Participant factors associated with psychosocial impacts of lung cancer screening: A systematic review

BACKGROUND

Psychosocial impacts of lung cancer screening (LCS) can cause both harm to individuals and serve as barriers to screening participation and adherence. Early data suggest that the psychosocial impacts of LCS are moderated by certain factors (e.g. sociodemographic characteristics and beliefs), but evidence synthesis is lacking. This systematic review aimed to understand individual-level risk factors for psychosocial burden during LCS as a precursor to developing strategies to identify and support participants, and improve LCS engagement.

METHODS

Four databases were searched for full-text articles published in English reporting any association between participant factors and psychosocial outcomes experienced during LCS. Study quality was assessed by two independent investigators; findings were synthesised narratively. The review was pre-registered with PROSPERO and adhered to PRISMA guidelines.

RESULTS

Thirty-five articles were included; most (33/35) studies were assessed at high or moderate risk of bias. Study designs were pre-post (n = 13), cross-sectional (n = 13), qualitative (n = 8) and mixed-methods (n = 1) and conducted primarily in the United States (n = 17). Psychological burden in LCS varied, and was often associated with younger age, female gender, current smoking status or increased smoking history, lower education, lower socio-economic group, not being married or co-habiting and experience with cancer. However, results were mixed, and non-significant associations were also reported across all factors. Beliefs (e.g. fatalism, stigma and expectation of LDCT results) and comorbid psychological burden were also linked to psychosocial outcomes, but evidence was sparse. Associations between risk perception, other participant factors and other psychosocial outcomes was inconclusive, likely reflecting individual biases in risk conceptualisation.

CONCLUSION(S)

Several participant factors are consistently reported to be associated with psychosocial impacts of LCS, though study heterogeneity and high risk of bias necessitate more robust evaluation. Further research on how perceptions, beliefs and expectations can be used to improve psychosocial outcomes during LCS is needed.

Lung cancer screening program factors that influence psychosocial outcomes: A systematic review

OBJECTIVES

Lung cancer screening (LCS) programs are being designed and implemented globally. Early data suggests that the psychosocial impacts of LCS are influenced by program factors, but evidence synthesis is needed. This systematic review aimed to elucidate the impact of service-level factors on psychosocial outcomes to inform optimal LCS program design and future implementation.

METHODS

Four databases were searched from inception to July 2023. Inclusion criteria were full-text articles published in English that reported an association between any program factors and psychosocial outcomes experienced during LCS. Study quality was appraised, and findings were synthesised narratively.

RESULTS

Thirty-two articles were included; 29 studies were assessed at high or moderate risk of bias. Study designs were RCT (n = 3), pre-post (n = 6), cross-sectional (n = 12), mixed-methods (n = 1), and qualitative (n = 10) studies, and conducted primarily in the USA (n = 25). Findings suggested that targeted interventions can improve smoking-related or decisional psychosocial outcomes (e.g., smoking cessation interventions increase readiness/motivation to quit) but impacts of interventions on other psychological outcomes were varied. There was limited evidence reporting association between service delivery components and psychological outcomes, and results suggested moderation by individual aspects (e.g., expectation of results, baseline anxiety). Opportunities for discussion were key in reducing psychological harm.

CONCLUSIONS

Certain program factors are reportedly associated with psychosocial impacts of LCS, but study heterogeneity and quality necessitate more real-world studies. Future work should examine (a) implementation of targeted interventions and high-value discussion during LCS, and (b) optimal methods and timing of risk and result communication, to improve psychosocial outcomes while reducing time burden for clinicians.

Variation in Reporting of Incidental Findings on Initial Lung Cancer Screening and Associations With Clinician Assessment

PURPOSE

The aim of this study was to quantify the distribution, frequency, and clinical significance of incidental findings (IFs) on initial lung cancer screening (LCS) and the association of report characteristics with subsequent assessment.

METHODS

Health records of patients undergoing initial LCS from 2015 to 2018 in the Minneapolis VA Health Care System were retrospectively reviewed for demographics, Lung CT Screening Reporting & Data System coding, IFs, and subsequent clinical assessment. IFs were considered potentially significant if they were likely to require any follow-up. High-risk significant IFs (SIFs) were potentially malignant. The primary outcome was the SIF being addressed. Outcomes were analyzed using a mixed-effects model.

RESULTS

Patients (n = 901) were primarily male (94.1%) smokers (62.1%) with a mean age of 65.2 years. IFs were extremely common (93.9%), with an average of 2.6 IFs per scan (n = 2,296). Seven hundred eighty-six IFs (34.2%) were deemed likely SIFs, of which 58 (7.4%) were high risk. Two hundred twenty-two (28.2%) were addressed by clinicians, of which 104 (13.2%) underwent testing. Reporting of SIFs varied among radiologists, with at least one SIF in the impression in 24% to 78% of low-dose CT studies with the S modifier, used to indicate the presence of a SIF, applied to 0% to 51% of reports. In the mutually adjusted model, radiologist recommendation (adjusted odds ratio [OR], 4.67; 95% confidence interval [CI], 2.23-9.76), high-risk finding (adjusted OR, 4.35; 95% CI, 1.81-10.45), and reporting in the impression (adjusted OR, 2.58; 95% CI, 1.28-5.18) were associated with increased odds of the SIF's being addressed.

CONCLUSIONS

Radiologists vary in their reporting of IFs on LCS. Further standardization of reporting of SIFs may improve this process, with the simultaneous goals of generating appropriate testing when needed and minimizing low-value care.

[Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer - Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society - Abridged Version]

The current S3 Lung Cancer Guidelines are edited with fundamental changes to the previous edition based on the dynamic influx of information to this field:The recommendations include de novo a mandatory case presentation for all patients with lung cancer in a multidisciplinary tumor board before initiation of treatment, furthermore CT-Screening for asymptomatic patients at risk (after federal approval), recommendations for incidental lung nodule management , molecular testing of all NSCLC independent of subtypes, EGFR-mutations in resectable early stage lung cancer in relapsed or recurrent disease, adjuvant TKI-therapy in the presence of common EGFR-mutations, adjuvant consolidation treatment with checkpoint inhibitors in resected lung cancer with PD-L1 ≥ 50%, obligatory evaluation of PD-L1-status, consolidation treatment with checkpoint inhibition after radiochemotherapy in patients with PD-L1-pos. tumor, adjuvant consolidation treatment with checkpoint inhibition in patients withPD-L1 ≥ 50% stage IIIA and treatment options in PD-L1 ≥ 50% tumors independent of PD-L1status and targeted therapy and treatment option immune chemotherapy in first line SCLC patients.Based on the current dynamic status of information in this field and the turnaround time required to implement new options, a transformation to a "living guideline" was proposed.

