Lung cancer screening: New evidence, updated guidance

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doi:doi: 10.12788/jfp.0499

Applied Evidence

Lung cancer screening: New evidence, updated guidance

J Fam Pract. 2022 November;71(9):398-402,415 | doi: 10.12788/jfp.0499

By

Carlton J. Covey, MD

Stephen D. Cagle Jr, MD

Emerging evidence supports lower thresholds for age and smoking history when screening for lung cancer. Here’s how the USPSTF and others have updated their guidelines in response.

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PRACTICE RECOMMENDATIONS

› Recommend annual lung cancer screening for all highrisk adults ages 50 to 80 years using low-dose computed tomography. A

› Do not pursue lung cancer screening in patients who quit smoking ≥ 15 years ago, have a health problem that limits their life expectancy, or are unwilling to undergo lung surgery. A

› Recommend varenicline as first-line pharmacotherapy for smokers who would like to quit. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

1. National Cancer Institute. Cancer Stat Facts: lung and bronchus cancer. Accessed October 12, 2022. https://seer.cancer.gov/statfacts/html/lungb.html

2. American Cancer Society. Key statistics for lung cancer. Accessed October 12, 2022. https://www.cancer.org/cancer/lung-cancer/about/key-statistics.html

3. Wilson JMG, Junger G. Principles and Practice of Screening for Disease. World Health Organization; 1968:21-25, 100. https://apps.who.int/iris/handle/10665/37650

4. Humphrey LL, Teutsch S, Johnson M. Lung cancer screening with sputum cytologic examination, chest radiography, and computed tomography: an update for the United States preventive services task force. Ann Intern Med. 2004;140:740-753. doi: 10.7326/0003-4819-140-9-200405040-00015

5. Oken MM, Hocking WG, Kvale PA, et al. Screening by chest radiograph and lung cancer mortality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized trial. JAMA. 2011;306:1865-1873. doi: 10.1001/jama.2011.1591

6. US Preventive Services Task Force. Screening for lung cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325:962-970. doi: 10.1001/jama.2021.1117

7. Centers for Medicare & Medicaid Services. Screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439R). Accessed October 14, 2022. www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=304

8. Smith RA, Andrews KS, Brooks D, et al. Cancer screening in the United States, 2018: a review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin. 2018;68:297-316. doi: 10.3322/caac.21446

9. American Academy of Family Physicians. AAFP updates recommendation on lung cancer screening. Published April 6, 2021. Accessed October 12, 2022. www.aafp.org/news/health-of-the-public/20210406lungcancer.html

10. Mazzone PJ, Silvestri GA, Souter LH, et al. Screening for lung cancer: CHEST Guideline and Expert Panel Report. CHEST. 2021;160:E427-E494. doi: 10.1016/j.chest.2021.06.063

11. The National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409. doi: 10.1056/NEJMoa1102873

12. The National Lung Screening Trial Research Team. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med. 2013;368:1980-1991. doi: 10.1056/NEJMoa1209120

13. de Koning HJ, van der Aalst CM, et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382:503-513. doi: 10.1056/NEJMoa1911793

14. American Cancer Society. Lung cancer screening guidelines. Accessed October 14, 2022. www.cancer.org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/lung-cancer-screening-guidelines.html

15. Pirie K, Peto R, Reeves GK, et al. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet. 2013;381:133-141. doi: 10.1016/S0140-6736(12)61720-6

16. Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ. 2004;328:1519. doi: 10.1136/bmj.38142.554479.AE

17. O’Keefe LM, Gemma T, Huxley R, et al. Smoking as a risk factor for lung cancer in women and men: a systematic review and meta-analysis. BMJ Open. 2018;8:e021611. doi: 10.1136/bmjopen-2018-021611

18. Criss SD, Pianpian C, Bastani M, et al. Cost-effectiveness analysis of lung cancer screening in the United States: a comparative modeling study. Ann Intern Med. 2019;171:796-805. doi: 10.7326/M19-0322

19. Lazris A, Roth RA. Lung cancer screening: pros and cons. Am Fam Physician. 2019;99:740-742.

20. Ali MU, Miller J, Peirson L, et al. Screening for lung cancer: a systematic review and meta-analysis. Prev Med. 2016;89:301-314. doi: 10.1016/j.ypmed.2016.04.015

