Acknowledgments
The authors would like to thank Kathryn Krages, A.M.L.S., M.A.; Susan Wingenfeld; and Kim Peterson, M.S., for their help in preparation of the full Systematic Evidence Review and this manuscript. They also thank Mark Helfand, M.D., M.P.H.; William Holden, M.D.; John McAnulty, M.D.; and James Reuler, M.D., for their helpful reviews of the manuscript.
This study was conducted by the Oregon Health & Science University Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality Contract No. 290-97-0018, Task Order No. 2, Rockville, MD.
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References
1. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion; 1996
2. American Cancer Society. Cancer Facts and Figures 2003. Available at: http://www.cancer.org/downloads/STT/CAFF2003PWSecured.pdf. Accessed March 11, 2004.
3. Strauss GM. Bronchiogenic carcinoma. Textbook of Pulmonary Diseases, 6th ed. Philadelphia, PA: Lippincott-Raven Publishers; 1998.
4. Zang EA, Wynder EL. Differences in lung cancer risk between men and women: examination of the evidence. J Natl Cancer Inst 1996;88(3-4):183-92.
5. Strauss GM. Screening for lung cancer: An evidence-based synthesis. Surg Oncol Clin N Am 1999;8(4):747-74, viii.
6. Osann KE. Lung cancer in women: the importance of smoking, family history of cancer, and medical history of respiratory disease. Cancer Res 1991;51(18):4893-7.
7. Tockman MS, Anthonisen NR, Wright EC, Donithan MG. Airways obstruction and the risk for lung cancer. Ann Intern Med. 1987;106(4):512-8.
8. Hole DJ, Watt GC, Davey-Smith G, Hart CL, Gillis CR, Hawthorne VM. Impaired lung function and mortality risk in men and women: findings from the Renfrew and Paisley prospective population study. BMJ 1996;313(7059):711-5; discussion 715-6.
9. Trichopoulos D, Mollo F, Tomatis L, et al. Active and passive smoking and pathological indicators of lung cancer risk in an autopsy study. JAMA 1992;268(13):1697-701.
10. Davila DG, Williams DE. The etiology of lung cancer. Mayo Clin Proc 1993;68(2):170-82.
11. Morbidity and Mortality Weekly Report. Cigarette smoking among adults—United States, 1999. MMWR 2001;50(40):869-73.
12. Tonnesen P, Norregaard J, Simonsen K, Sawe U. A double-blind trial of a 16-hour transdermal nicotine patch in smoking cessation. N Engl J Med. 1991;325(5):311-5.
13. Hurt RD, Sachs DP, Glover ED, et al. A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med. 1997;337(17):1195-202.
14. Jorenby DE, Leischow SJ, Nides MA, et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med. 1999;340(9):685-91.
15. Burns DM. Primary prevention, smoking, and smoking cessation: implications for future trends in lung cancer prevention. Cancer 2000;89(11 Suppl):2506-9.
16. Halpern MT, Gillespie BW, Warner KE. Patterns of absolute risk of lung cancer mortality in former smokers. J Natl Cancer Inst 1993;85(6):457-64.
17. Tong L, Spitz MR, Fueger JJ, Amos CA. Lung carcinoma in former smokers. Cancer 1996;78(5):1004-10.
18. Fontham ET, Correa P, Reynolds P, et al. Environmental tobacco smoke and lung cancer in nonsmoking women. A multicenter study. JAMA 1994;271(22):1752-9.
19. Jett JR. Current treatment of unresectable lung cancer. Mayo Clin Proc 1993;68(6):603-11.
20. Mountain CF. Revisions in the International System for Staging Lung Cancer. Chest 1997;111(6):1710-7.
21. American Cancer Society. Cancer Facts and Figures 2000. Available at: http://www.cancer.org/downloads/STT/F&F00.pdf. Accessed March 11, 2004.
22. Keller SM, Adak S, Wagner H, Johnson DH. Mediastinal lymph node dissection improves survival in patients with stages II and IIIa non-small cell lung cancer. Ann Thorac Surg 2000;70(2):358-65; discussion 365-6.
