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

A pragmatic randomized clinical trial of multilevel interventions to improve adherence to lung cancer screening (The Larch Study): Study protocol

BACKGROUND

In real-world settings, low adherence to lung cancer screening (LCS) diminishes population-level benefits of reducing lung cancer mortality. We describe the Larch Study protocol, which tests the effectiveness of two patient-centered interventions (Patient Voices Video and Stepped Reminders) designed to address barriers and improve annual LCS adherence.

METHODS

The Larch Study is a pragmatic randomized clinical trial conducted within Kaiser Permanente Washington. Eligible patients (target n = 1606) are aged 50-78 years with an index low-dose CT (LDCT) of the chest with negative or benign findings. With a 2 × 2 factorial-design, patients are individually randomized to 1 of 4 arms: video only, reminders only, both video and reminders, or usual care. The Patient Voices video addresses patient education needs by normalizing LCS, reminding patients when LCS is due, and encouraging social support. Stepped Reminders prompts primary care physicians to order patient's repeat screening LDCT and patients to schedule their scan. Intervention delivery is embedded within routine healthcare, facilitated by shared electronic health record components. Primary outcome is adherence to national LCS clinical guidelines, defined as repeat LDCT within 9-15 months. Patient-reported outcomes are measured via survey (knowledge of LCS, perception of stigma) approximately 8 weeks after index LDCT. Our mixed-methods formative evaluation includes process data, collected during the trial, and interviews with trial participants and stakeholders.

DISCUSSION

Results will fill an important scientific gap on multilevel interventions to increase annual LCS adherence and provide opportunities for spread and scale to other healthcare settings.

REGISTRATION

Trial is registered at clinicaltrials.gov (#NCT05747443).

VLST: Virtual Lung Screening Trial for Lung Cancer Detection Using Virtual Imaging Trial

Importance

The efficacy of lung cancer screening can be significantly impacted by the imaging modality used. This Virtual Lung Screening Trial (VLST) addresses the critical need for precision in lung cancer diagnostics and the potential for reducing unnecessary radiation exposure in clinical settings.

Objectives

To establish a virtual imaging trial (VIT) platform that accurately simulates real-world lung screening trials (LSTs) to assess the diagnostic accuracy of CT and CXR modalities.

Design Setting and Participants

Utilizing computational models and machine learning algorithms, we created a diverse virtual patient population. The cohort, designed to mirror real-world demographics, was assessed using virtual imaging techniques that reflect historical imaging technologies.

Main Outcomes and Measures

The primary outcome was the difference in the Area Under the Curve (AUC) for CT and CXR modalities across lesion types and sizes.

Results

The study analyzed 298 CT and 313 CXR simulated images from 313 virtual patients, with a lesion-level AUC of 0.81 (95% CI: 0.78-0.84) for CT and 0.55 (95% CI: 0.53-0.56) for CXR. At the patient level, CT demonstrated an AUC of 0.85 (95% CI: 0.80-0.89), compared to 0.53 (95% CI: 0.47-0.60) for CXR. Subgroup analyses indicated CT's superior performance in detecting homogeneous lesions (AUC of 0.97 for lesion-level) and heterogeneous lesions (AUC of 0.71 for lesion-level) as well as in identifying larger nodules (AUC of 0.98 for nodules > 8 mm).

Conclusion and Relevance

The VIT platform validated the superior diagnostic accuracy of CT over CXR, especially for smaller nodules, underscoring its potential to replicate real clinical imaging trials. These findings advocate for the integration of virtual trials in the evaluation and improvement of imaging-based diagnostic tools.

Lung cancer screening use among screening-eligible adults with disabilities

BACKGROUND

Lung cancer screening (LCS) use among adults with disabilities has not been well characterized. We estimated the prevalence of LCS use by disability types and counts and investigated the association between disability counts and LCS utilization among LCS-eligible adults.

METHODS

We used cross-sectional data from the 2019 Behavioral Risk Factor Surveillance System, Lung Cancer Screening Module. Based on the 2013 US Preventive Services Task Force criteria for LCS, the sample included 4407 LCS-eligible adults, aged 55-79 years, with current or former (quit smoking in the past 15 years) tobacco use history of at least 30 pack-years. Disability types included limitations in hearing, vision, cognition, mobility, self-care, and independent living. We also categorized respondents by number of disabilities (no disability, 1 disability, 2 disabilities, 3+ disabilities). We utilized descriptive statistics and multivariable logistic regression analyses to determine the association between disability counts and the receipt of LCS (yes/no) in the past 12 months.

RESULTS

In 2019, 16.4% of LCS-eligible adults were screened for lung cancer. Overall, 49.6% of participants had no disability, and 14.5% had >3 disabilities. Mobility was the most prevalent disability type (35.4%), followed by cognitive impairment (18.2%) and hearing (16.6%). LCS was more prevalent in adults with disability in self-care versus no disability in self-care (24.0% vs. 15.5%, p = 0.01), disability in independent living versus no disability in independent living (22.2% vs. 15.4%, p = 0.02), and cognitive impairment disability versus no cognitive impairment (22.1% vs. 15.3%, p = 0.03). The prevalence rates of LCS among groups of LCS-eligible adults with different disability counts were not significant (p = 0.17).

CONCLUSIONS

Despite the lack of clinical guidelines on LCS among individuals with disabilities, some individuals with disabilities are being screened for lung cancer. Future research should address this knowledge gap to determine clinical benefit versus harm of LCS among those with disabilities.

Cardiac troponin I as predictor for cardiac and other mortality in the German randomized lung cancer screening trial (LUSI)

Cardiac Troponin I (cTnI) could be used to identify individuals at elevated risk of cardiac death in lung cancer (LC) screening settings. In a population-based, randomized LC screening trial in Germany ("LUSI" study) serum cTnI was measured by high-sensitivity assay in blood samples collected at baseline, and categorized into unquantifiable/low (< 6 ng/L), intermediate (≥ 6-15 ng/L), and elevated (≥ 16 ng/L). Cox proportional-hazard models were used to estimate risk of all-cause and cardiac mortality with cTnI levels. After exclusion criteria, 3653 participants were included for our analyses, of which 82.4% had low, 12.8% intermediate and 4.8% elevated cTnI, respectively. Over a median follow up of 11.87 years a total of 439 deaths occurred, including 67 caused by cardiac events. Within the first 5 years after cTnI measurement, intermediate or elevated cTnI levels showed approximately 1.7 (HR = 1.69 [95% CI 0.57-5.02) and 4.7-fold (HR = 4.66 [1.73-12.50]) increases in risk of cardiac death relative to individuals with unquantifiable/low cTnI, independently of age, sex, smoking and other risk factors. Within this time interval, a risk model based on age, sex, BMI, smoking history and cTnI showed a combined area under the ROC curve (AUC) of 73.6 (58.1-87.3), as compared to 70.4 (53.3-83.5) for a model without cTnI. Over the time interval of > 5-10 years after blood donation, the relative risk associations with cTnI and were weaker. cTnI showed no association with mortality from any other (non-cardiac) cause. Our findings show that cTnI may be of use for identifying individuals at elevated risk specifically of short-term cardiac mortality in the context of LC screening.

