Long-Term Follow-up Results of the DANTE Trial, a Randomized Study of Lung Cancer Screening with Spiral Computed Tomography

Comparison of computer-aided detection (CADe) capability for pulmonary nodules among standard-, reduced- and ultra-low-dose CTs with and without hybrid type iterative reconstruction technique

PURPOSE

To directly compare the effect of a reconstruction algorithm on nodule detection capability of the computer-aided detection (CADe) system using standard-dose, reduced-dose and ultra-low dose chest CTs with and without adaptive iterative dose reduction 3D (AIDR 3D).

MATERIALS AND METHODS

Our institutional review board approved this study, and written informed consent was obtained from each patient. Standard-, reduced- and ultra-low-dose chest CTs (250 mA, 50 mA and 10 mA) were used to examine 40 patients, 21 males (mean age ± standard deviation: 63.1 ± 11.0 years) and 19 females (mean age, 65.1 ± 12.7 years), and reconstructed as 1 mm-thick sections. Detection of nodule equal to more than 4 mm in dimeter was automatically performed by our proprietary CADe software. The utility of iterative reconstruction method for improving nodule detection capability, sensitivity and false positive rate (/case) of the CADe system using all protocols were compared by means of McNemar's test or signed rank test.

RESULTS

Sensitivity (SE: 0.43) and false-positive rate (FPR: 7.88) of ultra-low-dose CT without AIDR 3D was significantly inferior to those of standard-dose CTs (with AIDR 3D: SE, 0.78, p < .0001, FPR, 3.05, p < .0001; and without AIDR 3D: SE, 0.80, p < .0001, FPR: 2.63, p < .0001), reduced-dose CTs (with AIDR 3D: SE, 0.81, p < .0001, FPR, 3.05, p < .0001; and without AIDR 3D: SE, 0.62, p < .0001, FPR: 2.95, p < .0001) and ultra-low-dose CT with AIDR 3D (SE, 0.79, p < .0001, FPR, 4.88, p = .0001).

CONCLUSION

The AIDR 3D has a significant positive effect on nodule detection capability of the CADe system even when radiation dose is reduced.

Factors Associated with a Positive Baseline Screening Exam Result in the National Lung Screening Trial

RATIONALE

Lung cancer screening with low-dose computed tomography (LDCT) has been shown to decrease mortality in eligible high-risk patients. However, this mortality benefit comes with a high rate of false-positive findings, which require further evaluation.

OBJECTIVES

To identify patient- and center-specific factors associated with having a pulmonary nodule on baseline LDCT, and to develop a prediction rule to help in shared decision making.

METHODS

We identified individuals who underwent baseline LDCT screening as part of the National Lung Screening Trial. A positive screen was defined as a nodule 4 mm or greater in largest dimension. Using multiple logistic regression, we identified variables independently associated with having a positive screen.

MEASUREMENTS AND MAIN RESULTS

Among the 26,004 patients with complete data who underwent baseline LDCT, 7,123 patients (27%) had a positive screen. In a multivariate analysis, older age (odds ratio [OR] = 1.03 per 1-year increase, 95% confidence interval [CI] = 1.03-1.04), female sex (OR = 1.08, 95% CI = 1.01-1.14), white race (OR = 1.39, 95% CI = 1.25-1.55), heavier smoking history (OR = 1.02 per 5 pack-years smoked over 30, 95% CI = 1.00-1.04), history of chronic obstructive pulmonary disease (OR = 1.08, 95% CI = 1.01-1.17), being married (OR = 1.08, 95% CI = 1.02-1.15), hard rock mining (OR = 1.40, 95% CI = 1.04-1.89), and farm work (OR = 1.13, 95% CI = 1.03-1.23) were independently associated with having a positive screen, whereas having a college degree (OR = 0.94, 95% CI = 0.86-1.00) and abstinence from smoking (OR = 0.98 per year, 95% CI = 0.98-0.99) were associated with not having a positive screen. Patients enrolled at a site in an area highly endemic for histoplasma were 30% more likely to have a positive baseline LDCT screen (OR = 1.30, 95% CI = 1.21-1.40). The area under the receiver operator characteristic curve for the full model was 0.57 (0.56-0.58); including enrollment center as a random effect increased the area under the receiver operator characteristic curve to 0.65.

CONCLUSIONS

In the National Lung Screening Trial, both patient- and center-specific factors were associated with having a positive baseline screen. Although the model does not have sufficient accuracy to provide personalized risk estimates to guide shared decision making on an individual basis, it can nonetheless inform screening centers of the likelihood of further follow-up testing for their populations at large when allocating resources. Data collected from centers as broad-based screening is implemented can be used to improve model accuracy further.

Adherence to Radiology Recommendations in a Clinical CT Lung Screening Program

BACKGROUND

Assess patient adherence to radiologist recommendations in a clinical CT lung cancer screening program.

