Survival of Patients With Stage I Lung Cancer Detected On CT SCR 2006

new england
The
journal of medicine
established in 1812 october 26, 2006 vol. 355 no. 17
Survival of Patients with Stage I Lung Cancer

Detected on CT Screening
The International Early Lung Cancer Action Program Investigators*
A bs t r ac t
Background
The outcome among patients with clinical stage I cancer that is detected on annual The members of the Writing Committee
screening using spiral computed tomography (CT) is unknown. (Claudia I. Henschke, M.D., Ph.D., David F.
Yankelevitz, M.D., Daniel M. Libby, M.D.,
Mark W. Pasmantier, M.D., and James P.
Methods Smith, M.D., New York Presbyterian Hos-
In a large collaborative study, we screened 31,567 asymptomatic persons at risk for pital–Weill Medical College of Cornell Uni-
versity, New York; and Olli S. Miettinen,
lung cancer using low-dose CT from 1993 through 2005, and from 1994 through M.D., Ph.D., McGill University, Montre-
2005, 27,456 repeated screenings were performed 7 to 18 months after the previ- al) of the International Early Lung Cancer
ous screening. We estimated the 10-year lung-cancer–specific survival rate among Action Program assume responsibility
for the overall content and integrity of the
participants with clinical stage I lung cancer that was detected on CT screening and article. Address reprint requests to Dr. Hen-
diagnosed by biopsy, regardless of the type of treatment received, and among those schke at New York Presbyterian Hospi-
who underwent surgical resection of clinical stage I cancer within 1 month. A pathol- tal–Weill Medical College of Cornell Univer-
sity, 525 E. 168th St., New York, NY 10021,
ogy panel reviewed the surgical specimens obtained from participants who under- or at [email protected].
went resection.
*The International Early Lung Cancer Ac-
tion Program investigators are listed in
Results the Appendix.
Screening resulted in a diagnosis of lung cancer in 484 participants. Of these par-
ticipants, 412 (85%) had clinical stage I lung cancer, and the estimated 10-year sur- N Engl J Med 2006;355:1763-71.
Copyright © 2006 Massachusetts Medical Society.
vival rate was 88% in this subgroup (95% confidence interval [CI], 84 to 91). Among
the 302 participants with clinical stage I cancer who underwent surgical resection
within 1 month after diagnosis, the survival rate was 92% (95% CI, 88 to 95). The
8 participants with clinical stage I cancer who did not receive treatment died within
5 years after diagnosis.
Conclusions
Annual spiral CT screening can detect lung cancer that is curable.
n engl j med 355;17 www.nejm.org october 26, 2006 1763

