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Lung Cancer Screening: Confession of a Skeptic

Ravenel, James G. MD

Journal of Thoracic Imaging: July 2012 - Volume 27 - Issue 4 - p 207
doi: 10.1097/RTI.0b013e318257f435
Editor's Section

Department of Radiology and Radiological Sciences, Medical University of South Carolina, Charleston, SC

Dr Ravenel receives royalties from Amirsys and received payment for lectures from Novant Health Care.

Reprints: James G. Ravenel, MD, Medical University of South Carolina, 96 Jonathan Lucas St MSC 323, Charleston, SC 29425 (e-mail:

I admit it. I was skeptical. At the start of the National Lung Screening Trial (NLST), I firmly believed that the results would recapitulate prior chest radiograph randomized trials. Screening would detect more cancers, detect more early stage cancers and have little or no impact on lung cancer mortality. In my view, joining the NLST as a site was important because it was scientifically rigorous and designed to answer the key question attached to screening. Moreover, if screening was not going to impact mortality, we could move on to refining and identifying high risk groups. I remember the day in the fall of 2010 when I heard the data monitoring safety board (DMSB) say it had an important announcement. Why when the trial was so close to final follow-up would they have something to say? It had to be that the trial was a positive trial, screening for lung cancer was a scientifically sound proposition. The DMSB confirmed that a 20% mortality reduction due to lung cancer had been seen with CT screening when compared to chest radiograph.

Great news? Or is it the dog who chased cars and finally caught one? The results of the NLST have changed many attitudes toward lung cancer screening from nihilism to hope, but the skeptic in me is plagued with many new questions. What will it cost? Who will pay for it? What about all those tiny nodules? How will this affect tobacco use and tobacco control? Will it bring a false sense of security to smokers? Does the at risk population even want to be screened?

To a large extent, many of these questions will eventually be answered from data contained within the NLST and ongoing European randomized trials. Much of the refinement in nodule management has already been driven from non-randomized screening trials, and it will be critical to continually refine these methods to mitigate against needless repeat studies and interventions.

This symposium is dedicated to lung cancer screening and perhaps should be dedicated to all participants of lung cancer screening trials who have been in many way pioneers of a new reality. They are the ones who have had to “sweat out” the false positives, undergo additional studies and invasive procedures that sometimes detected benign disease in search of a benefit that may or may not have been present.

This symposium is a collaborative project that has benefited from the help of many. I would like to thank all of the contributing authors and the editorial and publishing team at the Journal of Thoracic Imaging, without whom this symposium would not be possible.

We are at a new dawn in the fight against lung cancer with the realization that early detection can provide a benefit to those at greatest risk. I hope that the insights and information provided in this symposium provide a scaffolding on which to build and grow our knowledge to combat lung cancer, the number 1 cause of cancer deaths in the world.

© 2012 Lippincott Williams & Wilkins, Inc.