Screening for Lung Cancer: The Guidelines

doi:10.1378/chest.123.1_suppl.83S

Chest

Volume 123, Issue 1, Supplement, January 2003, Pages 83S-88S

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Although virtually all individuals with advanced lung cancer succumb to the disease, a substantial portion of individuals diagnosed at an earlier stage can be cured. This dichotomy has provoked interest in lung cancer screening. To date, randomized controlled trials of chest x-ray and sputum cytology have failed to demonstrate that screening with either modality decreases lung cancer mortality; neither of these technologies can be recommended. Early studies of lung cancer screening with low-dose CT (LDCT) appear promising; however, only data from observational studies are available. We recommend that individuals should only be screened with LDCT in the context of well-designed clinical trials.

Section snippets

Background

The rationale for CXR screening is based on the observation that most patients who are diagnosed with lung cancer have advanced stage disease that causes them to have symptoms. In contrast, CXR has sufficient resolution to detect small asymptomatic nodules that are often stage I disease. As stage I lung cancer can be treated through surgery, the efficacy of CXR would be mediated through the detection of lung cancer at an earlier stage, followed by a curative intervention such as removal of the

Background

The rationale for sputum cytology is based on the observation that many individuals have cancerous cells in their sputum at the time of lung cancer diagnosis. Sputum cytology is more sensitive for detecting squamous cell carcinomas, which tend to occur proximally in the bronchial tree, than for adenocarcinomas, which tend to arise more peripherally. Hence, the recent shift in histologic cell type from predominantly squamous cell to predominantly adenocarcinoma, noted in epidemiologic studies,

Background

LDCT scanning is a technique that allows a low-resolution image of the entire thorax to be obtained in a single breath-hold with low radiation exposure. The test is very sensitive, and is capable of routinely detecting nodules as small as 2 to 3 mm in their greatest diameter. In addition, data obtained through LDCT and standard CT scans can be used to reconstruct three-dimensional images that can be assessed sequentially for evidence of growth. The rationale for LDCT as an improved early

Conclusion

The most effective treatment for lung cancer remains surgical resection of early stage disease; however, sporadic lung cancer is rarely diagnosed in its earliest stages. The promise of screening techniques for increasing rates of early stage lung cancer detection, and thus the expectation of more treatable cases, has driven considerable research and ongoing development of screening technologies. RCTs of CXR and sputum cytology have failed to demonstrate a mortality benefit for either technique,

Recommendations

1.
For individuals without symptoms or a history of cancer, we recommend against the use of serial CXRs to screen for the presence of lung cancer. Level of evidence, good; benefit, none or negative; grade of recommendation, D
2.
For individuals without either symptoms or a history of cancer, we recommend against the use of single or serial sputum cytologic evaluation to screen for the presence of lung cancer. Level of evidence, fair; benefit, none or negative; grade of recommendation, D
3.
For individuals

References (19)

PC Prorok et al.
Design of the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial
Control Clin Trials
(2000)
MS Tockman et al.
Sputum screening by quantitative microscopy: a new dawn for detection of lung cancer?
Mayo Clin Proc
(1997)
PW Payne et al.
Sputum screening by quantitative microscopy: a reexamination of a portion of the National Cancer Institute Cooperative Early Lung Cancer Study
Mayo Clin Proc
(1997)
R Ginsberg et al.
Lung cancer surgical practice guidelines: Society of Surgical Oncology practice guidelines
Oncology
(1997)
T Lawrence
Screening for lung cancer. HCHP Adult Screening and Prevention Task Force. Harvard Community Health Plan Clinical Guidelines and Algorithms
(1989)
R Smith et al.
American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers. Also: update 2001; testing for early lung cancer detection
CA Cancer J Clin
(2001)
National Cancer Institute
Screening for lung cancer (PDQ). National Cancer Institute CancerNet Web site
Screening for lung cancer United States Preventive Services Task Force ed. Guide to clinical preventive services
(1996)
DR Aberle et al.
A consensus statement of the Society of Thoracic Radiology: screening for lung cancer with helical computed tomography
J Thorac Imaging
(2001)

There are more references available in the full text version of this article.

