Lung cancer screening: Difference between revisions

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Revision as of 19:58, 7 March 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

Overview

Lung cancer screening is a strategy used to identify early lung cancer in people, before they develop symptoms. Screening refers to the use of medical tests to detect disease in asymptomatic people. Screening studies for lung cancer have only been done in high risk populations, such as smokers and workers with occupational exposure to certain substances. This is because radiation exposure from screening could actually induce carcinogenesis cancer formation in a small percentage of screened subjects, so this risk should be mitigated by a (relatively) high prevalence of lung cancer in the population being screened. A pulmonary nodule larger than 5 to 6 mm is considered a positive result for screening with x-ray or computed tomography.

Practice Guidelines

Current Guidelines

In 2013, a clinical practice guideline by the U.S. Preventive Services Task Force (USPSTF) recommended screening for lung cancer among smokers and former smokers who are between 55 to 80 years old and who have smoked 30 pack-years or more and either continue to smoke or have quit within the past 15 years (grade B recommendation).^[1]

The USPSTF guideline was based on a modeling study^[2] using data from the National Lung Screening Trial (NLST)^[3] and Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO)^[4] randomized controlled trials . The modeling study did not include the MILD randomized controlled trial^[5].

Clinical practice guidelines issued by the American College of Chest Physicians in 2013 recommend:^[6] ^[7]^[8]

For smokers and former smokers who are age 55 to 74 and who have smoked for 30 pack-years or more and either continue to smoke or have quit within the past 15 years, it was suggest that annual screening with low dose computed tomography (LDCT) should be offered in settings that can deliver the comprehensive care provided to National Lung Screening Trial (NLST) participants.

Previous Guidelines

In 2004, a clinical practice guideline by the U.S. Preventive Services Task Force (USPSTF) gave a grade I recommendation indicating that "the evidence is insufficient to recommend for or against screening asymptomatic persons for lung cancer".^[9]^[10]

In 2007, a clinical practice guideline by American College of Chest Physicians recommended not to screen for lung cancer.^[11]

Studies of efficacy

Regular chest radiography and sputum examination programs were not effective in reducing mortality from lung cancer.^[12] Earlier studies (Mayo Lung Project and Czechoslovakia lung cancer screening study, combining over 17,000 smokers) showed earlier detection of lung cancer was possible but mortality was not improved. Simply detecting a tumor at an earlier stage may not necessarily yield improved mortality. For example, plain radiography resulted in increased time from diagnosis of cancer until death and those cancers being detected by screening tended to be earlier stages. However, these patients continued to die at the same rate as those who are not screened. At present, no professional or specialty organization advocates screening for lung cancer outside of clinical trials.

A computed tomography (CT) scan can uncover tumors not yet visible on an X-ray. CT scanning is now being actively evaluated as a screening tool for lung cancer in high risk patients, and it is showing promising results. The USA-based National Cancer Institute is currently completing a randomized trial comparing CT scans with chest radiographs. Several single-institution trials are ongoing around the world.^[13]

The International Early Lung Cancer Action Project is a cohort study 31,000 high-risk patients that found benefit from screening.^[14] In this study 85% of the 484 detected lung cancers were stage I and thus highly treatable. Mathematically these stage I patients would have an expected 10-year survival of 88%. However, there was no randomization of patients (all received CT scans and there was no comparison group receiving only x-rays) and the patients were not actually followed out to 10 years post detection (the median followup was 40 months).

A cohort of 3,200 current or former smokers found no benefit. These patients were screened for 4 years and offered 3 or 4 CT scans. Lung cancer diagnoses were 3 times as high, and surgeries were 10 times as high, as predicted by a model, but there were no significant differences between observed and expected numbers of advanced cancers or deaths.^[15]

The National Lung Screening Trial (NLST) reported reduction advanced-stage cancers diagnosed.^[16]
The DANTE trial has been inconclusive.^[17]

Screening for Lung Cancer U.S. Preventive Services Task Force Recommendation Statement 2013 (DO NOT EDIT)^[1]

"1. The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. (Grade B)"

