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Lung cancer is a major global health burden: it was responsible for 1.3 million deaths in 2004, equating to 2.3% of all deaths. Death rates from lung cancer are predicted to continue to rise, with the disease being responsible for 2.8% of all deaths (1.67 million) by 2015.1
Despite advances in treatment, survival rates from lung cancer in the UK have improved by only a few per cent in the last 40 years. The fiveyear survival rate for patients diagnosed between 1991 and 1993 was 5%.2 The EUROpean CAncer REgistry-based study on survival and CARE of cancer patients 4 (EUROCARE-4)3 has highlighted the difference in survival between England and other European countries. The fiveyear survival rate in England for patients diagnosed between 1995 and 1999 was 8.4% compared with the average European rate of 12%. These figures are in even greater contrast to reported five-year survival rates in the US of 15.7% for patients diagnosed between 1995 and 2001.4 Analysis of EUROCARE-4 also showed that one-year survival rates in England were lower than the European average, probably reflecting poorer access to care. This would suggest a particular need to promote earlier diagnosis in the UK, to try to improve survival.
Survival is dependent on the disease stage at diagnosis, with a marked variation between earlier- and later-stage disease. Five-year survival for localised disease is around 49% compared with 2% for disease with distant metastases at presentation.4 Unfortunately, the majority of lung cancers have already been disseminated at the time of presentation.4,5
Much interest has focused on diagnosing lung cancer earlier in order to try to improve radical treatment rates and reduce mortality. Initially, this interest focused on screening. The first randomised controlled trial took place in London in the 1960s.6 This looked at a chest X-ray every six months for three years versus a chest X-ray at the beginning and end of the three-year period. Diagnosis and resection rates were higher in the group receiving more frequent chest X-rays, but lung cancer mortality was similar in both groups. Three US studies7 in the 1970s and 1980s looked at the use of either chest X-ray alone or in combination with sputum cytology.
The Mayo Lung Project8 compared chest X-ray and sputum cytology every four months with standard care. Participants randomised to the standard care arm were advised to have a yearly chest X-ray and sputum cytology. This showed that resection rates increased by 14% (32–46%) in the group undergoing screening compared with the group receiving standard care alone, but no stage shift was evident. Fiveyear survival in the screened group reached 33% compared with 15% in the non-screened group.