Non small cell lung cancer screening
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shanshan Cen, M.D. [2]
Overview
Screening
Guidelines
- According to the clinical practice guideline by the U.S. Preventive Services Task Force (USPSTF), screening for lung cancer by low-dose computed tomography (LDCT) is recommended every year 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]
- According to the clinical practice guideline issued by the American College of Chest Physicians (CHEST) in 2013, screening for lung cancer by low-dose CT (LDCT) is recommended every year among 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.[2]
Strategies Evidence of Benefit Associated With Screening Screening by low-dose helical computed tomography Benefits
There is evidence that screening persons aged 55 to 74 years who have cigarette smoking histories of 30 or more pack-years and who, if they are former smokers, have quit within the last 15 years reduces lung cancer mortality by 20% and all-cause mortality by 6.7%.
Magnitude of Effect: 16% relative reduction in lung cancer–specific mortality.
Study Design: Evidence obtained from a randomized controlled trial. Internal Validity: Good. Consistency: Not applicable (N/A)—one randomized trial to date. External Validity: Fair.
Harms
Based on solid evidence, at least 98% of all positive low-dose helical computed tomography screening exams (but not all) do not result in a lung cancer diagnosis. False-positive exams may result in unnecessary invasive diagnostic procedures.
Magnitude of Effect: Large.
Study Design: Evidence obtained from a randomized controlled trial. Internal Validity: Good. Consistency: Good. External Validity: Fair.
Evidence of No Benefit Associated With Screening Screening by chest x-ray and/or sputum cytology Benefits
Based on solid evidence, screening with chest x-ray and/or sputum cytology does not reduce mortality from lung cancer in the general population or in ever-smokers.
Magnitude of Effect: N/A.
Study Design: Randomized controlled trials. Internal Validity: Good. Consistency: Good. External Validity: Good.
Harms False positive exams
Based on solid evidence, at least 95% of all positive chest x-ray screening exams (but not all) do not result in a lung cancer diagnosis. False-positive exams result in unnecessary invasive diagnostic procedures.
Study Design: Randomized controlled trials. Internal Validity: Good. Consistency: Good. External Validity: Good.
Overdiagnosis
Based on solid evidence, a modest but non-negligible percentage of lung cancers detected by screening chest x-ray and/or sputum cytology appear to represent overdiagnosed cancer; the magnitude of overdiagnosis appears to be between 5% and 25%. These cancers result in unnecessary diagnostic procedures and also lead to unnecessary treatment. Harms of diagnostic procedures and treatment occur most frequently among long-term and/or heavy smokers because of smoking-associated comorbidities that increase risk propagation.
Magnitude of Effect: Between 5% and 25%, depending on characteristics of screened population and screening regimen.
Study Design: Randomized controlled trials. Internal Validity: Good. Consistency: Good. External Validity: Good.
Studies of efficacy
Regular chest radiography and sputum examination programs were not effective in reducing mortality from lung cancer.[3] 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.
The International Early Lung Cancer Action Project is a cohort study 31,000 high-risk patients that found benefit from screening.[4] 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.[5]
Subsequent randomized controlled trials have been performed or are in progress[6].
- The National Lung Screening Trial (NLST) reported reduction advanced-stage cancers diagnosed.[7]
- The DANTE trial has been inconclusive.[8]
References
- ↑ Lung Cancer Screening. U.S. Preventive Services Task Force 2015. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening Accessed on December 20, 2015
- ↑ 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
- ↑ 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, 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.
- ↑ Gohagan JK, Marcus PM, Fagerstrom RM; et al. (2005). "Final results of the Lung Screening Study, a randomized feasibility study of spiral CT versus chest X-ray screening for lung cancer". Lung Cancer. 47 (1): 9–15. doi:10.1016/j.lungcan.2004.06.007. PMID 15603850.
- ↑ 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.