References

↑ ^1.0 ^1.1 "http://www.uspreventiveservicestaskforce.org/uspstf13/lungcan/lungcanfinalrs.htm". Retrieved 31 December 2013. External link in |title= (help)
↑ de Koning HJ, Meza R, Plevritis SK, ten Haaf K, Munshi VN, Jeon J; et al. (2014). "Benefits and harms of computed tomography lung cancer screening strategies: a comparative modeling study for the U.S. Preventive Services Task Force". Ann Intern Med. 160 (5): 311–20. doi:10.7326/M13-2316. PMC 4116741. PMID 24379002.
↑ Black WC, Gareen IF, Soneji SS, Sicks JD, Keeler EB, Aberle DR; et al. (2014). "Cost-effectiveness of CT screening in the National Lung Screening Trial". N Engl J Med. 371 (19): 1793–802. doi:10.1056/NEJMoa1312547. PMC 4335305. PMID 25372087. Review in: Evid Based Med. 2015 Apr;20(2):78
↑ Oken MM, Hocking WG, Kvale PA, Andriole GL, Buys SS, Church TR; et al. (2011). "Screening by chest radiograph and lung cancer mortality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized trial". JAMA. 306 (17): 1865–73. doi:10.1001/jama.2011.1591. PMID 22031728. Review in: Evid Based Med. 2012 Oct;17(5):149-50 Review in: Ann Intern Med. 2012 Mar 20;156(6):JC3-8
↑ Pastorino U, Rossi M, Rosato V, Marchianò A, Sverzellati N, Morosi C; et al. (2012). "Annual or biennial CT screening versus observation in heavy smokers: 5-year results of the MILD trial". Eur J Cancer Prev. 21 (3): 308–15. doi:10.1097/CEJ.0b013e328351e1b6. PMID 22465911.
↑ Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB (2013). "Screening for Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 143 (5 Suppl): e78S–92S. doi:10.1378/chest.12-2350. PMID 23649455. Summary in JournalWatch
↑ Midthun, David E. (2016). "Early detection of lung cancer". F1000Research. 5: 739. doi:10.12688/f1000research.7313.1. ISSN 2046-1402.
↑ Midthun, David E. (2011). "Screening for Lung Cancer". Clinics in Chest Medicine. 32 (4): 659–668. doi:10.1016/j.ccm.2011.08.014. ISSN 0272-5231.
↑ U.S. Preventive Services Task Force (2004). "Lung cancer screening: recommendation statement". Ann. Intern. Med. 140 (9): 738–9. PMID 15126258.
↑ Humphrey LL, Teutsch S, Johnson M (2004). "Lung cancer screening with sputum cytologic examination, chest radiography, and computed tomography: an update for the U.S. Preventive Services Task Force". Ann. Intern. Med. 140 (9): 740–53. PMID 15126259.
↑ Alberts WM (2007). "Diagnosis and Management of Lung Cancer Executive Summary: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)". 132 (3_suppl): 1S–19S. doi:10.1378/chest.07-1860. PMID 17873156.
↑ Manser RL, Irving LB, Stone C, Byrnes G, Abramson M, Campbell D (2004). "Screening for lung cancer". Cochrane database of systematic reviews (Online) (1): CD001991. doi:10.1002/14651858.CD001991.pub2. PMID 14973979.
↑ Henschke CI, Yip R, Yankelevitz DF, Smith JP, International Early Lung Cancer Action Program Investigators* (2013). "Definition of a positive test result in computed tomography screening for lung cancer: a cohort study". Ann Intern Med. 158 (4): 246–52. doi:10.7326/0003-4819-158-4-201302190-00004. PMID 23420233.
↑ Henschke CI, Yankelevitz DF, Libby DM, Pasmantier MW, Smith JP, Miettinen OS (2006). "Survival of patients with stage I lung cancer detected on CT screening". N. Engl. J. Med. 355 (17): 1763–71. doi:10.1056/NEJMoa060476. PMID 17065637.
↑ Bach PB, Jett JR, Pastorino U, Tockman MS, Swensen SJ, Begg CB (2007). "Computed tomography screening and lung cancer outcomes". JAMA. 297 (9): 953–61. doi:10.1001/jama.297.9.953. PMID 17341709.
↑ Aberle DR, DeMello S, Berg CD, Black WC, Brewer B, Church TR; et al. (2013). "Results of the two incidence screenings in the National Lung Screening Trial". N Engl J Med. 369 (10): 920–31. doi:10.1056/NEJMoa1208962. PMC 4307922. PMID 24004119.
↑ Infante M, Cavuto S, Lutman FR, Passera E, Chiarenza M, Chiesa G; et al. (2015). "Long-Term Follow-up Results of the DANTE Trial, a Randomized Study of Lung Cancer Screening with Spiral Computed Tomography". Am J Respir Crit Care Med. 191 (10): 1166–75. doi:10.1164/rccm.201408-1475OC. PMID 25760561.

