Results of the Randomized Danish Lung Cancer Screening Trial with Focus on High-Risk Profiling

Lung Cancer Screening by Low-Dose Computed Tomography: Part 2 - Key Elements for Programmatic Implementation of Lung Cancer Screening

PURPOSE

 For screening with low-dose CT (LDCT) to be effective, the benefits must outweigh the potential risks. In large lung cancer screening studies, a mortality reduction of approx. 20 % has been reported, which requires several organizational elements to be achieved in practice.

MATERIALS AND METHODS

 The elements to be set up are an effective invitation strategy, uniform and quality-assured assessment criteria, and computer-assisted evaluation tools resulting in a nodule management algorithm to assign each nodule the needed workup intensity. For patients with confirmed lung cancer, immediate counseling and guideline-compliant treatment in tightly integrated regional expert centers with expert skills are required. First, pulmonology contacts as well as CT facilities should be available in the participant's neighborhood. IT infrastructure, linkage to clinical cancer registries, quality management as well as epidemiologic surveillance are also required.

RESULTS

 An effective organization of screening will result in an articulated structure of both widely distributed pulmonology offices as the participants' primary contacts and CT facilities as well as central expert facilities for supervision of screening activities, individual clarification of suspicious findings, and treatment of proven cancer.

CONCLUSION

 In order to ensure that the benefits of screening more than outweigh the potential harms and that it will be accepted by the public, a tightly organized structure is needed to ensure wide availability of pulmonologists as first contacts and CT facilities with expert skills and high-level equipment concentrated in central facilities.

KEY POINTS

  · For lung cancer screening, elements must function optimally and be tightly organized.. · Lung cancer screening requires a network of expert centers and collaborating facilities.. · IT infrastructure, QM, epidemiological surveillance, and linkage to cancer registries are essential..

CITATION FORMAT

· Delorme S, Kaaks R: Lung Cancer Screening by Low-Dose Computed Tomography: Part 2 - Key Elements for Programmatic Implementation of Lung Cancer Screening. Fortschr Röntgenstr 2021; 193: 644 - 651.

Lung Cancer Screening by Low-Dose Computed Tomography - Part 1: Expected Benefits, Possible Harms, and Criteria for Eligibility and Population Targeting

BACKGROUND

 Trials in the USA and Europe have convincingly demonstrated the efficacy of screening by low-dose computed tomography (LDCT) as a means to lower lung cancer mortality, but also document potential harms related to radiation, psychosocial stress, and invasive examinations triggered by false-positive screening tests and overdiagnosis. To ensure that benefits (lung cancer deaths averted; life years gained) outweigh the risk of harm, lung cancer screening should be targeted exclusively to individuals who have an elevated risk of lung cancer, plus sufficient residual life expectancy.

METHODS AND CONCLUSIONS

 Overall, randomized screening trials show an approximate 20 % reduction in lung cancer mortality by LDCT screening. In view of declining residual life expectancy, especially among continuing long-term smokers, risk of being over-diagnosed is likely to increase rapidly above the age of 75. In contrast, before age 50, the incidence of LC may be generally too low for screening to provide a positive balance of benefits to harms and financial costs. Concise criteria as used in the NLST or NELSON trials may provide a basic guideline for screening eligibility. An alternative would be the use of risk prediction models based on smoking history, sex, and age as a continuous risk factor. Compared to concise criteria, such models have been found to identify a 10 % to 20 % larger number of LC patients for an equivalent number of individuals to be screened, and additionally may help provide security that screening participants will all have a high-enough LC risk to balance out harm potentially caused by radiation or false-positive screening tests.

KEY POINTS

  · LDCT screening can significantly reduce lung cancer mortality. · Screening until the age of 80 was shown to be efficient in terms of cancer deaths averted; in terms of LYG relative to overdiagnosis, stopping at a younger age (e. g. 75) may have greater efficiency. · Risk models may improve the overall net benefit of lung cancer screening.

CITATION FORMAT

· Kaaks R, Delorme S. Lung Cancer Screening by Low-Dose Computed Tomography - Part 1: Expected Benefits, Possible Harms, and Criteria for Eligibility and Population Targeting. Fortschr Röntgenstr 2021; 193: 527 - 536.

Cancer-Specific Mortality, All-Cause Mortality, and Overdiagnosis in Lung Cancer Screening Trials: A Meta-Analysis

PURPOSE

Benefit of lung cancer screening using low-dose computed tomography (LDCT) in reducing lung cancer-specific and all-cause mortality is unclear. We undertook a meta-analysis to assess its associations with outcomes.

METHODS

We searched the literature and previous systematic reviews to identify randomized controlled trials comparing LDCT screening with usual care or chest radiography. We performed meta-analysis using a random effects model. The primary outcomes were lung cancer-specific mortality, all-cause mortality, and the cumulative incidence ratio of lung cancer between screened and unscreened groups as a measure of overdiagnosis.

RESULTS

Meta-analysis was based on 8 trials with 90,475 patients that had a low risk of bias. There was a significant reduction in lung cancer-specific mortality with LDCT screening (relative risk = 0.81; 95% CI, 0.74-0.89); the estimated absolute risk reduction was 0.4% (number needed to screen = 250). The reduction in all-cause mortality was not statistically significant (relative risk = 0.96; 95% CI, 0.92-1.01), but the absolute reduction was consistent with that for lung cancer-specific mortality (0.34%; number needed to screen = 294). In the studies with the longest duration of follow-up, the incidence of lung cancer was 25% higher in the screened group, corresponding to a 20% rate of overdiagnosis.

CONCLUSIONS

This meta-analysis showing a significant reduction in lung cancer-specific mortality, albeit with a tradeoff of likely overdiagnosis, supports recommendations to screen individuals at elevated risk for lung cancer with LDCT.

Commonly Applied Selection Criteria for Lung Cancer Screening May Have Strongly Varying Diagnostic Performance in Different Countries

Simple Summary

Smoking causes the majority of lung cancers. Smoking history is thus used to select individuals among whom screening for lung cancer could be the most beneficial. The aim of our study was to estimate sensitivity and specificity of pre-selection by heavy smoking in individual European countries. Due to differences in smoking histories across the countries and sexes within the countries, the sensitivities were found to be between 33 and 80% for men and between 9 and 79% for women. Corresponding specificities of heavy smoking varied between 48 and 90% (men) and 70 and 99% (women). Our results may inform the design of lung cancer screening programs in European countries and serve as benchmarks for novel alternative or complementary tests for selecting people at high risk for computed tomography-based lung cancer screening.

Abstract

Lung cancer (LC) screening often focuses heavy smokers as a target for screening group. Heavy smoking can thus be regarded as an LC pre-screening test with sensitivities and specificities being different in various populations due to the differences in smoking histories. We derive here expected sensitivities and specificities of various criteria to preselect individuals for LC screening in 27 European countries with diverse smoking prevalences. Sensitivities of various heavy-smoking-based pre-screening criteria were estimated by combining sex-specific proportions of people meeting these criteria in the target population for screening with associations of heavy smoking with LC risk. Expected specificities were approximated by the proportion of individuals not meeting the heavy smoking definition. Estimated sensitivities and specificities varied widely across countries, with sensitivities being generally higher among men (range: 33–80%) than among women (range: 9–79%), and specificities being generally lower among men (range: 48–90%) than among women (range: 70–99%). Major variation in sensitivities and specificities was also seen across different pre-selection criteria for LC screening within individual countries. Our results may inform the design of LC screening programs in European countries and serve as benchmarks for novel alternative or complementary tests for selecting people at high risk for CT-based LC screening.

Lung Cancer Screening with Low-Dose CT: a Meta-Analysis

BACKGROUND

Randomized controlled trials have evaluated the efficacy of low-dose CT (LDCT) lung cancer screening on lung cancer (LC) outcomes.

OBJECTIVE

Meta-analyze LDCT lung cancer screening trials.

METHODS

We identified studies by searching PubMed, Google Scholar, the Cochrane Registry, ClinicalTrials.gov , and reference lists from retrieved publications. We abstracted data on study design features, stage I LC diagnoses, LC and overall mortality, false positive results, harm from invasive diagnostic procedures, overdiagnosis, and significant incidental findings. We assessed study quality using the Cochrane risk-of-bias tool. We used random-effects models to calculate relative risks and assessed effect modulators with subgroup analyses and meta-regression.

