American Journal of Epidemiology Vol. 128, No. 5: 1016-1026
Copyright © 1988 by The Johns Hopkins University School of Hygiene and Public Health
research-article |
DETECTION BIAS IN THE DIAGNOSTIC PURSUIT OF LUNG CANCER
1Department of Internal Medicine, Yale University School of Medicine New Haven, CT
2Departments of Internal Medicine and Epidemiology, Yale University School of Medicine New Haven, CT Cooperative Studies Program Coordinating Center, Veterans Administration Medical Center West Haven, CT
Reprint requests to Carolyn K. Wells, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, I-456 SHM, New Haven, CT 06510
Autopsy studies have shown that lung cancer is often not detected during life and that a correct antemortem diagnosis is made preferentially in patients with pulmonary symptoms, in smokers, and in men. The current research was done as a case-control study to determine whether the autopsy suggestions of detection bias in diagnostic pursuit of lung cancer were confirmed by the way that sputum Papanicolaou smears (Pap smears) were ordered in an inpatient setting. The cases were 385 hospitalized patients in whom sputum Pap tests had been newly performed from October 1977 to September 1980. Each case was matched by age, admission date, and admission diagnosis to a control patient who had not received a Pap test. Excluded from the study were patients in whom sputum Pap tests were obligatory (e.g., those with manifestations of hemoptysis) or unnecessary (e.g., those with a previous diagnosis of lung cancer or multiple previous sputum Pap tests). Demographic data, amount and duration of cigarette smoking, and details of clinical manifestations were extracted from the patients' medical records by research assistants blind to the study hypothesis. Compared with controls, the cases had distinctive elevations in odds ratios for chronic cough, recent cough, male sex, and cigarette smoking, which also showed a distinctive dose-response relation. In multivanate analyses, all four of these "risk factors" for selective ordering of a sputum Pap smear remained Independently highly significant. In the extreme category, men who smoked and coughed were 22 times more likely to have a sputum Pap test ordered than were nonsmoking women who did not cough. Clinically, the results suggest that women and nonsmokers may be deprived of appropriate diagnosis and therapy unless a diagnostic workup for lung cancer is guided mainly by radiographic findings and presenting manifestations. Statistically, detection bias has probably led to an excessively elevated magnitude for the cigarette smoking-lung cancer association and to a falsely low estimate of Incidence rates in women.
diagnosis; diagnostic tests; routine; lung neoplasms
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