The impact of population screening for cardiovascular disease on quality of life

Aims

To examine the impact of population screening-generated events on quality of life: invitation, positive test result, initiation of preventive medication, enrolment in follow-up at the surgical department, and preventive surgical repair.

Methods and results

A difference-in-difference design based on data collected alongside two randomized controlled trials where general population men were randomized to screening for cardiovascular disease or to no screening. Repeated measurements of health-related quality of life (HRQoL) were conducted up to 3 years after inclusion using all relevant scales of the EuroQol instrument: the anxiety/depression dimension, the EuroQol 5-dimension profile index (using Danish preference weights), and the visual analogue scale for global health. We compare the mean change scores from before to after events for groups experiencing vs. not experiencing the events. Propensity score matching is additionally used to provide both unmatched and matched results. Invitees reported to be marginally better off than non-invitees on all scales of the EuroQol. For events of receiving the test result, initiating preventive medication, being enrolled in surveillance, and undergoing surgical repair, we observed no impact on overall HRQoL but a minor impact of being enrolled in surveillance on emotional distress, which did not persist after matching.

Conclusion

The often-claimed detrimental consequences of screening to HRQoL could not be generally confirmed. Amongst the screening events assessed, only two possible consequences were revealed: a reassurance effect after a negative screening test and a minor negative impact to emotional distress of being enrolled in surveillance that did not spill over to overall HRQoL.

Updated cost-effectiveness analysis of lung cancer screening for Australia, capturing differences in the health economic impact of NELSON and NLST outcomes

BACKGROUND

A national, lung cancer screening programme is under consideration in Australia, and we assessed cost-effectiveness using updated data and assumptions.

METHODS

We estimated the cost-effectiveness of lung screening by applying screening parameters and outcomes from either the National Lung Screening Trial (NLST) or the NEderlands-Leuvens Longkanker Screenings ONderzoek (NELSON) to Australian data on lung cancer risk, mortality, health-system costs, and smoking trends using a deterministic, multi-cohort model. Incremental cost-effectiveness ratios (ICERs) were calculated for a lifetime horizon.

RESULTS

The ICER for lung screening compared to usual care in the NELSON-based scenario was AU$39,250 (95% CI $18,150-108,300) per quality-adjusted life year (QALY); lower than the NLST-based estimate (ICER = $76,300, 95% CI $41,750-236,500). In probabilistic sensitivity analyses, lung screening was cost-effective in 15%/60% of NELSON-like simulations, assuming a willingness-to-pay threshold of $30,000/$50,000 per QALY, respectively, compared to 0.5%/6.7% for the NLST. ICERs were most sensitive to assumptions regarding the screening-related lung cancer mortality benefit and duration of benefit over time. The cost of screening had a larger impact on ICERs than the cost of treatment, even after quadrupling the 2006-2016 healthcare costs of stage IV lung cancer.

DISCUSSION

Lung screening could be cost-effective in Australia, contingent on translating trial-like lung cancer mortality benefits to the clinic.

Impact of low-dose computed tomography (LDCT) screening on lung cancer-related mortality

BACKGROUND

Lung cancer is the most common cause of cancer-related death in the world, however lung cancer screening has not been implemented in most countries at a population level. A previous Cochrane Review found limited evidence for the effectiveness of lung cancer screening with chest radiography (CXR) or sputum cytology in reducing lung cancer-related mortality, however there has been increasing evidence supporting screening with low-dose computed tomography (LDCT).  OBJECTIVES: To determine whether screening for lung cancer using LDCT of the chest reduces lung cancer-related mortality and to evaluate the possible harms of LDCT screening.

SEARCH METHODS

We performed the search in collaboration with the Information Specialist of the Cochrane Lung Cancer Group and included the Cochrane Lung Cancer Group Trial Register, Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library, current issue), MEDLINE (accessed via PubMed) and Embase in our search. We also searched the clinical trial registries to identify unpublished and ongoing trials. We did not impose any restriction on language of publication. The search was performed up to 31 July 2021.  SELECTION CRITERIA: Randomised controlled trials (RCTs) of lung cancer screening using LDCT and reporting mortality or harm outcomes.  DATA COLLECTION AND ANALYSIS: Two review authors were involved in independently assessing trials for eligibility, extraction of trial data and characteristics, and assessing risk of bias of the included trials using the Cochrane RoB 1 tool. We assessed the certainty of evidence using GRADE. Primary outcomes were lung cancer-related mortality and harms of screening. We performed a meta-analysis, where appropriate, for all outcomes using a random-effects model. We only included trials in the analysis of mortality outcomes if they had at least 5 years of follow-up. We reported risk ratios (RRs) and hazard ratios (HRs), with 95% confidence intervals (CIs) and used the I2 statistic to investigate heterogeneity.  MAIN RESULTS: We included 11 trials in this review with a total of 94,445 participants. Trials were conducted in Europe and the USA in people aged 40 years or older, with most trials having an entry requirement of ≥ 20 pack-year smoking history (e.g. 1 pack of cigarettes/day for 20 years or 2 packs/day for 10 years etc.). One trial included male participants only. Eight trials were phase three RCTs, with two feasibility RCTs and one pilot RCT. Seven of the included trials had no screening as a comparison, and four trials had CXR screening as a comparator. Screening frequency included annual, biennial and incrementing intervals. The duration of screening ranged from 1 year to 10 years. Mortality follow-up was from 5 years to approximately 12 years.  None of the included trials were at low risk of bias across all domains. The certainty of evidence was moderate to low across different outcomes, as assessed by GRADE. In the meta-analysis of trials assessing lung cancer-related mortality, we included eight trials (91,122 participants), and there was a reduction in mortality of 21% with LDCT screening compared to control groups of no screening or CXR screening (RR 0.79, 95% CI 0.72 to 0.87; 8 trials, 91,122 participants; moderate-certainty evidence). There were probably no differences in subgroups for analyses by control type, sex, geographical region, and nodule management algorithm. Females appeared to have a larger lung cancer-related mortality benefit compared to males with LDCT screening. There was also a reduction in all-cause mortality (including lung cancer-related) of 5% (RR 0.95, 95% CI 0.91 to 0.99; 8 trials, 91,107 participants; moderate-certainty evidence).  Invasive tests occurred more frequently in the LDCT group (RR 2.60, 95% CI 2.41 to 2.80; 3 trials, 60,003 participants; moderate-certainty evidence). However, analysis of 60-day postoperative mortality was not significant between groups (RR 0.68, 95% CI 0.24 to 1.94; 2 trials, 409 participants; moderate-certainty evidence).  False-positive results and recall rates were higher with LDCT screening compared to screening with CXR, however there was low-certainty evidence in the meta-analyses due to heterogeneity and risk of bias concerns. Estimated overdiagnosis with LDCT screening was 18%, however the 95% CI was 0 to 36% (risk difference (RD) 0.18, 95% CI -0.00 to 0.36; 5 trials, 28,656 participants; low-certainty evidence). Four trials compared different aspects of health-related quality of life (HRQoL) using various measures. Anxiety was pooled from three trials, with participants in LDCT screening reporting lower anxiety scores than in the control group (standardised mean difference (SMD) -0.43, 95% CI -0.59 to -0.27; 3 trials, 8153 participants; low-certainty evidence). There were insufficient data to comment on the impact of LDCT screening on smoking behaviour.  AUTHORS' CONCLUSIONS: The current evidence supports a reduction in lung cancer-related mortality with the use of LDCT for lung cancer screening in high-risk populations (those over the age of 40 with a significant smoking exposure). However, there are limited data on harms and further trials are required to determine participant selection and optimal frequency and duration of screening, with potential for significant overdiagnosis of lung cancer. Trials are ongoing for lung cancer screening in non-smokers.

