Lungs in focus

“Place your feet  on the spot. Now, take a deep breath and hold it in. Quick click. All done. Next, please!” Just a few decades ago, this was how most people experienced mass X-ray screening programs aimed at bringing tuberculosis under control.

If an X-ray reveals nodules or cavities in the lungs or accumulations of fluid in the chest cavity, it may be an indication of  tuberculosis (TB). Visualizing these changes in the lungs has only been possible since the discovery of X-rays. Before that, all physicians could do was look for external signs of disease, as well as percussing and listening to the patient’s chest with a stethoscope. The problem was that, as people with tuberculosis often show only mild symptoms, if any at all, the disease frequently went undiagnosed and continued to spread. This is why early diagnosis is so vital in the fight against tuberculosis.

Once X-ray technology developed into a reliable means of diagnosing tuberculosis in the 1920s, it promised to serve as an important tool for the early diagnosis of this pernicious disease. First, however, there was one major obstacle to overcome. Specifically, large swathes of the population would need to be examined in order to effectively suppress the disease—but it was simply far too expensive and laborious to take diagnostic X-rays of thousands of people.

At that time, Rio de Janeiro was undergoing a serious TB epidemic. Brazilian physician Manoel de Abreu, head of the public health system’s local radiology department, witnessed the impact of the disease firsthand. In the mid-1930s, as part of his desperate search for a solution, Abreu succeeded in developing a new kind of photofluorography unit. This, he designed and built with the help of the Brazilian Siemens subsidiary, Casa Lohner. Although the idea behind the technology was nothing new, Abreu was the first to implement it into a working device. Instead of capturing an expensive X-ray image, the technique of photofluorography used a small-format camera to photograph the image that appeared on a fluorescent screen during an examination. This method was not only significantly cheaper but also much faster and represented a major breakthrough, ushering in the widespread introduction of mass X-ray screening for tuberculosis. From 1936 onward, Abreu used photofluorographic equipment to examine thousands of people in Rio. A year later, Professor Holfelder traveled to Brazil on behalf of Siemens-Reiniger-Werke. There, he spoke with Abreu and saw the device for himself. On his return to Germany, Holfelder made a few technical modifications and eventually presented an extended version of Abreu’s device in the form of the Abreu-Holfelder mass radiography unit.

Over the years, the technique of photofluorography was implemented in various Siemens X-ray units, including the Seriomat. This device was easy to set up, dismantle, and transport—and was therefore used in mass X-ray screening programs all over the world in the 1950s and 1960s.

The advantages of lung screening were aptly summarized in 1963 by Dr. Gerhart Habenicht, Berlin’s Senator for Health at the time: “The idea is to examine a section of our fellow citizens for tuberculosis and, at the same time, for lung cancer.” After all, X-ray images can reveal other diseases in addition to tuberculosis. Ultimately, the development of effective antibiotic treatment in combination with screening measures, TB vaccines, and better living and sanitary conditions meant it was possible to win the fight against tuberculosis—indeed, the morbidity rate became so low in the 1980s that many countries, including Germany and the USA, discontinued their lung screening programs. The abandonment of mass X-ray screening programs, however, also meant losing a tool for the early diagnosis of lung cancer.

At the global level, lung cancer is the second most common form of cancer. According to a report by the World Health Organization (WHO), over 2 million people worldwide developed the disease in 2020. Lung cancer is just as pernicious as tuberculosis: Given that patients initially experience only very slight discomfort, if any at all, the disease is often spotted (too) late. As a result, lung cancer is the deadliest form of cancer worldwide¬—and it is vital that it be detected as early as possible in order to boost patients’ chances of survival.

The key may lie in screening programs based on low-dose computed tomography (LDCT) , which can be used to diagnose lung cancer at an early stage. As well as lung cancer, the CT scan can also help to detect other diseases—such as deposits in the coronary vessels—as a secondary finding, making screening more valuable for patients.

Lung cancer screening is a long way from becoming established worldwide, and there are still many questions to be answered. For example, if we assume that the implementation of screening programs will lead to a sharp increase in the number of examinations, this raises several questions, including: How can we avoid overloading medical and radiological practices while also facilitating universal access to screening? The answer to that question may lie in experience gained during previous screening programs. After all, the same problem was encountered when mass X-ray screening for TB was introduced on a widespread basis. To examine as many patients as possible outside the confines of medical practices, photofluorography units were installed on buses or even on ships. Accordingly, these mobile examination rooms could be driven to schools or workplaces, for example, and therefore reached people all over the world—even in remote regions. Not only X-ray units but also CT scanners can be used in mobile applications. For example, a mobile CT screening unit on board a truck or a converted motorhome can travel to wherever lung cancer screening is needed, such as a supermarket parking lot.

If screening results in a lung cancer diagnosis, various treatment options are available depending on the stage and type of cancer—ranging from surgery to chemotherapy, radiotherapy, and immunotherapy. We provide support along the entire treatment pathway—from initial diagnosis to therapeutic planning, treatment, and follow-up care—through a combination of modern imaging techniques, radiotherapy systems, software applications, and laboratory diagnostics. Provided it is spotted in time, lung cancer is now a curable disease thanks to modern medicine and medical technology.

Screening of any kind—whether it’s mass X-ray screening for tuberculosis or lung cancer screening using computed tomography—has always had the same objective: diagnose diseases early to save lives.