METHODS

Patients undergoing CT lung cancer screening between January 12, 2012, and June 12, 2013, were included in this institutional review board-approved retrospective review. Patients referred from outside our institution were excluded. All patients met National Comprehensive Cancer Network Guidelines Lung Cancer Screening high-risk criteria. Full-time program navigators used a CT lung screening program management system to schedule patient appointments, generate patient result notification letters detailing the radiologist follow-up recommendation, and track patient and referring physician notification of missed appointments at 30, 60, and 90 days. To be considered adherent, patients could be no more than 90 days past due for their next recommended examination as of September 12, 2014. Patients who died, were diagnosed with cancer, or otherwise became ineligible for screening were considered adherent. Adherence rates were assessed across multiple variables.

RESULTS

During the study interval, 1,162 high-risk patients were screened, and 261 of 1,162 (22.5%) outside referrals were excluded. Of the remaining 901 patients, 503 (55.8%) were male, 414 (45.9%) were active smokers, 377 (41.8%) were aged 65 to 73, and >95% were white. Of the 901 patients, 772 (85.7%) were adherent. Most common reasons for nonadherence were patient refusal of follow-up exam (66.7%), inability to successfully contact the patient (20.9%), and inability to obtain the follow-up order from the referring provider (7.8%); 23 of 901 (2.6%) were discharged for other reasons.

CONCLUSIONS

High rates of adherence to radiologist recommendations are achievable for in-network patients enrolled in a clinical CT lung screening program.

Low-dose CT for lung cancer screening: opportunities and challenges

Lung cancer is among the most frequently diagnosed cancers worldwide and the leading cause of cancer death in both males and females. Screening for lung cancer coupled with earlier intervention has long been studied as an approach to mortality reduction. However, minimal progress was achieved until recently, when lowdose spiral computed tomography (LDCT) screening demonstrated a 20% reduction in mortality from lung cancer in a randomized controlled trial (RCT), the National Lung Screening Trial, from the United States. On the basis of this finding, LDCT has been recommended for lung cancer screening in high-risk populations by several clinical guidelines. However, results from the following independent RCTs in Europe failed to show consistent conclusions. In addition, intractable problems gradually emerged with the progress of LDCTscreening. This paper summarizes and discusses the main observations and challenges of LDCT screening for lung cancer. Before spreading implementation of LDCTscreening, challenges, including high false-positive rates, overdiagnosis, enormous costs, and radiation risk, must be addressed. Complementary biomarkers and technical improvement are expected in the field of lung cancer screening in the near future.

Lung cancer screening: latest developments and unanswered questions

The US National Lung Screening Trial showed that individuals randomly assigned to screening with low-dose CT scans had 20% lower lung cancer mortality than did those screened with conventional chest radiography. On the basis of a review of the literature and a modelling study, the US Preventive Services Task Force recommends annual screening for lung cancer for individuals aged 55-80 years who have a 30 pack-year smoking history and either currently smoke or quit smoking within the past 15 years. However, the balance between benefits and harms of lung cancer screening is still greatly debated. The large number of false-positive results and the potential for overdiagnosis are causes for concern. Some investigators suggest the ratio between benefits and harms could be improved through various means. Nevertheless, many questions remain with regard to the implementation of lung cancer screening. This paper highlights the latest developments in CT lung cancer screening and provides an overview of the main unanswered questions.

Assessing the extent of non-aggressive cancer in clinically detected stage I non-small cell lung cancer

BACKGROUND

Overdiagnosis among clinically detected lung cancers likely consists of cases that are non-aggressive and slowly progressive and will never disseminate, cause symptoms or be a threat to a subject's survival, even if untreated. In this study, we estimate the prevalence of non-aggressive lung cancers from a large, population-based cancer registry.

METHODS

We identified individuals ≥65 years with histologically confirmed, untreated stage I non-small cell lung cancers (NSCLCs) from the Surveillance, Epidemiology, and End Results-Medicare registry. We estimated the rate of non-aggressive lung cancers by determining the point at which the cumulative lung cancer-specific survival curve no longer changed (ie, the slope approaches zero). At this point, there are no additional deaths due to progressive lung cancer observed among untreated patients after adjusting for deaths from competing risks (these long-term survivors can be considered 'non-aggressive cases).

RESULTS

The overall rate of non-aggressive cancers among 2197 clinically detected cases of untreated stage I NSCLC was 2.4%, 95% CI: 1.0% to 3.8%. The rate of non-aggressive cancer was 1.9% (95% CI: 0.0% to 4.9%) for women and 2.4% (95% CI: 0.7% to 4.1%) for men (p=0.84). When stratifying by tumour size, non-aggressive cancer rates were 10.2% (95% CI: 0.0% to 29.3%), 2.1% (95% CI: 0.0% to 9.2%), 4.9% (95% CI: 0.0% to 10.3%), 1.8% (95% CI: 0.0% to 5.2%) and 0.0% (95% CI: 0.0% to 1.0%) for tumour sizes <15 mm, 15-24 mm, 25-34 mm, 35-44 mm and ≥45 mm, respectively. In comparison with the smallest tumour sizes (<15 mm), the rates of non-aggressive cancers were not statistically significantly different for tumour sizes 15-24 mm (p=0.36), 25-34 mm (p=0.57), 35-44 mm (p=0.38) and tumour sizes >45 mm (p=0.30).