Study rationale and design of the PEOPLHE trial

PURPOSE

Lung cancer screening (LCS) by low-dose computed tomography (LDCT) demonstrated a 20-40% reduction in lung cancer mortality. National stakeholders and international scientific societies are increasingly endorsing LCS programs, but translating their benefits into practice is rather challenging. The "Model for Optimized Implementation of Early Lung Cancer Detection: Prospective Evaluation Of Preventive Lung HEalth" (PEOPLHE) is an Italian multicentric LCS program aiming at testing LCS feasibility and implementation within the national healthcare system. PEOPLHE is intended to assess (i) strategies to optimize LCS workflow, (ii) radiological quality assurance, and (iii) the need for dedicated resources, including smoking cessation facilities.

METHODS

PEOPLHE aims to recruit 1.500 high-risk individuals across three tertiary general hospitals in three different Italian regions that provide comprehensive services to large populations to explore geographic, demographic, and socioeconomic diversities. Screening by LDCT will target current or former (quitting < 10 years) smokers (> 15 cigarettes/day for > 25 years, or > 10 cigarettes/day for > 30 years) aged 50-75 years. Lung nodules will be volumetric measured and classified by a modified PEOPLHE Lung-RADS 1.1 system. Current smokers will be offered smoking cessation support.

CONCLUSION

The PEOPLHE program will provide information on strategies for screening enrollment and smoking cessation interventions; administrative, organizational, and radiological needs for performing a state-of-the-art LCS; collateral and incidental findings (both pulmonary and extrapulmonary), contributing to the LCS implementation within national healthcare systems.

Increased expression of individual genes in whole blood is associated with late-stage lung cancer at and close to diagnosis

Lung cancer (LC) mortality rates are still increasing globally. As survival is linked to stage, there is a need to identify markers for earlier LC diagnosis and individualized treatment. The whole blood transcriptome of LC patients represents a source of potential LC biomarkers. We compared expression of > 60,000 genes in whole blood specimens taken from LC cases at diagnosis (n = 128) and controls (n = 62) using genome-wide RNA sequencing, and identified 14 candidate genes associated with LC. High expression of ANXA3, ARG1 and HP was strongly associated with lower survival in late-stage LC cases (hazard ratios (HRs) = 2.81, 2.16 and 2.54, respectively). We validated these markers in two independent population-based studies with pre-diagnostic whole blood specimens taken up to eight years prior to LC diagnosis (n = 163 cases, 184 matched controls). ANXA3 and ARG1 expression was strongly associated with LC in these specimens, especially with late-stage LC within two years of diagnosis (odds ratios (ORs) = 3.47 and 5.00, respectively). Additionally, blood CD4 T cells, NK cells and neutrophils were associated with LC at diagnosis and improved LC discriminative ability beyond candidate genes. Our results indicate that in whole blood, increased expression levels of ANXA3, ARG1 and HP are diagnostic and prognostic markers of late-stage LC.

Primary care outreach and decision counseling for lung cancer screening

INTRODUCTION

Lung cancer screening rates are very low despite a level B recommendation from the United States Preventive Services Task Force since 2013 and clear evidence that lung cancer screening reduces mortality. The Center for Medicare and Medicaid Services requires shared decision-making (SDM) for lung cancer screening reimbursement. The objective of this study was to determine the effect of an SDM intervention on lung cancer screening in primary care.

METHODS

The study design was a single-arm clinical trial design. The intervention included phone contact outside of a primary care visit and the use of the Decision Counseling Program ®, an online interactive decision aid focused on determining the factors which influence patients to screen or not screen, prioritizing those factors, and determining a decision preference score. The primary outcome was the completion of low-dose computed tomography scan (LDCT) 1 year after the SDM session compared in participants versus nonparticipants.

RESULTS

From six practices, there were 1359 potentially eligible patients in electronic medical record data, and 336 were reached to assess eligibility criteria. A total of 80 patients consented to be in the study, 64 completed a decision counseling session and 16 did not complete a session. Among the 64 people who agreed to have decision counseling, 45% had LDCT, higher than typically seen in routine clinical practice. Although not a comparable group, among the 16 people who declined decision counseling, none had LDCT.

CONCLUSIONS

Decision counseling is a promising intervention that might support SDM in the context of improving uptake of lung cancer screening in primary care. However, further, larger studies are needed.

Deaths averted: An unbiased alternative to rate ratios for measuring the performance of cancer screening programs

INTRODUCTION

Screening trials and meta-analyses emphasize the ratio of cancer death rates in screening and control arms. However, this measure is diluted by the inclusion of deaths from cancers that only became detectable after the end of active screening.

METHODS

We review traditional analysis of cancer screening trials and show that ratio estimates are inevitably biased to the null, because follow-up (FU) must continue beyond the end of the screening period and thus includes cases only becoming detectable after screening ends. But because such cases are expected to occur in equal numbers in the two arms, calculation of the difference between the number of cancer deaths in the screening and control arms avoids this dilutional bias. This difference can be set against the number of invitations to screening; we illustrate by reanalyzing data from all trials of tomography screening of lung cancer (LC) using this measure.

RESULTS

In nine trials of LC screening from 2000 to 2013, a total of 94,441 high-risk patients were invited to be in screening or control groups, with high participation rates (average 95%). In the older trials comparing computed tomography to chest X-ray, 88,285 invitations averted 83 deaths (1068 per death averted (DA)). In the six more recent trials with no screening in the control group, 69,976 invitations averted 121 deaths (577 invitations per DA).

DISCUSSION

Screens per DA is an undiluted measure of screening's effect and it is unperturbed by the arbitrary duration of FU. This estimate can be useful for program planning and informed consent.

