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Spiral CT scan screening detects lung cancers at an average size of 1.5 versus 3.0 cm for chest X-ray-detected lung cancers (1). Patz and coworkers argue that size does not matter and they quote their own data on T1N0M0-resected cancers (2). If they are right, then the entire premise of the staging system is wrong. The current staging system is based on tumor size and lymph node status. The 5-yr survival of patients with pathologic stage T1N0M0 cancer is 67 versus 57% for T2N0M0 (3). Recent data from the SEER (Surveillance, Epidemiology, and End Results) database show that the percentage of Stage I lung cancers decreases with increasing tumor size from 15 mm up to 55 mm (4). In addition, data from Martini and coworkers also demonstrate better survival based on size from < 1 to 1-3 to 3-5 cm (5). Collectively, these data demonstrate that tumor size is related to survival.
Screening programs for breast cancer and colorectal cancer have reduced mortality. Mammography detects breast cancer at an average size of 10-12 mm and the 5-yr survival is 86%. Colorectal cancer screening detects cancers earlier and the 5-yr survival is 62%. Why should detecting lung cancer at a smaller size not matter?
I would agree that reduction in lung cancer mortality and cost effectiveness need to be proved. These are likely to be achieved only with a randomized control trial, and this should be done. Without the randomized control trial to prove efficacy, the government and third party payers are unlikely to cover the cost of spiral CT screening.
If you want to continue with the current state of affairs, in which 70-75% of lung cancer patients have nodal or distant metastases at diagnosis, only 20% have Stage IA disease at diagnosis, and the overall 5-yr survival is 14%, then do not screen your patients. If, however, you are looking to improve on current outcomes, then screening with spiral CT scan offers that strong possibility. Low-dose spiral CT may be the mammogram equivalent for lung cancer.
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1. Omatsu H, Kakinuma R, Kaneko M, Moriyama N, Kusumoto M, Eguchi K. Successful lung cancer screening with low-dose helical CT in addition to chest X-ray and sputum cytology: the comparison of two screening periods with or without helical CT [abstract 182]. Radiology 2000; 217(Suppl):242.
2.
Patz EF,
Rossi S,
Harpole DH Jr,,
Herndon JE,
Goodman PC.
Correlation of tumor size and survival in patients with stage IA non-small cell
lung cancer.
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1568-1571
3.
Mountain CF.
Revisions in the International System for Staging Lung
Cancer.
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4. Wisniversky JP, Bratz-Parente D, Yankelevitz DF, Henschke CI. Prognosis of stage I non-small cell lung canfer by tumor size [abstract 1104]. Radiology 2000;217(Suppl):469.
5.
Martini N,
Bains MS,
Burt ME,
Zakowski MF,
McCormack P,
Rusch VW,
Ginsberg RJ.
Incidence of local recurrence and second primary
tumors in resected stage I lung cancer.
J Thorac Cardiovasc Surg
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  M. J. TOBIN Chronic Obstructive Pulmonary Disease, Pollution, Pulmonary Vascular Disease, Transplantation, Pleural Disease, and Lung Cancer in AJRCCM 2001 Am. J. Respir. Crit. Care Med., March 1, 2002; 165(5): 642 - 662. [Full Text] [PDF]
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