DISCUSSION

We found relatively low rates of non-aggressive cancers among clinically detected, stage I NSCLC regardless of sex or size. Our findings suggest that most clinically diagnosed early stage cancers should be treated with curative intent.

Lung cancer screening-low dose CT for lung cancer screening: recent trial results and next steps

Screening for lung cancer using low-dose CT has already been implemented in North America following the results of the National Lung Screening Trial. Outside North America, clinicians and researchers are addressing issues that may have a major impact on the success of screening programmes by reviewing results of existing trials and by designing new research and pilot programmes. This review summarizes the work that has been done to try to answer the remaining questions and highlights potential barriers which may affect screening uptake and cost-effectiveness.

Early detection of lung cancer by using an autoantibody panel in Chinese population

We have previously identified a panel of autoantibodies (AABs), including p53, GAGE7, PGP9.5, CAGE, MAGEA1, SOX2 and GBU4-5, that was helpful in the early diagnosis of lung cancer. This large-scale, multicenter study was undertaken to validate the clinical value of this 7-AABs panel for early detection of lung cancer in a Chinese population. Two independent sets of plasma samples from 2308 participants were available for the assay of AABs (training set = 300; validation set = 2008). The concentrations of AABs were quantitated by enzyme-linked immunosorbent assay (ELISA), and the optimal cutoff value for each AAB was determined in the training set and then applied in the validation set. The value of the 7-AABs panel for the early detection of lung cancer was assessed in 540 patients who presented with ground-glass nodules (GGNs) and/or solid nodules. In the validation set, the sensitivity and specificity of the 7-AABs panel were 61% and 90%, respectively. For stage I and stage II non-small cell lung cancer (NSCLC), the sensitivity of the 7-AABs panel was 62% and 59%, respectively, and for limited stage small cell lung cancer (SCLC) it was 59%; these sensitivity values were considerably higher than for traditional biomarkers (including CEA, NSE and CYFRA21-1). Importantly, the combination of the 7-AABs panel and low-dose computed tomography (CT) scanning significantly improved the diagnostic yield in patients presenting with GGNs and/or solid nodules. In conclusion, our 7-AABs panel has clinical value for early detection of lung cancer, including early-stage lung cancer presenting as GGNs.

Lung cancer screening

PURPOSE OF REVIEW

Lung cancer screening with low-dose chest computed tomography is now recommended for high-risk individuals by the US Preventive Services Task Force. This recommendation was informed by several randomized controlled trials, the largest of which, the National Lung Screening Trial, demonstrated a 20% relative reduction in lung cancer mortality with annual low-dose chest computed tomography compared with chest radiography.

RECENT FINDINGS

The benefit of lung cancer screening must be balanced against potential harms, including a high false-positive rate with consequent further evaluative studies and invasive testing. It is critical that harms be minimized as screening generalizes to the broad community. Informed decision making between providers and patients should include individualized risk assessment, a discussion of both potential benefit and harm, and tobacco treatment. Given the multiple components required for high quality, screening should ideally occur in the context of a multidisciplinary program.

SUMMARY

We are in the early days of lung cancer screening, still with much to learn. Ongoing studies are necessary to refine the definition of a positive screen and develop better methods of distinguishing between true positive and false-positive results. Novel approaches, including the development of multicomponent lung cancer biomarkers, will likely inform and improve our future screening practice.

Probability of cancer in high-risk patients predicted by the protein-based lung cancer biomarker panel in China: LCBP study

BACKGROUND

The authors built a model for lung cancer diagnosis previously based on the blood biomarkers progastrin-releasing peptide (ProGRP), carcinoembryonic antigen (CEA), squamous cell carcinoma antigen (SCC), and cytokeratin 19 fragment (CYFRA21-1). In the current study, they examined whether modification of the model to include relevant clinical information, risk factors, and low-dose chest computed tomography screening would improve the performance of the biomarker panel in large cohorts of Chinese adults.

METHODS

The current study was a large-scale multicenter study (ClinicalTrials.gov identifier NCT01928836) performed in a Chinese population. A total of 715 participants were enrolled from 5 regional centers in Beijing, Henan, Nanjing, Shanghai, and Chongqing between October 2012 and February 2014. Serum biomarkers ProGRP, CEA, SCC, and CYFRA21-1 were analyzed on the ARCHITECT i2000SR. Relevant clinical information was collected and used to develop a patient risk model and a nodule risk model.

RESULTS

The resulting patient risk model had an area under the receiver operating characteristic (ROC) curve of 0.7037 in the training data set and 0.7190 in the validation data set. The resulting nodule risk model had an area under the ROC curve of 0.9151 in the training data set and 0.5836 in the validation data set. Moreover, the nodule risk model had a relatively higher area under the ROC curve (0.9151 vs 0.8360; P = 0.001) compared with the American College of Chest Physician model in patients with lung nodules.

CONCLUSIONS

Both the patient risk model and the nodule risk model, developed for the early diagnosis of lung cancer, demonstrated excellent discrimination, allowing for the stratification of patients with different levels of lung cancer risk. These new models are applicable in high-risk Chinese populations. Cancer 2018;124:262-70. © 2017 American Cancer Society.

