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.
Lung Cancer Alliance sports celebrity advertisement.
Lead-time bias. The diagram shows how earlier diagnosis will increase the survival statistic, even if death is not delayed.
Overdiagnosis bias. The diagram shows how the detection of pseudodisease inflates the survival statistic even when the number of deaths is stable.
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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