Template:WH Template:WS

[www.uspreventiveservicestaskforce.org-1] 1.0 ^1.1 "http://www.uspreventiveservicestaskforce.org/uspstf13/lungcan/lungcanfinalrs.htm". Retrieved 31 December 2013. External link in |title= (help)

[pmid24379002-2] Koning HJ, Meza R, Plevritis SK, ten Haaf K, Munshi VN, Jeon J; et al. (2014). "Benefits and harms of computed tomography lung cancer screening strategies: a comparative modeling study for the U.S. Preventive Services Task Force". Ann Intern Med. 160 (5): 311–20. doi:10.7326/M13-2316. PMC 4116741. PMID 24379002.

[pmid25372087-3] Black WC, Gareen IF, Soneji SS, Sicks JD, Keeler EB, Aberle DR; et al. (2014). "Cost-effectiveness of CT screening in the National Lung Screening Trial". N Engl J Med. 371 (19): 1793–802. doi:10.1056/NEJMoa1312547. PMC 4335305. PMID 25372087. Review in: Evid Based Med. 2015 Apr;20(2):78

[pmid22031728-4] Oken MM, Hocking WG, Kvale PA, Andriole GL, Buys SS, Church TR; et al. (2011). "Screening by chest radiograph and lung cancer mortality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized trial". JAMA. 306 (17): 1865–73. doi:10.1001/jama.2011.1591. PMID 22031728. Review in: Evid Based Med. 2012 Oct;17(5):149-50 Review in: Ann Intern Med. 2012 Mar 20;156(6):JC3-8

[pmid22465911-5] Pastorino U, Rossi M, Rosato V, Marchianò A, Sverzellati N, Morosi C; et al. (2012). "Annual or biennial CT screening versus observation in heavy smokers: 5-year results of the MILD trial". Eur J Cancer Prev. 21 (3): 308–15. doi:10.1097/CEJ.0b013e328351e1b6. PMID 22465911.

[pmid23649455-6] Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB (2013). "Screening for Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 143 (5 Suppl): e78S–92S. doi:10.1378/chest.12-2350. PMID 23649455. Summary in JournalWatch

[Midthun2016-7] Midthun, David E. (2016). "Early detection of lung cancer". F1000Research. 5: 739. doi:10.12688/f1000research.7313.1. ISSN 2046-1402.

[Midthun2011-8] Midthun, David E. (2011). "Screening for Lung Cancer". Clinics in Chest Medicine. 32 (4): 659–668. doi:10.1016/j.ccm.2011.08.014. ISSN 0272-5231.

[pmid15126258-9] U.S. Preventive Services Task Force (2004). "Lung cancer screening: recommendation statement". Ann. Intern. Med. 140 (9): 738–9. PMID 15126258.

[pmid15126259-10] Humphrey LL, Teutsch S, Johnson M (2004). "Lung cancer screening with sputum cytologic examination, chest radiography, and computed tomography: an update for the U.S. Preventive Services Task Force". Ann. Intern. Med. 140 (9): 740–53. PMID 15126259.

[pmid17873156-11] Alberts WM (2007). "Diagnosis and Management of Lung Cancer Executive Summary: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)". 132 (3_suppl): 1S–19S. doi:10.1378/chest.07-1860. PMID 17873156.

[pmid14973979-12] Manser RL, Irving LB, Stone C, Byrnes G, Abramson M, Campbell D (2004). "Screening for lung cancer". Cochrane database of systematic reviews (Online) (1): CD001991. doi:10.1002/14651858.CD001991.pub2. PMID 14973979.

[pmid23420233-13] Henschke CI, Yip R, Yankelevitz DF, Smith JP, International Early Lung Cancer Action Program Investigators* (2013). "Definition of a positive test result in computed tomography screening for lung cancer: a cohort study". Ann Intern Med. 158 (4): 246–52. doi:10.7326/0003-4819-158-4-201302190-00004. PMID 23420233.

[pmid17065637-14] Henschke CI, Yankelevitz DF, Libby DM, Pasmantier MW, Smith JP, Miettinen OS (2006). "Survival of patients with stage I lung cancer detected on CT screening". N. Engl. J. Med. 355 (17): 1763–71. doi:10.1056/NEJMoa060476. PMID 17065637.

[pmid17341709-15] Bach PB, Jett JR, Pastorino U, Tockman MS, Swensen SJ, Begg CB (2007). "Computed tomography screening and lung cancer outcomes". JAMA. 297 (9): 953–61. doi:10.1001/jama.297.9.953. PMID 17341709.

[pmid24004119-16] Aberle DR, DeMello S, Berg CD, Black WC, Brewer B, Church TR; et al. (2013). "Results of the two incidence screenings in the National Lung Screening Trial". N Engl J Med. 369 (10): 920–31. doi:10.1056/NEJMoa1208962. PMC 4307922. PMID 24004119.