RESULTS

We identified 9 studies that enrolled 96,559 subjects. The risk of bias across studies was judged to be low. Overall, LDCT screening significantly increased the detection of stage I LC, RR = 2.93 (95% CI, 2.16-3.98), I² = 19%, and reduced LC mortality, RR = 0.84 (95% CI, 0.75-0.93), I² = 0%. The number needed to screen to prevent an LC death was 265. Women had a lower risk of LC death (RR = 0.69, 95% CI, 0.40-1.21) than men (RR = 0.86, 95% CI, 0.66-1.13), p value for interaction = 0.11. LDCT screening did not reduce overall mortality, RR = 0.96 (95% CI, 0.91-1.01), I² = 0%. The pooled false positive rate was 8% (95% CI, 4-18); subjects with false positive results had < 1 in 1000 risk of major complications following invasive diagnostic procedures. The most valid estimates for overdiagnosis and significant incidental findings were 8.9% and 7.5%, respectively.

DISCUSSION

LDCT screening significantly reduced LC mortality, though not overall mortality, with women appearing to benefit more than men. The estimated risks for false positive results, screening complications, overdiagnosis, and incidental findings were low. Long-term survival data were available only for North American and European studies limiting generalizability.

Detection of circulating genetically abnormal cells in peripheral blood for early diagnosis of non-small cell lung cancer

BACKGROUND

Circulating genetically abnormal cells (CACs) with specific chromosome variations have been confirmed to be present in non-small cell lung cancer (NSCLC). However, the diagnostic performance of CAC detection remains unclear. This study aimed to evaluate the potential clinical application of the CAC test for the early diagnosis of NSCLC.

METHODS

In this prospective study, a total of 339 participants (261 lung cancer patients and 78 healthy volunteers) were enrolled. An antigen-independent fluorescence in situ hybridization was used to enumerate the number of CACs in peripheral blood.

RESULTS

Patients with early-stage NSCLC were found to have a significantly higher number of CACs than those of healthy participants (1.34 vs. 0.19; P < 0.001). The CAC test displayed an area under the receiver operating characteristic (ROC) curve of 0.76139 for discriminating stage I NSCLC from healthy participants with 67.2% sensitivity and 80.8% specificity, respectively. Compared with serum tumor markers, the sensitivity of CAC assays for distinguishing early-stage NSCLC was higher (67.2% vs. 48.7%, P < 0.001), especially in NSCLC patients with small nodules (65.4% vs. 36.5%, P = 0.003) and ground-glass nodules (pure GGNs: 66.7% vs. 40.9%, P = 0.003; mixed GGNs: 73.0% vs. 43.2%, P < 0.001).

CONCLUSIONS

CAC detection in early stage NSCLC was feasible. Our study showed that CACs could be used as a promising noninvasive biomarker for the early diagnosis of NSCLC.

KEY POINTS

What this study adds: This study aimed to evaluate the potential clinical application of the CAC test for the early diagnosis of NSCLC. Significant findings of the study: CAC detection in early stage NSCLC was feasible. Our study showed that CACs could be used as a promising noninvasive biomarker for the early diagnosis of NSCLC.

Idiopathic Pulmonary Fibrosis and Lung Cancer. A Systematic Review and Meta-analysis

Rationale: The association between idiopathic pulmonary fibrosis (IPF) and lung cancer has been previously reported. However, there is the potential for significant confounding by age and smoking, and an accurate summary risk estimate has not been previously ascertained.Objectives: To determine the risk and burden of lung cancer in patients with IPF, accounting for known confounders.Methods: We conducted a comprehensive literature search of MEDLINE, EMBASE, and SCOPUS databases and used the Newcastle Ottawa criteria to assess study quality. We then assessed the quality of ascertainment of IPF cases based on modern consensus criteria. Data that relied on administrative claims or autopsies were excluded. We calculated summary risk estimates using a random effects model.Results: Twenty-five cohort studies were included in the final analysis. The estimated adjusted incidence rate ratio from two studies was 6.42 (95% confidence interval [CI], 3.21-9.62) and accounted for age, sex, and smoking. The summary incidence rate from 11 studies was 2.07 per 100 person-years (95% CI, 1.46-2.67), and the summary mortality rate was 1.06 per 100 person-years (95% CI, 0.62-1.51) obtained from three studies. The summary prevalence from 11 studies was 13.74% (95% CI, 10.17-17.30), and the proportion of deaths attributable to lung cancer was 10.20 (95% CI, 8.52-11.87) and was obtained from nine studies.Conclusions: IPF is an increased independent risk factor for lung cancer, even after accounting for smoking. Further well-designed studies using modern consensus criteria are needed to explore mechanisms of this association.

Overdiagnosis in lung cancer screening: Estimates from the German Lung Cancer Screening Intervention Trial

Overdiagnosis is a major potential harm of lung cancer screening; knowing its potential magnitude helps to optimize screening eligibility criteria. The German Lung Screening Intervention Trial ("LUSI") is a randomized trial among 4052 long-term smokers (2622 men), 50.3 to 71.9 years of age from the general population around Heidelberg, Germany, comparing five annual rounds of low-dose computed tomography (n = 2029) with a control arm without intervention (n = 2023). After a median follow-up of 9.77 years postrandomization and 5.73 years since last screening, 74 participants were diagnosed with lung cancer in the control arm and 90 in the screening arm: 69 during the active screening period; of which 63 screen-detected and 6 interval cancers. The excess cumulative incidence in the screening arm (N = 16) represented 25.4% (95% confidence interval: -11.3, 64.3] of screen-detected cancer cases (N = 63). Analyzed by histologic subtype, excess incidence in the screening arm appeared largely driven by adenocarcinomas. Statistical modeling yielded an estimated mean preclinical sojourn time (MPST) of 5.38 (4.76, 5.88) years and a screen-test sensitivity of 81.6 (74.4%, 88.8%) for lung cancer overall, all histologic subtypes combined. Based on modeling, we further estimated that about 48% (47.5% [43.2%, 50.7%]) of screen-detected tumors have a lead time ≥4 years, whereas about 33% (32.8% [28.4%, 36.1%]) have a lead time ≥6 years, 23% (22.6% [18.6%, 25.7%]) ≥8 years, 16% (15.6% [12.2%, 18.3%]) ≥10 years and 11% (10.7% [8.0%, 13.0%]) ≥12 years. The high proportions of tumors with relatively long lead times suggest a major risk of overdiagnosis for individuals with comparatively short remaining life expectancies.

Performance of a Deep Learning Algorithm Compared with Radiologic Interpretation for Lung Cancer Detection on Chest Radiographs in a Health Screening Population

Background The performance of a deep learning algorithm for lung cancer detection on chest radiographs in a health screening population is unknown. Purpose To validate a commercially available deep learning algorithm for lung cancer detection on chest radiographs in a health screening population. Materials and Methods Out-of-sample testing of a deep learning algorithm was retrospectively performed using chest radiographs from individuals undergoing a comprehensive medical check-up between July 2008 and December 2008 (validation test). To evaluate the algorithm performance for visible lung cancer detection, the area under the receiver operating characteristic curve (AUC) and diagnostic measures, including sensitivity and false-positive rate (FPR), were calculated. The algorithm performance was compared with that of radiologists using the McNemar test and the Moskowitz method. Additionally, the deep learning algorithm was applied to a screening cohort undergoing chest radiography between January 2008 and December 2012, and its performances were calculated. Results In a validation test comprising 10 285 radiographs from 10 202 individuals (mean age, 54 years ± 11 [standard deviation]; 5857 men) with 10 radiographs of visible lung cancers, the algorithm's AUC was 0.99 (95% confidence interval: 0.97, 1), and it showed comparable sensitivity (90% [nine of 10 radiographs]) to that of the radiologists (60% [six of 10 radiographs]; P = .25) with a higher FPR (3.1% [319 of 10 275 radiographs] vs 0.3% [26 of 10 275 radiographs]; P < .001). In the screening cohort of 100 525 chest radiographs from 50 070 individuals (mean age, 53 years ± 11; 28 090 men) with 47 radiographs of visible lung cancers, the algorithm's AUC was 0.97 (95% confidence interval: 0.95, 0.99), and its sensitivity and FPR were 83% (39 of 47 radiographs) and 3% (2999 of 100 478 radiographs), respectively. Conclusion A deep learning algorithm detected lung cancers on chest radiographs with a performance comparable to that of radiologists, which will be helpful for radiologists in healthy populations with a low prevalence of lung cancer. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Armato in this issue.