Development and Evaluation of a Lung Cancer Screening Decision Aid

Lung cancer is the second most common cancer; however, it often is not diagnosed until the advanced stages. Early-stage lung cancer is curable, but screening tools are not usually implemented in practice because of a lack of provider awareness. A lung cancer screening decision aid may increase screening use and, ultimately, reduce lung cancer deaths.


Progress and prospects of early detection in lung cancer

Lung cancer is the leading cause of cancer-related death in the world. It is broadly divided into small cell (SCLC, approx. 15% cases) and non-small cell lung cancer (NSCLC, approx. 85% cases). The main histological subtypes of NSCLC are adenocarcinoma and squamous cell carcinoma, with the presence of specific DNA mutations allowing further molecular stratification. If identified at an early stage, surgical resection of NSCLC offers a favourable prognosis, with published case series reporting 5-year survival rates of up to 70% for small, localized tumours (stage I). However, most patients (approx. 75%) have advanced disease at the time of diagnosis (stage III/IV) and despite significant developments in the oncological management of late stage lung cancer over recent years, survival remains poor. In 2014, the UK Office for National Statistics reported that patients diagnosed with distant metastatic disease (stage IV) had a 1-year survival rate of just 15-19% compared with 81-85% for stage I.

Liquid biopsy for early detection of lung cancer

PURPOSE OF REVIEW

The possibility of complete recovery for a lung cancer patient depends on very early diagnosis, as it allows total surgical resection. Screening for this cancer in a high-risk population can be performed using a radiological approach, but this holds a certain number of limitations. Liquid biopsy could become an alternative and complementary screening approach to chest imaging for early diagnosis of lung cancer.

RECENT FINDINGS

Several circulating biomarkers indicative of lung cancer can be investigated in blood, such as circulating tumor cells, circulating free nucleic acids (RNA and DNA) and proteins. However, none of these biomarkers have yet been adopted in routine clinical practice and studies are ongoing to confirm or not the usefulness and practical interest in routine early diagnosis and screening for lung cancers.

SUMMARY

Several potential circulating biomarkers for the early detection of lung cancer exist. When coupled to thoracic imaging, these biomarkers must give diagnosis of a totally resectable lung cancer and potentially provide new recommendations for surveillance by imagery of high-risk populations without a detectable nodule. Optimization of the specificity and sensitivity of the detection methods as well as standardization of the techniques is essential before considering for daily practice a liquid biopsy as an early diagnostic tool, or possibly as a predictive test, of lung cancer.

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary

This Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 report focuses primarily on the revised and novel parts of the document. The most significant changes include: (1) the assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; (2) for each of the groups A to D, escalation strategies for pharmacologic treatments are proposed; (3) the concept of deescalation of therapy is introduced in the treatment assessment scheme; (4) nonpharmacologic therapies are comprehensively presented; and (5) the importance of comorbid conditions in managing chronic obstructive pulmonary disease is reviewed.

Lung Cancer Screening

Lung cancer is the leading cause of cancer death in the United States. More than 80% of these deaths are attributed to tobacco use, and primary prevention can effectively reduce the cancer burden. The National Lung Screening Trial showed that low-dose computed tomography (LDCT) screening could reduce lung cancer mortality in high-risk patients by 20% compared with chest radiography. The US Preventive Services Task Force recommends annual LDCT screening for persons aged 55 to 80 years with a 30-pack-year smoking history, either currently smoking or having quit within 15 years.

Biopsy first: Lessons learned from Cancer and Leukemia Group B (CALGB) 140503

OBJECTIVE

Cancer and Leukemia Group B 140503 is an ongoing, multicenter randomized trial assessing whether sublobar resection is equivalent to lobectomy for the treatment of stage I A non-small cell lung cancer (NSCLC) ≤2 cm in diameter. The objective of this report is to determine the reasons precluding intraoperative randomization.

METHODS

From June 15, 2007, to March 22, 2013, 637 patients were preregistered to the trial. Three hundred eighty-nine were randomized successfully (61%), and 248 patients were not randomized (39%). We analyzed the reasons for nonrandomization among a subset of the nonrandomized patients (208) for whom additional data were available.

RESULTS

Of these 208 patients, undiagnosed benign nodules (n =104, 16% of all registered patients) and understaging of NSCLC (n =45, 7% of all registered patients) were the dominant reasons precluding randomization. Granulomas represent one-quarter of the benign nodules. The understaged patients had unsuspected nodal metastases (n =28) or other more advanced NSCLC. The rate of randomization was significantly greater in those patients who had a preoperative biopsy (P <.001).

CONCLUSIONS

In a carefully monitored cohort of patients with suspected small NSCLC ≤2 cm, a substantial number are misdiagnosed (benign nodules) or understaged. These patients may not have benefited from a thoracic surgical procedure. Preoperative biopsy significantly increased the rate of correct diagnosis. Preoperative biopsy of small suspected NSCLC will reduce the number of nontherapeutic or unnecessary thoracic procedures. Accuracy in preoperative diagnosis is increasingly important as more such small nodules are discovered through lung cancer screening.

