 658 - 663. [Abstract] [Full Text] [PDF]
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 D. D. Sin, R. L. Jones, and S. F. P. Man Obesity Is a Risk Factor for Dyspnea but Not for Airflow Obstruction Arch Intern Med, July 8, 2002; 162(13): 1477 - 1481. [Abstract] [Full Text] [PDF]
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 T. L. Petty Screening Strategies for Early Detection of Lung Cancer: The Time Is Now JAMA, October 18, 2000; 284(15): 1977 - 1980. [Full Text] [PDF]
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