By way of orientation, I-ELCAP type screening is a clinical activity; a positive test CT initiates a process that leads to early diagnosis. Such diagnostic activity, as it is pursued in an individual, is squarely in the domain of clinicians. In this context, we suggest that it is the responsibility of the individual clinician to decide, from the evidence at hand, whether or not to recommend screening to individuals at risk for lung cancer. The clinician should not be deterred by those who remain pessimistic concerning CT screening, or by those health policy authorities who presume to be qualified to discourage high-risk members of the population from seeking early diagnosis and potentially curative treatment of lung cancer. In a matter as important as this, clinicians should not defer to non-clinical authorities. By definition, candidates for screening must be asymptomatic and without clinical signs to suggest lung cancer. Members of the high-risk population are identified at present according to age, exposure to cigarette smoke (current, former, or passive smoker), occupational hazards, co-existing lung disease, and family history of lung cancer.

Research efforts to refine the risk profile so that it reliably identifies an individual’s unique profile are underway and will inform the screening tests of the future, which will be discussed. In the meantime, lowradiation- dose chest CT has been shown to be the most sensitive test available. Obtaining the CT is not what we consider to be screening. The CT initiates the ‘regimen of screening’: a management algorithm initially derived empirically and regularly revised from the data of ongoing research. When judiciously followed, this regimen leads to early diagnoses and minimizes unnecessary tests and invasive interventions, namely biopsies and surgeries.² We believe that it is not appropriate to initiate a screening program without coupling the CT to a regimen of screening of the I-ELCAP type. Also essential is a team of interested specialists to collaborate and monitor compliance with the management algorithm and the quality of its diagnostic components. Regular meetings of the team, which consists of pulmonologists, chest radiologists (trained in diagnostic and needle biopsy), cytologists, pathologists, thoracic surgeons, and medical and radiation oncologists, are essential to insure the timeliness and efficiency of the diagnostic pursuit. Successful programs have been active in community hospitals and occupational settings; an academic medical center is not essential.