23. Greenwald HP, Polissar NL, Borgatta EF, McCorkle R, Goodman G. Social factors, treatment, and survival in early-stage non-small cell lung cancer. Am J Public Health 1998;88(11):1681-4.
24. Yoshino I, Baba H, Fukuyama S, et al. A time trend of profile and surgical results in 1123 patients with non-small cell lung cancer. Surgery 2002;131(1 Suppl):S242-S248.
25. Flehinger BJ, Kimmel M, Melamed MR. The effect of surgical treatment on survival from early lung cancer. Implications for screening. Chest 1992;101(4):1013-8.
26. Sobue T, Suzuki T, Matsuda M, Kuroishi T, Ikeda S, Naruke T. Survival for clinical stage I lung cancer not surgically treated. Comparison between screen-detected and symptom-detected cases. The Japanese Lung Cancer Screening Research Group. Cancer 1992;69(3):685-92.
27. Snijder RJ, Brutel de la Riviere A, Elbers HJ, van den Bosch JM. Survival in resected stage I lung cancer with residual tumor at the bronchial resection margin. Ann Thorac Surg 1998;65(1):212-6.
28. Fang D, Zhang D, Huang G, Zhang R, Wang L, Zhang D. Results of surgical resection of patients with primary lung cancer: a retrospective analysis of 1,905 cases. Ann Thorac Surg 2001;72(4):1155-9.
29. Manser RL, Irving LB, Stone C, Byrnes G, Abramson M, Campbell D. Screening for lung cancer. Cochrane Database Syst Rev 2001;(3):CD001991.
30. Harris RP, Helfand M, Woolf SH, et al. Current methods of the U.S. Preventive Services Task Force: a review of the process. Am J Prev Med 2001;20(3S):21-35.
31. Cole P, Morrison AS. Basic issues in population screening for cancer. J Natl Cancer Inst 1980;64(5):1263-72.
32. Fletcher RH, Fletcher SW, Wagner EH. Clinical Epidemiology, the Essentials, 3rd ed. Baltimore: Williams & Wilkins; 1996:128.
33. Dales LG, Friedman GD, Collen MF. Evaluating periodic multiphasic health checkups: a controlled trial. J Chron Dis 1979;32(5):385-404.
34. Friedman GD, Collen MF, Fireman BH. Multiphasic Health Checkup Evaluation: a 16-year followup. J Chron Dis 1986;39(6):453-63.
35. Brett GZ. The value of lung cancer detection by six-monthly chest radiographs. Thorax 1968;23(4):414-20.
36. Brett GZ. Earlier diagnosis and survival in lung cancer. Br Med J 1969;4(678):260-2.
37. Melamed MR, Flehinger BJ, Zaman MB, Heelan RT, Perchick WA, Martini N. Screening for early lung cancer. Results of the Memorial Sloan-Kettering study in New York. Chest 1984;86(1):44-53.
38. Frost JK, Ball WC Jr, Levin ML, et al. Early lung cancer detection: results of the initial (prevalence) radiologic and cytologic screening in the Johns Hopkins study. Am Rev Respir Dis 1984;130(4):549-54.
39. Fontana RS, Sanderson DR, Taylor WF, et al. Early lung cancer detection: results of the initial (prevalence) radiologic and cytologic screening in the Mayo Clinic study. Am Rev Respir Dis 1984;130(4):561-5.
40. Kubik A, Polak J. Lung cancer detection. Results of a randomized prospective study in Czechoslovakia. Cancer 1986;57(12):2427-2437.
41. Ebeling K, Nischan P. Screening for lung cancer—results from a case-control study. Int J Cancer 1987;40(2):141-4.
42. Okamoto N, Suzuki T, Hasegawa H, et al. Evaluation of a clinic-based screening program for lung cancer with a case-control design in Kanagawa, Japan. Lung Cancer 1999;25(2):77-85.
43. Sobue T. A case-control study for evaluating lung cancer screening in Japan. Cancer 2000;89(11 Suppl):2392-6.
44. Sagawa M, Tsubono Y, Saito Y, et al. A case-control study for evaluating the efficacy of mass screening program for lung cancer in Miyagi Prefecture, Japan. Cancer 2001;92(3):588-94.