AJRCCM: 100-Year Anniversary. The Shifting Landscape for Lung Cancer: Past, Present, and Future

The past century has witnessed a transformative shift in lung cancer from a rare reportable disease to the leading cause of cancer death among men and women worldwide. This historic shift reflects the increase in tobacco consumption worldwide, spurring public health efforts over the past several decades directed at tobacco cessation and control. Although most lung cancers are still diagnosed at a late stage, there have been significant advances in screening high-risk smokers, diagnostic modalities, and chemopreventive approaches. Improvements in surgery and radiation are advancing our ability to manage early-stage disease, particularly among patients considered unfit for traditional open resection. Arguably, the most dramatic progress has occurred on the therapeutic side, with the development of targeted and immune-based therapy over the past decade. This article reviews the major shifts in the lung cancer landscape over the past 100 years. Although many ongoing clinical challenges remain, this review will also highlight emerging molecular and imaging-based approaches that represent opportunities to transform the prevention, early detection, and treatment of lung cancer in the years ahead.

Mutational Profile from Targeted NGS Predicts Survival in LDCT Screening-Detected Lung Cancers

Background:

The issue of overdiagnosis in low-dose computed tomography (LDCT) screening trials could be addressed by the development of complementary bio-markers able to improve detection of aggressive disease. The mutation profile of LDCT screening–detected lung tumors is currently unknown.

Methods:

Targeted next-generation sequencing was performed on 94 LDCT screening–detected lung tumors. Associations with clinicopathologic features, survival, and the risk profile of a plasma microRNA signature classifier were analyzed.

Results:

The mutational spectrum and frequency observed in screening series was similar to that reported in public data sets, although a larger number of tumors without mutations in driver genes was detected. The 5-year overall survival (OS) rates of patients with and without mutations in the tumors were 66% and 100%, respectively (p = 0.015). By combining the mutational status with the microRNA signature classifier risk profile, patients were stratified into three groups with 5-year OS rates ranging from 42% to 97% (p < 0.0001) and the prognostic value was significant after controlling for stage (p = 0.02).

Conclusion:

Tumor mutational status along with a microRNA-based liquid biopsy can provide additional information in planning clinical follow-up in lung cancer LDCT screening programs.

Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary

This Executive Summary of the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 Report focuses primarily on the revised and novel parts of the document. The most significant changes include: (i) the assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; (ii) for each of the groups A to D, escalation strategies for pharmacological treatments are proposed; (iii) the concept of de-escalation of therapy is introduced in the treatment assessment scheme; (iv)non-pharmacological therapies are comprehensively presented and (v) the importance of co-morbid conditions in managing COPD is reviewed.

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary

This Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report focuses primarily on the revised and novel parts of the document. The most significant changes include: 1) the assessment of COPD has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; 2) for each of the groups A to D, escalation strategies for pharmacological treatments are proposed; 3) the concept of de-escalation of therapy is introduced in the treatment assessment scheme; 4) nonpharmacologic therapies are comprehensively presented and; 5) the importance of comorbid conditions in managing COPD is reviewed.

Recommendations from the European Society of Thoracic Surgeons (ESTS) regarding computed tomography screening for lung cancer in Europe

In order to provide recommendations regarding implementation of computed tomography (CT) screening in Europe the ESTS established a working group with eight experts in the field. On a background of the current situation regarding CT screening in Europe and the available evidence, ten recommendations have been prepared that cover the essential aspects to be taken into account when considering implementation of CT screening in Europe. These issues are: (i) Implementation of CT screening in Europe, (ii) Participation of thoracic surgeons in CT screening programs, (iii) Training and clinical profile for surgeons participating in screening programs, (iv) the use of minimally invasive thoracic surgery and other relevant surgical issues and (v) Associated elements of CT screening programs (i.e. smoking cessation programs, radiological interpretation, nodule evaluation algorithms and pathology reports). Thoracic Surgeons will play a key role in this process and therefore the ESTS is committed to providing guidance and facilitating this process for the benefit of patients and surgeons.

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary

This Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report focuses primarily on the revised and novel parts of the document. The most significant changes include: 1) the assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; 2) for each of the groups A to D, escalation strategies for pharmacological treatments are proposed; 3) the concept of de-escalation of therapy is introduced in the treatment assessment scheme; 4) nonpharmacologic therapies are comprehensively presented and; 5) the importance of comorbid conditions in managing COPD is reviewed.

Screening for lung cancer

This review will comprise a general overview of the epidemiology of lung cancer, as well as lung cancer risk factors, screening modalities, current guideline recommendations for screening, and our approach to lung cancer screening.

Medical follow-up of workers exposed to lung carcinogens: French evidence-based and pragmatic recommendations

Background

The aim of this work was to establish recommendations for the medical follow-up of workers currently or previously exposed to lung carcinogens.

Methods

A critical synthesis of the literature was conducted. Occupational lung carcinogenic substances were listed and classified according to their level of lung cancer risk. A targeted screening protocol was defined.