Long-term outcomes of lung cancer screening in males and females

BACKGROUND

This study explored female and male overall mortality and lung cancer (LC) survival in two LC screening (LCS) populations, focusing on the predictive value of coronary artery calcification (CAC) at baseline low-dose computed tomography (LDCT).

METHODS

This retrospective study analysed data of 6495 heavy smokers enrolled in the MILD and BioMILD LCS trials between 2005 and 2016. The primary objective of the study was to assess sex differences in all-cause mortality and LC survival. CAC scores were automatically calculated on LDCT images by a validated artificial intelligence (AI) software. Sex differences in 12-year cause-specific mortality rates were stratified by age, pack-years and CAC score.

RESULTS

The study included 2368 females and 4127 males. The 12-year all-cause mortality rates were 4.1 % in females and 7.7 % in males (p < 0.0001), and median CAC score was 8.7 vs. 41 respectively (p < 0.0001). All-cause mortality increased with rising CAC scores (log-rank test, p < 0.0001) for both sexes. Although LC incidence was not different between the two sexes, females had lower rates of 12-year LC mortality (1.0 % vs. 1.9 %, p = 0.0052), and better LC survival from diagnosis (72.3 % vs. 51.7 %; p = 0.0005), with a similar proportion of stage I (58.1 % vs. 51.2 %, p = 0.2782).

CONCLUSIONS

Our findings demonstrate that female LCS participants had lower rates of all-cause mortality at 12 years and better LC survival than their male counterparts, with similar LC incidence rates and stage at diagnosis. The lower CAC burden observed in women at all ages might contribute to explain their lower rates of all-cause mortality and better LC survival.

Asian Perspective on Lung Cancer Screening

Lung cancer is the leading cause of cancer-related mortality in Japan and worldwide. Early detection of lung cancer is an important strategy for decreasing mortality. Advances in diagnostic imaging have made it possible to detect lung cancer at an early stage in medical practice. Conversely, screening of asymptomatic healthy populations is recommended only when the evidence shows the benefits of regular intervention. Due to a variety of evidence and racial differences, screening methods vary from country to country. This article focused on the perspective of lung cancer screening in Japan.

Ten reasons to screen women at risk of lung cancer

This opinion piece reviews major reasons for promoting lung cancer screening in at-risk women who are smokers or ex-smokers, from the age of 50. The epidemiology of lung cancer in European women is extremely worrying, with lung cancer mortality expected to surpass breast cancer mortality in most European countries. There are conflicting data as to whether women are at increased risk of developing lung cancer compared to men who have a similar tobacco exposure. The sharp increase in the incidence of lung cancer in women exceeds the increase in their smoking exposure which is in favor of greater susceptibility. Lung and breast cancer screening could be carried out simultaneously, as the screening ages largely coincide. In addition, lung cancer screening could be carried out every 2 years, as is the case for breast cancer screening, if the baseline CT scan is negative.As well as detecting early curable lung cancer, screening can also detect coronary heart disease and osteoporosis induced by smoking. This enables preventive measures to be taken in addition to smoking cessation assistance, to reduce morbidity and mortality in the female population. Key points • The epidemiology of lung cancer in European women is very worrying.• Lung cancer is becoming the leading cause of cancer mortality in European women.• Women benefit greatly from screening in terms of reduced risk of death from lung cancer.

Artificial Intelligence in Lung Cancer Screening: The Future Is Now

Lung cancer has one of the worst morbidity and fatality rates of any malignant tumour. Most lung cancers are discovered in the middle and late stages of the disease, when treatment choices are limited, and patients' survival rate is low. The aim of lung cancer screening is the identification of lung malignancies in the early stage of the disease, when more options for effective treatments are available, to improve the patients' outcomes. The desire to improve the efficacy and efficiency of clinical care continues to drive multiple innovations into practice for better patient management, and in this context, artificial intelligence (AI) plays a key role. AI may have a role in each process of the lung cancer screening workflow. First, in the acquisition of low-dose computed tomography for screening programs, AI-based reconstruction allows a further dose reduction, while still maintaining an optimal image quality. AI can help the personalization of screening programs through risk stratification based on the collection and analysis of a huge amount of imaging and clinical data. A computer-aided detection (CAD) system provides automatic detection of potential lung nodules with high sensitivity, working as a concurrent or second reader and reducing the time needed for image interpretation. Once a nodule has been detected, it should be characterized as benign or malignant. Two AI-based approaches are available to perform this task: the first one is represented by automatic segmentation with a consequent assessment of the lesion size, volume, and densitometric features; the second consists of segmentation first, followed by radiomic features extraction to characterize the whole abnormalities providing the so-called "virtual biopsy". This narrative review aims to provide an overview of all possible AI applications in lung cancer screening.

ACR Appropriateness Criteria® Lung Cancer Screening: 2022 Update

Lung cancer remains the leading cause of cancer-related mortality for men and women in the United States. Screening for lung cancer with annual low-dose CT is saving lives, and the continued implementation of lung screening can save many more. In 2015, the CMS began covering annual lung screening for those who qualified based on the original United States Preventive Services Task Force (USPSTF) lung screening criteria, which included patients 55 to 77 year of age with a 30 pack-year history of smoking, who were either currently using tobacco or who had smoked within the previous 15 years. In 2021, the USPSTF issued new screening guidelines, decreasing the age of eligibility to 80 years of age and pack-years to 20. Lung screening remains controversial for those who do not meet the updated USPSTF criteria, but who have additional risk factors for the development of lung cancer. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Ultra-low dose computed tomography protocols using spectral shaping for lung cancer screening: Comparison with low-dose for volumetric LungRADS classification

PURPOSE

To compare Low-Dose Computed Tomography (LDCT) with four different Ultra-Low-Dose Computed Tomography (ULDCT) protocols for PN classification according to the Lung Reporting and Data System (LungRADS).

METHODS

Three hundred sixty-one participants of an ongoing lung cancer screening (LCS) underwent single-breath-hold double chest Computed Tomography (CT), including LDCT (120kVp, 25mAs; CTDIvol 1,62 mGy) and one ULDCT among: fully automated exposure control ("ULDCT₁"); fixed tube-voltage and current according to patient size ("ULDCT₂"); hybrid approach with fixed tube-voltage ("ULDCT₃") and tube current automated exposure control ("ULDCT₄"). Two radiologists (R1, R2) assessed LungRADS 2022 categories on LDCT, and then after 2 weeks on ULDCT using two different kernels (R1: Qr49_{ADMIRE 4}; R2: Br49_{ADMIRE 3}). Intra-subject agreement for LungRADS categories between LDCT and ULDCT was measured by the k-Cohen Index with Fleiss-Cohen weights.