The New England Journal of Medicine
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The n e w e ng l a n d j o u r na l of m e dic i n e
I
n 1993, the early lung cancer action nodule 8 mm or more in diameter, or a solid en-
Project (ELCAP) initiated a study of the early dobronchial nodule.10 If none of the noncalcified
diagnosis of lung cancer in cigarette smokers nodules identified met the study criteria for a posi-
with the use of annual screening with spiral com- tive result or if the test was negative, CT was re-
puted tomography (CT).1,2 The principal finding peated 12 months later. The diameter of the nodule
was that more than 80% of persons given a diag- was defined as the average of the length and width
nosis of lung cancer as a result of annual CT screen- of the cross-sectional area of the largest nodule
ing had clinical stage I cancer.3 This result has in the CT images. The consistency of the nodule
been confirmed by others4 who have adopted the was defined as solid if the nodule obscured the
updated protocol.5,6 The question remains, how- entire lung parenchyma, partly solid if it obscured
ever, whether early intervention in such patients part of the lung parenchyma, and nonsolid if it
is sufficiently effective to justify screening large obscured none of the parenchyma.11 If the result
asymptomatic populations who are at risk for lung was positive, the type of workup depended on the
cancer.7,8 We report the results of all patients in the diameter of the largest nodule. For nodules 5 to
study with stage I lung cancer detected with the 14 mm in diameter, the preferred option was to
use of spiral CT screening, including those who perform another CT at 3 months; if the images
underwent surgical resection. showed growth of the nodule,12 then biopsy, ide-
ally by fine-needle aspiration, was to be performed,
Me thods whereas if there was no growth, the workup was
stopped. The other option was to perform posi-
Screening was defined according to the Interna- tron-emission tomography (PET) immediately,
tional ELCAP (I-ELCAP) protocol6 so that data and if the results were positive, biopsy was to be
from participating institutions could be pooled. performed; otherwise, CT was to be performed
Each institution was required to document the at 3 months. For nodules 15 mm in diameter or
initiation of screening in each participant and all larger (whether solid, partly solid, or nonsolid),
subsequent screenings of that participant for as immediate biopsy was an option in addition to the
long as the screening continued, transmit the data options already specified for smaller nodules.
and images to the coordinating center at Weill When infection was suspected, a 2-week course
Medical College of Cornell University by means of antibiotics followed 1 month later by CT was an
of the study’s Web-based management system for alternative to all the options mentioned,13 and
CT screening for lung cancer,9 submit pathologi- if no resolution or growth was observed, biopsy
cal specimens to the coordinating center, and fol- was to be performed; otherwise, the workup was
low quality-assurance procedures specified by the stopped. For all participants for whom the workup
protocol. All participants gave written informed was stopped or for whom the biopsy did not lead
consent, and the institutional review board at to a diagnosis of lung cancer, CT was to be re-
each participating institution approved the pro- peated 12 months after the baseline CT.
tocols (Fig. 1). For annual screenings, a positive result was
The protocol specified a common regimen of considered to be any newly identified noncalci-
screening but allowed each participating institu- fied nodule, regardless of size. If no new nodule
tion to specify its criteria for enrollment. The regi- was identified, CT was to be repeated 12 months
men included the technical variables for the initial later. If one or more new nodules were identified,
low-dose spiral CT scan, which were the same for the workup depended on the diameter of the larg-
the baseline and annual screenings. However, the est nodule. If all nodules were less than 3.0 mm
definition of a positive result on the initial CT scan in diameter, or if the largest nodule was more
and the diagnostic workup leading to a diagnosis than 3.0 mm but less than 5.0 mm in diameter, CT
of lung cancer were different for the baseline 6 or 3 months later, respectively, was to be per-
screening and annual screening. formed. If no growth was seen in any of the nod-
For baseline screening, a positive result on the ules, the workup was stopped. If at least one of
initial low-dose CT scan was defined as the iden- the noncalcified nodules was 5.0 mm or larger in
tification of at least one solid or partly solid non- diameter, then an immediate 2-week course of a
calcified pulmonary nodule 5 mm or more in diam- broad-spectrum antibiotic was prescribed, followed
eter, at least one nonsolid noncalcified pulmonary 1 month later by CT. If the nodules showed no
1764 n engl j med 355;17 www.nejm.org october 26, 2006

stage i lung cancer detected on ct screening
31,567 Asymptomatic participants

27,456 Annual screenings
underwent baseline screening
4186 Had at least 1 solid or 27,381 Had no nodule or 1460 Showed newly identified 25,996 Showed no newly identi-
partly solid nodule ≥5 mm nodules not qualifying as noncalcified nodules fied noncalcified nodules
in diameter or had at least a positive result
1 nonsolid nodule ≥8 mm
in diameter
Baseline management Workup within 12 mo after Annual management algorithm Workup within 12 mo after
algorithm initial CT prompted previous CT prompted
by symptoms by symptoms
405 Found to have lung 5 Received interim diagnosis 74 Showed lung cancer None received interim diagnosis
cancer on baseline CT of lung cancer on annual CT of lung cancer
484 Received a diagnosis