Lung Cancer Screening

Lung cancer is the leading cause of US cancer-related deaths. Lung cancer screening with a low radiation dose chest computed tomography scan is now standard of care for a high-risk eligible population. It is imperative for clinicians and surgeons to evaluate the trade-offs of benefits and harms, including the identification of many benign lung nodules, overdiagnosis, and complications. Integration of smoking cessation interventions augments the clinical benefits of screening. Screening programs must develop strategies to manage screening-detected findings to minimize potential harms. Further research should focus on how to improve patient selection, minimize harms, and facilitate access to screening.

Impact of smoking amount on clinicopathological features and survival in non-small cell lung cancer

BACKGROUND

Screening for early detection of lung cancer has been performed in high-risk individuals with smoking history. However, researches on the distribution, clinical characteristics, and prognosis of these high-risk individuals in an actual cohort are lacking. Thus, the objective of this study was to retrospectively review characteristics and prognosis of patients with smoking history in an actual lung cancer cohort.

METHODS

The present study used the lung cancer cohort of the Catholic Medical Centers at the Catholic University of Korea from 2014 to 2017. Patients with non-small cell lung cancer were enrolled. They were categorized into high and low-risk groups based on their smoking history using the national lung screening trial guideline. Distribution, clinical characteristics, and survival data of each group were estimated.

RESULTS

Of 439 patients, 223 (50.8%) patients were in the high-risk group. Patients in the high-risk group had unfavorable clinical characteristics and tumor biologic features. Overall survival of the high-risk group was significantly shorter than that of the low-risk group with both early (I, II) and advanced stages (III, IV). In multivariate analysis, heavy smoking remained one of the most important poor clinical prognostic factors in patients with lung cancer. It showed a dose-dependent relationship with patients' survival.

CONCLUSIONS

High-risk individuals had poor clinical outcomes. Patients' prognosis seemed to be deteriorated as smoking amount increased. Therefore, active screening and clinical attention are needed for high-risk individuals.

Milestones towards lung cancer screening implementation

The European Society of Radiology (ESR) and European Respiratory Society (ERS) published their joint statement paper on lung cancer screening (LCS), on 12 February 2020. This document joins and completes previous recommendations on LCS with specific emphasis on the analysis of issues encountered in the practical implementation of LCS in the community. Major milestones to enable the most efficient and equal dissemination of LCS are recognised as engagement of all stakeholders (e.g. candidate/participant, general practitioners, up to the specialised LCS facility), quality assurance, and primary prevention in the form of provision of counselling for smoking cessation.

Circulating tumour cells as a potential biomarker for lung cancer screening: a prospective cohort study

BACKGROUND

Lung cancer screening with low-dose chest CT (LDCT) reduces the mortality of eligible individuals. Blood signatures might act as a standalone screening tool, refine the selection of patients at risk, or help to classify undetermined nodules detected on LDCT. We previously showed that circulating tumour cells (CTCs) could be detected, using the isolation by size of epithelial tumour cell technique (ISET), long before the cancer was diagnosed radiologically. We aimed to test whether CTCs could be used as a biomarker for lung cancer screening.

METHODS

We did a prospective, multicentre, cohort study in 21 French university centres. Participants had to be eligible for lung cancer screening as per National Lung Screening Trial criteria and have chronic obstructive pulmonary disease with a fixed airflow limitation defined as post-bronchodilator FEV1/FVC ratio of less than 0·7. Any cancer, other than basocellular skin carcinomas, detected within the previous 5 years was the main exclusion criterion. Participants had three screening rounds at 1-year intervals (T0 [baseline], T1, and T2), which involved LDCT, clinical examination, and a blood test for CTCs detection. Participants and investigators were masked to the results of CTC detection, and cytopathologists were masked to clinical and radiological findings. Our primary objective was to test the diagnostic performance of CTC detection using the ISET technique in lung cancer screening, compared with cancers diagnosed by final pathology, or follow up if pathology was unavailable as the gold standard. This study is registered with ClinicalTrials.gov identifier, number NCT02500693.

FINDINGS

Between Oct 30, 2015, and Feb 2, 2017, we enrolled 614 participants, predominantly men (437 [71%]), aged 65·1 years (SD 6·5), and heavy smokers (52·7 pack-years [SD 21·5]). 81 (13%) participants dropped out between baseline and T1, and 56 (11%) did between T1 and T2. Nodules were detected on 178 (29%) of 614 baseline LDCTs. 19 participants (3%) were diagnosed with a prevalent lung cancer at T0 and 19 were diagnosed with incident lung cancer (15 (3%) of 533 at T1 and four (1%) of 477 at T2). Extrapulmonary cancers were diagnosed in 27 (4%) of participants. Overall 28 (2%) of 1187 blood samples were not analysable. At baseline, the sensitivity of CTC detection for lung cancer detection was 26·3% (95% CI 11·8-48·8). ISET was unable to predict lung cancer or extrapulmonary cancer development.

INTERPRETATION

CTC detection using ISET is not suitable for lung cancer screening.

FUNDING

French Government, Conseil Départemental 06, Fondation UNICE, Fondation Aveni, Fondation de France, Ligue Contre le Cancer-Comité des Alpes-Maritimes, ARC (Canc'Air Genexposomics), Claire de Divonne-Pollner, Enca Faidhi, Basil Faidhi, Fabienne Mourou, Michel Mourou, Leonid Fridlyand, cogs4cancer, and the Fondation Masikini.

Analysis of lung cancer risk model (PLCOM2012 and LLPv2) performance in a community-based lung cancer screening programme

INTRODUCTION

Low-dose CT (LDCT) screening of high-risk smokers reduces lung cancer (LC) specific mortality. Determining screening eligibility using individualised risk may improve screening effectiveness and reduce harm. Here, we compare the performance of two risk prediction models (PLCOM2012 and Liverpool Lung Project model (LLPv2)) and National Lung Screening Trial (NLST) eligibility criteria in a community-based screening programme.

METHODS

Ever-smokers aged 55-74, from deprived areas of Manchester, were invited to a Lung Health Check (LHC). Individuals at higher risk (PLCOM2012 score ≥1.51%) were offered annual LDCT screening over two rounds. LLPv2 score was calculated but not used for screening selection; ≥2.5% and ≥5% thresholds were used for analysis.

RESULTS

PLCOM2012 ≥1.51% selected 56% (n=1429) of LHC attendees for screening. LLPv2 ≥2.5% also selected 56% (n=1430) whereas NLST (47%, n=1188) and LLPv2 ≥5% (33%, n=826) selected fewer. Over two screening rounds 62 individuals were diagnosed with LC; representing 87% (n=62/71) of 6-year incidence predicted by mean PLCOM2012 score (5.0%). 26% (n=16/62) of individuals with LC were not eligible for screening using LLPv2 ≥5%, 18% (n=11/62) with NLST criteria and 7% (n=5/62) with LLPv2 ≥2.5%. NLST eligible Manchester attendees had 2.5 times the LC detection rate than NLST participants after two annual screens (≈4.3% (n=51/1188) vs 1.7% (n=438/26 309); p<0.0001). Adverse measures of health, including airflow obstruction, respiratory symptoms and cardiovascular disease, were positively correlated with LC risk. Coronary artery calcification was predictive of LC (adjOR 2.50, 95% CI 1.11 to 5.64; p=0.028).

CONCLUSION

Prospective comparisons of risk prediction tools are required to optimise screening selection in different settings. The PLCOM2012 model may underestimate risk in deprived UK populations; further research focused on model calibration is required.