45. Tsukada H, Kurita Y, Yokoyama A, et al. An evaluation of screening for lung cancer in Niigata Prefecture, Japan: a population-based case-control study. Br J Cancer 2001;85(9):1326-31.
46. Nishii K, Ueoka H, Kiura K, et al. A case-control study of lung cancer screening in Okayama Prefecture, Japan. Lung Cancer 2001;34(3):325-32.
47. Wilde J. A 10 year followup of semiannual screening for early detection of lung cancer in the Erfurt country, GDR. Eur Respir J 1989;2:656-62.
48. Weiss W, Boucot KR, Cooper DA. The Philadelphia pulmonary neoplasm research project. Survival factors in bronchogenic carcinoma. JAMA 1971;216(13):2119-23.
49. Weiss W, Boucot KR. The Philadelphia Pulmonary Neoplasm Research Project. Early roentgenographic appearance of bronchogenic carcinoma. Arch Intern Med 1974;134(2):306-11.
50. An evaluation of radiologic and cytologic screening for the early detection of lung cancer: a cooperative pilot study of the American Cancer Society and the Veterans Administration. Cancer Res 1966;26(10):2083-121.
51. Hayata Y, Funatsu H, Kato H, Saito Y, Sawamura K, Furose K. Results of lung cancer screening programs in Japan. Recent Results Cancer Res 1982;82:163-73.
52. Nash FA, Morgan JM, Tomkins JG. South London Lung Cancer Study. Br Med J. 1968;2(607):715-21.
53. Diederich S, Wormanns D, Semik M, et al. Screening for early lung cancer with low-dose spiral CT: prevalence in 817 asymptomatic smokers. Radiology 2002;222(3):773-81.
54. Henschke CI, McCauley DI, Yankelevitz DF, et al. Early Lung Cancer Action Project: overall design and findings from baseline screening. Lancet 1999;354(9173):99-105.
55. Henschke CI, Yankelevitz DF, Libby DM, et al. Early lung cancer action project: annual screening using single-slice helical CT. Ann N Y Acad Sci 2001;952:124-34.
56. Nawa T, Nakagawa T, Kusano S, Kawasaki Y, Sugawara Y, Nakata H. Lung cancer screening using low-dose spiral CT: results of baseline and 1-year followup studies. Chest 2002;122(1):15-20.
57. Sone S, Takashima S, Li F, et al. Mass screening for lung cancer with mobile spiral computed tomography scanner. Lancet 1998;351(9111):1242-5.
58. Sone S, Li F, Yang ZG, et al. Results of three-year mass screening programme for lung cancer using mobile low-dose spiral computed tomography scanner. Br J Cancer 2001;84(1):25-32.
59. Sobue T, Moriyama N, Kaneko M, et al. Screening for lung cancer with low-dose helical computer tomography: anti-lung cancer association project. J Clin Oncol 2002;20(4):911-20.
60. Jett JR. Spiral computed tomography screening for lung cancer is ready for prime time. Am J Respir Crit Care Med 2001;163(4):812; discussion 814-5.
61. Swensen SJ, Jett JR, Sloan JA, et al. Screening for lung cancer with low-dose spiral computed tomography. Am J Respir Crit Care Med 2002;165(4):508-13.
62. Swensen SJ, Jett JR, Hartman TE, et al. Lung Cancer Screening with CT: Mayo Clinic experience. Radiology 2003;226:756-61.
63. Flehinger BJ, Melamed MR, Zaman MB, Heelan RT, Perchick WB, Martini N. Early lung cancer detection: results of the initial (prevalence) radiologic and cytologic screening in the Memorial Sloan-Kettering study. Am Rev Respir Dis 1984;130(4):555-60.
64. Martini N. Results of the Memorial Sloan-Kettering study in screening for early lung cancer. Chest 1986;89(4 Suppl):S325.
65. Heelan RT, Flehinger BJ, Melamed MR, et al. Non-small-cell lung cancer: results of the New York screening program. Radiology 1984;151(2):289-93.
66. Melamed M, Flehinger B, Miller D, et al. Preliminary report of the lung cancer detection program in New York. Cancer 1977;39(2):369-82.