of lung cancer
412 Had clinical stage I

lung cancer
Figure 1. Diagnoses of Lung Cancer Resulting from Baseline Screening and Annual Screening with CT.
6
A description of the I-ELCAP management algorithm
ICM
for baseline
AUTHOR: CT and repeated RETAKE
Henschke CT screening
1st is available in the study protocol.
FIGURE: 1 of 2 2nd
REG F
3rd
CASE Revised
resolution or growth, biopsy was to be performed;
EMail
documentation
Line of the workup
4-C SIZE
in the management
ARTIST: ts
otherwise, the workup was stopped. PET Enon was an system. After
H/T the
H/T diagnosis of lung cancer was
39p6
Combo
alternative to immediate biopsy; if the result was established, the type of intervention, if any, was
AUTHOR, PLEASE NOTE:
positive, biopsy was to follow. If the result was
Figure leftredrawn
has been to theanddiscretion
type has been of the participant and the
reset.
indeterminate or negative, CT was to be performed physician.Please check carefully.
Documentation in the management
3 months later, and if the scans showed growth, system of the timing
JOB: 35517
and type of intervention, if
ISSUE: 10-26-06
biopsy was to follow. Otherwise, the workup was any, and follow-up with respect to manifestations
stopped. For all patients for whom the workup was of spread or death up to 10 years after diagnosis,
stopped or when biopsy did not result in a diag- were required.
nosis of lung cancer, CT was to be repeated 12 A total of 31,567 asymptomatic men and wom-
months after the previous annual CT. en underwent baseline screening between 1993
The protocol provided recommendations for and 2005 (median, 2001). The participants, who
the diagnostic workup in participants with a posi- were 40 years of age and older, were at risk for lung
tive result on CT, with the decision regarding how cancer because of a history of cigarette smoking,
to proceed left to each participant and the refer- occupational exposure (to asbestos, beryllium, ura-
ring physician. The I-ELCAP protocol did not re- nium, or radon), or exposure to secondhand smoke
quire that its recommendations for the workup without having smoked themselves; in Azumi,
of a nodule be followed, but it did require a firmly Japan, they participated as part of the annual
established final diagnosis of lung cancer and health screening program (Table 1). All partici-