Should psychological distress be listed as a surgical indication for indeterminate pulmonary nodules: protocol for a prospective cohort study in real-world settings

BACKGROUND

Pulmonary nodules (PNs) are documented in up to 30% of computed tomography (CT) reports. PNs of indeterminate nature (IPN) have been reported to be associated with increased psychological distress and deterioration of the quality of life. Despite lack of solid evidence, severe anxiety or depression has been proposed to be one of the surgical indications in expert consensus for IPN management. So far, there is no established criterion to guide the decision-making process, or to ensure evidence-based management. This study aims to evaluate whether psychological distress could be a surgical indication for IPN, and to establish an evidence-based distress threshold for necessary surgical intervention.

METHODS

This prospective observational study in real-world setting will involve an expected sample size of 1,253 IPN patients from the thoracic clinic of Guangdong Provincial People's Hospital. Web-based questionnaires powered by Wen Juan Xing (WJX) platform will be delivered to the patients for baseline data collection and psychological screening. Based on our pilot study, a total of 376 IPN patients with abnormal or borderline abnormal psychological states, as assessed by the Hospital Anxiety and Depression Scale (HADS), will be followed for 1 year before proceeding to the final analysis. The planned study period is from Jan 1, 2021, to Sept 30, 2022, and will entail two HADS assessments at baseline and follow-up. Sleep quality and indicators of healthcare-seeking behavior, such as the number of unplanned clinic visits or CT scans per year, will be used as anchors of psychological state. Patients who undergo surgical resection against the follow-up plan will be enrolled into a surgical group (expected n=94), while those who adhere to their plan will be automatically classified as a follow-up group after 1-year follow-up (expected n=282). Statistical measures such as independent-samples t-test and receiver operating characteristics (ROC) analysis will be used to assess the difference in psychological changes between the groups, and to generate an optimal threshold alerting surgical need. A Chi-square test or nonparametric test will be used to compare the baseline characteristics. Contributors to psychological burden and their effect sizes will be evaluated using general linear regression.

DISCUSSION

To date, data on the psychological benefits of surgical resection of IPN remains scanty. Evidence-based procedure of patient selection using appropriate psychological screening tools is crucial in improving the quality of care and preventing overtreatment. This protocol describes the rationale and methodology to address this unmet clinical need using real-world data, aiming to bridge the gap between clinical guidelines and real-world practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04857333. Registered April 23, 2021.

Patient-reported outcomes associated with cancer screening: a systematic review

Background

Multi-cancer early detection tests have been developed to enable earlier detection of multiple cancer types through screening. As reflected by patient-reported outcomes (PROs), the psychosocial impact of cancer screening is not yet clear. Our aim is to evaluate the impact of cancer screening through PRO assessment.

Methods

A systematic review was conducted using MEDLINE, EMBASE, and reference lists of articles from January 2000 to August 2020 for relevant publications assessing the psychosocial impact of cancer screening before and within 1 year after screening in the general asymptomatic population, including following receipt of results. Studies focused on diagnostic evaluation or involving patients previously diagnosed with cancer were excluded.

Results

In total, 31 studies (12 randomized controlled trials; 19 observational studies) were included, reflecting PRO assessments associated with lung, breast, colorectal, anal, ovarian, cervical, and prostate cancer screening procedures. The most commonly assessed construct was symptoms of anxiety, using the State-Trait Anxiety Inventory. Cancer-specific distress and worry were also assessed using a broad range of measures. Overall, individuals tolerated screening procedures well with no major psychosocial effects. Of note, increases in symptoms of anxiety and levels of distress and worry were generally found prior to communication of screening results and following communication of indeterminate or positive results that required further testing. These negative psychosocial effects were, however, not long-lasting and returned to baseline relatively soon after screening. Furthermore, individuals with higher cancer risk, such as current smokers and those with a family history of cancer, tended to have higher levels of anxiety and distress throughout the screening process, including following negative or indeterminate results.

Conclusions

The psychosocial impact of cancer screening is relatively low overall and short-lived, even following false-positive test results. Individuals with a higher risk of cancer tend to experience more symptoms of anxiety and distress during the screening process; thus, more attention to this group is recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09261-5.

Lung Cancer Screening with Low-Dose CT in Smokers: A Systematic Review and Meta-Analysis

Lung cancer continues to be one of the main causes of cancer death in Europe. Low-dose computed tomography (LDCT) has shown high potential for screening of lung cancer in smokers, most recently in two European trials. The aim of this review was to assess lung cancer screening of smokers by LDCT with respect to clinical effectiveness, radiological procedures, quality of life, and changes in smoking behavior. We searched electronic databases in April 2020 for publications of randomized controlled trials (RCT) reporting on lung cancer and overall mortality, lung cancer morbidity, and harms of LDCT screening. A meta-analysis was performed to estimate effects on mortality. Forty-three publications on 10 RCTs were included. The meta-analysis of eight studies showed a statistically significant relative reduction of lung cancer mortality of 12% in the screening group (risk ratio = 0.88; 95% CI: 0.79-0.97). Between 4% and 24% of screening-LDCT scans were classified as positive, and 84-96% of them turned out to be false positive. The risk of overdiagnosis was estimated between 19% and 69% of diagnosed lung cancers. Lung cancer screening can reduce disease-specific mortality in (former) smokers when stringent requirements and quality standards for performance are met.

Scanxiety: a scoping review about scan-associated anxiety

OBJECTIVES

To identify available literature on prevalence, severity and contributing factors of scan-associated anxiety ('scanxiety') and interventions to reduce it.

DESIGN

Systematic scoping review.

DATA SOURCES

Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, Ovid Cochrane Central Register of Controlled Trials, Scopus, EBSCO CINAHL and PubMed up to July 2020.

