Lung Cancer is now the commonest cause of premature death in our
industrial conurbations. It presents late and tends to be investigated on prolonged
pathways, often with a stage shift along the way. Survival rates are closely related to
stage at diagnosis, leading to a number of approaches to early diagnosis, most of which
have not been validated as population screening tools. Most early screening trials used
imaging, sometimes supplemented by sputum cytology, and achieved improved
survival but did not reduce overall mortality, a rigorous benchmark that avoids the
pitfalls of lead-time bias and overdiagnosis. The landmark National Lung Cancer
Screening Study (NLST) a targeted screening study now nearly a decade old, achieved
a 20% mortality improvement but this did not lead to the clinical implementation of
screening programs in Europe or in the UK, where there is still an unaccountable
scepticism, despite recent confirmatory evidence that the targeted screening of highrisk
populations can save many lives. The Manchester implementation pilot used
community-based health-checks and CT scans to access a very deprived population,
detecting one lung cancer for every 23 scans, most at early stage and nearly all suitable
for curative-intent treatments, with the almost complete avoidance of inappropriate
interventions for non-malignant disease. Substantial numbers of non-malignant
respiratory and cardiac conditions were also identified and referred for treatment. The
programme is now being rolled out across the Greater Manchester conurbation and has
been incorporated into the NHS Long-term Plan. It is to be hoped that the
implementation of targeted screening, together with a step-change in the pace of
diagnostic and treatment pathways, will start to make a real difference, assisted by a reinvigoration
of evidence-based smoking cessation programmes for this uniquely
preventable disease.
Keywords: Cytology, DNA biomarkers, Fluorescence bronchoscopy, Lung
cancer, Mortality, NHS plan, Risk-assessment, Screening, Stage-shift, VOC’s.