ment interim diagnoses of lung cancer, the proto-

Table 1. I-ELCAP Participants, According to the Smoking Status, Exposure
to Secondhand Smoke, and Occupational Exposures. col required that each enrolled participant who
had not returned for the next scheduled screen-
Participants ing be contacted 1 year after the previous screen-
Program (N = 31,567)
ing. If contact could not be made either directly or
no. (%)
through relatives of the participant, the referring
Azumi Health Care Program in Japan
physician was contacted to ascertain whether a
Current or former smokers 3,087 (10)
diagnosis of lung cancer had been made.
Persons who had never smoked with exposure 3,299 (10)
to secondhand smoke We determined the distribution of the base-
Programs in the United States, Europe, Israel, and China line and annual screenings and the resulting diag-
Current or former smokers 23,052 (73) noses according to age and median pack-years
Persons who had never smoked of cigarette smoking (Table 2). Each diagnosis
Occupational exposure* 1,690 (5) of lung cancer was classified according to clinical
Exposure to secondhand smoke with or without 439 (1) stage with the use of standard criteria based on
family history of lung cancer the clinical examination and the results of imag-
ing.14 The presence or absence of lymph-node (N)
* This category includes exposure to asbestos, beryllium, uranium, or radon. and distant metastases (M) was assessed on the
most recent CT obtained before diagnosis and
pants were considered fit to undergo thoracic from PET (performed in 166 of the 484 partici-
surgery. A total of 27,456 annual screenings were pants who received a diagnosis of lung cancer).
conducted between 1994 and 2005 (median, 2002), The cancer was classified as N0M0 if on CT the
each of which was performed 7 to 18 months widths of all mediastinal lymph nodes were less
after the previous screening. At baseline, the me- than 10 mm and no hilar lymph nodes or distant
dian age of the participants was 61 years (range, metastases were identified (and PET, if performed,
40 to 85), and the median number of pack-years showed no abnormal uptake). For the purpose
of smoking was 30 (range, 0 to 141); on annual of this study, stage I cancers included those clas-
CT, the median values were an age of 62 years sified as N0M0 with more than 1 adenocarcinoma
(range, 41 to 86) and 35 pack-years (range, 0 to so long as all adenocarcinomas were 30 mm or
141). Among the participants, 13% (4186 of 31,567) less in diameter.6
who underwent baseline CT and 5% (1460 of The specimens obtained from participants who
27,456) who underwent annual CT had a positive underwent surgical resection were examined at
result that required immediate further workup. each institution according to the I-ELCAP pathol-
A biopsy of a pulmonary nodule as recommended ogy protocol,15 which specified the preparation
in the protocol was performed in 535 of the par- of the specimen and the findings that were to be
ticipants with a positive result on the baseline documented by the pathologist at the hospital
or annual CT and led to a diagnosis of malignant where the resection was performed. The protocol
disease in 492 of the participants (lung cancer was also specified the review process: a five-member
diagnosed in 479 and lymphoma or metastases pathology-review panel consisting of expert pul-
from cancers other than lung cancer in 13) and no monary pathologists was to reach a consensus
evidence of malignant disease in 43. The diagno- diagnosis for each case of cancer and identify
sis was classified as having been identified dur- lymph-node involvement, additional cancers, and
ing baseline screening when the nodule was first pleural, lymphatic, vascular, bronchial, and base-
identified on the baseline CT, even for cases not ment-membrane invasion by the cancer. For 22 of
meeting the criteria for a positive result, regardless the 411 participants who underwent resection
of when the diagnosis was made. When the nod- (5%), specimens could not be obtained from a non-
ule was first identified on an annual CT, it was participating hospital, and the panel therefore re-
attributed to the annual screening. If the result on viewed the detailed surgical and pathological re-
the baseline or annual CT was negative and a di- ports for the relevant information.
agnostic workup was subsequently prompted by All patients given a diagnosis of lung cancer
suggestive symptoms (or incidental findings) be- were followed annually by the principal investi-
fore the next scheduled annual CT, the finding was gator and by the study coordinator at each partici-
classified as an interim diagnosis. To fully docu- pating institution, who submitted the information

Table 2. Frequency Distribution of Lung-Cancer Diagnoses on Baseline and Annual CT Screening, According to Age and Median Pack-Years
of Cigarette Smoking.
Age Baseline Screening Annual Screening