STUDY SELECTION

Eligible studies recruited people having cancer-related non-invasive scans (including screening) and contained a quantitative assessment of scanxiety.

DATA EXTRACTION

Demographics and scanxiety outcomes were recorded, and data were summarised by descriptive statistics.

RESULTS

Of 26 693 citations, 57 studies were included across a range of scan types (mammogram: 26/57, 46%; positron-emission tomography: 14/57, 25%; CT: 14/57, 25%) and designs (observation: 47/57, 82%; intervention: 10/57, 18%). Eighty-one measurement tools were used to quantify prevalence and/or severity of scanxiety, including purpose-designed Likert scales (17/81, 21%); the State Trait Anxiety Inventory (14/81, 17%) and the Hospital Anxiety and Depression Scale (9/81, 11%). Scanxiety prevalence ranged from 0% to 64% (above prespecified thresholds) or from 13% to 83% ('any' anxiety, if no threshold). Mean severity scores appeared low in almost all measures that quantitatively measured scanxiety (54/62, 87%), regardless of whether anxiety thresholds were prespecified. Moderate to severe scanxiety occurred in 4%-28% of people in studies using descriptive measures. Nine of 20 studies assessing scanxiety prescan and postscan reported significant postscan reduction in scanxiety. Lower education, smoking, higher levels of pain, higher perceived risk of cancer and diagnostic scans (vs screening scans) consistently correlated with higher scanxiety severity but not age, gender, ethnicity or marital status. Interventions included relaxation, distraction, education and psychological support. Six of 10 interventions showed a reduction in scanxiety.

CONCLUSIONS

Prevalence and severity of scanxiety varied widely likely due to heterogeneous methods of measurement. A uniform approach to evaluating scanxiety will improve understanding of the phenomenon and help guide interventions.

[Lung cancer screening with low dose computed tomography : a systematic review]

INTRODUCTION

Bronchial cancer, often diagnosed at a late stage, is the leading cause of cancer death. As early detection could potentially lead to curative treatment, several studies have evaluated low-dose chest CT (LDCT) as a screening method. The main objective of this work is to determine the impact of LDCT screening on overall mortality of a smoking population.

METHODS

Systematic review of randomised controlled screening trials comparing LDCT with no screening or chest x-ray.

RESULTS

Thirteen randomised controlled trials were identified, seven of which reported mortality results. NSLT showed a significant reduction of 6.7% in overall mortality and 20% in lung cancer mortality after 6.5 years of follow-up. NELSON showed a significant reduction in lung cancer mortality of 24% at 10 years among men. LUSI and MILD showed a reduction in lung cancer mortality of 69% at 8 years among women and 39% at 10 years, respectively.

CONCLUSION

Screening for bronchial cancer is a complex issue. Clarification is needed regarding the selection of individuals, the definition of a positive result and the attitude towards a suspicious nodule.

Ongoing challenges in implementation of lung cancer screening

Lung cancer is the leading cause of cancer deaths in Europe and around the world. Although available therapies have undergone considerable development in the past decades, the five-year survival rate for lung cancer remains low. This sobering outlook results mainly from the advanced stages of cancer most patients are diagnosed with. As the population at risk is relatively well defined and early stage disease is potentially curable, lung cancer outcomes may be improved by screening. Several studies already show that lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality. However, for a successful implementation of LCS programmes, several challenges have to be overcome: selection of high-risk individuals, standardization of nodule classification and measurement, specific training of radiologists, optimization of screening intervals and screening duration, handling of ancillary findings are some of the major points which should be addressed. Last but not least, the psychological impact of screening on screened individuals and the impact of potential false positive findings should not be neglected. The aim of this review is to discuss the different challenges of implementing LCS programmes and to give some hints on how to overcome them. Finally, we will also discuss the psychological impact of screening on quality of life and the importance of smoking cessation.

The person behind the nodule: a narrative review of the psychological impact of lung cancer screening

Lung cancer is the leading cause of cancer mortality globally, responsible for an estimated 1.76 million deaths worldwide in 2018 alone. Screening adults at high risk of lung cancer using low-dose computed tomography (LDCT) significantly reduces lung cancer mortality by finding the disease at an early, treatable stage. Many countries are actively considering whether to implement screening for their high-risk populations in light of the recently published Dutch-Belgian trial 'NELSON'. In deciding whether to implement a national screening programme, policymakers must weigh up the evidence for the relative risks posed to the entire screened population, including the potential psychological burden. This narrative review aimed to critically summarise the evidence for both negative and positive psychological responses experienced throughout the LDCT screening pathway, to describe their magnitude, duration and clinical relevance, and to draw out different aspects of measurement design crucial to their interpretation. A further aim was to discuss the available evidence for individual differences in psychological response, as well as interventions designed to promote psychological well-being. In summary, there was no evidence that the LDCT screening process caused adverse psychological outcomes overall, although those receiving indeterminate and suspicious LDCT results did report clinically raised anxiety and lung cancer-specific distress in the short-term. There was early evidence that demographic factors, smoking status and screening-ineligibility could be associated with individual differences in propensity to experience distress. Qualitative data suggested health beliefs could be modifiable mediators of these individual differences, but their aetiology requires quantitative and prospective research. There was also some evidence of positive psychological responses that could be capitalised on, and of the potential for person-centred communication interventions to achieve this. Further research needs to be embedded in real-world LDCT lung cancer screening services and use condition-specific measures to monitor outcomes and test evidence-based communication interventions in promoting psychological well-being.

Patient vs Clinician Perspectives on Communication About Results of Lung Cancer Screening: A Qualitative Study

BACKGROUND

In the incidental pulmonary nodule and breast cancer screening settings, high-quality patient-centered communication can improve adherence to evaluation and mitigate patient distress. Although guidelines emphasize shared decision-making before lung cancer screening, little is known about patient-clinician communication after lung cancer screening.

RESEARCH QUESTION

How do patients and clinicians perceive communication and results notification after lung cancer screening, and are there approaches that may mitigate or exacerbate distress?

STUDY DESIGN AND METHODS

We conducted interviews and focus groups with 49 patients who underwent lung cancer screening in the prior year and 36 clinicians who communicate screening results (primary care providers, pulmonologists, nurses), recruited from lung cancer screening programs at 4 hospitals. We analyzed transcripts using conventional content analysis.

RESULTS

Clinicians and patients diverged in their impressions of the quality of communication after lung cancer screening. Clinicians recognized the potential for patient distress and tailored their approach to disclosure based on how clinically concerning they perceived results to be. Disclosure of normal or low-risk findings usually occurred by letter; clinicians believed this process was efficient and well received by patients. Yet many patients were dissatisfied: several could not recall receiving results at all, and others reported that receiving results by letter left them confused and concerned, with little opportunity to ask questions. By contrast, patients with larger nodules typically received results during an immediate phone call or clinic visit, and both patients and clinicians agreed that these conversations represented high-quality communication that met patient needs. Regardless of their cancer risk, patients who learned their results in a conversation appreciated the opportunity to discuss both the meaning of the nodule and the evaluation plan, and to have their concerns addressed, preempting distress.