Results

A clinical trial, National Lung Screnning Trial (NLST), showed the efficacy of chest CAT scan (CT) screening for populations of smokers aged 55–74 years with over 30 pack-years of exposure who had stopped smoking for less than 15 years. To propose screening in accordance with NLST criteria, and to account for occupational risk factors, screening among smokers and former smokers needs to consider the types of occupational exposure for which the risk level is at least equivalent to the risk of the subjects included in the NLST. The working group proposes an algorithm that estimates the relative risk of each occupational lung carcinogen, taking into account exposure to tobacco, based on available data from the literature.

Conclusion

Given the lack of data on bronchopulmonary cancer (BPC) screening in occupationally exposed workers, the working group proposed implementing a screening experiment for bronchopulmonary cancer in subjects occupationally exposed or having been occupationally exposed to lung carcinogens who are confirmed as having high risk factors for BPC. A specific algorithm is proposed to determine the level of risk of BPC, taking into account the different occupational lung carcinogens and tobacco smoking at the individual level.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4114-1) contains supplementary material, which is available to authorized users.

Lung cancer screening with low-dose CT in Europe: strength and weakness of diverse independent screening trials

A North American trial reported a significant reduction of lung cancer mortality and overall mortality as a result of annual screening using low-dose computed tomography (LDCT). European trials prospectively tested a variety of possible screening strategies. The main topics of current discussion regarding the optimal screening strategy are pre-test selection of the high-risk population, interval length of LDCT rounds, definition of positive finding, and post-test apportioning of lung cancer risk based on LDCT findings. Despite the current lack of statistical evidence regarding mortality reduction, the European independent diverse strategies offer a multi-perspective view on screening complexity, with remarkable indications for improvements in cost-effectiveness and harm-benefit balance. The UKLS trial reported the advantage of a comprehensive and simple risk model for selection of patients with 5% risk of lung cancer in 5 years. Subjective risk prediction by biological sampling is under investigation. The MILD trial reported equal efficiency for biennial and annual screening rounds, with a significant reduction in the total number of LDCT examinations. The NELSON trial introduced volumetric quantification of nodules at baseline and volume-doubling time (VDT) for assessment of progression. Post-test risk refinement based on LDCT findings (qualitative or quantitative) is under investigation. Smoking cessation remains the most appropriate strategy for mortality reduction, and it must therefore remain an integral component of any lung cancer screening programme.

Necessity of organized low-dose computed tomography screening for lung cancer: From epidemiologic comparisons between China and the Western nations

OBJECTIVES

To compare the proportion of stage I lung cancer and population mortality in China to those in U.S. and Europe where lung cancer screening by low-dose computed tomography (LDCT) has been already well practiced.

METHODS

The proportions of stage I lung cancer in LDCT screening population in U.S. and Europe were retrieved from NLST and NELSON trials. The general proportion of stage I lung cancer in China was retrieved from a rapid meta-analysis, based on a literature search in the China National Knowledge Infrastructure database. The lung cancer mortality and prevalence of China, U.S. and Europe was retrieved from Globocan 2012 fact sheet. Mortality-to-prevalence ratio (MPR) was applied to compare the population survival outcome of lung cancer.

RESULTS

The estimated proportion of stage I lung cancer in China is merely 20.8% among hospital-based cross-sectional population, with relative ratios (RRs) being 2.40 (95% CI 2.18-2.65) and 2.98 (95% CI 2.62-3.38) compared by LDCT-screening population in U.S. and Europe trials, respectively. MPR of lung cancer is as high as 58.9% in China, with RRs being 0.46 (95% CI 0.31-0.67) and 0.58 (95% CI 0.39-0.85) compared by U.S. and Europe, respectively.

CONCLUSIONS

By the epidemiological inference, the LDCT mass screening might be associated with increasing stage I lung cancer and therefore improving population survival outcome. How to translate the experiences of lung cancer screening by LDCT from developed counties to China in a cost-effective manner needs to be further investigated.

Efficacy of low-dose computed tomography screening for lung cancer: the current state of evidence of mortality reduction

The interim and final results of randomized controlled trials on the efficacy of lung cancer computed tomography (CT) screening have been reported recently from Western countries. The outcome of the National Lung Screening Trial (NLST) demonstrated the efficacy of low-dose thoracic CT screening for heavy smokers; however, other studies have found no apparent reduction in the mortality rate, and the outcome of the NELSON study is awaited. To date, a few studies have reported on the efficacy of lung cancer CT screening for non-/light smokers. A report from the Hitachi district, which is an ecological/time series study where non-/light smokers account for approximately half of the CT screening examinees, was published in 2012, with an outcome suggesting efficacy. Currently, a randomized controlled trial (JECS Study) is underway in Japan with non-/light smokers as the subjects, and this trial is very important in terms of cancer prevention.

Circulating Tumor Cell and Cell-free Circulating Tumor DNA in Lung Cancer

Circulating tumor cells (CTCs) are tumor cells that are separated from the primary site or metastatic lesion and disseminate in blood circulation. CTCs are considered to be part of the long process of cancer metastasis. As a 'liquid biopsy', CTC molecular examination and investigation of single cancer cells create an important opportunity for providing an understanding of cancer biology and the process of metastasis. In the last decade, we have seen dramatic development in defining the role of CTCs in lung cancer in terms of diagnosis, genomic alteration determination, treatment response and, finally, prognosis prediction. The aims of this review are to understand the basic biology and to review methods of detection of CTCs that apply to the various types of solid tumor. Furthermore, we explored clinical applications, including treatment monitoring to anticipate therapy resistance as well as biomarker analysis, in the context of lung cancer. We also explored the potential use of cell-free circulating tumor DNA (ctDNA) in the genomic alteration analysis of lung cancer.

