Linda L. Humphrey, MD, MPH; Steven Teutsch, MD, MPH; Mark Johnson, MD, MPH
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or Merck & Co., Inc.
Acknowledgments: The authors thank Kathryn Krages, AMLS, MA; Susan Wingenfeld; and Kim Peterson, MS, for their help in preparation of the full evidence report and the manuscript. They also thank Mark Helfand, MD, MPH; William Holden, MD; John McAnulty, MD; and James Reuler, MD, for their helpful reviews of the manuscript.
Grant Support: This study was conducted by the Oregon Health & Science University Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (contract no. 290-97-0018, Task Order 2, Rockville, Maryland).
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Reprints are available from the Agency for Healthcare Research and Quality Web site (www.preventiveservices.ahrq.gov) and through the Agency for Healthcare Research and Quality Publications Clearinghouse (telephone, 800-358-9295).
Current Author Addresses: Dr. Humphrey: Oregon Health & Science University, Mailcode BICC, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098.
Dr. Teutsch: Merck & Co., Inc., Sumneytown Pike and Broad Street, PO Box 4, West Point, PA 19437.
Dr. Johnson: Department of Family Medicine, University of Medicine and Dentistry–New Jersey Medical School, 185 South Orange Avenue, MSB-B648, Newark, NJ 07103.
Lung cancer is the leading cause of cancer-related death in the United States and worldwide. No major professional organizations, including the U.S. Preventive Services Task Force (USPSTF), currently recommend screening for lung cancer.
To examine the evidence evaluating screening for lung cancer with chest radiography, sputum cytologic examination, and low-dose computed tomography (CT) to aid the USPSTF in updating its recommendation on lung cancer screening.
MEDLINE, the Cochrane Library, reviews, editorials, and experts.
Studies that evaluated mass screening programs for lung cancer involving the tests of interest were selected. All studies were reviewed, but only studies with control groups were rated in quality since these would most directly influence the USPSTF screening recommendation.
Data were abstracted to data collection forms. Studies were graded according to criteria developed by the USPSTF.
None of the 6 randomized trials of screening for lung cancer with chest radiography alone or in combination with sputum cytologic examination showed benefit among those screened. All studies were limited because some level of screening occurred in the control population. Five case–control studies from Japan suggested benefit to both high- and low-risk men and women. All studies were limited by potential healthy screenee bias. Six cohort studies showed that when CT was used to screen for lung cancer, lung cancer was diagnosed at an earlier stage than in usual clinical care. However, these studies did not have control groups, making mortality evaluation difficult. In addition, the studies demonstrated a high rate of false-positive findings.
Current data do not support screening for lung cancer with any method. These data, however, are also insufficient to conclude that screening does not work, particularly in women. Two randomized trials of screening with chest radiography or low-dose CT are currently under way and will better inform lung cancer screening decisions.
Table 1. Controlled Trials of Lung Cancer Screening with Chest Radiography with or without Sputum Cytologic Examination
Table 2. Methods and Quality of Controlled Trials of Lung Cancer Screening
Mortality in randomized, controlled trials of lung cancer screening with chest radiography with or without sputum cytologic examination.
Table 3. Case–Control Studies of Lung Cancer Screening with Chest Radiography and Lung Cancer Mortality Rates
Table 4. Outcomes of Lung Cancer Screening with Low-Dose Computed Tomography
Table 5. Lung Cancer Screening Studies Including Women
Appendix Table 1. Search Strategy
Appendix Table 2. Cohort Studies of Lung Cancer Screening with Chest Radiography
Initial assembly of comparable groups: adequate randomization, including first concealment and whether potential confounders were distributed equally among groups.
Maintenance of comparable groups (includes attrition, crossovers, adherence, contamination).
Levels of follow-up: differential loss between groups; overall loss to follow-up.
Measurements: equal, reliable, and valid, including masking of outcome assessment.
Clear definition of interventions.
Important outcomes considered.
Analysis: intention to treat.
Accurate ascertainment of case-patients.
Nonbiased selection of case-patients and controls with exclusion criteria applied equally to both.
Diagnostic testing procedures applied equally to each group.
Measurement of exposure accurate and applied equally to each group.
Appropriate attention to potential confounding variables.
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Linda L. Humphrey, Steven Teutsch, Mark Johnson. Lung Cancer Screening with Sputum Cytologic Examination, Chest Radiography, and Computed Tomography: An Update for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140:740–753. doi: 10.7326/0003-4819-140-9-200405040-00015
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Published: Ann Intern Med. 2004;140(9):740-753.
Cancer Screening/Prevention, Guidelines, Hematology/Oncology, Lung Cancer, Prevention/Screening.
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