Commentary: lung cancer screening--progress or peril.

INTRODUCTION Two reviews of lung cancer screening have been presented in this journal across the last two journal issues [1, 2]. These articles differ markedly in content and tone. Lung cancer screening is a topic that has commanded considerable recent attention. This is a result, in part, of the fact that this cancer is the leading cause of cancer death worldwide, with a 15%, 5-year survival rate in the U.S. [3]. Considerable attention may also be related to the numerous papers reporting the utility of spiral computed tomography (CT) to find early lung cancer. Most notable was the recent report of an international observational trial using spiral CT screening in a cohort of 31,000 generally high-risk individuals suggesting that the stage I disease detection rate and 10-year survival rate could both exceed 80% [4]. Adding to the media attention was a second article some months later that was a modeling report analyzing data from three previously published trials involving 3,246 individuals [5]. The central finding of that article was that the use of spiral CT screening may not reduce the risk for dying from lung cancer in a meaningful way. Both articles were extensively discussed in a variety of forums. The issue to the readership of The Oncologist, who may be called upon to provide patient recommendations in this context, is what to make of this confusing situation. From a general perspective, it is evident that, even outside lung cancer, there is much controversy about the cost, complexity, and feasibility of providing cancerscreening services [6, 7]. For gold standard– evaluated screening services, such as with breast cancer and colon cancer, there is a major challenge in how to effectively deliver these services [8, 9]. For prostate cancer, where the level of evidence supporting a benefit from screening for prostate-specific antigen (PSA) is classified by the U.S. Preventive Services Task Force as comparable with lung cancer screening, the Center for Medicare and Medicaid Services provides reimbursement nationally for PSA screening [10]. The American Cancer Society [11] recommends that PSA testing and digital rectal examination be offered annually, starting at age 50, for men who have a life expectancy of at least 10 years, but expresses concerns about the strength of the data supporting that recommendation. This confusion is further reflected in the current situation, with more states mandating that insurers cover PSA screening compared with colon cancer screening, despite the strength of the recommendation from the U.S. Preventive Services Task Force [10] being much stronger for colon cancer screening. The issue of lung cancer screening has recruited considerable attention from authors who have also previously published extensively on the issue of breast cancer screening [12–14]. In a recent paper, these authors have taken issue with a number of issues with lung cancer screening that include concerns previously discussed in the context of breast cancer [15, 16]. The very long-standing controversy about breast cancer screening took a major coordinated screening benefit modeling effort to resolve [17, 18]. In part, this controversy re-