Circulating microRNA signature as liquid-biopsy to monitor lung cancer in low-dose computed tomography screening

Liquid biopsies can detect biomarkers carrying information on the development and progression of cancer. We demonstrated that a 24 plasma-based microRNA signature classifier (MSC) was capable of increasing the specificity of low dose computed tomography (LDCT) in a lung cancer screening trial. In the present study, we tested the prognostic performance of MSC, and its ability to monitor disease status recurrence in LDCT screening-detected lung cancers.Between 2000 and 2010, 3411 heavy smokers enrolled in two screening programmes, underwent annual or biennial LDCT. During the first five years of screening, 84 lung cancer patients were classified according to one of the three MSC levels of risk: high, intermediate or low. Kaplan-Meier survival analysis was performed according to MSC and clinico-pathological information. Follow-up MSC analysis was performed on longitudinal plasma samples (n = 100) collected from 31 patients before and after surgical resection.Five-year survival was 88.9% for low risk, 79.5% for intermediate risk and 40.1% for high risk MSC (p = 0.001). The prognostic power of MSC persisted after adjusting for tumor stage (p = 0.02) and when the analysis was restricted to LDCT-detected cases after exclusion of interval cancers (p < 0.001). The MSC risk level decreased after surgery in 76% of the 25 high-intermediate subjects who remained disease free, whereas in relapsing patients an increase of the MSC risk level was observed at the time of detection of second primary tumor or metastatic progression.These results encourage exploiting the MSC test for lung cancer monitoring in LDCT screening for lung cancer.

Screening for lung cancer: A systematic review and meta-analysis

OBJECTIVES

To examine evidence on benefits and harms of screening average to high-risk adults for lung cancer using chest radiology (CXR), sputum cytology (SC) and low-dose computed tomography (LDCT).

METHODS

This systematic review was conducted to provide up to date evidence for Canadian Task Force on Preventive Health Care (CTFPHC) lung cancer screening guidelines. Four databases were searched to March 31, 2015 along with utilizing a previous Cochrane review search. Randomized trials reporting benefits were included; any design was included for harms. Meta-analyses were performed if possible. PROSPERO #CRD42014009984.

RESULTS

Thirty-four studies were included. For lung cancer mortality there was no benefit of CXR screening, with or without SC. Pooled results from three small trials comparing LDCT to usual care found no significant benefits for lung cancer mortality. One large high quality trial showed statistically significant reductions of 20% in lung cancer mortality over a follow-up of 6.5years, for LDCT compared with CXR. LDCT screening was associated with: overdiagnosis of 10.99-25.83%; 11.18 deaths and 52.03 patients with major complications per 1000 undergoing invasive follow-up procedures; median estimate for false positives of 25.53% for baseline/once-only screening and 23.28% for multiple rounds; and 9.74 and 5.28 individuals per 1000 screened, with benign conditions underwent minor and major invasive follow-up procedures.

CONCLUSION

The evidence does not support CXR screening with or without sputum cytology for lung cancer. High quality evidence showed that in selected high-risk individuals, LDCT screening significantly reduced lung cancer mortality and all-cause mortality. However, for its implementation at a population level, the current evidence warrants the development of standardized practices for screening with LDCT and follow-up invasive testing to maximize accuracy and reduce potential associated harms.

Lung Cancer Screening with Chest Computed Tomography in People Living with HIV: A Review by the Multidisciplinary CANCERVIH Working Group

A shift in mortality and morbidity has been observed in people living with human immunodeficiency virus (PLWHIV) from acquired immunodeficiency syndrome (AIDS) to non-AIDS diseases. Lung cancer has the highest incidence rates among all the non-AIDS-defining malignancies and is associated with mortality rates that exceed those of other cancers. Strategies to increase lung cancer survival in PLWHIV are needed. Lung cancer screening with chest LDCT has been shown to be efficient in the general population at risk. The objective of this review is to discuss lung cancer screening with chest computed tomography in PLWHIV. Lung cancer screening in PLWHIV is feasible. Whether PLWHIV could benefit from an age threshold for screening that is earlier than the minimum age of 55 years usually required in the general population still needs further investigation. Studies evaluating smoking cessation programs and how they could be articulated with lung cancer screening programs are also needed in PLWHIV.

