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ACS revises screening recommendations for high-risk lung cancer patients
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Clinicians with access to high-volume lung cancer screening and treatment centers should discuss screening with patients aged 55 to 74 years who have a 30-pack-year smoking history and who currently smoke or have quit within the past 15 years, according to new American Cancer Society guidelines.
Data from the NCI National Lung Screening Trial demonstrated a statistically significant 20% reduction in lung cancer mortality in a group of adults at high risk for lung cancer who were randomly assigned to receive three consecutive annual lung cancer screening examinations with low-dose CT vs. an equivalent-risk group of adults randomly selected to receive three consecutive annual chest X-rays.
Based on these findings, ACS — combined with the American College of Chest Physicians, ASCO and the National Comprehensive Cancer Network — formulated a systematic review of evidence related to lung cancer screening with low-dose CT, highlighting four primary questions:
- What are the potential benefits of screening individuals at high risk of developing lung cancer using low-dose CT?
- What are the potential harms of screening individuals at high risk of developing lung cancer using low-dose CT?
- Which groups are likely to benefit or not benefit?
- In what setting is screening likely to be effective?
Results from this review formed the basis of the new ACS recommendations, intended to provide clinicians with guidance about screening for lung cancer, and specifically address what patients are eligible for lung cancer screening and available information about the benefits, limitations and harms associated with lung cancer screening.
Additionally, these recommendations highlight the importance of informed and shared decision-making before committing to undergo lung cancer screening, as well as specific recommendations about the screening process and the importance of smoking cessation for current smokers.
“At this time, there is sufficient evidence to support screening provided that the patient has undergone a thorough discussion of the benefits, limitations and risks, and can be screened in a setting with experience in lung cancer screening,” the researchers wrote. “Many questions remain to be answered, and an experience base and infrastructure to support population-based lung cancer screening is not yet in place and needs to be built.”
Key to the recommendations is the thoughtful discussion between clinicians and patients regarding possible harms associated with low-dose CT screening, including anxiety associated with abnormal testing results, additional imaging tests and biopsy procedures linked to false-positive results, as well as investigations for incidental findings outside of the lung field.
“As with other guidelines for cancer screening, we can expect that this initial guideline will be revised as new data become available,” the researchers wrote. “Whether community-based screening for lung cancer with [low-dose CT] will exceed or fail to achieve the benefit observed in the [National Lung Screening Trial] could be influenced by many factors, and the answer awaits the results of further observation and research.”
Perspective
Back to TopPeter Mazzone, MD, MPH, FCCP
The National Lung Screening Trial, a randomized controlled trial of low-dose chest CT screening for lung cancer, was the first lung cancer screening trial to show lung cancer mortality could be reduced by screening a high-risk population. A series of guidelines from interested organizations have since been published. This latest set of guidelines, from the ACS, provides a balanced overview of the evidence of benefit and harm from low-dose CT- based screening. Key to the recommendations is the recognition: of the magnitude of benefit and potential harms; that screening does not replace smoking cessation; that the decision to screen must include consideration of the patient's values; that screening should only be offered to those who would have met National Lung Screening Trial entry criteria; and that screening should occur in an organized screening program with access to teams experienced in the management of the imaging findings. These are sound principles for all considering the development of a lung cancer screening program to follow.
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