INTERPRETATION

Tension exists between clinicians' interest in efficiency of results notification by letter in low-risk cases and patients' need to understand and be reassured about screening results, their implications, and the plan for subsequent screening or nodule evaluation-even when clinicians did not perceive results as concerning. Brief conversations to discuss lung cancer screening results may improve patient understanding and satisfaction while reducing distress.

Common mental disorders in Taiwanese consumers of commercial low-dose computed tomography lung cancer screening: Comparison with a nationally representative sample

BACKGROUND/PURPOSE

We examined the prevalence of probable common mental disorders (CMDs) in commercial low-dose computed tomography (LDCT) lung cancer screening consumers relative to the general population and to determine the correlates of probable CMDs among screening participants.

METHODS

Commercial LDCT lung cancer screening consumers (N = 1323) were compared with a nationally representative sample from the Taiwan Social Change Survey (TSCS) (N = 2034). Respondents scoring ≥3 on the Chinese Health Questionnaire were classified as having a probable CMD. Logistic regression was used to investigate differences between the two groups and correlates of probable CMDs among LDCT lung cancer screening participants.

RESULTS

The prevalence of probable CMDs was higher among LDCT lung cancer screening participants (25.47%) than among TSCS adults (21.56%). Compared with the TSCS sample, the screening participants had a higher probability of CMDs (OR = 1.40, 95% CI = 1.13-1.73), higher education levels (OR = 7.95, 95% CI = 6.00-10.53), and a history of drinking (OR = 11.85, 95% CI = 9.45-14.85) or betel-quid use (OR = 5.43, 95% CI = 3.98-7.42) but were less likely to smoke (OR = 0.52, 95% CI = 0.40-0.68). Among the screening participants, being female (OR = 1.37, 95% CI = 1.02-1.84) and a current smoker (OR = 1.74, 1.19-2.54) and living near ≥2 smoking family members (OR = 2.30, 95% CI 1.57-3.38) were associated with an increased likelihood of having CMDs.

CONCLUSION

Commercial LDCT lung cancer screening users may have a positive association with probable CMDs compared to the general population. Screening programs should consider including criteria and providing psychoeducation to improve the physical and mental outcomes of participants.

CLINICAL TRIAL REGISTRATION

Purely observational studies (those in which the assignment of the medical intervention is not at the discretion of the investigator) do not require registration.

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.

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.

CT screening for lung cancer: Are we ready to implement in Europe?

Lung cancer screening with low-dose CT (LDCT) is already available in certain parts of the world, such as the United States, but not yet in Europe. The recently published European position statement on lung cancer screening has recommended planning for implementation of screening to start within 18-months [1]. Pilot European programmes are already underway, primarily in the United Kingdom (UK), delivering lung cancer screening to their local populations. This review article acknowledges the evidence base for LDCT screening and will discuss the challenges that still need to be overcome in an attempt to answer the question: are we ready to implement in Europe?

Cost-Effectiveness Analysis of Lung Cancer Screening Accounting for the Effect of Indeterminate Findings

Background

Numerous health policy organizations recommend lung cancer screening, but no consensus exists on the optimal policy. Moreover, the impact of the Lung CT screening reporting and data system guidelines to manage small pulmonary nodules of unknown significance (a.k.a. indeterminate nodules) on the cost-effectiveness of lung cancer screening is not well established.

Methods

We assess the cost-effectiveness of 199 screening strategies that vary in terms of age and smoking eligibility criteria, using a microsimulation model. We simulate lung cancer-related events throughout the lifetime of US-representative current and former smokers. We conduct sensitivity analyses to test key model inputs and assumptions.

Results

The cost-effectiveness efficiency frontier consists of both annual and biennial screening strategies. Current guidelines are not on the frontier. Assuming 4% disutility associated with indeterminate findings, biennial screening for smokers aged 50–70 years with at least 40 pack-years and less than 10 years since smoking cessation is the cost-effective strategy using $100 000 willingness-to-pay threshold yielding the highest health benefit. Among all health utilities, the cost-effectiveness of screening is most sensitive to changes in the disutility of indeterminate findings. As the disutility of indeterminate findings decreases, screening eligibility criteria become less stringent and eventually annual screening for smokers aged 50–70 years with at least 30 pack-years and less than 10 years since smoking cessation is the cost-effective strategy yielding the highest health benefit.

Conclusions

The disutility associated with indeterminate findings impacts the cost-effectiveness of lung cancer screening. Efforts to quantify and better understand the impact of indeterminate findings on the effectiveness and cost-effectiveness of lung cancer screening are warranted.

Sodium-glucose transporter 2 is a diagnostic and therapeutic target for early-stage lung adenocarcinoma

The diagnostic definition of indeterminate lung nodules as malignant or benign poses a major challenge for clinicians. We discovered a potential marker, the sodium-dependent glucose transporter 2 (SGLT2), whose activity identified metabolically active lung premalignancy and early-stage lung adenocarcinoma (LADC). We found that SGLT2 is expressed early in lung tumorigenesis and is found specifically in premalignant lesions and well-differentiated adenocarcinomas. SGLT2 activity could be detected in vivo by positron emission tomography (PET) with the tracer methyl 4-deoxy-4-[18F] fluoro-alpha-d-glucopyranoside (Me4FDG), which specifically detects SGLT activity. Using a combination of immunohistochemistry and Me4FDG PET, we identified high expression and functional activity of SGLT2 in lung premalignancy and early-stage/low-grade LADC. Furthermore, selective targeting of SGLT2 with FDA-approved small-molecule inhibitors, the gliflozins, greatly reduced tumor growth and prolonged survival in autochthonous mouse models and patient-derived xenografts of LADC. Targeting SGLT2 in lung tumors may intercept lung cancer progression at early stages of development by pairing Me4FDG PET imaging with therapy using SGLT2 inhibitors.