RESULTS

LDCT-dominant PNs were detected in ULDCT in 87 % of cases on Qr49_{ADMIRE 4} and 88 % on Br49_{ADMIRE 3}. The intra-subject agreement was: κULDCT₁ = 0.89 [95 %CI 0.82-0.96]; κULDCT₂ = 0.90 [0.81-0.98]; κULDCT₃ = 0.91 [0.84-0.99]; κULDCT₄ = 0.88 [0.78-0.97] on Qr49_{ADMIRE 4}, and κULDCT₁ = 0.88 [0.80-0.95]; κULDCT₂ = 0.91 [0.86-0.96]; κULDCT₃ = 0.87 [0.78-0.95]; and κULDCT₄ = 0.88 [0.82-0.94] on Br49_{ADMIRE 3}. LDCT classified as LungRADS 4B were correctly identified as LungRADS 4B at ULDCT₃, with the lowest radiation exposure among the tested protocols (median effective doses were 0.31, 0.36, 0.27 and 0.37 mSv for ULDCT₁, ULDCT₂, ULDCT₃, and ULDCT₄, respectively).

CONCLUSIONS

ULDCT by spectral shaping allows the detection and characterization of PNs with an excellent agreement with LDCT and can be proposed as a feasible approach in LCS.

Clinical Utility and Application of Liquid Biopsy Genotyping in Lung Cancer: A Comprehensive Review

Precision medicine has revolutionized the therapeutic management of cancer patients with a major impact on non-small cell lung cancer (NSCLC), particularly lung adenocarcinoma, where advances have been remarkable. Tissue biopsy, required for tumor molecular testing, has significant limitations due to the difficulty of the biopsy site or the inadequacy of the histological specimen. In this context, liquid biopsy, consisting of the analysis of tumor-released materials circulating in body fluids, such as blood, is increasingly emerging as a valuable and non-invasive biomarker for detecting circulating tumor DNA (ctDNA) carrying molecular tumor signatures. In advanced/metastatic NSCLC, liquid biopsy drives target therapy by monitoring response to treatment and identifying eventual genomic mechanisms of resistance. In addition, recent data have shown a significant ability to detect minimal residual disease in early-stage lung cancer, underlying the potential application of liquid biopsy in the adjuvant setting, in early detection of recurrence, and also in the screening field. In this article, we present a review of the currently available data about the utility and application of liquid biopsy in lung cancer, with a particular focus on the approach to different techniques of analysis for liquid biopsy and a comparison with tissue samples as well as the potential practical uses in early and advanced/metastatic NSCLC.

Increased levels of microRNA-320 in blood serum and plasma is associated with imminent and advanced lung cancer

Lung cancer (LC) incidence is increasing globally and altered levels of microRNAs (miRNAs) in blood may contribute to identification of individuals with LC. We identified miRNAs differentially expressed in peripheral blood at LC diagnosis and evaluated, in pre-diagnostic blood specimens, how long before diagnosis expression changes in such candidate miRNAs could be detected. We identified upregulated candidate miRNAs in plasma specimens from a hospital-based study sample of 128 patients with confirmed LC and 62 individuals with suspected but confirmed negative LC (FalsePos). We then evaluated the expression of candidate miRNAs in pre-diagnostic plasma or serum specimens of 360 future LC cases and 375 matched controls. There were 1663 miRNAs detected in diagnostic specimens, nine of which met our criteria for candidate miRNAs. Higher expression of three candidates, miR-320b, 320c, and 320d, was associated with poor survival, independent of LC stage and subtype. Moreover, miR-320c and miR-320d expression was higher in pre-diagnostic specimens collected within 2 years of LC diagnosis. Our results indicated that elevated levels of miR-320c and miR-320d may be early indications of imminent and advanced LC.

Radiation Exposure to Low-Dose Computed Tomography for Lung Cancer Screening: Should We Be Concerned?

Lung cancer screening (LCS) programs through low-dose Computed Tomography (LDCT) are being implemented in several countries worldwide. Radiation exposure of healthy individuals due to prolonged CT screening rounds and, eventually, the additional examinations required in case of suspicious findings may represent a concern, thus eventually reducing the participation in an LCS program. Therefore, the present review aims to assess the potential radiation risk from LDCT in this setting, providing estimates of cumulative dose and radiation-related risk in LCS in order to improve awareness for an informed and complete attendance to the program. After summarizing the results of the international trials on LCS to introduce the benefits coming from the implementation of a dedicated program, the screening-related and participant-related factors determining the radiation risk will be introduced and their burden assessed. Finally, future directions for a personalized screening program as well as technical improvements to reduce the delivered dose will be presented.

[China National Lung Cancer Screening Guideline with Low-dose Computed Tomography (2023 Version)]

Lung cancer is the leading cause of cancer-related death in China. The effectiveness of low-dose computed tomography (LDCT) screening has been further validated in recent years, and significant progress has been made in research on identifying high-risk individuals, personalizing screening interval, and management of screen-detected findings. The aim of this study is to revise China national lung cancer screening guideline with LDCT (2018 version). The China Lung Cancer Early Detection and Treatment Expert Group (CLCEDTEG) designated by the China's National Health Commission, and China Lung Oncolgy Group experts, jointly participated in the revision of Chinese lung cancer screening guideline (2023 version). This revision is based on the recent advances in LDCT lung cancer screening at home and abroad, and the epidemiology of lung cancer in China. The following aspects of the guideline were revised: (1) lung cancer risk factors besides smoking were considered for the identification of high risk population; (2) LDCT scan parameters were further classified; (3) longer screening interval is recommended for individuals who had negative LDCT screening results for two consecutive rounds; (4) the follow-up interval for positive nodules was extended from 3 months to 6 months; (5) the role of multi-disciplinary treatment (MDT) in the management of positive nodules, diagnosis and treatment of lung cancer were emphasized. This revision clarifies the screening, intervention and treatment pathways, making the LDCT screening guideline more appropriate for China. Future researches based on emerging technologies, including biomarkers and artificial intelligence, are needed to optimize LDCT screening in China in the future.
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Fully automated calcium scoring predicts all-cause mortality at 12 years in the MILD lung cancer screening trial