Baseline Results of the West London lung cancer screening pilot study - Impact of mobile scanners and dual risk model utilisation

OBJECTIVES

The West London lung screening pilot aimed to identify early-stage lung cancer by targeting low-dose CT (LDCT) to high risk participants. Successful implementation of screening requires maximising participant uptake and identifying those at highest risk. As well as reporting pre-specified baseline screening metrics, additional objectives were to 1) compare participant uptake between a mobile and hospital-based CT scanner and 2) evaluate the impact on cancer detection using two lung cancer risk models.

METHODS

From primary care records, ever-smokers aged 60-75 were invited to a lung health check at a hospital or mobile site. Participants with PLCO_M2012 6-yr risk ≥1.51 % and/or LLP_v2 5-yr risk ≥2.0 % were offered a LDCT. Lung cancer detection rate, stage, and recall rates are reported. Participant uptake was compared at both sites (chi-squared test). LDCT eligibility and cancer detection rate were compared between those recruited under each risk model.

RESULTS

Of 8366 potential participants invited, 1047/5135 (20.4 %) invitees responded to an invitation to the hospital site, and 702/3231 (21.7 %) to the mobile site (p = 0.14). The median distance travelled to the hospital site was less than to the mobile site (3.3 km vs 6.4 km, p < 0.01). Of 1159 participants eligible for a scan, 451/1159 (38.9 %) had a LLP_v2 ≥2.0 % only, 71/1159 (6.1 %) had a PLCO_M2012 ≥1.5 % only; 637/1159 (55.0 %) met both risk thresholds. Recall rate was 15.9 %. Lung cancer was detected in 29/1145 (2.5 %) participants scanned (stage 1, 58.6 %); 5/29 participants with lung cancer did not meet a PLCO_M2012 threshold of ≥1.51 %; all had a LLP_v2 ≥2.0 %.

CONCLUSION

Targeted screening is effective in detecting early-stage lung cancer. Similar levels of participant uptake at a mobile and fixed site scanner were demonstrated, indicating that uptake was driven by factors in addition to scanner location. The LLP_v2 model was more permissive; recruitment with PLCO_M2012 alone would have missed several cancers.

Focus on lung cancer screening

Poor survival of lung cancer (LC) patients depends on several factors first of all the delay in the diagnosis, considering that the majority of patients have an advanced-stage disease at the time of diagnosis. In this context, use of screening to increase the percentage of early LC detection can play a crucial role. After the preliminary unsatisfactory experiences with chest X-rays and sputum cytology, low dose computed tomography (LDCT) has become the best method for LC screening. In particular, several randomized LDCT screening trials conducted in the last year showed significant reductions in LC mortality in high-risk subjects. This review focuses on both recent advances in LC screening and some open questions.

Risk prediction models versus simplified selection criteria to determine eligibility for lung cancer screening: an analysis of German federal-wide survey and incidence data

As randomized trials in the USA and Europe have convincingly demonstrated efficacy of lung cancer screening by computed tomography (CT), European countries are discussing the introduction of screening programs. To maintain acceptable cost-benefit and clinical benefit-to-harm ratios, screening should be offered to individuals at sufficiently elevated risk of having lung cancer. Using federal-wide survey and lung cancer incidence data (2008–2013), we examined the performance of four well-established risk models from the USA (PLCO_M2012, LCRAT, Bach) and the UK (LLP₂₀₀₈) in the German population, comparing with standard eligibility criteria based on age limits, minimal pack years of smoking (or combination of total duration with average intensity) and maximum years since smoking cessation. The eligibility criterion recommended by the United States Preventive Services Taskforce (USPSTF) would select about 3.2 million individuals, a group equal in size to the upper fifth of ever smokers age 50–79 at highest risk, and to 11% of all adults aged 50–79. According to PLCO_M2012, the model showing best concordance between numbers of lung cancer cases predicted and reported in registries, persons with 5-year risk ≥ 1.7% included about half of all lung cancer incidence in the full German population. Compared to eligibility criteria (e.g. USPSTF), risk models elected individuals in higher age groups, including ex-smokers with longer average quitting times. Further studies should address how in Germany these shifts may affect expected benefits of CT screening in terms of life-years gained versus the potential harm of age-specific increasing risk of over-diagnosis.

Systematic review and meta-analysis on the impact of lung cancer screening by low-dose computed tomography

INTRODUCTION

Lung cancer (LC) has the highest cancer mortality worldwide with poor prognosis. Screening with low-dose computed tomography (LDCT) in populations highly exposed to tobacco has been proposed to improve LC prognosis. Our objective was to perform a systematic review and meta-analysis to evaluate the efficacy of screening by LDCT compared with any other intervention in populations who reported tobacco consumption for more than 15 years on LC and overall mortality.

METHODS

We searched randomised controlled trials (RCTs) studying screening by LDCT compared with any other intervention in a population who reported an average smoking history greater than 15 pack-years from inception until the 19th February 2018 using Medline and Cochrane Library databases. Publication selection and data extraction were made independently by two double-blind reviewers.

RESULTS

Seven RCTs were included in the meta-analysis which corresponds to 84,558 participants. A significant relative reduction of LC-specific mortality of 17% (risk ratio [RR] = 0.83, 95% confidence interval [CI]: 0.76-0.91) and a relative reduction of overall mortality of 4% (RR = 0.96, 95% CI: 0.92-1.00) was observed in the screening group compared with the control group.

CONCLUSION

In populations highly exposed to tobacco, screening by LDCT reduces lung cancer mortality.

Noninvasive biomarkers for lung cancer diagnosis, where do we stand?

The 2010's saw demonstration of the power of lung cancer screening to reduce mortality. However, with implementation of lung cancer screening comes the challenge of diagnosing millions of lung nodules every year. When compared to other cancers with widespread screening strategies (breast, colorectal, cervical, prostate, and skin), obtaining a lung nodule tissue biopsy to confirm a positive screening test remains associated with higher morbidity and cost. Therefore, non-invasive diagnostic biomarkers may have a unique opportunity in lung cancer to greatly improve the management of patients at risk. This review covers recent advances in the field of liquid biomarkers and computed tomographic imaging features, with special attention to new methods for combination of biomarkers as well as the use of artificial intelligence for the discrimination of benign from malignant nodules.

Prognostic selection and long-term survival analysis to assess overdiagnosis risk in lung cancer screening randomized trials

OBJECTIVES

Overdiagnosis in low-dose computed tomography randomized screening trials varies from 0 to 67%. The National Lung Screening Trial (extended follow-up) and ITALUNG (Italian Lung Cancer Screening Trial) have reported cumulative incidence estimates at long-term follow-up showing low or no overdiagnosis. The Danish Lung Cancer Screening Trial attributed the high overdiagnosis estimate to a likely selection for risk of the active arm. Here, we applied a method already used in benefit and overdiagnosis assessments to compute the long-term survival rates in the ITALUNG arms in order to confirm incidence-excess method assessment.

METHODS

Subjects in the active arm were invited for four screening rounds, while controls were in usual care. Follow-up was extended to 11.3 years. Kaplan-Meyer 5- and 10-year survivals of "resected and early" (stage I or II and resected) and "unresected or late" (stage III or IV or not resected or unclassified) lung cancer cases were compared between arms.

RESULTS

The updated ITALUNG control arm cumulative incidence rate was lower than in the active arm, but this was not statistically significant (RR: 0.89; 95% CI: 0.67-1.18). A compensatory drop of late cases was observed after baseline screening. The proportion of "resected and early" cases was 38% and 19%, in the active and control arms, respectively. The 10-year survival rates were 64% and 60% in the active and control arms, respectively (p = 0.689). The five-year survival rates for "unresected or late" cases were 10% and 7% in the active and control arms, respectively (p = 0.679).

CONCLUSIONS

This long-term survival analysis, by prognostic categories, concluded against the long-term risk of overdiagnosis and contributed to revealing how screening works.

The growth feature and its diagnostic value for benign and malignant pulmonary nodules met in routine clinical practice

Background

Growth rate is an independent risk factor for lung cancer in screened pulmonary nodules. This study aimed to clarify growth characteristics of pulmonary nodules in routine clinical practice and examine whether volume doubling time (VDT) can predict the malignancy of these nodules.