Smoking History No. Screened Diagnosis of Lung Cancer Smoking History No. Screened Diagnosis of Lung Cancer
median pack-yr no. (%) median pack-yr no. (%)
40–49 yr 15 4,066 8 (<1) 20 1,324 1 (<1)
50–59 yr 28 9,948 67 (1) 30 6,678 7 (<1)
60–69 yr 38 12,184 206 (2) 40 11,879 29 (<1)
70–79 yr 38 4,840 116 (2) 40 6,692 33 (<1)
80–86 yr 30 529 13 (2) 37 883 4 (<1)
Total 30 31,567 410 (1)* 35 27,456 74 (<1)
* The number includes five participants with interim diagnoses.
required by the protocol to the coordinating center. 484 participants given a diagnosis of lung cancer,
When a participant was known to have died, the 411 underwent resection; 57 received radiation,
date and cause were obtained from the participant’s chemotherapy, or both; and 16 received no treat-
physician, family members, or both. Death result- ment. Because survival rates among the partici-
ing from treatment was considered to have been pants who underwent baseline screening and those
caused by lung cancer. Follow-up from diagnosis who underwent annual screening did not differ
to death from lung cancer, the last contact, or May significantly, Kaplan–Meier estimates of lung-can-
30, 2006, whichever came first, was document- cer–specific survival were calculated for all 484
ed for each participant. The duration of follow- participants (Fig. 2). The estimated 10-year sur-
up ranged from 1 to 123 months (median, 40). vival rate for all participants, regardless of tumor
Kaplan–Meier curves were calculated for lung- stage and treatment, was 80% (95% confidence
cancer–specific survival as of the date of diagno- interval [CI], 74 to 85); as of May 2006, 75 of the
sis, irrespective of the type of treatment, includ- 484 participants had died of lung cancer, includ-
ing no treatment, for all participants with lung ing 2 who died within 4 weeks after surgery, yield-
cancer, irrespective of the stage of the cancer, and ing an operative mortality rate of 0.5% (2 of 411
for the subgroup with clinical stage I cancer. Sur- participants).
vival curves were also calculated for participants Of the 484 participants who received a di-
who underwent resection of clinical stage I can- agnosis of lung cancer, 412 (85%) had clinical
cer within 1 month after diagnosis and those who stage I lung cancer. In this subgroup, the esti-
did not receive treatment. On the basis of these mated 10-year survival rate regardless of treat-
curves, we estimated the 10-year survival rates. ment was 88% (95% CI, 84 to 91); as of May 2006,
The curves were constructed with the use of SAS 39 of these 412 patients had died of lung cancer.
statistical software (version 8), which also pro- Of these 412 participants, 375 had undergone
duced the standard error for the estimates. surgical resection (284 lobectomy, 60 wedge re-
section, 21 segmentectomy, and 10 bilobectomy);
R e sult s 29 did not undergo resection but received che-
motherapy, radiation, or both; and the remaining
Baseline screening of 31,567 asymptomatic per- 8 did not receive treatment. Figure 2 also shows
sons who were at risk for lung cancer and annual the lung-cancer–specific survival rate among the
screening of 27,456 resulted in the diagnosis of 302 participants who underwent resection with-
lung cancer in 405 and 74 participants, respec- in 1 month after diagnosis, among whom the es-
tively (Fig. 1). Another five participants received timated 10-year survival rate was 92% (95% CI,
interim diagnoses of lung cancer that were prompt- 88 to 95). All eight untreated patients died within
ed by the development of symptoms within 12 5 years after diagnosis.
months after the baseline screening. Of these Among the 412 participants with clinical

