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Special Article |

Overstating the Evidence for Lung Cancer Screening:  The International Early Lung Cancer Action Program (I-ELCAP) Study

H. Gilbert Welch, MD, MPH; Steven Woloshin, MD, MS; Lisa M. Schwartz, MD, MS; Leon Gordis, MD, MPH, DrPH; Peter C. Gøtzsche, MD, MPH; Russell Harris, MD, MPH; Barnett S. Kramer, MD, MPH; David F. Ransohoff, MD
Arch Intern Med. 2007;167(21):2289-2295. doi:10.1001/archinte.167.21.2289.
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Last year, the New England Journal of Medicine ran a lead article reporting that patients with lung cancer had a 10-year survival approaching 90% if detected by screening spiral computed tomography. The publication garnered considerable media attention, and some felt that its findings provided a persuasive case for the immediate initiation of lung cancer screening. We strongly disagree. In this article, we highlight 4 reasons why the publication does not make a persuasive case for screening: the study had no control group, it lacked an unbiased outcome measure, it did not consider what is already known about this topic from previous studies, and it did not address the harms of screening. We conclude with 2 fundamental principles that physicians should remember when thinking about screening: (1) survival is always prolonged by early detection, even when deaths are not delayed nor any lives saved, and (2) randomized trials are the only way to reliably determine whether screening does more good than harm.

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Figure 1.

Lung Cancer Alliance sports celebrity advertisement.

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Figure 2.

Lead-time bias. The diagram shows how earlier diagnosis will increase the survival statistic, even if death is not delayed.

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Figure 3.

Overdiagnosis bias. The diagram shows how the detection of pseudodisease inflates the survival statistic even when the number of deaths is stable.

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Figure 4.

Cycle of scans required in initial case series of spiral computed tomographic (CT) screening.42,43 The asterisk indicates that 9 patients were recommended to have only 1 year of follow-up.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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