Methods

We retrospectively enrolled patients with 5-30-mm-sized pulmonary nodules that had been surgically resected after a follow-up of at least 3 months. Two follow-up computed tomography (CT) images with similar thickness and long interval were obtained. Then, three-dimensional (3D) manual segmentation for all nodules was performed on two follow-up CT scans. Subsequently, VDT was calculated for nodules with a change in volume of at least 25%.

Results

Overall, 305 pulmonary nodules in 305 patients (men, 36.7%; median age, 57) were included. The mean increased diameter, mass, and volume of benign (n=86) and malignant (n=219) nodules were 0.09 vs. 2.37 mm, 0.10 vs. 0.66 g, and 32.74 vs. 1,871.28 mm3, respectively (P<0.05). In total, 24 of 86 benign nodules (28%, 18 grew and 6 shrank) and 121 of 219 malignant nodules (55%, 114 grew and 7 shrank) changed over time. The median VDTs of growing benign and malignant nodules were 389 and 526 days, respectively, (P=0.18), and the area under the receiver operating characteristic (ROC) curve was 0.67 (0.55-0.78), with a sensitivity and specificity of 69% and 58%, respectively. The median VDT for growing nodules was 339 days for inflammatory pseudotumors, 226 days for granulomas, 640 days for benign tumors, 1,541 days for enlarged lymph nodes, 762 days for adenocarcinoma in situ, 954 days for microinvasive adenocarcinoma, 534 days for invasive adenocarcinoma, and 118 days for squamous cell carcinoma.

Conclusions

In routine clinical practice, many malignant nodules could grow slowly or even remain stable over time. Regarding growing nodules, the diagnostic value of VDT was limited.

Enhanced antitumour efficacy of functionalized doxorubicin plus schisandrin B co-delivery liposomes via inhibiting epithelial-mesenchymal transition

Non-small cell lung cancer (NSCLC) is a malignant cancer characterized by easy invasion, metastasis and poor prognosis, so that conventional chemotherapy cannot inhibit its invasion and metastasis. Doxorubicin (DOX), as a broad-spectrum antitumour drug, cannot be widely used in clinic because of its poor targeting, short half-life, strong toxicity and side effects. Therefore, the aim of our study is to construct a kind of PFV modified DOX plus schisandrin B liposomes to solve the above problems, and to explore its potential mechanism of inhibiting NSCLC invasion and metastasis. The antitumour efficiency of the targeting liposomes was carried out by cytotoxicity, heating ablation, wound healing, transwell, vasculogenic mimicry channels formation and metastasis-related protein tests in vitro. Pharmacodynamics were evaluated by tumour inhibition rate, HE staining and TUNEL test in vivo. The enhanced anti-metastatic mechanism of the targeting liposomes was attributed to the downregulation of vimentin, vascular endothelial growth factor, matrix metalloproteinase 9 and upregulation of E-cadherin. In conclusion, the PFV modified DOX plus schisandrin B liposomes prepared in this study provided a treatment strategy with high efficiency for NSCLC.

Low-Dose CT Screening for Lung Cancer: Evidence from 2 Decades of Study

Lung cancer remains the overwhelmingly greatest cause of cancer death in the United States, accounting for more annual deaths than breast, prostate, and colon cancer combined. Accumulated evidence since the mid to late 1990s, however, indicates that low-dose CT screening of high-risk patients enables detection of lung cancer at an early stage and can reduce the risk of dying from lung cancer. CT screening is now a recommended clinical service in the United States, subject to guidelines and reimbursement requirements intended to standardize practice and optimize the balance of benefits and risks. In this review, the evidence on the effectiveness of CT screening will be summarized and the current guidelines and standards will be described in the context of knowledge gained from lung cancer screening studies. In addition, an overview of the potential advances that may improve CT screening will be presented, and the need to better understand the performance in clinical practice outside of the research trial setting will be discussed. © RSNA, 2020.

Electronic Medical Record Inaccuracies: Multicenter Analysis of Challenges with Modified Lung Cancer Screening Criteria

The National Comprehensive Cancer Network expanded their lung cancer screening (LCS) criteria to comprise one additional clinical risk factor, including chronic obstructive pulmonary disease (COPD). The electronic medical record (EMR) is a source of clinical information that could identify high-risk populations for LCS, including a diagnosis of COPD; however, an unsubstantiated COPD diagnosis in the EMR may lead to inappropriate LCS referrals. We aimed to detect the prevalence of unsubstantiated COPD diagnosis in the EMR for LCS referrals, to determine the efficacy of utilizing the EMR as an accurate population-based eligibility screening "trigger" using modified clinical criteria. We performed a multicenter review of all individuals referred to three LCS programs from 2012 to 2015. Each individual's EMR was searched for COPD diagnostic terms and the presence of a diagnostic pulmonary functionality test (PFT). An unsubstantiated COPD diagnosis was defined by an individual's EMR containing a COPD term with no PFTs present, or the presence of PFTs without evidence of obstruction. A total of 2834 referred individuals were identified, of which 30% (840/2834) had a COPD term present in their EMR. Of these, 68% (571/840) were considered unsubstantiated diagnoses: 86% (489/571) due to absent PFTs and 14% (82/571) due to PFTs demonstrating no evidence of postbronchodilation obstruction. A large proportion of individuals referred for LCS may have an unsubstantiated COPD diagnosis within their EMR. Thus, utilizing the EMR as a population-based eligibility screening tool, employing expanded criteria, may lead to individuals being referred, potentially, inappropriately for LCS.

Increased respiratory morbidity in individuals with interstitial lung abnormalities

Background

Interstitial lung abnormalities (ILA) are common in participants of lung cancer screening trials and broad population-based cohorts. They are associated with increased mortality, but less is known about disease specific morbidity and healthcare utilisation in individuals with ILA.

Methods

We included all participants from the screening arm of the Danish Lung Cancer Screening Trial with available baseline CT scan data (n = 1990) in this cohort study. The baseline scan was scored for the presence of ILA and patients were followed for up to 12 years. Data about all hospital admissions, primary healthcare visits and medicine prescriptions were collected from the Danish National Health Registries and used to determine the participants’ disease specific morbidity and healthcare utilisation using Cox proportional hazards models.

Results

The 332 (16.7%) participants with ILA were more likely to be diagnosed with one of several respiratory diseases, including interstitial lung disease (HR: 4.9, 95% CI: 1.8–13.3, p = 0.008), COPD (HR: 1.7, 95% CI: 1.2–2.3, p = 0.01), pneumonia (HR: 2.0, 95% CI: 1.4–2.7, p <  0.001), lung cancer (HR: 2.7, 95% CI: 1.8–4.0, p <  0.001) and respiratory failure (HR: 1.8, 95% CI: 1.1–3.0, p = 0.03) compared with participants without ILA. These findings were confirmed by increased hospital admission rates with these diagnoses and more frequent prescriptions for inhalation medicine and antibiotics in participants with ILA.

Conclusions

Individuals with ILA are more likely to receive a diagnosis and treatment for several respiratory diseases, including interstitial lung disease, COPD, pneumonia, lung cancer and respiratory failure during long-term follow-up.

Direct and indirect healthcare costs of lung cancer CT screening in Denmark: a registry study

INTRODUCTION

A study based on the Danish Randomised Controlled Lung Cancer Screening Trial (DLCST) calculated the healthcare costs of lung cancer screening by comparing costs in an intervention group with a control group. Participants in both groups, however, experienced significantly increased negative psychosocial consequences after randomisation. Substantial participation bias has also been documented: The DLCST participants reported fewer negative psychosocial aspects and experienced better living conditions compared with the random sample.

OBJECTIVE

To comprehensively analyse the costs of lung cancer CT screening and to determine whether invitations to mass screening alter the utilisation of the healthcare system resulting in indirect costs. Healthcare utilisation and costs are analysed in the primary care sector (general practitioner psychologists, physiotherapists, other specialists, drugs) and the secondary care sector (emergency room contacts, outpatient visits, hospitalisation days, surgical procedures and non-surgical procedures).

DESIGN

To account for bias in the original trial, the costs and utilisation of healthcare by participants in DLCST were compared with a new reference group, selected in the period from randomisation (2004-2006) until 2014.

SETTING

Four Danish national registers.