who underwent resection according to World

100 Resected clinical stage I cancer, 92% (95% CI, 88–95)
Health Organization criteria of 2004.16 With re-
gard to spread or invasion (Table 4), the panel
80 All lung cancers, 80% (95% CI, 74–85) identified lymph-node metastases (hilar or ipsi-
lateral mediastinal) in 28 participants (7%) and
Survival (%)
60
more than one cancer, either in the same or in
40 different lobes, in another 35 (9%). Among the re-
maining participants, each with a solitary cancer,
20
the panel identified invasion of the pleura in 62
0
(17%); bronchial, vascular, or lymphatic invasion
0 12 24 36 48 60 72 84 96 108 120 or a combination in another 28 (7%); invasion of
Months the basement membrane alone in 203 (54%), and
No. at Risk no invasion in the remaining 19 (5%). (Because of
All participants 484 433 356 280 183 90 50 28 16 9 2 rounding, percentages may not total 100.) Thus,
Participants 302 280 242 191 120 59 34 18 12 7 1
undergoing of the 375 participants who underwent resection,
resection 347 had pathological stage I cancer, and their es-
Figure 2. Kaplan–Meier Survival Curves for 484 Participants with Lung timated 10-year survival rate was 94% (95% CI,
Cancer and 302 Participants with Clinical Stage I Cancer Resected 91 to 97).
within 1 MonthICM
after AUTHOR:
Diagnosis.
Henschke RETAKE 1st
FIGURE: 2nd
The diagnosesREGwere
F made on2the
of 2basis of CT screening at baseline com- Dis cus sion
3rd
bined with cycles
CASE of annual CT. Revised
Line 4-C
EMail
ARTIST: ts H/T H/T
SIZE In making decisions about instituting CT screen-
22p3
Enon
Combo ing for lung cancer, a major consideration is the
Table 3. Types of Cancer among AUTHOR, PLEASE NOTE:
412 Participants with Clinical Stage I Lung outcome of treating a cancer detected on screen-
Figure has been redrawnCT
andScreening.
type has been reset.
Cancer Detected on Baseline or Annual
Please check carefully. ing. In our study, the estimated 10-year lung-can-
Diagnosed on Baseline Diagnosed on
cer–specific survival rate among the 484 partici-
JOB: 35517 Screening ISSUE: 10-26-06
Annual Screening pants with disease diagnosed on CT, regardless
Type of Cancer (N = 348) (N = 64) of the stage at diagnosis or type of treatment (in-
no. of participants cluding no treatment), was 80% (95% CI, 74 to 85)
Adenocarcinoma (Fig. 2). Among the 412 participants with clini-
Bronchioloalveolar subtype 20 1
cal stage I lung cancer — the only stage at which
cure by surgery is highly likely — the estimated
Other subtypes 243 30
10-year survival rate was 88% (95% CI, 84 to 91),
Squamous cell 45 14 and among those with clinical stage I lung cancer
Adenosquamous 3 0 who underwent surgical resection within 1 month
Non–small-cell* 5 2 after the diagnosis, the rate was 92% (95% CI, 88
Neuroendocrine
to 95). The diagnosis of lung cancer of one type
or another was verified by a panel of five expert
Atypical carcinoid 2 1
pulmonary pathologists. In our series, the opera-
Large cell 15 8 tive mortality rate was low — 0.5% — and was less
Small cell 9 7 than the 1.0% reported with lobectomy in a large
Other 6 1 cooperative study.17
Sobue et al.18 reported a 5-year survival rate of
* If this cell type cannot be differentiated, the category is known as “not other- 100% in their series of 29 patients who underwent
wise specified.”
resection after pathological stage I cancer was
detected on CT. Before CT screening, reports based
stage I cancer, the distribution according to the on registries showed 10-year survival rates of 80%
type of cell is shown in Table 3. The median tu- among 17 patients with pathological stage I lung
mor diameter was 13 mm at baseline and 9 mm cancer 20 mm or less in diameter19 and 93% among
on annual CT. The pathology-review panel con- 35 patients with pathological stage I cancer less
firmed the diagnosis of clinical stage I cancer in than 10 mm in diameter.20 The National Cancer
the specimens obtained from the 375 participants Institute’s Surveillance, Epidemiology, and End

