Thoracic oncology providers confronted with the task of diagnosing and following patients at risk for cancer of the lung face a number of major dilemmas, some of which directly affect the ability to diagnose. First, the majority of patients with lung cancer are diagnosed at a late stage and <15% survive 5 years, so a degree of nihilism is present in patients, providers and policy makers. Second, risk paradigms are changing, from smoking only to occupational, environmental or home carcinogens to the risk associated with premalignant airway changes. Third, advances in early diagnostic options have the potential to discover lung carcinoma while still in a pre-invasive, minimally invasive stage or as small peripheral nodules. These points, taken in conjunction with the initial clinical results of the ELCAP study suggesting that cure is possible,¹ raise the need to examine early diagnostic strategies critically.

In this issue of Thorax (see page 335) Loewen et al report their initial clinical findings in bimodality surveillance of high risk for lung cancer populations using low dose spiral CT scanning (SCT) and autofluorescence bronchoscopy (AFB).² They examined two null hypotheses: (1) AFB was equivalent to conventional sputum cytology (CSC) for the detection of pre-malignant lesions and (2) AFB and SCT would be equivalent to SCT alone for the detection of lung cancer in high-risk patients. The authors conclude that AFB is significantly superior to CSC for the detection of airway pre-malignancy in this cohort of high-risk patients and, in fact, argue that, as a surveillance tool, AFB exceeds the cancer detection rate of colonoscopy in patients with positive fecal occult blood. However, the authors were not able to demonstrate a significant superiority of bimodality surveillance with both AFB and SCT over SCT alone, but question whether a larger …