Coronary artery calcium (CAC) is a known risk factor for cardiovascular (CV) events and mortality but is not yet routinely evaluated in low-dose computed tomography (LDCT)-based lung cancer screening (LCS). The present analysis explored the capacity of a fully automated CAC scoring to predict 12-year mortality in the Multicentric Italian Lung Detection (MILD) LCS trial. The study included 2239 volunteers of the MILD trial who underwent a baseline LDCT from September 2005 to January 2011, with a median follow-up of 190 months. The CAC score was measured by a commercially available fully automated artificial intelligence (AI) software and stratified into five strata: 0, 1-10, 11-100, 101-400, and > 400. Twelve-year all-cause mortality was 8.5% (191/2239) overall, 3.2% with CAC = 0, 4.9% with CAC = 1-10, 8.0% with CAC = 11-100, 11.5% with CAC = 101-400, and 17% with CAC > 400. In Cox proportional hazards regression analysis, CAC > 400 was associated with a higher 12-year all-cause mortality both in a univariate model (hazard ratio, HR, 5.75 [95% confidence interval, CI, 2.08-15.92] compared to CAC = 0) and after adjustment for baseline confounders (HR, 3.80 [95%CI, 1.35-10.74] compared to CAC = 0). All-cause mortality significantly increased with increasing CAC (7% in CAC ≤ 400 vs. 17% in CAC > 400, Log-Rank p-value <0.001). Non-cancer at 12 years mortality was 3% (67/2239) overall, 0.8% with CAC = 0, 1.0% with CAC = 1-10, 2.9% with CAC = 11-100, 3.6% with CAC = 101-400, and 8.2% with CAC > 400 (Grey's test p < 0.001). In Fine and Gray's competing risk model, CAC > 400 predicted 12-year non-cancer mortality in a univariate model (sub-distribution hazard ratio, SHR, 10.62 [95% confidence interval, CI, 1.43-78.98] compared to CAC = 0), but the association was no longer significant after adjustment for baseline confounders. In conclusion, fully automated CAC scoring was effective in predicting all-cause mortality at 12 years in a LCS setting.

Single CT Appointment for Double Lung and Colorectal Cancer Screening: Is the Time Ripe?

Annual screening of lung cancer (LC) with chest low-dose computed tomography (CT) and screening of colorectal cancer (CRC) with CT colonography every 5 years are recommended by the United States Prevention Service Task Force. We review epidemiological and pathological data on LC and CRC, and the features of screening chest low-dose CT and CT colonography comprising execution, reading, radiation exposure and harm, and the cost effectiveness of the two CT screening interventions. The possibility of combining chest low-dose CT and CT colonography examinations for double LC and CRC screening in a single CT appointment is then addressed. We demonstrate how this approach appears feasible and is already reasonable as an opportunistic screening intervention in 50–75-year-old subjects with smoking history and average CRC risk. In addition to the crucial role Computer Assisted Diagnosis systems play in decreasing the test reading times and the need to educate radiologists in screening chest LDCT and CT colonography, in view of a single CT appointment for double screening, the following uncertainties need to be solved: (1) the schedule of the screening CT; (2) the effectiveness of iterative reconstruction and deep learning algorithms affording an ultra-low-dose CT acquisition technique and (3) management of incidental findings. Resolving these issues will imply new cost-effectiveness analyses for LC screening with chest low dose CT and for CRC screening with CT colonography and, especially, for the double LC and CRC screening with a single-appointment CT.

The 50-Year Journey of Lung Cancer Screening: A Narrative Review

Early diagnosis and treatment are associated with better outcomes in oncology. We reviewed the existing literature using the search terms “low dose computed tomography” and “lung cancer screening” for systematic reviews, metanalyses, and randomized as well as non-randomized clinical trials in PubMed from January 1, 1963 to April 30, 2022. The studies were heterogeneous and included people with different age groups, smoking histories, and other specific risk scores for lung cancer screening. Based on the available evidence, almost all the guidelines recommend screening for lung cancer by annual low dose CT (LDCT) in populations over 50 to 55 years of age, who are either current smokers or have left smoking less than 15 years back with more than 20 to 30 pack-years of smoking. “LDCT screening” can reduce lung cancer mortality if carried out judiciously in countries with adequate resources and infrastructure.

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.

Chronic Obstructive Pulmonary Disease and Lung Cancer: A Review for Clinicians

Chronic obstructive pulmonary disease (COPD) and lung cancer are common global causes of morbidity and mortality. Because both diseases share several predisposing risks, the 2 diseases may occur concurrently in susceptible individuals. The diagnosis of COPD has important implications for the diagnostic approach and treatment options if lesions concerning for lung cancer are identified during screening. Importantly, the presence of COPD has significant implications on prognosis and management of patients with lung cancer. In this monograph, we review the mechanistic linkage between lung cancer and COPD, the impact of lung cancer screening on patients at risk, and the implications of the presence of COPD on the approach to the diagnosis and treatment of lung cancer. This manuscript succinctly reviews the epidemiology and common pathogenetic factors for the concurrence of COPD and lung cancer. Importantly for the clinician, it summarizes the indications, benefits, and complications of lung cancer screening in patients with COPD, and the assessment of risk factors for patients with COPD undergoing consideration of various treatment options for lung cancer.

New Implications of Patients’ Sex in Today’s Lung Cancer Management

Simple Summary

We aim to raise awareness that sex is an important factor to take into account in modern-day thoracic oncology practice. Summarized, women should be specifically targeted in smoking cessation campaigns and sex-specific barriers should be addressed. Women present more often with adenocarcinoma histology and EGFR/ALK alterations, as lung cancer in never-smokers is more common in women compared to men. Lung cancer in female patients may show a poorer response to immune checkpoint inhibition; therefore, the addition of chemotherapy should be considered. On the other hand, women experience more benefits from targeted therapy against EGFR. In general, prognosis for women is better compared to that in men. Lung cancer screening trials report that women derive more benefit from screening, although they have not been designed for women. Future trial designs should take this into account and encourage participation of women.