Low-dose computed tomography screening reduces lung cancer mortality

Lung cancer causes an estimated 1.6 million deaths each year, being the leading cause of cancer-related deaths in the world. Late diagnosis and, in some cases, the high aggressiveness of the tumour result in low overall five-year survival rates of 12% among men and 7% among women. The cure is most likely in early-stage disease. The poor outcomes of treatment in lung cancer resulting from the fact that most cases are diagnosed in the advanced stage of the disease justify the implementation of an optimal lung cancer prevention in the form of smoking cessation and screening programmes that would offer a chance to detect early stages of the disease, while fitting within specific economic constraints. The National Lung Screening Trial (NLST) - the largest and most expensive randomised, clinical trial in the USA demonstrated a 20% mortality rate reduction in patients who had undergone chest low-dose computed tomography (LDCT) screening, as compared to patients screened with a conventional chest X-ray. Results of the NLST enabled the implementation of lung cancer screening programme among highrisk patients in the USA and parts of China. In 2017, recommendations of the European Society of Thoracic Surgeons also strongly recommend an implementation of a screening programme in the EU. Further studies of improved lung cancer risk assessment scores and of effective molecular markers should intensify in order to reduce all potential harms to the high-risk group and to increase cost-effectiveness of the screening.

Low-dose computed tomography (LDCT) versus other cancer screenings in early diagnosis of lung cancer: A meta-analysis

BACKGROUND

Lung cancer is the leading cause of cancer mortality worldwide. It is often diagnosed at an advanced stage when treatment is no longer possible. Early population-based screening may provide an opportunity for early diagnosis and reduce mortality rates.

METHODS

Study characteristics were collected and outcome data (lung cancer diagnosis and mortality) were extracted and used for meta-analysis. Statistical analyses were performed using OpenMetaAnalyst-0.1503 software. The odds ratio (OR) and 95% confidence interval (CI) were used to assess LDCT compared to other screening methods under the random-effects model. The I2 statistic was used to assess heterogeneity.

RESULTS

Pooling data from 4 studies (64,129 patients) showed a higher incidence of diagnosed lung cancer with LDCT screening (OR = 1.86, 95% CI: 1.02-3.37), compared to other screening tools. However, no significant difference (OR = 1.13, 95% CI: 0.78-1.64) was found in lung cancer mortality between both groups.

CONCLUSIONS

Although no significant difference was found between LDCT and other control groups in terms of lung cancer mortality, this meta-analysis suggests an increased diagnosis of lung cancer with LDCT as compared with other screening modalities. This meta-analysis displays the potential but also the limitations of LDCT for early lung cancer detection.

Pilot study of a video intervention to reduce anxiety and promote preparedness for lung cancer screening

BACKGROUND

Lung cancer screening (LCS) with low dose computed tomography (LDCT) is associated with a 20% reduction in lung cancer mortality. Psychological burden is a potential harm associated with LCS, and is a major barrier to utilization. We aimed to examine the feasibility and acceptability of a video intervention designed to reduce anxiety and promote psychological preparedness of LCS.

PATIENTS AND METHODS

This is a two group, sequential enrollment pilot study of a video intervention that integrates information on screen criteria, procedures, benefits and harms, and follow-up plan. Participants were enrolled 1-2 weeks prior to baseline LDCT, and the intervention was administered in one in-person session on the day of LDCT. Outcomes were assessed at baseline (pre-screen), immediately after LDCT, and at 1 week, 3 months, and 7 months post-screen. Outcome measures included the SF-12 (HRQOL), STAI (anxiety), psychosocial consequences of LCS (COS-LC), risk perceptions for lung cancer, and a satisfaction tool. The student's t-test was used for exploratory evaluations on change from baseline scores both within and between groups.

RESULTS

Sixteen participants (8 intervention, 8 controls) enrolled and completed the study (61.5% retention). Participants in the control group reported a significantly increased sense of dejection at 1-month and 7-months post-screen as measured by the COS-LC (p = 0.01). Participants were highly satisfied with the intervention.

CONCLUSION

A video intervention that promoted psychological preparedness for LCS was feasible to implement as part of an LCS program and highly accepted by participants.

Lung cancer screening with low-dose spiral computed tomography: evidence from a pooled analysis of two Italian randomized trials

The benefits and harms of lung cancer (LC) screening with low-dose computed tomography (LDCT) are debatable. Positive results from the US National Lung Screening Trial were not evident in the European trials, possibly due to their smaller sample sizes. To address this issue, we conducted a patient-level pooled analysis of two Italian randomized controlled trials. Data from DANTE and MILD trials were combined for a total of 3640 individuals in the LDCT arm and 2909 in the control arm. LC and overall mortality were analyzed using multivariate hazard ratios (HRs) and log-rank tests stratified by study. The median follow-up was 8.2 years, with a total of 30 480 person-years in the LDCT arm and 22 157 in the control arm. A total of 192 patients developed LC in the LDCT arm and 105 in the control arm. Half of the LC cases in the LDCT arm had stage IA or IB cancer, as compared with 21% in the control arm. Overall mortality rates/100 000 person-years were 925 in the LDCT arm and 1074 in the control arm, and LC mortality rates were 299 and 357, respectively. The multivariate pooled overall mortality HR was 0.89 (95% confidence interval: 0.74-1.06) and the LC mortality HR was 0.83 (95% confidence interval: 0.61-1.12) for the LDCT arm as compared with the control arm. The present pooled analysis shows a nonsignificant 11% reduction in overall mortality in individuals undergoing LDCT screening as compared with the control arm. A pooled analysis of all European trials would be a useful contribution to assess the real benefit of LDCT screening.

Lung Cancer Screening and Its Impact on Surgical Volume

Lung cancer screening has demonstrated a reduction in lung cancer mortality by 20%. Annual low-dose computed tomography examination in high-risk individuals is now recommended by multiple national health care organizations and is covered under Medicare and Medicaid services. The impact of this public health intervention is projected to increase the case load for the thoracic surgery workforce.

Scan-associated distress in lung cancer: Quantifying the impact of "scanxiety"

OBJECTIVES

Diagnostic imaging may be a major source of cancer-related distress, a condition known as "scanxiety". Scant scholarly work has been performed to evaluate scan-associated distress in cancer. We sought to characterize risk factors for scan-associated distress among patients with Non-Small Cell Lung Cancer (NSCLC), and to evaluate the impact of scan-associated distress on quality of life.

MATERIALS AND METHODS

We conducted a cross-sectional survey study of patients with recurrent/metastatic NSCLC treated at an academic medical center. Clinical and demographic variables were obtained through chart abstraction and patient self-report. We used a modified version of the Impact of Event Scale 6 (IES-6) to specifically assess distress associated with scans, and quality of life was measured using the Functional Assessment of Cancer Therapy - Lung (FACT-L).

RESULTS

Among 103 participants (survey response rate 76.3%), median age was 67, 61.2% were women, and 82.5% were white. At the study visit, 72.8% of subjects discussed a recent scan, and 83% reported some scan-associated distress. Scan-associated distress was not associated with whether the patient had a recent scan, progressive disease or time from diagnosis. Scan-associated distress was associated with impaired quality of life (p=0.004); each unit increase in IES-6 corresponded to an approximately one-unit decrease in FACT-L score.