PARTICIPANTS

DLCST included 4104 current or former heavy smokers, randomly assigned to the CT group or the control group. The new reference group comprised a random sample of 535 current or former heavy smokers in the general Danish population who were never invited to participate in a cancer screening test.

MAIN OUTCOME MEASURES

Total healthcare costs including costs and utilisation of healthcare in both the primary and the secondary care sector.

RESULTS

Compared with the reference group, the participants in both the CT group (offered annual CT screening, lung function test and smoking counselling) and the control group (offered annual lung function test and smoking counselling) had significantly increased total healthcare costs, calculated at 60% and 48% respectively. The increase in costs was caused by increased use of healthcare in both the primary and the secondary sectors.

CONCLUSION

CT screening leads to 60% increased total healthcare costs. Such increase would raise the expected annual healthcare cost per participant from EUR 2348 to EUR 3756. Cost analysis that only includes costs directly related to the CT scan and follow-up procedures most likely underestimates total costs. Our data show that the increased costs are not limited to the secondary sector.

TRIAL REGISTRATION NUMBER

NCT00496977.

Innovations in Human Resources Management: Mediating Role of Intrinsic Motivation

This study determines the impact of loneliness on creativity through a powerful and essential mediator of intrinsic motivation. The ability to motivate oneself leads towards the accomplishment of tasks and creative work. In recent years, workplace loneliness has become a more critical issue in both academic and practical debates. So, this study highlighted the significant cause of creativity which could help the organization to handle the problem of loneliness. The study assumes that when isolation at the workplace is high, employees are less approachable towards their tasks. So, their performance and creativity reduced. Because loneliness leads to stress, depression and anger, it reduces the creative skills of employees. To enhance creativity, lonely employees must be motivated to minimise their adverse outcomes. So, the research question arises: Does intrinsic motivation (IM) intervene in between the workplace loneliness (WL) and employees' creativity? This study is also significant because employees and employers' relations are the backbone of their respective organizations and directly affect the performance and growth of their respective organizations. A data collection survey method was held on employees of Banking Sector currently working in Vehari district of Pakistan. Sample space was the employees of Pakistani banks working on officer grades. There is a total of 124 bank branches in Vehari District of Pakistan. In these 124 branches, a total of 726 employees were working on managerial positions which were targeted for data collection. Simple random sampling technique was employed to collect the information from the respondents. Simple random sampling techniques were used to avoid from the busyness and undesirable unknown effects from the target population. Data were obtained from 400 banking officers. For data collection, validated and adapted questionnaires were used. Each variable of the survey was measured through a Likert scale of 5 points. For statistics evaluation, the statistical tools such as reliability of data, collinearity of data, the association of variable's, mediation and Regression were tested. For data reliability and validation, Statistical Package for Social Sciences (SPSS) was used while to measure the direct, indirect or mediation effect was measured through smart pls 3. Smart PLS3 is a landmark in latent variable modelling. It combines state of the art methods with an easy to use and in-built graphical user interface. Structural Equation Modeling (SEM) is utilized to quantify the power of essential philosophies with spotted data. Results showed Workplace Loneliness has a definite and meaningful relationship with employee's creativity. Results also supported the intervening role of Intrinsic motivation (IM) between the relationship Workplace Loneliness (WL) on Employees’ creativity (EC). The study provides significant implications in literature and for practitioners who are interested in measuring the profound effect of loneliness on creativity. Hypotheses are tested through mediation and for mediation analysis through the most commonly used approach of baron and Kenny. From results, it is stated that workplace loneliness is predicting the intrinsic motivation and creativity. Intrinsic motivation is the mediator in the current study, which partially intermediates the relation of WL and EC. So, it can be stated that employees can only be creative and able to utilize their cognition abilities for creativity when they are socially isolated from other works. The findings authenticate all hypotheses and their correspondence between the workplace loneliness, creativity and intrinsic motivation. In a nutshell, intrinsic motivation is the crucial element for creativity because when employees are internally satisfied with their work, they become energized and motivated and perform their work in a creative way. Keywords employees creativity, intrinsic motivation, mediation analysis, structural equation modeling, workplace loneliness.

Current Controversies in Cardiothoracic Imaging: Low-dose Computerized Tomographic Overdiagnosis of Lung Cancer is Substantial; Its Consequences are Underappreciated-Point

Lung cancer seems an ideal screening candidate because of its frequency and lethality, its well-known risk factors, and because it can often be identified at a curable stage with noninvasive procedures. The lethality of clinically diagnosed lung cancers rendered the possibility of material overdiagnosis (OD) (by means of screening) implausible in the judgment of experienced clinicians. Increased experience with lung cancer screening trials, which showed an excess of cases in screened versus control cohorts, led to broader acceptance of its existence. The magnitude of OD and the appropriate methodology for its assessment are disputed. Overdiagnosed individuals experience substantial surgical mortality and their loss of pulmonary reserve leads, in many, to a material reduction in the duration and quality of life. To estimate the scale of computerized tomographic OD, taken as the excess of screen-identified cases versus unscreened controls, we pooled the long-term findings in the 3 reporting European trials comprising 10,675 subjects. There were 263 detected lung cancers in the low-dose, computerized tomographic-screened versus 153 in controls, a 42% excess.

Low-dose CT screening can reduce cancer mortality: A meta-analysis

SUMMARY OBJECTIVE Lung cancer is the leading cause of cancer-related death. To reduce lung cancer mortality and detect lung cancer in early stages, low dose CT screening is required. A meta-analysis was conducted to verify whether screening could reduce lung cancer mortality and to determine the optimal screening program. METHODS We searched PubMed, Web of Science, Cochrane library, ScienceDirect, and relevant Chinese databases. Randomized controlled trial studies with participants that were smokers older than 49 years (smoking >15 years or quit smoking 10 or 15 years ago) were included. RESULTS Nine RCT studies met the criteria. LDCT screening could find more lung cancer cases (RR=1.58, 95%CI=1.25-1.99, P<0.001) and more stage I lung cancers (RR=3.45, 95%CI=2.08-5.72, P<0.001) compared to chest-X ray or the no screening group. This indicated a statistically significant reduction in lung-cancer-specific mortality (RR=0.84, 95%CI=0.75-0.95, P=0.004), but without a statistically reduction in mortality due to all causes (RR=1.26, 95%CI=0.89-1.78, P=0.193). Annually, LDCT screening was sensitive in finding more lung cancers. CONCLUSIONS Low-dose CT screening is effective in finding more lung cancer cases and decreasing the deaths from lung cancer. Annual low-dose CT screening may be better than a biennial screening to detect more early-stage lung cancer cases.

Questions and Answers on Smoking in Patients With Diffuse ILD. Use of PICO Methodology

INTRODUCTION

The Smoking and the Diffuse Interstitial Lung Diseases (ILD) groups of ALAT and SEPAR collaborated in the preparation of this document.

MATERIALS AND METHODS

This document uses PICO methodology to answer various questions on the relationship between tobacco use and diffuse ILD.

RESULTS AND CONCLUSIONS

The main recommendations are: a) moderate level of evidence and strong recommendation to consider smoking as a risk factor for the development and/or modification of the progression of diffuse ILD; b) moderate level of evidence to identify an increase in mortality in diffuse ILD, irrespective of histologic pattern. Low evidence for ascribing it to smoking and strong recommendation for the early identification of patients with diffuse ILD. Further studies are needed to evaluate the effect of smoking cessation in patients with diffuse ILD; c) low level of evidence and weak recommendation for defining the impact of passive smoking in diffuse ILD; d) low level of evidence to demonstrate that smoking cessation improves the outcomes of patients diagnosed with diffuse ILD and strong recommendation to advise smoking cessation in smokers with diffuse ILD, and e) low level of evidence to support the clinical or epidemiological usefulness of active case finding for diffuse ILD in smoking cessation programs, and strong recommendation justifying the performance of spirometry in active case finding, based not on current smoking status, but on previous accumulated consumption, even in asymptomatic cases.

'Reduced' HUNT model outperforms NLST and NELSON study criteria in predicting lung cancer in the Danish screening trial

Hypothesis

We hypothesise that the validated HUNT Lung Cancer Risk Model would perform better than the NLST (USA) and the NELSON (Dutch‐Belgian) criteria in the Danish Lung Cancer Screening Trial (DLCST).