Abstract

This paper describes where and how sex matters in today’s management of lung cancer. We consecutively describe the differences between males and females in lung cancer demographics; sex-based differences in the immune system (including the poorer outcomes in women who are treated with immunotherapy but no chemotherapy); the presence of oncogenic drivers and the response to targeted therapies according to sex; the greater benefit women derive from lung cancer screening and why they get screened less; and finally, the barriers to smoking cessation that women experience. We conclude that sex is an important but often overlooked factor in modern-day thoracic oncology practice.

Outreach to primary care patients in lung cancer screening: A randomized controlled trial

Current guidelines recommend annual lung cancer screening (LCS), but rates are low. The current study evaluated strategies to increase LCS. This study was a randomized controlled trial designed to evaluate the effects of patient outreach and shared decision making (SDM) about LCS among patients in four primary care practices. Patients 50 to 80 years of age and at high risk for lung cancer were randomized to Outreach Contact plus Decision Counseling (OC-DC, n = 314), Outreach Contact alone (OC, n = 314), or usual care (UC, n = 1748). LCS was significantly higher in the combined OC/OC-DC group versus UC controls (5.5% vs. 1.8%; hazard ratio, HR = 3.28; 95% confidence interval, CI: 1.98 to 5.41; p = 0.001). LCS was higher in the OC-DC group than in the OC group, although not significantly so (7% vs. 4%, respectively; HR = 1.75; 95% CI: 0.86 to 3.55; p = 0.123). LCS referral/scheduling was also significantly higher in the OC/OC-DC group compared to controls (11% v. 5%; odds ratio, OR = 2.02; p = 0.001). We observed a similar trend for appointment keeping, but the effect was not statistically significant (86% v. 76%; OR = 1.93; p = 0.351). Outreach contacts significantly increased LCS among primary care patients. Research is needed to assess the additional value of SDM on screening uptake.

European lung cancer screening: valuable trial evidence for optimal practice implementation

Lung cancer screening (LCS) by low-dose computed tomography is a strategy for secondary prevention of lung cancer. In the last two decades, LCS trials showed several options to practice secondary prevention in association with primary prevention, however, the translation from trial to practice is everything but simple. In 2020, the European Society of Radiology and European Respiratory Society published their joint statement paper on LCS. This commentary aims to provide the readership with detailed description about hurdles and potential solutions that could be encountered in the practice of LCS.

Cancer statistics for African American/Black People 2022

African American/Black individuals have a disproportionate cancer burden, including the highest mortality and the lowest survival of any racial/ethnic group for most cancers. Every 3 years, the American Cancer Society estimates the number of new cancer cases and deaths for Black people in the United States and compiles the most recent data on cancer incidence (herein through 2018), mortality (through 2019), survival, screening, and risk factors using population-based data from the National Cancer Institute and the Centers for Disease Control and Prevention. In 2022, there will be approximately 224,080 new cancer cases and 73,680 cancer deaths among Black people in the United States. During the most recent 5-year period, Black men had a 6% higher incidence rate but 19% higher mortality than White men overall, including an approximately 2-fold higher risk of death from myeloma, stomach cancer, and prostate cancer. The overall cancer mortality disparity is narrowing between Black and White men because of a steeper drop in Black men for lung and prostate cancers. However, the decline in prostate cancer mortality in Black men slowed from 5% annually during 2010 through 2014 to 1.3% during 2015 through 2019, likely reflecting the 5% annual increase in advanced-stage diagnoses since 2012. Black women have an 8% lower incidence rate than White women but a 12% higher mortality; further, mortality rates are 2-fold higher for endometrial cancer and 41% higher for breast cancer despite similar or lower incidence rates. The wide breast cancer disparity reflects both later stage diagnosis (57% localized stage vs 67% in White women) and lower 5-year survival overall (82% vs 92%, respectively) and for every stage of disease (eg, 20% vs 30%, respectively, for distant stage). Breast cancer surpassed lung cancer as the leading cause of cancer death among Black women in 2019. Targeted interventions are needed to reduce stark cancer inequalities in the Black community.

Prevalence, symptom burden and under-diagnosis of chronic obstructive pulmonary disease in Polish lung cancer screening population: a cohort observational study

OBJECTIVES

Lung cancer screening using low-dose CT may be not effective without considering the presence of comorbidities related to chronic smoking. The aim of the study was to establish the prevalence of chronic obstructive pulmonary disease (COPD) in group of phighlight the potential benefits atients participating in the largest Polish lung cancer screening programme MOLTEST-BIS and attempt to confirm the necessity of combined lung cancer and COPD screening.

DESIGN

Cohort, prospective study.

SETTING

Medical University of Gdańsk, Poland PARTICIPANTS: The study included 754 participants in lung cancer screening trial from the Pomeranian region, aged 50-70 years old, current and former smokers with a smoking history ≥30 pack-years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Questionnaire, physical examination, anthropometric measurements, spirometry test before and after inhaled bronchodilator (400 µg of salbutamol) RESULTS: Obstructive disorders were diagnosed in 186 cases (103 male and 83 female). In the case of 144 participants (19.73%), COPD was diagnosed. Only 13.3% of participants with COPD were known about the disease earlier. According to classification of airflow limitation 55.6% of diagnosed COPD were in Global Initiative for Chronic Obstructive Lung Disease (GOLD) 1 (mild), 38.9% in GOLD 2 (moderate), 4.9% in GOLD 3 (severe) and 0.7% in GOLD 4 (very severe) stage. Women with recognition of COPD were younger than men (63.7 vs 66.3 age) and they smoked less cigarettes (41.1 vs 51.9 pack-years).

CONCLUSIONS

Prevalence of COPD in Polish lung cancer screening cohort is significant. The COPD in this group is remarkably under-diagnosed. Most diagnosed COPD cases were in the initial stage of advancement. This early detection of airflow limitation highlights the potential benefits arising from combined oncological-pulmonary screening.NKBBN.

Low-dose CT for lung cancer screening: position paper from the Italian college of thoracic radiology

Smoking is the main risk factor for lung cancer (LC), which is the leading cause of cancer-related death worldwide. Independent randomized controlled trials, governmental and inter-governmental task forces, and meta-analyses established that LC screening (LCS) with chest low dose computed tomography (LDCT) decreases the mortality of LC in smokers and former smokers, compared to no-screening, especially in women. Accordingly, several Italian initiatives are offering LCS by LDCT and smoking cessation to about 10,000 high-risk subjects, supported by Private or Public Health Institutions, envisaging a possible population-based screening program. Because LDCT is the backbone of LCS, Italian radiologists with LCS expertise are presenting this position paper that encompasses recommendations for LDCT scan protocol and its reading. Moreover, fundamentals for classification of lung nodules and other findings at LDCT test are detailed along with international guidelines, from the European Society of Thoracic Imaging, the British Thoracic Society, and the American College of Radiology, for their reporting and management in LCS. The Italian College of Thoracic Radiologists produced this document to provide the basics for radiologists who plan to set up or to be involved in LCS, thus fostering homogenous evidence-based approach to the LDCT test over the Italian territory and warrant comparison and analyses throughout National and International practices.