CONCLUSION

Scan-associated distress is a common problem among patients with NSCLC, and is associated with impaired quality of life. Scan-associated distress severity was not associated with time since diagnosis or whether a recent scan was discussed at the study visit, which implies scan-associated distress may be a persistent problem.

Implementing low-dose computed tomography screening for lung cancer in Canada: implications of alternative at-risk populations, screening frequency, and duration

BACKGROUND

Low-dose computed tomography (ldct) screening has been shown to reduce mortality from lung cancer; however, the optimal screening duration and "at risk" population are not known.

METHODS

The Cancer Risk Management Model developed by Statistics Canada for the Canadian Partnership Against Cancer includes a lung screening module based on data from the U.S. National Lung Screening Trial (nlst). The base-case scenario reproduces nlst outcomes with high fidelity. The impact in Canada of annual screening on the number of incident cases and life-years gained, with a wider range of age and smoking history eligibility criteria and varied participation rates, was modelled to show the magnitude of clinical benefit nationally and by province. Life-years gained, costs (discounted and undiscounted), and resource requirements were also estimated.

RESULTS

In 2014, 1.4 million Canadians were eligible for screening according to nlst criteria. Over 10 years, screening would detect 12,500 more lung cancers than the expected 268,300 and would gain 9200 life-years. The computed tomography imaging requirement of 24,000-30,000 at program initiation would rise to between 87,000 and 113,000 by the 5th year of an annual nlst-like screening program. Costs would increase from approximately $75 million to $128 million at 10 years, and the cumulative cost nationally over 10 years would approach $1 billion, partially offset by a reduction in the costs of managing advanced lung cancer.

CONCLUSIONS

Modelling various ways in which ldct might be implemented provides decision-makers with estimates of the effect on clinical benefit and on resource needs that clinical trial results are unable to provide.

Organ Dose and Attributable Cancer Risk in Lung Cancer Screening with Low-Dose Computed Tomography

Purpose

Lung cancer screening with CT has been recently recommended for decreasing lung cancer mortality. The radiation dose of CT, however, must be kept as low as reasonably achievable for reducing potential stochastic risks from ionizing radiation. The purpose of this study was to calculate individual patients’ lung doses and to estimate cancer risks in low-dose CT (LDCT) in comparison with a standard dose CT (SDCT) protocol.

Materials and Methods

This study included 47 adult patients (mean age 63.0 ± 5.7 years) undergoing chest CT on a third-generation dual-source scanner. 23/47 patients (49%) had a non-enhanced chest SDCT, 24 patients (51%) underwent LDCT at 100 kVp with spectral shaping at a dose equivalent to a chest x-ray. 3D-dose distributions were obtained from Monte Carlo simulations for each patient, taking into account their body size and individual CT protocol. Based on the dose distributions, patient-specific lung doses were calculated and relative cancer risk was estimated according to BEIR VII recommendations.

Results

As compared to SDCT, the LDCT protocol allowed for significant organ dose and cancer risk reductions (p<0.001). On average, lung dose was reduced from 7.7 mGy to 0.3 mGy when using LDCT, which was associated with lowering of the cancer risk from 8.6 to 0.35 per 100’000 cases. A strong linear correlation between lung dose and patient effective diameter was found for both protocols (R² = 0.72 and R² = 0.75 for SDCT and LDCT, respectively).

Conclusion

Use of a LDCT protocol for chest CT with a dose equivalent to a chest x-ray allows for significant lung dose and cancer risk reduction from ionizing radiation.

Burden of waiting for surveillance CT colonography in patients with screen-detected 6-9 mm polyps

Purpose

We assessed the burden of waiting for surveillance CT colonography (CTC) performed in patients having 6–9 mm colorectal polyps on primary screening CTC. Additionally, we compared the burden of primary and surveillance CTC.

Materials and methods

In an invitational population-based CTC screening trial, 101 persons were diagnosed with <3 polyps 6–9 mm, for which surveillance CTC after 3 years was advised. Validated questionnaires regarding expected and perceived burden (5-point Likert scales) were completed before and after index and surveillance CTC, also including items on burden of waiting for surveillance CTC. McNemar’s test was used for comparison after dichotomization.

Results

Seventy-eight (77 %) of 101 invitees underwent surveillance CTC, of which 66 (85 %) completed the expected and 62 (79 %) the perceived burden questionnaire. The majority of participants (73 %) reported the experience of waiting for surveillance CTC as ‘never’ or ‘only sometimes’ burdensome. There was almost no difference in expected and perceived burden between surveillance and index CTC. Waiting for the results after the procedure was significantly more burdensome for surveillance CTC than for index CTC (23 vs. 8 %; p = 0.012).

Conclusion

Waiting for surveillance CTC after primary CTC screening caused little or no burden for surveillance participants. In general, the burden of surveillance and index CTC were comparable.

Key points

• Waiting for surveillance CTC within a CRC screening caused little burden

• The vast majority never or only sometimes thought about their polyp(s)

• In general, the burden of index and surveillance CTC were comparable

• Awaiting results was more burdensome for surveillance than for index CTC

Psychological Burden Associated With Lung Cancer Screening: A Systematic Review

Lung cancer screening (LCS) with low-dose radiation computed tomography (LDCT) reduces mortality and is recommended for high-risk current and former smokers. Several potential harms associated with LCS have been identified, including the potential for psychological burden. To summarize the current state of the scientific knowledge on psychological burden associated with LCS, we performed a systematic search of the contemporary quantitative and qualitative research literature. We included randomized controlled trials and cohort studies that evaluated the effect of LCS with LDCT on psychological burden and health-related quality of life assessed using validated and nonvalidated measures. PubMed, CINAHL, PsychINFO, and Scopus were searched for English language articles published between 2004 and January 2015. Data abstraction and quality assessment were conducted by 2 independent reviewers. Thirteen studies were included that met our inclusion criteria. Overall, results were variable with some studies reporting worse psychological burden for patients with indeterminate results at prescreening, after screening, and at short-term follow-up (<6 months after screen). These adverse effects diminished or resolved at long-term follow-up (> 6 months after screen). LCS might be associated with short-term adverse psychological burden, particularly after a false positive result. However, these adverse effects diminished over time. The amount of current evidence is small, with limitations in study design and use of outcome measures. More high-quality research is needed to determine the frequency, duration, and overall magnitude of LCS-related psychological burden in nonclinical trial settings.

Lung Cancer Screening

Screening for lung cancer in high-risk individuals with annual low-dose computed tomography has been shown to reduce lung cancer mortality by 20% and is recommended by multiple health care organizations. Lung cancer screening is not a specific test; it is a process that involves appropriate selection of high-risk individuals, careful interpretation and follow-up of imaging, and annual testing. Screening should be performed in the context of a multidisciplinary program experienced in the diagnosis and management of lung nodules and early-stage lung cancer.