Methods

The DLCST measured only five out of the seven variables included in validated HUNT Lung Cancer Model. Therefore a ‘Reduced’ model was retrained in the Norwegian HUNT2-cohort using the same statistical methodology as in the original HUNT model but based only on age, pack years, smoking intensity, quit time and body mass index (BMI), adjusted for sex. The model was applied on the DLCST-cohort and contrasted against the NLST and NELSON criteria.

Results

Among the 4051 smokers in the DLCST with 10 years follow-up, median age was 57.6, BMI 24.75, pack years 33.8, cigarettes per day 20 and most were current smokers. For the same number of individuals selected for screening, the performance of the ‘Reduced’ HUNT was increased in all metrics compared with both the NLST and the NELSON criteria. In addition, to achieve the same sensitivity, one would need to screen fewer people by the ‘Reduced’ HUNT model versus using either the NLST or the NELSON criteria (709 vs 918, p=1.02e-11 and 1317 vs 1668, p=2.2e-16, respectively).

Conclusions

The ‘Reduced’ HUNT model is superior in predicting lung cancer to both the NLST and NELSON criteria in a cost-effective way. This study supports the use of the HUNT Lung Cancer Model for selection based on risk ranking rather than age, pack year and quit time cut-off values. When we know how to rank personal risk, it will be up to the medical community and lawmakers to decide which risk threshold will be set for screening.

Estimation of the Risk of Lung Cancer in Women Participating in a Population-Based Breast Cancer Screening Program

INTRODUCTION

Lung cancer mortality is increasing in women. In Spain, estimates suggest that lung cancer mortality may soon surpass breast cancer mortality, the main cause of cancer mortality among women. The aim of this study was to estimate the proportion of women at high risk of developing lung cancer in a group of participants in a population-based breast cancer screening program.

METHODS

Cross-sectional study in a sample of women who participated in a population-based breast cancer screening program in 2016 in Hospitalet de Llobregat (n=1,601). High risk of lung cancer was defined according to the criteria of the National Lung Screening Trial (NLST) and the Dutch-Belgian randomized lung cancer screening trial (NELSON).

RESULTS

Around 20% of smokers according to NLST criteria and 40% of smokers according to NELSON criteria, and around 20% of former smokers according to both criteria, are at high risk of developing lung cancer. A positive and statistically significant trend is observed between the proportion of women at high risk and nicotine dependence measured with the brief Fagerström test.

CONCLUSIONS

A high proportion of participants in this breast cancer screening program have a high risk of developing lung cancer and would be eligible to participate in a lung cancer screening program. Population-based breast cancer screening programs may be useful to implement lung cancer primary prevention activities.

Sequential screening for lung cancer in a high-risk group: randomised controlled trial: LungSEARCH: a randomised controlled trial of Surveillance using sputum and imaging for the EARly detection of lung Cancer in a High-risk group

BACKGROUND

Low-dose computed tomography (LDCT) screening detects early-stage lung cancer and reduces mortality. We proposed a sequential approach targeted to a high-risk group as a potentially efficient screening strategy.

METHODS

LungSEARCH was a national multicentre randomised trial. Current/ex-smokers with mild/moderate chronic obstructive pulmonary disease (COPD) were allocated (1:1) to have 5 years surveillance or not. Screened participants provided annual sputum samples for cytology and cytometry, and if abnormal were offered annual LDCT and autofluorescence bronchoscopy (AFB). Those with normal sputum provided annual samples. The primary end-point was the percentage of lung cancers diagnosed at stage I/II (nonsmall cell) or limited disease (small cell).

RESULTS

1568 participants were randomised during 2007-2011 from 10 UK centres. 85.2% of those screened provided an adequate baseline sputum sample. There were 42 lung cancers among 785 screened individuals and 36 lung cancers among 783 controls. 54.8% (23 out of 42) of screened individuals versus 45.2% (14 out of 31) of controls with known staging were diagnosed with early-stage disease (one-sided p=0.24). Relative risk was 1.21 (95% CI 0.75-1.95) or 0.82 (95% CI 0.52-1.31) for early-stage or advanced cancers, respectively. Overall sensitivity for sputum (in those randomised to surveillance) was low (40.5%) with a cumulative false-positive rate (FPR) of 32.8%. 55% of cancers had normal sputum results throughout. Among sputum-positive individuals who had AFB, sensitivity was 45.5% and cumulative FPR was 39.5%; the corresponding measures for those who had LDCT were 100% and 16.1%, respectively.

CONCLUSIONS

Our sequential strategy, using sputum cytology/cytometry to select high-risk individuals for AFB and LDCT, did not lead to a clear stage shift and did not improve the efficiency of lung cancer screening.

Lung Cancer Incidence and Mortality with Extended Follow-up in the National Lung Screening Trial

INTRODUCTION

The National Lung Screening Trial (NLST) randomized high-risk current and former smokers to three annual screens with either low-dose computed tomography (LDCT) or chest radiography (CXR) and demonstrated a significant reduction in lung cancer mortality in the LDCT arm after a median of 6.5 years' follow-up. We report on extended follow-up of NLST subjects.

METHODS

Subjects were followed by linkage to state cancer registries and the National Death Index. The number needed to screen (NNS) to prevent one lung cancer death was computed as the reciprocal of the difference in the proportion of patients dying of lung cancer across arms. Lung cancer mortality rate ratios (RRs) were computed overall and adjusted for dilution effect, with the latter including only deaths with a corresponding diagnosis close enough to the end of protocol screening.

RESULTS

The median follow-up times were 11.3 years for incidence and 12.3 years for mortality. In all, 1701 and 1681 lung cancers were diagnosed in the LDCT and CXR arms, respectively (RR = 1.01, 95% confidence interval [CI]: 0.95-1.09). The observed numbers of lung cancer deaths were 1147 (with LDCT) versus 1236 (with CXR) (RR = 0.92, 95% CI: 0.85-1.00). The difference in the number of patients dying of lung cancer (per 1000) across arms was 3.3, translating into an NNS of 303, which is similar to the original NNS estimate of around 320. The dilution-adjusted lung cancer mortality RR was 0.89 (95% CI: 0.80-0.997). With regard to overall mortality, there were 5253 (with LDCT) and 5366 (with CXR) deaths, for a difference across arms (per 1000) of 4.2 (95% CI: -2.6 to 10.9).

CONCLUSION

Extended follow-up of the NLST showed an NNS similar to that of the original analysis. There was no overall increase in lung cancer incidence in the LDCT arm versus in the CXR arm.

Lung Cancer Screening, Version 3.2018, NCCN Clinical Practice Guidelines in Oncology

Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. Early detection of lung cancer is an important opportunity for decreasing mortality. Data support using low-dose computed tomography (LDCT) of the chest to screen select patients who are at high risk for lung cancer. Lung screening is covered under the Affordable Care Act for individuals with high-risk factors. The Centers for Medicare & Medicaid Services (CMS) covers annual screening LDCT for appropriate Medicare beneficiaries at high risk for lung cancer if they also receive counseling and participate in shared decision-making before screening. The complete version of the NCCN Guidelines for Lung Cancer Screening provides recommendations for initial and subsequent LDCT screening and provides more detail about LDCT screening. This manuscript focuses on identifying patients at high risk for lung cancer who are candidates for LDCT of the chest and on evaluating initial screening findings.

[Lung cancer screening]

CLINICAL/METHODICAL ISSUE

The National Lung Screening Trial (NLST) in 2011 was able to prove for the first time that screening with a low-dose CT can reduce lung carcinoma mortality by 20%. Despite the positive outcome of the NLST, there is-unlike in the USA-currently no systematic lung cancer screening in Europe. This is partly because several significantly smaller screening studies in Europe failed to show any improvement in lung cancer mortality.

STANDARD RADIOLOGICAL METHODS

On the other hand, Europe's healthcare systems differ substantially from those in the United States, so that a direct transfer of US experience to Europe is not possible. For this reason, guidelines for lung cancer screening must be developed in the individual European countries to ensure that lung cancer mortality can be reduced by means of a quality-assured and cost-effective lung cancer screening.