67. Melamed MR. Lung cancer screening results in the National Cancer Institute New York study. Cancer 2000;89(11 Suppl):2356-62.
68. Berlin NI, Buncher CR, Fontana RS, Frost JK, Melamed MR. The National Cancer Institute Cooperative Early Lung Cancer Detection Program. Results of the initial screen (prevalence). Early lung cancer detection: Introduction. Am Rev Respir Dis 1984;130(4):545-9.
69. Stitik FP, Tockman MS. Radiographic screening in the early detection of lung cancer. Radiol Clin North Am 1978;16(3):347-66.
70. Baker RR, Tockman MS, Marsh BR, et al. Screening for bronchogenic carcinoma: the surgical experience. J Thorac Cardiovasc Surg 1979;78(6):876-82.
71. Levin ML, Tockman MS, Frost JK, Ball WC Jr. Lung cancer mortality in males screened by chest X-ray and cytologic sputum examination: a preliminary report. Recent Results Cancer Res 1982;82:138-46.
72. Tockman M. Survival and mortality from lung cancer in a screened population: the Johns Hopkins study. Chest 1986;89(Suppl):325s-6s.
73. Fontana RS, Sanderson DR, Woolner LB, et al. Screening for lung cancer. A critique of the Mayo Lung Project. Cancer 1991;67(4 Suppl):1155-64.
74. Flehinger BJ, Kimmel M, Polyak T, Melamed MR. Screening for lung cancer. The Mayo Lung Project revisited. Cancer 1993;72(5):1573-80.
75. Fontana RS, Sanderson DR, Woolner LB, Taylor WF, Miller WE, Muhm JR. Lung cancer screening: the Mayo program. J Occup Med 1986;28(8):746-50.
76. Woolner LB, Fontana RS, Sanderson DR, et al. Mayo Lung Project: evaluation of lung cancer screening through December 1979. Mayo Clin Proc 1981;56(9):544-55.
77. Taylor WF, Fontana RS, Uhlenhopp MA, Davis CS. Some results of screening for early lung cancer. Cancer 1981;47:1114-20.
78. Taylor WF, Fontana RS. Biometric design of the Mayo Lung project for early detection and localization of bronchogenic carcinoma. Cancer 1972;30(5):1344-7.
79. Sanderson D, Fontana R. Results of Mayo lung project: an interim report. Recent Results Cancer Res. 1982;82:179-86.
80. Marcus PM, Bergstralh EJ, Fagerstrom RM, et al. Lung cancer mortality in the Mayo Lung Project: impact of extended followup. J Natl Cancer Inst 2000;92(16):1308-16.
81. Marcus PM, Prorok PC. Reanalysis of the Mayo Lung Project data: the impact of confounding and effect modification. J Med Screen 1999;6(1):47-9.
82. Muhm JR, Miller WE, Fontana RS, Sanderson DR, Uhlenhopp MA. Lung cancer detected during a screening program using four-month chest radiographs. Radiology 1983;148(3):609-15.
83. Fontana TR, Sanderson DR, Woolner LB, et al. The Mayo Lung Project for early detection and localization of bronchogenic carcinoma: a status report. Chest 1975;67(5):511-22.
84. Kubik A, Parkin DM, Khlat M, Erban J, Polak J, Adamec M. Lack of benefit from semi-annual screening for cancer of the lung: followup report of a randomized controlled trial on a population of high-risk males in Czechoslovakia. Int J Cancer 1990;45(1):26-33.
85. Kubik AK, Parkin DM, Zatloukal P. Czech Study on Lung Cancer Screening: post-trial followup of lung cancer deaths up to year 15 since enrollment. Cancer 2000;89(11):2363-8.
86. Diederich S, Lenzen H. Radiation exposure associated with imaging of the chest: comparison of different radiographic and computed tomography techniques. Cancer 2000;89(11 Suppl):2457-60.
87. Osann KE, Anton-Culver H, Kurosaki T, Taylor T. Sex differences in lung-cancer risk associated with cigarette smoking. Int J Cancer 1993;54(1):44-8.