Automatic classification of pulmonary peri-fissural nodules in computed tomography using an ensemble of 2D views and a convolutional neural network out-of-the-box

In this paper, we tackle the problem of automatic classification of pulmonary peri-fissural nodules (PFNs). The classification problem is formulated as a machine learning approach, where detected nodule candidates are classified as PFNs or non-PFNs. Supervised learning is used, where a classifier is trained to label the detected nodule. The classification of the nodule in 3D is formulated as an ensemble of classifiers trained to recognize PFNs based on 2D views of the nodule. In order to describe nodule morphology in 2D views, we use the output of a pre-trained convolutional neural network known as OverFeat. We compare our approach with a recently presented descriptor of pulmonary nodule morphology, namely Bag of Frequencies, and illustrate the advantages offered by the two strategies, achieving performance of AUC = 0.868, which is close to the one of human experts.

The Solitary Pulmonary Nodule

Due to the high etiological diversity and the potential for malignancy, pulmonary nodules represent a clinical challenge, becoming increasingly frequent as the number of CT examinations rises. The topic gains even more importance as clear evidence for the effectiveness of CT screening was provided by the National Lung Screening Trial (NLST). Yet, the results were tempered by the high false-positive rate and the requirement of performing further diagnostic procedures. The management of those detected solitary pulmonary nodules is currently based on the individuals' risk of developing lung cancer, the pulmonary nodule characteristics and the capability of diagnostic and therapeutic approaches.

Patient-centered outcomes among lung cancer screening recipients with computed tomography: a systematic review

INTRODUCTION

Lung cancer screening using low-dose computed tomography (LDCT) is now widely recommended for adults who are current or former heavy smokers. It is important to evaluate the impact of screening on patient-centered outcomes. Among current and former smokers eligible for lung cancer screening, we sought to determine the consequences of screening with LDCT, and subsequent results, on patient-centered outcomes such as quality of life, distress, and anxiety.

METHODS

We searched the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the fourth Quarter 2012), MEDLINE (2000 to May 31, 2013), reference lists of articles, and Scopus for relevant English-language studies and systematic reviews. To evaluate the effect of LDCT screening on patient-centered outcomes, we included only randomized controlled trials (RCTs) involving asymptomatic adults. To evaluate the association of particular results and/or recommendations from a screening LDCT with patient-centered outcomes, we included results from RCTs as well as from cohort studies.

RESULTS

A total of 8215 abstracts were reviewed. Five publications from two European RCTs and one publication from a cohort study conducted in the United States met inclusion criteria. The process of LDCT lung cancer screening was associated with short-term psychologic discomfort in many people but did not affect distress, worry, or health-related quality of life. False-positive results were associated with short-term increases in distress that returned to levels that were similar to those among people with negative results. Negative results were associated with short-term decreases in distress.

CONCLUSIONS

As lung cancer screening is implemented in the general population, it will be important to evaluate its association with patient-centered outcomes. People considering lung cancer screening should be aware of the possibility of distress caused by false-positive results. Clinicians may want to consider tailoring communication strategies that can decrease the distress associated with these results.

Surgeons and lung cancer screening: rules of engagement

To understand the challenges of screening for lung cancer, surgeons should be familiar with fundamental epidemiologic concepts pertaining to screening and have an understanding of the evidence regarding the various modalities used for screening lung cancer. One large, recent study has confirmed that screening for lung cancer with low-dose computed tomography decreases mortality in high-risk individuals. As a result of these findings, comprehensive screening programs are being developed. High-quality programs should be safe, cost-effective, accessible to high-risk patients, and involve the participation of a multidisciplinary team. Surgeons should be engaged in the implementation of screening programs for lung cancer.

Anxiety of patients undergoing CT imaging-an underestimated problem?

RATIONALE AND OBJECTIVES

Prospective evaluation of anxiety in patients undergoing computed tomography (CT) imaging using a standardized state-trait anxiety inventory (STAI-S) and identification of possible risk factors.

MATERIAL AND METHODS

During a 9-month interval, patients undergoing CT were questioned using STAI-S. Additionally, 10 questions concerning specific procedure-related features (claustrophobia, radiation, administration of contrast, and so forth) were added. Moreover, sex, age, admitting subspecialty, organ region, reason for imaging, and prior imaging studies were recorded. Statistical analysis was performed using the Student t test and linear regression analysis; significance level was set to 5%.

RESULTS

Of 6122 patients, 825 patients undergoing CT (14%) were included (67% men; average age, 54 ± 17 years). Average STAI was 42 ± 10 with women (45 ± 11 vs. 41 ± 10; P < .001) and patients who received intravenous contrast (43 ± 10 vs. 42 ± 11; P = .021) showing significantly higher anxiety levels compared to those without contrast. Patients with investigations of their extremities (41 ± 11 vs. 43 ± 10; P = .020) and trauma patients (41 ± 11 vs. 43 ± 10; P = .006) revealed significantly lower STAI results. Patients who had never received a CT scan before showed significantly greater STAI-S values than those with repeat studies (42 ± 10 vs. 41 ± 11; P = .036). Females had greater fears concerning examination results (P < .001), radiation exposure (P = .032), administration of contrast (P = .014), and claustrophobia (P < .001). Patients with known malignancies had a significantly higher level of anxiety concerning their CT results (P = .002).

CONCLUSIONS

Anxiety does not only occur before MRI but also occur before CT. Its sources are manifold and include communication of CT results, administration of contrast agents, radiation exposure, and claustrophobia. In this setting, women seemed to be more receptive than men.

Screening for lung cancer

PURPOSE OF REVIEW

The purpose of this review is to provide an update on the current data about low-dose computed tomography (LD-CT) lung cancer screening.

RECENT FINDINGS

The National Lung Screening Trial (NLST) was the first study that provided statistical evidence that LD-CT screening for lung cancer significantly reduces lung cancer mortality by 20%. Three statistically underpowered European trials could not confirm the positive effect of LD-CT screening on lung cancer mortality. Major obstacles in lung cancer screening are overdiagnosis and the large number of false-positive results. In the NLST, more than 24% of the screens were positive, most of which (96.4%) proved to be benign in nature. Optimized protocols for the workup of detected nodules may help to reduce the number of false-positive screens.

SUMMARY

Currently, the NLST is the only sufficiently powered trial to report a lower mortality rate with LD-CT screening. Long-term follow-up data are still anticipated on the European screening trials. Furthermore, data on the extent of the potential dangers of LD-CT screening, such as overdiagnosis, false-positive results, and the effect of cumulative radiation dose, have yet to be investigated thoroughly.