Table 4. Extent of Spread of Cancer in 375 Participants Who Underwent Resection of Clinical Stage I Lung Cancer
According to Whether Cancer was Detected on Baseline or Annual CT Screening.
Diagnosed on Diagnosed on
Baseline Screening Annual Screening
Extent of Spread (N = 320) (N = 55)
no. of participants
Metastases to lymph nodes 22 6
No metastases to lymph nodes
More than 1 cancer 29 6
Solitary cancer with invasion
Pleural invasion 51 11
No pleural invasion but lymphatic, vascular, or bronchial spread 24 4
(or a combination)
Basement membrane only 175 28
Solitary cancer without invasion 19 0
Results (SEER) registry, the largest U.S. cancer who were former and current smokers 60 years
registry, reported an 8-year survival rate of 75% of age and older,1,2 was more productive in detect-
among patients with pathological stage I cancer ing lung cancer (detection rates, 2.7% on baseline
with nodules less than 15 mm in diameter who had screening and 0.6% on annual screening) than
undergone resection.8 Although the lung cancers among participants in the expanded study. The
in these three series were not detected on CT cost of low-dose CT is below $200,23-26 and sur-
screening, most were presumably incidentally de- gery for stage I lung cancer is less than half the
tected on imaging performed for other reasons cost of late-stage treatment.26,27 Using the origi-
in people who had no symptoms of lung cancer. nal ELCAP data and the actual hospital costs for
CT screening according to the I-ELCAP regimen the workup, we found CT screening for lung can-
can detect clinical stage I lung cancer in a high cer to be highly cost-effective.23 Other estimates
proportion of persons when it is curable by surgery. of the cost-effectiveness of CT screening for lung
In a population at risk for lung cancer, such screen- cancer for various risk profiles24-26,28 are similar
ing could prevent some 80% of deaths from lung to that for mammography screening.29,30
cancer. In comparison, in the United States at pres- Supported in part by the National Institutes of Health (grants
ent, annually approximately 173,000 persons are R01-CA-633931, to Dr. Henschke, and R01-CA-78905, to Dr. Yan-
diagnosed with lung cancer and 164,000 deaths kelevitz); the Department of Energy (DE-FG02-96SF21260, to Dr.
Markowitz); the Department of Defense to Dr. Tockman; Depart-
are attributed to this disease,21 so that approxi- ment of Health and Mental Hygiene of the City of New York; New
mately 95% of those who are diagnosed with lung York State Office of Science, Technology, and Academic Research;
cancer die from it. American Cancer Society; Israel Cancer Association; Starr Foun-
dation; New York Community Trust; Rogers Family Fund; Foun-
Are these results sufficiently effective to justify dation for Lung Cancer: Early Detection, Prevention, and Treat-
screening people who are at risk of lung cancer? ment; Foundation for Early Detection of Lung Cancer; Dorothy
As compared with mammographic screening for R. Cohen Foundation; Research Foundation of Clinic Hirslanden;
Clinic Hirslanden; Swedish Hospital; Yad-Hanadiv Foundation;
breast cancer, for lung cancer the rates of detec- Jacob and Malka Goldfarb Charitable Foundation; Auen–Berger
tion among the participants in this study who Foundation; Princess Margaret Foundation; Tenet Healthcare
were 40 years of age and older were 1.3% on base- Foundation; Ernest E. Stempel Foundation, Academic Medical
Development; Empire Blue Cross and Blue Shield; Eastman Kodak;
line CT screening and 0.3% on annual screening General Electric; Weill Medical College of Cornell University; New
(Table 2), values that were slightly higher than York Presbyterian Hospital; Christiana Care Helen F. Graham Can-
those for the detection of breast cancer (0.6 to cer Center; Holy Cross Hospital; Eisenhower Hospital; Jackson
Memorial Hospital Health System; and Evanston Northwestern
1.0% on baseline screening) and similar to those Healthcare.
for annual screening (0.2 to 0.4%) among wom- Drs. Henschke and Yankelevitz report receiving royalties from
en 40 years of age and older.22 The rate of cancer Cornell Research Foundation as inventors of methods to assess
detection depends on the risk profile of those un- tumor growth and regression on imaging tests for which pend-
ing patents are held by Cornell Research Foundation and li-
dergoing screening; the higher the risk, the more censed to General Electric. No other potential conflict of inter-
productive the screening. Thus, as expected, CT est relevant to this article was reported.