21. Rampinelli C, De Marco P, Origgi D, et al. Exposure to low dose computed tomography for lung cancer screening and risk of cancer: secondary analysis of trial data and risk-benefit analysis. BMJ. 2017;356:j347. doi: 10.1136/bmj.j347

22. Manser RL, Lethaby A, Irving LB, et al. Screening for lung cancer. Cochrane Database Syst Rev. 2013;CD001991. doi: 10.1002/14651858.CD001991.pub3

23. Mazzone PJ, Silvestri GA, Patel S, et al. Screening for lung cancer: CHEST guideline and expert panel report. CHEST. 2018;153:954-985. doi: 10.1016/j.chest.2018.01.016

24. US Public Health Service Office of the Surgeon General; National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking. and Health. Smoking Cessation: A Report of the Surgeon General. US Department of Health and Human Services; 2020. www.ncbi.nlm.nih.gov/books/NBK555591/

25. Leone FT, Zhang Y, Evers-Casey S, et al, on behalf of the American Thoracic Society Assembly on Clinical Problems. Initiating pharmacologic treatment in tobacco-dependent adults: an official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2020;202:e5-e31. doi: 10.1164/rccm.202005-1982ST

CASE

A 51-year-old man presents to your office to discuss lung cancer screening. He has a history of hypertension and prediabetes. His father died of lung cancer 5 years ago, at age 77. The patient stopped smoking soon thereafter; prior to that, he smoked 1 pack of cigarettes per day for 20 years. He wants to know if he should be screened for lung cancer.

The relative lack of symptoms during the early stages of lung cancer frequently results in a delayed diagnosis. This, and the speed at which the disease progresses, underscores the need for an effective screening modality. More than half of people with lung cancer die within 1 year of diagnosis.¹ Excluding skin cancer, lung cancer is the second most commonly diagnosed cancer, and more people die of lung cancer than of colon, breast, and prostate cancers combined.² In 2022, it was estimated that there would be 236,740 new cases of lung cancer and 130,180 deaths from lung cancer.^1,2 The average age at diagnosis is 70 years.²

Screening modalities: Only 1 has demonstrated mortality benefit

In 1968, Wilson and Junger³ outlined the characteristics of the ideal screening test for the World Health Organization: it should limit risk to the patient, be sensitive for detecting the disease early in its course, limit false-positive results, be acceptable to the patient, and be inexpensive to the health system.³ For decades, several screening modalities for lung cancer were trialed to fit the above guidance, but many of them fell short of the most important outcome: the impact on mortality.

Sputum cytology. The use of sputum cytology, either in combination with or without chest radiography, is not recommended. Several randomized controlled trials (RCTs) have failed to demonstrate improved lung cancer detection or mortality reduction in patients screened with this modality.⁴

Chest radiography (CXR). Several studies have assessed the efficacy of CXR as a screening modality. The best known was the Prostate, Lung, Colon, Ovarian (PLCO) Trial.⁵ This multicenter RCT enrolled more than 154,000 participants, half of whom received CXR at baseline and then annually for 3 years; the other half continued usual care (no screening). After 13 years of follow-up, there were no significant differences in lung cancer detection or mortality rates between the 2 groups.⁵

Low-dose computed tomography (LDCT). Several major medical societies recommend LDCT to screen high-risk individuals for lung cancer (TABLE 1^6-10). Results from 2 major RCTs have guided these recommendations.

At this time, low-dose computed tomography is the only lung cancer screening modality that has shown benefit for both disease-related and all-cause mortality.

The National Lung Screening Trial (NLST) was a multicenter RCT comparing 2 screening tests for lung cancer.¹¹ Approximately 54,000 high-risk participants were enrolled between 2002 and 2004 and were randomized to receive annual screening with either LDCT or single-view CXR. The trial was discontinued prematurely when investigators noted a 20% reduction in lung cancer mortality in the LDCT group vs the CXR group.¹² This equates to 3 fewer deaths for every 1000 people screened with LDCT vs CXR. There was also a 6% reduction in all-cause mortality noted in the LDCT vs the CXR group.¹²

Continue to: The NELSON trial...