[pmid25760561-17] Infante M, Cavuto S, Lutman FR, Passera E, Chiarenza M, Chiesa G; et al. (2015). "Long-Term Follow-up Results of the DANTE Trial, a Randomized Study of Lung Cancer Screening with Spiral Computed Tomography". Am J Respir Crit Care Med. 191 (10): 1166–75. doi:10.1164/rccm.201408-1475OC. PMID 25760561.

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@@ Line 9: / Line 9: @@
 ===Current Guidelines===
-* In 2013, a clinical practice guideline by the U.S. Preventive Services Task Force ([[USPSTF]]) recommended screening for lung cancer among smokers and former smokers who are between 55 to 80 years old and who have smoked 30 pack-years or more and either continue to smoke or have quit within the past 15 years (grade B recommendation).<ref name="www.uspreventiveservicestaskforce.org">{{Cite web  | last =  | first =  | title = http://www.uspreventiveservicestaskforce.org/uspstf13/lungcan/lungcanfinalrs.htm | url = http://www.uspreventiveservicestaskforce.org/uspstf13/lungcan/lungcanfinalrs.htm | publisher =  | date =  | accessdate = 31 December 2013 }}</ref>
+In 2013, a clinical practice guideline by the U.S. Preventive Services Task Force ([[USPSTF]]) recommended screening for lung cancer among smokers and former smokers who are between 55 to 80 years old and who have smoked 30 pack-years or more and either continue to smoke or have quit within the past 15 years (grade B recommendation).<ref name="www.uspreventiveservicestaskforce.org">{{Cite web  | last =  | first =  | title = http://www.uspreventiveservicestaskforce.org/uspstf13/lungcan/lungcanfinalrs.htm | url = http://www.uspreventiveservicestaskforce.org/uspstf13/lungcan/lungcanfinalrs.htm | publisher =  | date =  | accessdate = 31 December 2013 }}</ref>
-The USPSTF guideline was based on a modeling study<ref name="pmid24379002">{{cite journal| author=de Koning HJ, Meza R, Plevritis SK, ten Haaf K, Munshi VN, Jeon J et al.| title=Benefits and harms of computed tomography lung cancer screening strategies: a comparative modeling study for the U.S. Preventive Services Task Force. | journal=Ann Intern Med | year= 2014 | volume= 160 | issue= 5 | pages= 311-20 | pmid=24379002 | doi=10.7326/M13-2316 | pmc=4116741 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24379002  }} </ref> using data from the  National Lung Screening Trial (NLST)<ref name="pmid25372087">{{cite journal| author=Black WC, Gareen IF, Soneji SS, Sicks JD, Keeler EB, Aberle DR et al.| title=Cost-effectiveness of CT screening in the National Lung Screening Trial. | journal=N Engl J Med | year= 2014 | volume= 371 | issue= 19 | pages= 1793-802 | pmid=25372087 | doi=10.1056/NEJMoa1312547 | pmc=4335305 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25372087  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=25715973 Review in: Evid Based Med. 2015 Apr;20(2):78] </ref> and Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO)<ref name="pmid22031728">{{cite journal| author=Oken MM, Hocking WG, Kvale PA, Andriole GL, Buys SS, Church TR et al.| title=Screening by chest radiograph and lung cancer mortality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized trial. | journal=JAMA | year= 2011 | volume= 306 | issue= 17 | pages= 1865-73 | pmid=22031728 | doi=10.1001/jama.2011.1591 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22031728  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=22345033 Review in: Evid Based Med. 2012 Oct;17(5):149-50]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=22431694 Review in: Ann Intern Med. 2012 Mar 20;156(6):JC3-8] </ref> [[randomized controlled trial]]s . The modeling study did not include the MILD [[randomized controlled trial]]<ref name="pmid22465911">{{cite journal| author=Pastorino U, Rossi M, Rosato V, Marchianò A, Sverzellati N, Morosi C et al.| title=Annual or biennial CT screening versus observation in heavy smokers:  5-year results of the MILD trial. | journal=Eur J Cancer Prev | year= 2012 | volume= 21 | issue= 3 | pages= 308-15 | pmid=22465911 | doi=10.1097/CEJ.0b013e328351e1b6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22465911  }} </ref>.
