Low-dose CT scans were endorsed for lung cancer screening in select high-risk individuals in guidelines from the American Cancer Society.
"Clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening with patients aged 55 years to 74 years who have at least a 30–pack-year smoking history, currently smoke, or have quit within the past 15 years, and who are in relatively good health," wrote Dr. Richard Wender and the members of the guidelines committee in an article published online in CA: A Cancer Journal for Clinicians (doi: 10.3322/caac.21172).
The recommendations are centered on the eligibility criteria used in the NLST (National Lung Screening Trial). Because of the uncertainty regarding the balance of benefits and harms, low-dose CT screening is not recommended for individuals at younger or older ages, with less lifetime exposure to tobacco smoke, and with sufficiently severe lung damage to require oxygen. The guideline writers acknowledge that clinicians will need to rely on their best judgment in cases when risk seems to approximate or exceed the NLST eligibility criteria in one category but not in another.
Since few government or private insurance programs provide coverage for the initial low-dose CT for lung cancer screening, "clinicians who decide to offer screening bear the responsibility of helping patients determine if they will have to pay for the initial test themselves and to help the patient know how much they will have to pay," according to the guideline writers. "In light of the firm evidence that screening high-risk individuals can substantially reduce death rates from lung cancer, both private and public health care insurers should expand coverage to include the cost of annual (low-dose CT) screening for lung cancer in appropriate high-risk individuals."
The "meaningful use" criteria for electronic health records under the recent HITECH (Health Information Technology for Economic and Clinical Health) Act are likely to improve identification of patients eligible for this screening as clinicians are required to determine the smoking status of more than 50% of their patients who are aged 13 years or older and to track the percentage of patients aged 10 years and older who are current smokers, according to Dr. Wender, chair of the department of family and community medicine, Jefferson Medical College, Philadelphia, and the other guideline writers.
While low-dose CT screening has been shown to substantially reduce the risk of dying of lung cancer, the technology will not detect all lung cancers or all lung cancers in early enough stages to avoid death from lung cancer. Further, a false-positive finding runs the risk of prompting an invasive procedure for incidental findings. The guidelines also warn that current smokers should not view screening as a substitute for smoking cessation. Counseling is recommended for current smokers, and all patients eligible for annual screening should make the decision only if they are willing to accept the risks and costs of annual screening until they reach age 74 years.
The guidelines also note that chest x-rays should not be used for lung cancer screening.
Wherever possible, screening should be performed as part of an organized program at an institution with expertise in low-dose CT screening and a multidisciplinary team skilled in the evaluation, diagnosis, and treatment of abnormal lung lesions. When those options are available but patients strongly wish to be screened, they should be referred to a center that performs a reasonably high volume of lung CT scans, diagnostic tests, and lung cancer surgeries. Otherwise, "the risks of cancer screening may be substantially higher than the observed risks associated with screening in the NLST, and screening is not recommended."
Multiple members of the guideline committee had financial disclosures related to drug manufacturers. The single committee member with ties to a device manufacturer declared his work was not directly related to the article.
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