Misdiagnosis of bronchogenic carcinoma. The role of cigarette smoking, surveillance bias, and other factors

The effects of cigarette smoking and other factors on the accuracy of clinical diagnosis of bronchogenic carcinoma were studied retrospectively in 14,074 autopsies performed over 26 years (1948-1973) at University Hospitals of Cleveland. Within a selected study group of 415 cases diagnosed as bronchogenic carcinoma either clinically, at atuopsy, or both, the disease was diagnosed accurately in 260 cases (63%), overdiagnosed in 38 cases (9%), and underdiagnosed in 117 cases (28%). Misdiagnoses occurred in female patients nearly twice as frequently as in male patients. Elderly men were over- and underdiagnosed more frequently than were young men. An accurate diagnosis of this neoplasm was strongly associated with a histroy of smoking and was also related to the number of hospital admissions, the diagnostic procedures used, and surveillance bias associated with a history of smoking or coughing. In 88% of the misdiagnosed cases, the tumor was either simulated or masked by other diseases. It is estimated from these data that the rate of unavoidable clinical misdiagnosis of the disease is 32% and the true error (overt misjudgment) in clinical diagnosis, 5%. Previous estimates of causal association between smoking and lung cancer would not be affected by the findings of this study.