Cited by (83)

Screening for lung cancer: Diagnosis and management of lung cancer, 3rd ed: American college of chest physicians evidence-based clinical practice guidelines
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Citation Excerpt :
Furthermore, the compliance in these studies was generally only about 60%. Of note, these studies were not designed to assess screening vs no screening because they did not have a true observation-only arm.7,8 Since 2002, only one additional RCT has been conducted (the Prostate, Lung, Colorectal and Ovarian trial [PLCO]), and the results with respect to CXR screening for lung cancer were recently reported.9
Lung cancer is by far the major cause of cancer deaths largely because in the majority of patients it is at an advanced stage at the time it is discovered, when curative treatment is no longer feasible. This article examines the data regarding the ability of screening to decrease the number of lung cancer deaths.
A systematic review was conducted of controlled studies that address the effectiveness of methods of screening for lung cancer.
Several large randomized controlled trials (RCTs), including a recent one, have demonstrated that screening for lung cancer using a chest radiograph does not reduce the number of deaths from lung cancer. One large RCT involving low-dose CT (LDCT) screening demonstrated a significant reduction in lung cancer deaths, with few harms to individuals at elevated risk when done in the context of a structured program of selection, screening, evaluation, and management of the relatively high number of benign abnormalities. Whether other RCTs involving LDCT screening are consistent is unclear because data are limited or not yet mature.
Screening is a complex interplay of selection (a population with sufficient risk and few serious comorbidities), the value of the screening test, the interval between screening tests, the availability of effective treatment, the risk of complications or harms as a result of screening, and the degree with which the screened individuals comply with screening and treatment recommendations. Screening with LDCT of appropriate individuals in the context of a structured process is associated with a significant reduction in the number of lung cancer deaths in the screened population. Given the complex interplay of factors inherent in screening, many questions remain on how to effectively implement screening on a broader scale.
Analytical methods based on exhaled breath for early detection of lung cancer
2012, TrAC - Trends in Analytical Chemistry
Lung cancer is among the most common malignancies and among the most difficult to treat, mainly due to the lack of symptoms, which means that the vast majority of tumors to be diagnosed are at an advanced stage.
After reviewing the literature on this subject, with special emphasis on both canine smell and the potential of omics biomarkers for detecting lung cancer, we discuss the role of analytical chemists in the new steps to be taken for early detection. We also comment on the steps to be developed (from sampling to full validation of the biomarkers found).
The Future of Cancer Screening
2009, Primary Care - Clinics in Office Practice
Design, recruitment and baseline results of the ITALUNG trial for lung cancer screening with low-dose CT
2009, Lung Cancer
Citation Excerpt :
The increased survival demonstrated by observational studies is not sufficient to prove the efficacy of lung cancer screening with low-dose CT. In fact survival is influenced by lead time and length bias and overdiagnosis [7,19]. Only RCTs which are not affected by these confounders can reveal a real benefit of screening in terms of mortality reduction by comparing occurrence of the disease and mortality in the active and control group [7,19].
Results of randomized clinical trials (RCTs) are needed to assess the efficacy of lung cancer screening with low-dose chest computed tomography (CT) in reducing lung cancer mortality. We report design and results of enrolment and baseline screening test in the ITALUNG trial, a RCT.
Invitation letters were sent to subjects of 55–69 years of age clients of 269 general practitioners. Smokers or former smokers of at least 20 pack/years were eligible and after written consent were randomized in an active arm undergoing a low-dose CT annually for 4 years and in a control arm receiving no screening. Management of positive screening test was carried out using follow-up low-dose CT, fluorodeoxyglucose positron emission tomography, fine needle aspiration cytology and fiber optic bronchoscopy.