screening of the original participants in ELCAP,
appendix
The following investigators participated in I‑ELCAP: Joan and Sanford I. Weill Medical College of Cornell University, New York: C.I. Henschke
(principal investigator), D.F. Yankelevitz, D.I. McCauley; Azumi General Hospital, Nagano, Japan: S. Sone, T. Hanaoka; Center for the Biology of
Natural Systems, City University of New York at Queens College, Queens: S. Markowitz, A. Miller; LungenZentrum Hirslanden, Zurich: K. Klingler, T.
Scherer, R. Inderbitzi; Clinica Universitaria de Navarra, Pamplona, Spain: J. Zulueta, L. Montuenga, G. Bastarrika; National Cancer Institute Re-
gina Elena, Rome: S. Giunta, M. Crecco, P. Pugliese; H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL: M. Tockman; Hadassah Medical
Organization, Jerusalem, Israel: D. Shaham; Swedish Medical Center, Seattle: K. Rice, R. Aye; University of Toronto, Princess Margaret Hospital, Toronto:
H. Roberts, D. Patsios; Christiana Care Helen F. Graham Cancer Center, Newark, DE: T. Bauer, J. Lally; Columbia University Medical Center, New York:
J.H.M. Austin, G.D.N. Pearson; New York University Medical Center, New York: D. Naidich, G. McGuinness; State University of New York at Stony
Brook, Stony Brook: M. Rifkin, E. Fiore; Maimonides Medical Center, Brooklyn, NY: S. Kopel; Roswell Park Cancer Institute, Buffalo, NY: D. Klippen-
stein, A. Litwin, P.A. Loud; State University of New York Upstate Medical University, Syracuse: L.J. Kohman, E.M. Scalzetti; North Shore–Long Island
Jewish Health System, New Hyde Park, NY: A. Khan, R. Shah; Georgia Institute for Lung Cancer Research, Atlanta: M.V. Smith, H.T. Williams, L.
Lovett; Mount Sinai School of Medicine, New York: D.S. Mendelson; Jackson Memorial Hospital, University of Miami, Miami: R. Thurer; Memorial
Sloan-Kettering Cancer Center, New York: R.T. Heelan, M.S. Ginsberg; Holy Cross Hospital Cancer Institute, Silver Spring, MD: F. Sullivan, M. Ot-
tinger; Eisenhower Lucy Curci Cancer Center, Rancho Mirage, CA: D. Vafai; New York Medical College, Valhalla: T.A.S. Matalon; Mount Sinai Compre-
hensive Cancer Center, Miami Beach, FL: S.-L. Odzer; Fifth Affiliated Hospital (Zhuhai Hospital), of Sun Yat-Sen University, Zhuhai, China: X. Liu; Dorothy
E. Schneider Cancer Center, Mills-Peninsula Health Services, San Mateo, CA: B. Sheppard; St. Agnes Cancer Center, Baltimore: E. Cole; Our Lady of Mercy
Medical Center, Bronx, NY: P.H. Wiernik; Evanston Northwestern Healthcare Medical Group, Evanston, IL: D. Ray; Karmanos Cancer Institute, Detroit: H.
Pass, C. Endress; Greenwich Hospital, Greenwich, CT: D. Mullen; Sharp Memorial Hospital, San Diego, CA: M. Kalafer; City of Hope National Medical
Center, Duarte, CA: F. Grannis, A. Rotter; ProHealth Care Regional Cancer Center, Waukesha and Oconomowoc Memorial Hospitals, Oconomowoc, WI:
M.K. Thorsen, R. Hansen; Comprehensive Cancer Center, Desert Regional Medical Center, Palm Springs, CA: E. Camacho; St. Joseph Health Center, St.
Charles, MO: D. Luedke; Coordinating Center: C.I. Henschke, N. Altorki, A. Farooqi, J. Hess, D. Libby, D.I. McCauley, O.S. Miettinen, J.
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Iguassu Falls, Brazil Tricia Woo, M.D.


Survival of Patients With Stage I Lung Cancer Detected On CT SCR 2006

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Survival of Patients With Stage I Lung Cancer Detected On CT SCR 2006

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new england

Survival of Patients with Stage I Lung Cancer

n engl j med 355;17 www.nejm.org october 26, 2006 1763

1764 n engl j med 355;17 www.nejm.org october 26, 2006

The New England Journal of Medicine

31,567 Asymptomatic participants

484 Received a diagnosis

412 Had clinical stage I

n engl j med 355;17 www.nejm.org october 26, 2006 1765

ment interim diagnoses of lung cancer, the proto-

1766 n engl j med 355;17 www.nejm.org october 26, 2006

The New England Journal of Medicine

Age Baseline Screening Annual Screening

* The number includes five participants with interim diagnoses.

n engl j med 355;17 www.nejm.org october 26, 2006 1767

who underwent resection according to World

1768 n engl j med 355;17 www.nejm.org october 26, 2006

The New England Journal of Medicine

1770 n engl j med 355;17 www.nejm.org october 26, 2006

The New England Journal of Medicine

Iguassu Falls, Brazil Tricia Woo, M.D.

n engl j med 355;17 www.nejm.org october 26, 2006 1771

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