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CommentaryComponents Necessary for High-Quality Lung Cancer Screening: American College of Chest Physicians and American Thoracic Society Policy Statement
Section snippets
Materials and Methods
Committees with expertise in lung cancer screening were assembled by the Thoracic Oncology Network of the American College of Chest Physicians (CHEST) and the Thoracic Oncology Assembly of the American Thoracic Society (ATS). Participants included pulmonologists, thoracic surgeons, a chest radiologist, and health services policy experts with expertise in lung cancer CT scan screening as identified by their publications and involvement in professional societies. The committees reviewed
Component 1: Who Is Offered Lung Cancer Screening
The principal question is how do lung cancer screening programs identify a group at high enough risk of developing lung cancer to benefit more than they are harmed. The balance with this choice is that more lives can be saved by screening at lower thresholds of risk, but the relative harms of screening increase as the threshold is lowered. It is difficult to determine the ideal balance of benefit and harm, as the value of the benefit and harms is not equal and varies with patient preferences.
Component 2: How Often, and for How Long, to Screen
The principal question is whether the benefit seen in the NLST would be modified by screening for longer periods or at different intervals than were used in the NLST. The tradeoff with this choice is that the reduction in harm will lead to a reduction in the number of lung cancer deaths avoided.
Because of the expense and impracticality of performing a controlled trial lasting throughout the period of high risk (20–25 years), this question may never have direct evidence to inform its answer. The
Component 3: How the CT Scan Is Performed
This component refers to the ability of a program to ensure performance of the CT scan with reduced-dose techniques similar to those used in the NLST. The American College of Radiology (ACR) and Society of Thoracic Radiology (STR) have developed technical specifications for the performance of a LDCT13
Component 4: Lung Nodule Identification
The principal question is what nodule size threshold should be used to label the screen as positive. The balance with this choice is that a lower threshold will lead to fewer lung cancers being missed but will increase the false-positive rate.
The NLST and other screening trials have shown that the majority of the nodules identified are solid and ≤ 5 mm in diameter. These very small nodules have a very low probability of being malignant.14, 15 Based on current nodule management guidelines, most
Component 5: Structured Reporting
Screening programs should consider the format that they will use to report the results of the LDCT scan screen. A structured report must communicate the pertinent findings to the ordering provider, define what constitutes a positive finding on the LDCT, recommend nodule management strategies based on the algorithm accepted by the program, and be used to populate quality-control and evidence-development registries.
The ACR has developed a structured reporting system called LungRADS, based on the
Component 6: Lung Nodule Management Algorithms
Lung nodules should be managed based on the probability that they are malignant. Management algorithms, based on risk of malignancy, are available for solid subcentimeter nodules, solid larger nodules (1–3 cm), and subsolid nodules.20, 21, 22, 23 The appropriate management of screen-detected lung nodules will minimize additional imaging, minimize the number of invasive procedures performed for benign nodules, and facilitate the timely treatment of malignant nodules.
Solid subcentimeter nodules
Policy Statements
A lung cancer screening program must:
Include clinicians with expertise in the management of lung nodules and the treatment of lung cancer,
Have developed lung nodule care pathways,
Have the ability to characterize concerning nodules through PET imaging, nonsurgical, and minimally invasive surgical approaches,
Have an approach to communication with the ordering provider and/or patient,
Have a means to track nodule management, and
Collect data related to the use of, and outcomes from, surveillance and
For Qualification as a Lung Cancer Screening Facility
The lung cancer screening program has designated clinicians with expertise in lung nodule management, the performance of nonsurgical biopsies and minimally invasive surgical biopsies, and lung cancer treatment. The following specialties should be represented:
Radiology (diagnostic, interventional)
Pulmonary medicine
Thoracic surgery
Medical oncology
Radiation oncology
The lung cancer screening program has designated an acceptable lung nodule management strategy, such as the use of available published
Future Research
The impact of nodule management algorithms and communication tools on oncologic and patient-centered outcomes should be studied. The clinical usefulness of validated lung nodule molecular biomarkers should be studied. Means to characterize T1a lung cancers, and tools to estimate life expectancy, should be studied to better understand and minimize overdiagnosis.
Component 7: Smoking Cessation
The mortality reduction that could be achieved by smoking cessation exceeds that from lung cancer screening.28 The impact of lung cancer screening on smoking cessation rates is poorly defined. Limited evidence suggests LDCT scan screening itself does not influence smoking behavior; however, the reporting of positive results may be associated with increased smoking abstinence.19 The cost-effectiveness of screening improves with increasing rates of smoking cessation.29 lists smoking cessation
Component 8: Patient and Provider Education
Providers must understand the components of screening well enough that they can identify patients in the appropriate risk group, know how to interpret and manage the screening results, and be capable of helping their patients make value-based decisions about being screened. The lung cancer screening program is the source of education for the provider and should supplement the patient's education. e-Table 4 lists patient educational material resources.
Component 9: Data Collection
To ensure that a lung cancer screening program is maintaining quality standards, data collection and periodic review must occur. Data collection can also serve to advance our understanding of the science of screening. Ideally, a core set of data elements would be collected by all programs, and a means would be available to share data across programs, such as through a centralized lung cancer screening registry.
Multisociety, Multidisciplinary Governance
There are recognized implications of the content of this policy statement. The components of lung cancer screening programs outlined above demonstrate the multidisciplinary nature of the expertise required to develop and maintain a high-quality screening program. In addition, we have stressed that most of the components of a successful screening program will be optimized over time by incorporating knowledge gained through research. Finally, a credentialing system based on the qualifying
Acknowledgments
Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Mazzone has previously attended advisory panel meetings for Oncimmune and Varian. He has received research funding from Metabolomx and Integrated Diagnostics, paid to his institution. He directs the lung cancer screening program for the Cleveland Clinic. Dr Powell has previously served as a consultant for Pfizer Inc. Dr Arenberg is on the ACRIN DSMB for biomarker studies (voluntary
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