A sample of 3206 eligible subjects was achieved by sending 71,232 letters (enrolment efficacy = 4.5%). Subjects in control (n = 1593) and active (n = 1613) arm were balanced for age, gender and smoking history. Two-hundred and seven (12.8%) subjects did not undergo CT after randomization. The baseline screening test was positive in 426 (30.3%) of 1406 subjects.
Twenty-one lung cancers (prevalence = 1.5%) were found in 20 subjects: 18 non-small cell lung cancer (NSCLC), 2 small cell lung cancer (SCLC) and a case of typical carcinoid. Ten NSCLC (47.6%) were in Stage I.
Sixteen fine needle aspirations were performed in 15 lung cancers, with a positive result in 12 (75%) cases. One biopsy only (6.3%) was performed on a benign lesion. Seventeen lung cancers (81%) were treated with surgical resection in 16 subjects. One subject underwent surgery for a benign lesion (5.5% of all surgical resections).
Recruitment by mail of high risk subjects for a lung cancer screening RCT is feasible but not efficient. Results of the baseline screening test in the active arm of the ITALUNG trial are substantially in line with those of RCT and observational studies.
Cancer Screening in Men
2008, Revista Espanola de Cirugia Ortopedica y Traumatologia
Cancer screening is one of the most common requests directed to primary care physicians in the office setting. In this article, we look at current recommendations, evidence for, and controversy surrounding screening for cancers of the lung, colon, and prostate, which together account for 51% of cancer deaths in men. We also look at screening for testicular cancer, which, although a relatively minor contributor to cancer mortality, is a prototypically male cancer with a proposed screening test.
Lung cancer: Low-dose helical computed tomography
2008, Cancer Imaging
This chapter presents the usefulness and pitfalls of a mass screening for lung cancer with low-dose helical CT (LDHCT) scan and presents the Mayo Clinic project of lung cancer screening LDHCT scan. The helical CT scan has the highest sensitivity for the detection of pulmonary nodules compared to other examinations. LDHCT might be a promising method for screening early lung cancer at health examinations. Most of the lung cancers detected in lung cancer screening with LDHCT are stage I. Well-designed clinical trials are necessary to establish the guidelines for mass screening for lung cancer. The Mayo Clinic investigated the trial of LDHCT screening for lung cancer initiated in 1999. High-risk participants more than 50 years of age and with 20 pack-years of smoking or more were listed. Low-dose helical CT with multislice CT (MSCT, four detectors) was used under conditions that included 5 mm collimation with 3.75 mm reconstruction. At least one noncalcified nodule was detected in 780 of 1520 (51%) participants on the baseline CT scan, and a total of 3356 noncalcified nodules were detected in the 1118 participants from 2000 through 2003. Some participants with pulmonary nodules undergo thoracic surgery and/or biopsies, such as transbronchial lung biopsy (TBLB) for benign disease. The rate of invasive procedures, such as TBLB and conventional thoracotomy, for benign lesions detected by computed tomography (CT) screening was 22-55% of participants with abnormal CT findings. The General Rule for the Clinical and Pathological Record of Lung Cancer (GRCPRLC) notes that further clinical examinations are necessary for cases with nodules >10 mm in diameter in helical CT screening for lung cancer.

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: Department of Community and Family Medicine, Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH.

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Chest

Screening for Lung Cancer*: The Guidelines

Section snippets

Background

Background

Background

Conclusion

Recommendations

Control Clin Trials

Mayo Clin Proc

Mayo Clin Proc

Lung cancer surgical practice guidelines: Society of Surgical Oncology practice guidelines

Oncology

Screening for lung cancer. HCHP Adult Screening and Prevention Task Force. Harvard Community Health Plan Clinical Guidelines and Algorithms

American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers. Also: update 2001; testing for early lung cancer detection

CA Cancer J Clin

Screening for lung cancer (PDQ). National Cancer Institute CancerNet Web site

Screening for lung cancer United States Preventive Services Task Force ed. Guide to clinical preventive services

A consensus statement of the Society of Thoracic Radiology: screening for lung cancer with helical computed tomography

J Thorac Imaging

Screening for Lung Cancer^*: The Guidelines