MiR-486-5p Targets CD133+ Lung Cancer Stem Cells through the p85/AKT Pathway

Despite improvements in therapies and screening strategies, lung cancer prognosis still remains dismal, especially for metastatic tumors. Cancer stem cells (CSCs) are endowed with properties such as chemoresistance, dissemination, and stem-like features, that make them one of the main causes of the poor survival rate of lung cancer patients. MicroRNAs (miRNAs), small molecules regulating gene expression, have a role in lung cancer development and progression. In particular, miR-486-5p is an onco-suppressor miRNA found to be down-modulated in the tumor tissue of lung cancer patients. In this study, we investigate the role of this miRNA in CD133+ lung CSCs and evaluate the therapeutic efficacy of coated cationic lipid-nanoparticles entrapping the miR-486-5p miRNA mimic (CCL-486) using lung cancer patient-derived xenograft (PDX) models. In vitro, miR-486-5p overexpression impaired the PI3K/Akt pathway and decreased lung cancer cell viability. Moreover, miR-486-5p overexpression induced apoptosis also in CD133+ CSCs, thus affecting the in vivo tumor-initiating properties of these cells. Finally, we demonstrated that in vivo CCL-486 treatment decreased CD133+ percentage and inhibited tumor growth in PDX models. In conclusion, we provided insights on the efficacy of a novel miRNA-based compound to hit CD133+ lung CSCs, setting the basis for new combined therapeutic strategies.

Artificial intelligence for early diagnosis of lung cancer through incidental nodule detection in low- and middle-income countries-acceleration during the COVID-19 pandemic but here to stay

Although the coronavirus disease of 2019 (COVID-19) pandemic had profound pernicious effects, it revealed deficiencies in health systems, particularly among low- and middle-income countries (LMICs). With increasing uncertainty in healthcare, existing unmet needs such as poor outcomes of lung cancer (LC) patients in LMICs, mainly due to late stages at diagnosis, have been challenging-necessitating a shift in focus for judicious health resource utilization. Leveraging artificial intelligence (AI) for screening large volumes of pulmonary images performed for noncancerous reasons, such as health checks, immigration, tuberculosis screening, or other lung conditions, including but not limited to COVID-19, can facilitate easy and early identification of incidental pulmonary nodules (IPNs), which otherwise could have been missed. AI can review every chest X-ray or computed tomography scan through a trained pair of eyes, thus strengthening the infrastructure and enhancing capabilities of manpower for interpreting images in LMICs for streamlining accurate and early identification of IPNs. AI can be a catalyst for driving LC screening with enhanced efficiency, particularly in primary care settings, for timely referral and adequate management of coincidental IPN. AI can facilitate shift in the stage of LC diagnosis for improving survival, thus fostering optimal health-resource utilization and sustainable healthcare systems resilient to crisis. This article highlights the challenges for organized LC screening in LMICs and describes unique opportunities for leveraging AI. We present pilot initiatives from Asia, Latin America, and Russia illustrating AI-supported IPN identification from routine imaging to facilitate early diagnosis of LC at a potentially curable stage.

Molecular properties and survival of lung adenocarcinoma in young patients

OBJECTIVE

This study aims to investigate the molecular properties and factors of lung cancer in young patients aged 18-45 years, affecting survival in patients with pulmonary adenocarcinoma.

METHODS

Patients aged between 18 and 45 years who were diagnosed with lung adenocarcinoma in our hospital between January 2015 and December 2019 and their tumoural mutations were studied and included in this study and then reviewed retrospectively from the hospital records.

RESULTS

At the time of diagnosis, 71 (3.57%) of 1985 primary lung cancer patients were 45 years old, and 42 (59.2%) male and 29 (40.8%) female patients with a mean age of 39.9 were evaluated. Most of the patients were diagnosed with advanced-stage lung cancer, 55 (77.5%) of them were in stage IV. PET CT showed that the standard intake value (SUV) of 11.1 tended to be high. Multiple organ metastases were detected in 57 patients (80.3%). EGFR (epidermal growth factor receptor) mutation was positive in 13 patients (18.3%), ALK (anaplastic lymphoma kinase) mutation was positive in 13 patients (18.3%) and ROS (c-ros) mutation oncogene was positive in 2 (2.8%) patients. Surgical operation was performed in 21 (29.6%), radiotherapy was given to 29 (40.8%), chemotherapy to 48 (67.6%) and targeted therapy to 22 (31.0%) patients. The mean overall survival of the patients was 16 months. Within 1 year, 41 (57.7%) patients died.

CONCLUSION

In our study, significant efficacy of age, gender distribution, smoking, metastasis, ALK positivity, presence of chemotherapy, targeted therapy and surgical treatment was observed in young adenocarcinoma patients. The molecular properties of lung adenocarcinoma in young patients differ from those in the general population, and major driver genes are major factors influencing tumour differentiation and prognosis. In our study, we aimed to explain the molecular properties and results of pulmonary adenocarcinoma. In the future, we will provide constructive recommendations for the prevention and treatment of young patients.

Advances in Diagnostic Bronchoscopy

The increase in incidental discovery of pulmonary nodules has led to more urgent requirement of tissue diagnosis. The peripheral pulmonary nodules are especially challenging for clinicians. There are various modalities for diagnosis and tissue sampling of pulmonary lesions, but most of these modalities have their own limitations. This has led to the development of many advanced technical modalities, which have empowered pulmonologists to reach the periphery of the lung safely and effectively. These techniques include thin/ultrathin bronchoscopes, radial probe endobronchial ultrasound (RP-EBUS), and navigation bronchoscopy—including virtual navigation bronchoscopy (VNB) and electromagnetic navigation bronchoscopy (ENB). Recently, newer technologies—including robotic-assisted bronchoscopy (RAB), cone-beam CT (CBCT), and augmented fluoroscopy (AF)—have been introduced to aid in the navigation to peripheral pulmonary nodules. Technological advances will also enable more precise tissue sampling of smaller peripheral lung nodules for local ablative and other therapies of peripheral lung cancers in the future. However, we still need to overcome the CT-to-body divergence, among other limitations. In this review, our aim is to summarize the recent advances in diagnostic bronchoscopy technology.

