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Lung cancer outcomes have improved only marginally over the last 40 years and remain dismally poor in comparison to most other cancers: only 17.7% of women and 12.9% of men in the UK survive after diagnosis for 5 years or longer.1 This is despite significant investments, with notable recent improvements in diagnostic and staging tools, treatment options and the organisation of teams responsible for streamlined delivery of these. Poor survival is largely attributable to low rates of radically treatable disease at diagnosis. Given that survival rates do vary significantly both within and between countries,2 3 they should be amenable to improvement. How best to do this? Options might include increasing public awareness, improving identification and investigation of putative lung cancer symptoms in primary care, streamlining of secondary care service pathways and screening. All of these have been investigated and they are all of importance.
The finding of a 20% mortality reduction in the National Lung Screening Trial in the USA4 has prompted great interest in low-dose CT (LDCT) screening in high-risk groups. This should be tempered, however, for a number of reasons: only 27% of patients developing lung cancer in the USA would meet the NLST entry criteria, and it is unknown what proportion even of these would attend a screening programme outside a clinical trial; symptomatic presentation particularly of highly malignant forms including small cell lung cancers occurs between screening rounds; screening tends to identify cases of indolent disease (‘overdiagnosis’, estimated to have occurred in up to 18%of the cases in the NLST) as well as cancers with lethal potential ;5 LDCT screening programmes are very costly and only become reasonably cost effective when combined with smoking cessation programmes;6 knowledge regarding appropriate entry criteria, screening protocols and optimal management of lung nodules is still …
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