Intended for healthcare professionals

Clinical Review

The changing epidemiology of lung cancer with a focus on screening

BMJ 2009; 339 doi: (Published 17 August 2009) Cite this as: BMJ 2009;339:b3053
  1. Gerard A Silvestri, professor of medicine1,
  2. Anthony J Alberg, associate professor of epidemiology 2,
  3. James Ravenel, associate professor of radiology3
  1. 1Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
  2. 2Hollings Cancer Center and Department of Biostatistics, Bioinformatics, and Epidemiology, Medical University of South Carolina
  3. 3Department of Radiology, Medical University of South Carolina
  1. Correspondence to: G A Silvestri silvestri{at}

    Summary points

    • Lung cancer is the most common cancer worldwide

    • Incidence varies greatly between countries because of the varying prevalence of cigarette smoking

    • The epidemic of lung cancer has just begun in developing countries, although a decrease is being seen in some developed countries

    • Screening for lung cancer using low dose computed tomography has not been proved to be efficacious

    • Several large randomised controlled trials to assess the efficacy of screening for lung cancer are under way

    • Screening for lung cancer cannot be recommended outside a well designed clinical trial

    Lung cancer is a global public health problem of epidemic proportions, and the number of people affected is expected to grow in the near future. Worldwide, in 2002 more than 1.3 million people were newly diagnosed with lung cancer.1 It is the leading global cause of death from cancer, and it accounts for 18% of all deaths from cancer and more than one million deaths a year since as far back as 1993.2 3 Lung cancer is the 10th leading overall cause of death, and it is expected to move to fifth place as its incidence rises in developing countries. Lung cancer is a disease that seems to fit the profile for a successful screening programme. However, developing an efficacious screening test that meets the established criteria for screening has proved elusive, despite evidence from many screening trials, and screening remains controversial. This review aims to shed light on the questions surrounding screening for lung cancer.

    What are the established causes of lung cancer?

    Active cigarette smoking is the main cause—it accounts for 85-90% of all lung cancers.2 w1-w5 In addition, exposure to secondhand cigarette smoke; pipe and cigar smoking; occupational exposure to agents such as asbestos, nickel, chromium, and arsenic; exposure to radiation, including radon gas in homes; and exposure to air pollution are all established …

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