Low-dose computed tomography screening for lung cancer in populations highly exposed to tobacco: A systematic methodological appraisal of published randomised controlled trials

Low-dose computed tomography (LDCT) screening recommendations for lung cancer are contradictory. The French National Authority for Health commissioned experts to carry a systematic review on the effectiveness, acceptability and safety of lung cancer screening with LDCT in subjects highly exposed to tobacco. We used MEDLINE and Embase databases (2003-2014) and identified 83 publications representing ten randomised control trials. Control arms and methodology varied considerably, precluding a full comparison and questioning reproducibility of the findings. From five trials reporting mortality results, only the National Lung Screening Trial found a significant decrease of disease-specific and all-cause mortality with LDCT screening compared to chest X-ray screening. None of the studies provided all information needed to document the risk-benefit balance. The lack of statistical power and the methodological heterogeneity of European trials question on the possibility of obtaining valid results separately or by pooling. We conclude, in regard to the lack of strong scientific evidence, that LDCT screening should not be recommended in subjects highly exposed to tobacco.

Comparative evaluation of newly developed model-based and commercially available hybrid-type iterative reconstruction methods and filter back projection method in terms of accuracy of computer-aided volumetry (CADv) for low-dose CT protocols in phantom study

PURPOSE

To directly compare the capability of three reconstruction methods using, respectively, forward projected model-based iterative reconstruction (FIRST), adaptive iterative dose reduction using three dimensional processing (AIDR 3D) and filter back projection (FBP) for radiation dose reduction and accuracy of computer-aided volumetry (CADv) measurements on chest CT examination in a phantom study.

MATERIALS AND METHODS

An anthropomorphic thoracic phantom with 30 simulated nodules of three density types (100, -630, and -800 HU) and five different diameters was scanned with an area-detector CT at tube currents of 270, 200, 120, 80, 40, 20, and 10mA. Each scanned data set was reconstructed as thin-section CT with three methods, and all simulated nodules were measured with CADv software. For comparison of the capability for CADv at each tube current, Tukey's HSD test was used to compare the percentage of absolute measurement errors for all three reconstruction methods. Absolute percentage measurement errors were then compared by means of Dunett's test for each tube current at 270mA (standard tube current).

RESULTS

Mean absolute measurement errors of AIDR 3D and FIRST methods for each nodule type were significantly lower than those of the FBP method at 20mA and 10mA (p<0.05). In addition, absolute measurement errors of the FBP method at 20mA and 10mA was significantly higher than that at 270mA for all nodule types (p<0.05).

CONCLUSION

The FIRST and AIDR 3D methods are more effective than the FBP method for radiation dose reduction, while yielding better measurement accuracy of CADv for chest CT examination.

Lung cancer incidence and mortality in National Lung Screening Trial participants who underwent low-dose CT prevalence screening: a retrospective cohort analysis of a randomised, multicentre, diagnostic screening trial

BACKGROUND

Annual low-dose CT screening for lung cancer has been recommended for high-risk individuals, but the necessity of yearly low-dose CT in all eligible individuals is uncertain. This study examined rates of lung cancer in National Lung Screening Trial (NLST) participants who had a negative prevalence (initial) low-dose CT screen to explore whether less frequent screening could be justified in some lower-risk subpopulations.

METHODS

We did a retrospective cohort analysis of data from the NLST, a randomised, multicentre screening trial comparing three annual low-dose CT assessments with three annual chest radiographs for the early detection of lung cancer in high-risk, eligible individuals (aged 55-74 years with at least a 30 pack-year history of cigarette smoking, and, if a former smoker, had quit within the past 15 years), recruited from US medical centres between Aug 5, 2002, and April 26, 2004. Participants were followed up for up to 5 years after their last annual screen. For the purposes of this analysis, our cohort consisted of all NLST participants who had received a low-dose CT prevalence (T0) screen. We determined the frequency, stage, histology, study year of diagnosis, and incidence of lung cancer, as well as overall and lung cancer-specific mortality, and whether lung cancers were detected as a result of screening or within 1 year of a negative screen. We also estimated the effect on mortality if the first annual (T1) screen in participants with a negative T0 screen had not been done. The NLST is registered with ClinicalTrials.gov, number NCT00047385.

FINDINGS

Our cohort consisted of 26 231 participants assigned to the low-dose CT screening group who had undergone their T0 screen. The 19 066 participants with a negative T0 screen had a lower incidence of lung cancer than did all 26 231 T0-screened participants (371·88 [95% CI 337·97-408·26] per 100 000 person-years vs 661·23 [622·07-702·21]) and had lower lung cancer-related mortality (185·82 [95% CI 162·17-211·93] per 100 000 person-years vs 277·20 [252·28-303·90]). The yield of lung cancer at the T1 screen among participants with a negative T0 screen was 0·34% (62 screen-detected cancers out of 18 121 screened participants), compared with a yield at the T0 screen among all T0-screened participants of 1·0% (267 of 26 231). We estimated that if the T1 screen had not been done in the T0 negative group, at most, an additional 28 participants in the T0 negative group would have died from lung cancer (a rise in mortality from 185·82 [95% CI 162·17-211·93] per 100 000 person-years to 212·14 [186·80-239·96]) over the course of the trial.

INTERPRETATION

Participants with a negative low-dose CT prevalence screen had a lower incidence of lung cancer and lung cancer-specific mortality than did all participants who underwent a prevalence screen. Because overly frequent screening has associated harms, increasing the interval between screens in participants with a negative low-dose CT prevalence screen might be warranted.

FUNDING

None.