PRACTICAL RECOMMENDATIONS

The experience and the expected results of the European screening studies can provide valuable help for these purposes.

Ten years of experience in lung cancer screening in Gdańsk, Poland: a comparative study of the evaluation and surgical treatment of 14 200 participants of 2 lung cancer screening programmes†

OBJECTIVES

The European Society of Thoracic Surgeons' recommendations confirm the implementation of lung cancer screening in Europe. We compared 2 screening programmes, the Pilot Pomeranian Lung Cancer Screening Programme (pilot study) and the Moltest Bis programme, completed in a single centre.

METHODS

A total of 8649 healthy volunteers (aged 50-75 years, smoking history ≥20 pack-years) were enrolled in a pilot study between 2009 and 2011, and a total of 5534 healthy volunteers (aged 50-79, smoking history ≥30 pack-years) were enrolled in the Moltest Bis programme between 2016 and 2017. Each participant had a low-dose computed tomography scan of the chest. Participants with a nodule diameter of >10 mm or with suspected tumour morphology underwent a diagnostic work-up in the pilot study. In the Moltest Bis programme, the criteria were based on the volume of the detected nodule on the baseline low-dose computed tomography scan and the volume doubling time in the subsequent rounds.

RESULTS

Lung cancer was diagnosed in 107 (1.24%) and 105 (1.90%) participants of the pilot study and of the Moltest Bis programme, respectively (P = 0.002). A total of 300 (3.5%) and 199 (3.6%) patients, respectively, were referred for further invasive diagnostic work-ups (P = 0.69). A total of 125 (1.5%) and 80 (1.5%) patients, respectively, underwent surgical resection (P = 0.74). The number of resected benign lesions was similar: 44 (35.0%) and 20 (25.0%), respectively (P = 0.13), but with a downwards trend. Lobectomies and/or segmentectomies were performed in 84.0% and 90.0% of patients with lung cancer, respectively (P = 0.22). Notably, patients in the Moltest Bis programme underwent video-assisted thoracoscopic surgery more often than did those in the pilot study (72.5% vs 24.0%, P < 0.001). Surgical patients with stages I and II non-small-cell lung cancer (NSCLC) accounted for 83.4% of the Moltest patients and 86.4% of the pilot study patients (P = 0.44).

CONCLUSIONS

Modified inclusion criteria in the screening programme lead to a higher detection rate of NSCLC. Growing expertise in lung cancer screening leads to increased indications for minimally invasive surgery and an increased proportion of lung-sparing resections. A single-team experience in lung cancer screening does not lead to a major reduction in the rate of diagnostic procedures and operations for non-malignant lesions.

Ten-year results of the Multicentric Italian Lung Detection trial demonstrate the safety and efficacy of biennial lung cancer screening

BACKGROUND

The Multicentric Italian Lung Detection (MILD) trial demonstrated that prolonged low-dose computed tomography (LDCT) screening could achieve a 39% reduction in lung cancer (LC) mortality. We have here evaluated the long-term results of annual vs. biennial LDCT and the impact of screening intensity on overall and LC-specific mortality at 10 years.

PATIENTS AND METHODS

Between 2005 and 2018, the MILD trial prospectively randomised the 2376 screening arm participants to annual (n = 1190) or biennial (n = 1186) LDCT, for a median screening period of 6.2 years and 23,083 person-years of follow-up. The primary outcomes were 10-year overall and LC-specific mortality, and the secondary end-points were the frequency of advanced-stage and interval LCs.

RESULTS

The biennial LDCT arm showed a similar overall mortality (hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.57-1.12) and LC-specific mortality at 10 years (HR 1.10, 95% CI 0.59-2.05), as compared with the annual LDCT arm. Biennial screening saved 44% of follow-up LDCTs in subjects with negative baseline LDCT, and 38% of LDCTs in all participants, with no increase in the occurrence of stage II-IV or interval LCs.

CONCLUSIONS

The MILD trial provides original evidence that prolonged screening beyond five years with biennial LDCT can achieve an LC mortality reduction comparable to annual LDCT, in subjects with a negative baseline examination.

Effects of low-dose computed tomography on lung cancer screening: a systematic review, meta-analysis, and trial sequential analysis

BACKGROUND

The Nelson mortality results were presented in September 2018. Four other randomized control trials (RCTs) were also reported the latest mortality outcomes in 2018 and 2019. We therefore conducted a meta-analysis to update the evidence and investigate the benefits and harms of low-dose computed tomography (LDCT) in lung cancer screening.

METHODS

Detailed electronic database searches were performed to identify reports of RCTs that comparing LDCT to any other type of lung cancer screening. Pooled risk ratios (RRs) were calculated using random effects models.

RESULTS

We identified nine RCTs (n = 97,244 participants). In pooled analyses LDCT reduced lung cancer mortality (RR 0.83, 95% CI 0.76-0.90, I2 = 1%) but had no effect on all-cause mortality (RR 0.95, 95% CI 0.90-1.00). Trial sequential analysis (TSA) confirmed the results of our meta-analysis. Subgroup defined by high quality trials benefitted from LDCT screening in reducing lung cancer mortality (RR 0.82, 95% CI 0.73-0.91, I2 = 7%), whereas no benefit observed in other low quality RCTs. LDCT was associated with detection of a significantly higher number of early stage lung cancers than the control. No significant difference (RR 0.64, 95% CI 0.30-1.33) was found in mortality after invasive procedures between two groups.

CONCLUSIONS

In meta-analysis based on sufficient evidence demonstrated by TSA suggests that LDCT screening is superiority over usual care in lung cancer survival. The benefit of LDCT is expected to be heavily influenced by the risk of lung cancer in the different target group (smoking status, Asian) being screened.

Lung Cancer Screening in Patients with COPD-A Case Report

We present two cases demonstrating the nuances that must be considered when determining if a patient could benefit from low dose computed tomography (LDCT) lung cancer screening. Our case report discusses the available literature, where it exists, on lung cancer screening with special attention to the impact of chronic obstructive pulmonary disease (COPD), and poor functional status. Patients with COPD and concurrent smoking history are at higher risk of lung cancer and may therefore benefit from lung cancer screening. However, this population is at increased risk for complications related to biopsies and lobar resections. Appropriate interventions other than surgical resection exist for COPD patients with poor pulmonary reserve. Risks and benefits of lung cancer screening are unique to each patient and require shared decision-making.

Prolonged lung cancer screening reduced 10-year mortality in the MILD trial: new confirmation of lung cancer screening efficacy

BACKGROUND

The National Lung Screening Trial showed that lung cancer (LC) screening by three annual rounds of low-dose computed tomography (LDCT) reduces LC mortality. We evaluated the benefit of prolonged LDCT screening beyond 5 years, and its impact on overall and LC specific mortality at 10 years.

DESIGN

The Multicentric Italian Lung Detection (MILD) trial prospectively randomized 4099 participants, to a screening arm (n = 2376), with further randomization to annual (n = 1190) or biennial (n = 1186) LDCT for a median period of 6 years, or control arm (n = 1723) without intervention. Between 2005 and 2018, 39 293 person-years of follow-up were accumulated. The primary outcomes were 10-year overall and LC specific mortality. Landmark analysis was used to test the long-term effect of LC screening, beyond 5 years by exclusion of LCs and deaths that occurred in the first 5 years.

RESULTS

The LDCT arm showed a 39% reduced risk of LC mortality at 10 years [hazard ratio (HR) 0.61; 95% confidence interval (CI) 0.39-0.95], compared with control arm, and a 20% reduction of overall mortality (HR 0.80; 95% CI 0.62-1.03). LDCT benefit improved beyond the 5th year of screening, with a 58% reduced risk of LC mortality (HR 0.42; 95% CI 0.22-0.79), and 32% reduction of overall mortality (HR 0.68; 95% CI 0.49-0.94).

CONCLUSIONS

The MILD trial provides additional evidence that prolonged screening beyond 5 years can enhance the benefit of early detection and achieve a greater overall and LC mortality reduction compared with NLST trial.

CLINICALTRIALS.GOV IDENTIFIER

NCT02837809.