+* The USPSTF guideline was based on a modeling study<ref name="pmid24379002">{{cite journal| author=de Koning HJ, Meza R, Plevritis SK, ten Haaf K, Munshi VN, Jeon J et al.| title=Benefits and harms of computed tomography lung cancer screening strategies: a comparative modeling study for the U.S. Preventive Services Task Force. | journal=Ann Intern Med | year= 2014 | volume= 160 | issue= 5 | pages= 311-20 | pmid=24379002 | doi=10.7326/M13-2316 | pmc=4116741 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24379002  }} </ref> using data from the  National Lung Screening Trial (NLST)<ref name="pmid25372087">{{cite journal| author=Black WC, Gareen IF, Soneji SS, Sicks JD, Keeler EB, Aberle DR et al.| title=Cost-effectiveness of CT screening in the National Lung Screening Trial. | journal=N Engl J Med | year= 2014 | volume= 371 | issue= 19 | pages= 1793-802 | pmid=25372087 | doi=10.1056/NEJMoa1312547 | pmc=4335305 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25372087  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=25715973 Review in: Evid Based Med. 2015 Apr;20(2):78] </ref> and Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO)<ref name="pmid22031728">{{cite journal| author=Oken MM, Hocking WG, Kvale PA, Andriole GL, Buys SS, Church TR et al.| title=Screening by chest radiograph and lung cancer mortality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized trial. | journal=JAMA | year= 2011 | volume= 306 | issue= 17 | pages= 1865-73 | pmid=22031728 | doi=10.1001/jama.2011.1591 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22031728  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=22345033 Review in: Evid Based Med. 2012 Oct;17(5):149-50]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=22431694 Review in: Ann Intern Med. 2012 Mar 20;156(6):JC3-8] </ref> [[randomized controlled trial]]s . The modeling study did not include the MILD [[randomized controlled trial]]<ref name="pmid22465911">{{cite journal| author=Pastorino U, Rossi M, Rosato V, Marchianò A, Sverzellati N, Morosi C et al.| title=Annual or biennial CT screening versus observation in heavy smokers:  5-year results of the MILD trial. | journal=Eur J Cancer Prev | year= 2012 | volume= 21 | issue= 3 | pages= 308-15 | pmid=22465911 | doi=10.1097/CEJ.0b013e328351e1b6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22465911  }} </ref>.
+[[Clinical practice guideline]]s issued by the [[American College of Chest Physicians]] in 2013 recommend:<ref name="pmid23649455">{{cite journal| author=Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB| title=Screening for Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2013 | volume= 143 | issue= 5 Suppl | pages= e78S-92S | pmid=23649455 | doi=10.1378/chest.12-2350 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23649455  }} [http://general-medicine.jwatch.org/cgi/content/full/2013/522/2 Summary in JournalWatch]</ref> <ref name="Midthun2016">{{cite journal|last1=Midthun|first1=David E.|title=Early detection of lung cancer|journal=F1000Research|volume=5|year=2016|pages=739|issn=2046-1402|doi=10.12688/f1000research.7313.1}}</ref><ref name="Midthun2011">{{cite journal|last1=Midthun|first1=David E.|title=Screening for Lung Cancer|journal=Clinics in Chest Medicine|volume=32|issue=4|year=2011|pages=659–668|issn=02725231|doi=10.1016/j.ccm.2011.08.014}}</ref>
-* [[Clinical practice guideline]]s issued by the [[American College of Chest Physicians]] in 2013 recommend:<ref name="pmid23649455">{{cite journal| author=Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB| title=Screening for Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2013 | volume= 143 | issue= 5 Suppl | pages= e78S-92S | pmid=23649455 | doi=10.1378/chest.12-2350 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23649455  }} [http://general-medicine.jwatch.org/cgi/content/full/2013/522/2 Summary in JournalWatch]</ref> <ref name="Midthun2016">{{cite journal|last1=Midthun|first1=David E.|title=Early detection of lung cancer|journal=F1000Research|volume=5|year=2016|pages=739|issn=2046-1402|doi=10.12688/f1000research.7313.1}}</ref><ref name="Midthun2011">{{cite journal|last1=Midthun|first1=David E.|title=Screening for Lung Cancer|journal=Clinics in Chest Medicine|volume=32|issue=4|year=2011|pages=659–668|issn=02725231|doi=10.1016/j.ccm.2011.08.014}}</ref>
+* For smokers and former smokers who are age 55 to 74 and who have smoked for 30 pack-years or more and either continue to smoke or have quit within the past 15 years, it was suggest that annual screening with low dose computed tomography (LDCT) should be offered in settings that can deliver the comprehensive care provided to National Lung Screening Trial (NLST) participants.
-** For smokers and former smokers who are age 55 to 74 and who have smoked for 30 pack-years or more and either continue to smoke or have quit within the past 15 years, it was suggest that annual screening with low dose computed tomography (LDCT) should be offered in settings that can deliver the comprehensive care provided to National Lung Screening Trial (NLST) participants.
 ===Previous Guidelines===