Study objective: To assess the potential health and cost effects of in
itial testing with sputum cytology to diagnose lung cancer. Design: Co
st-effectiveness analysis. Data sources: Surveillance Epidemiology and
End Results (SEER) program; cost data from Northern California Kaiser
Permanente Hospitals and Universities of Stanford and Iowa; National
Center for Health Statistics; and a MEDLINE search.Interventions: The
use of sputum cytologies preceding other tests (ie, fine-needle aspira
tion, bronchoscopy, thoracoscopy) in patients with suspected lung canc
er. Main outcome measures: Mortality associated with testing and initi
al surgical treatment (eg, performance of thoracoscopy to remove a loc
al-stage, centrally located cancer), cost of testing and initial treat
ment, life expectancy, lifetime cost of medical care, and cost-effecti
veness. Results: In central lesions, sputum cytology as the first test
was the dominant strategy because it both lowers medical-care costs (
$2,516 per patient) and lowers the mortality risk (19 deaths in 100,00
0 patients) of the evaluation without adversely affecting long-term su
rvival. In peripheral lesions, sputum cytology costs less then $25,000
per year of life saved if the pretest probability of cancer exceeds 5
0%, The estimated annual savings of adopting sputum cytology as the fi
rst test for diagnosing lung cancer in the United States is at least $
30 million. Conclusions: Experience in regional centers indicates that
sputum cytologic testing is infrequently ordered before implementing
invasive diagnostic techniques, even in patients with central lung mas
ses, The study findings suggest that sputum cytology as the first test
in suspected lung cancer is likely to be cost saving without adversel
y affecting patient outcomes.