88. McDuffie HH, Klaassen DJ, Dosman JA. Men, women and primary lung cancer—a Saskatchewan personal interview study. J Clin Epidemiol 1991;44(6):537-44.
89. Nesbitt JC, Lee JL, Komaki R, Roth JA. Cancer of the lung. In: Holland JF, Bast RC Jr, Morton DL, Frei E III, Kufe DW, Weichselbaum RR, eds. Cancer Medicine. Baltimore: William & Wilkins; 1997.
90. Cotran RS, Kumar V, Robbins SL, Schoen FJ. Robbins Pathologic Basis of Disease, 5th ed. Philadelphia: WB Saunders; 1994.
91. Weiss NS, McKnight B, Stevens NG. Approaches to the analysis of case-control studies of the efficacy of screening for cancer. Am J Epidemiol 1992;135(7):817-23.
92. Weiss NS. Application of the case-control method in the evaluation of screening. Epidemiol Rev 1994;16(1):102-8.
93. Moss SM. Case-control studies of screening. Int J Epidemiol 1991;20(1):1-6.
94. Bernard A. Resection of pulmonary nodules using video-assisted thoracic surgery. The Thorax Group. Ann Thorac Surg 1996;61(1):202-4; discussion 204-5.
95. Schmuecking MW, Baum RP, Leonhardi J, Pichta K, Bonnet R, Presselt N. Evaluation of solitary pulmonary nodules: diagnostic accuracy of F-18 FDG PET in clinical routine [abstract]. Radiology 2000;217(Suppl):469.
96. Ostroff JS, Buckshee N, Mancuso CA, Yankelevitz DF, Henschke CI. Smoking cessation following CT screening for early detection of lung cancer. Prev Med 2001;33(6):613-21.
97. Pigula FA, Keenan RJ, Ferson PF, Landreneau RJ. Unsuspected lung cancer found in work-up for lung reduction operation. Ann Thorac Surg 1996;61(1):174-6.
98. Black WC. Overdiagnosis: An underrecognized cause of confusion and harm in cancer screening [editorial]. J Natl Cancer Inst 2000;92(16):1280-2.
99. Lindgren A. Autopsy and cause of death in randomized mammography studies. Qual Assur Health Care 1993;5(4):303-7.
100. Black WC, Haggstrom DA, Welch HG. All-cause mortality in randomized trials of cancer screening. J Natl Cancer Inst 2002;94(3):167-73.
101. McFarlane MJ, Feinstein AR, Wells CK. Clinical features of lung cancers discovered as a postmortem "surprise." Chest 1986;90(4):520-3.
102. Austin JH, Romney BM, Goldsmith LS. Missed bronchogenic carcinoma: radiographic findings in 27 patients with a potentially resectable lesion evident in retrospect. Radiology 1992;182(1):115-22.
103. Quekel LG, Kessels AG, Goei R, van Engelshoven JM. Miss rate of lung cancer on the chest radiograph in clinical practice. Chest 1999;115(3):720-4.
104. Bernard A, Bouchot O, Hagry O, Favre JP. Risk analysis and long-term survival in patients undergoing resection of T4 lung cancer. Eur J Cardiothorac Surg 2001;20(2):344-9.
105. Vaporciyan AA, Merriman KW, Ece F, et al. Incidence of major pulmonary morbidity after pneumonectomy: association with timing of smoking cessation. Ann Thorac Surg 2002;73(2):420-5; discussion 425-6.
106. Romano PS, Mark DH. Patient and hospital characteristics related to in-hospital mortality after lung cancer resection. Chest 1992;101(5):1332-7.
107. Myrdal G, Gustafsson G, Lambe M, Horte LG, Stahle E. Outcome after lung cancer surgery. Factors predicting early mortality and major morbidity. Eur J Cardiothorac Surg 2001;20(4):694-9.
108. Deslauriers J, Ginsberg RJ, Piantadosi S, Fournier B. Prospective assessment of 30-day operative morbidity for surgical resections in lung cancer. Chest 1994;106(6 Suppl):329S-30S.
