Diagnosis of Lung Cancer – Improving Survival Rates

European Oncology, 2010;6(2):26-30

Abstract:

Lung cancer is a major global health burden with high incidence rates but poor long-term survival. Currently, the majority of cases are diagnosed at an advanced stage when surgical resection is not feasible. Screening for lung cancer has been a major focus of research for the last 40 years. Despite this, there is still a lack of evidence to promote its use outside clinical trials. More recently, interest has focused on promoting earlier recognition of symptomatic disease among both the general public and primary care physicians in order to encourage more timely investigation and referral to secondary care. The hope is that this approach may increase the proportion of disease identified in the early stages, allowing more surgical resections and improved five-year survival rates. This article provides an overview of the current evidence base in terms of early diagnosis of lung cancer and provides some examples of innovations to promote this.
Keywords: Lung cancer, early diagnosis, screening, social marketing
Disclosure: The authors have no conflicts of interest to declare.
Received: July 01, 2010 Accepted July 29, 2010 Citation European Oncology, 2010;6(2):26-30
Correspondence: Victoria L Athey, Clinical Research Fellow, Chest Clinic, Doncaster Royal Infirmary, Armthorpe Road, Doncaster, DN2 5LT, UK. E: v.athey@sheffield.ac.uk

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

Screening
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.

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Keywords: Lung cancer, early diagnosis, screening, social marketing