109. Battafarano RJ, Piccirillo JF, Meyers BF, et al. Impact of comorbidity on survival after surgical resection in patients with stage I non-small cell lung cancer. J Thorac Cardiovasc Surg 2002;123(2):280-7.
110. Bach PB, Cramer LD, Schrag D, Downey RJ, Gelfand SE, Begg CB. The influence of hospital volume on survival after resection for lung cancer. N Engl J Med. 2001;345(3):181-8.
111. 1989 survey of physicians' attitudes and practices in early cancer detection. CA Cancer J Clin 1990;40(2):77-101.
112. Gohagan JK, Prorok PC, Hayes RB, Kramer BS. The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trail of the National Cancer Institute. Control Clin Trials 2000;21(6 Suppl):251S-72S.
113. Prorok PC, Andriole GL, Bresalier RS, et al. Design of the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. Control Clin Trials 2000;21(6 Suppl):273S-309S.
114. National Lung Screening Trial (NLST). 2002. National Institutes of Health. Available at: clinicaltrials.gov/ct/gui/show/NCT00047385;jsessionid=20DAB829F5C5A123FB490104A003A4BA?order=1. Accessed March 24, 2004.
115. Tockman MS, Gupta PK, Myers JD, et al. Sensitive and specific monoclonal antibody recognition of human lung cancer antigen on preserved sputum cells: a new approach to early lung cancer detection. J Clin Oncol 1988;6(11):1685-1693.
116. Mao L, Hruban RH, Boyle JO, Tockman M, Sidransky D. Detection of oncogene mutations in sputum precedes diagnosis of lung cancer. Cancer Res 1994;54(7):1634-1637.
117. Palmisano WA, Divine KK, Saccomanno G, et al. Predicting lung cancer by detecting aberrant promoter methylation in sputum. Cancer Res 2000;60(21):5954-8.
118. Tsou JA, Hagen JA, Carpenter CL, Laird-Offringa IA. DNA methylation analysis: a powerful new tool for lung cancer diagnosis. Oncogene 2002;21(35):5450-61.
119. Gazdar AF, Minna JD. Molecular detection of early lung cancer [editorial]. J Natl Cancer Inst 1999;91(4):299-301.
120. Patz EF, Goodman PC, Bepler G. Screening for lung cancer. N Engl J Med. 2000;343(22):1627-33.
121. Fong KM, Sekido Y, Minna JD. Molecular pathogenesis of lung cancer. J Thorac Cardiovasc Surg 1999;118(6):1136-52.
122. Tockman MS, Mulshine JL. Sputum screening by quantitative microscopy: a new dawn for detection of lung cancer? [editorial]. Mayo Clin Proc 1997;72(8):788-90.
123. Mulshine JL, Tockman MS, Smart CR. Considerations in the development of lung cancer screening tools. J Natl Cancer Inst 1989;81(12):900-6.
124. Rizvi N, Hayes DF. A "breathalyser" for lung cancer? Lancet 1999;353(9168):1897-8.
125. Mahadevia PJ, Fleisher LA, Frick KD, Eng J, Goodman SN, Powe NR. Lung cancer screening with helical computed tomography in older adult smokers: a decision and cost-effectiveness analysis. JAMA 2003;289(3):313-22.
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Notes
Author Affiliations
[a] Oregon Health & Science University, Evidence-based Practice Center, 3181 SW Sam Jackson Park Road, Portland, OR 97239
[b] Portland Veterans Affairs Medical Center, Portland, OR 97239
[c] Merck and Co., Inc., West Point, PA 19437
[d] University of Medicine and Dentistry-New Jersey Medical School, Newark, NJ 07103
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Source: Humphrey LL, Teutsch S, Johnson MS. Lung Cancer Screening with Sputum Cytologic Examination, Chest Radiography, and Computed Tomography: An Update for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140:740-53.
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Current as of May 2004
Internet Citation:
Humphrey LL, Teutsch S, Johnson MS. Lung Cancer Screening with Sputum Cytologic Examination, Chest Radiography, and Computed Tomography: An Update for the U.S. Preventive Services Task Force. May 2004. Originally in Ann Intern Med 2004;140:740-53. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/lungcancer/lungsum.htm
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