Overuse of follow-up chest computed tomography in patients with incidentally identified nodules suspicious for lung cancer

PURPOSE

Although professional societies agreed that CT screening inconsistent with recommendation leads to radiation-related cancer and unexpected cost, many patients still undergo unnecessary Chest CT before treatment. The goal of this study was to assess the overuse of Chest CT in different type of patients.

METHODS

Data on 1853 patients who underwent pulmonary resection from May 2019 to May 2020 were retrospectively analyzed. Data collected include age, sex, follow-up period, density and size of nodules and frequency of undergoing Chest CT. Pearson χ² test and logistic regression were conducted to compare the receipt of CT screening.

RESULTS

Among 1853 patients in the study, 689 (37.2%) overused Chest CT during follow-up of the pulmonary nodules. This rate was 16.2% among patients with solid nodules, 57.5% among patients with pure ground glass opacity (pGGO), and 41.4% among patients with mixed ground glass opacity (mGGO) (P < 0.001). 50.7% in the "age ≤ 40" group, 39.8% in the "41 ≤ age ≤ 50" group, 38.7% in the "51 ≤ age ≤ 60" group, 32.3% in the "61 ≤ age ≤ 70" group, 27.8% in the " > 70" group underwent unnecessary CT (P < 0.001). Female got more unnecessary CT than male (40.6% vs 32.8%, P < 0.001). Factors associated with a greater likelihood of overusing Chest CT was the density of nodules [odds ratios (ORs) of 0.53 for mGGO; 0.15 for solid nodule, P < 0.0001, vs patients with pGGO].

CONCLUSION

Roughly 37% patients with pulmonary nodules received Chest CT too frequently despite national recommendations against the practice. Closer adherence to clinical guidelines is likely to result in more cost-effective care.

Lung cancer screening implementation: Complexities and priorities

Lung cancer is the number one cause of cancer death worldwide. The benefits of lung cancer screening to reduce mortality and detect early-stage disease are no longer in any doubt based on the results of two landmark trials using LDCT. Lung cancer screening has been implemented in the US and South Korea and is under consideration by other communities. Successful translation of demonstrated research outcomes into the routine clinical setting requires careful implementation and co-ordinated input from multiple stakeholders. Implementation aspects may be specific to different healthcare settings. Important knowledge gaps remain, which must be addressed in order to optimize screening benefits and minimize screening harms. Lung cancer screening differs from all other cancer screening programmes as lung cancer risk is driven by smoking, a highly stigmatized behaviour. Stigma, along with other factors, can impact smokers' engagement with screening, meaning that smokers are generally 'hard to reach'. This review considers critical points along the patient journey. The first steps include selecting a risk threshold at which to screen, successfully engaging the target population and maximizing screening uptake. We review barriers to smoker engagement in lung and other cancer screening programmes. Recruitment strategies used in trials and real-world (clinical) programmes and associated screening uptake are reviewed. To aid cross-study comparisons, we propose a standardized nomenclature for recording and calculating recruitment outcomes. Once participants have engaged with the screening programme, we discuss programme components that are critical to maximize net benefit. A whole-of-programme approach is required including a standardized and multidisciplinary approach to pulmonary nodule management, incorporating probabilistic nodule risk assessment and longitudinal volumetric analysis, to reduce unnecessary downstream investigations and surgery; the integration of smoking cessation; and identification and intervention for other tobacco related diseases, such as coronary artery calcification and chronic obstructive pulmonary disease. National support, integrated with tobacco control programmes, and with appropriate funding, accreditation, data collection, quality assurance and reporting mechanisms will enhance lung cancer screening programme success and reduce the risks associated with opportunistic, ad hoc screening. Finally, implementation research must play a greater role in informing policy change about targeted LDCT screening programmes.

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.

[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.

Personalising lung cancer screening: An overview of risk-stratification opportunities and challenges

Randomised clinical trials have shown the efficacy of computed tomography lung cancer screening, initiating discussions on whether and how to implement population‐based screening programs. Due to smoking behaviour being the primary risk‐factor for lung cancer and part of the criteria for determining screening eligibility, lung cancer screening is inherently risk‐based. In fact, the selection of high‐risk individuals has been shown to be essential in implementing lung cancer screening in a cost‐effective manner. Furthermore, studies have shown that further risk‐stratification may improve screening efficiency, allow personalisation of the screening interval and reduce health disparities. However, implementing risk‐based lung cancer screening programs also requires overcoming a number of challenges. There are indications that risk‐based approaches can negatively influence the trade‐off between individual benefits and harms if not applied thoughtfully. Large‐scale implementation of targeted, risk‐based screening programs has been limited thus far. Consequently, questions remain on how to efficiently identify and invite high‐risk individuals from the general population. Finally, while risk‐based approaches may increase screening program efficiency, efficiency should be balanced with the overall impact of the screening program. In this review, we will address the opportunities and challenges in applying risk‐stratification in different aspects of lung cancer screening programs, as well as the balance between screening program efficiency and impact.

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 radiologist's role in lung cancer screening

Lung cancer is still the deadliest cancer in men and women worldwide. This high mortality is related to diagnosis in advanced stages, when curative treatment is no longer an option. Large randomized controlled trials have shown that lung cancer screening (LCS) with low-dose computed tomography (CT) can detect lung cancers at earlier stages and reduce lung cancer-specific mortality. The recent publication of the significant reduction of cancer-related mortality by 26% in the Dutch-Belgian NELSON LCS trial has increased the likelihood that implementation of LCS in Europe will move forward. Radiologists are important stakeholders in numerous aspects of the LCS pathway. Their role goes beyond nodule detection and nodule management. Being part of a multidisciplinary team, radiologists are key players in numerous aspects of implementation of a high quality LCS program. In this non-systematic review we discuss the multifaceted role of radiologists in LCS.

Screen-detected solid nodules: from detection of nodule to structured reporting

Lung cancer screening (LCS) is gaining some interest worldwide after positive results from International trials. Unlike other screening practices, LCS is performed by an extremely sensitive test, namely low-dose computed tomography (LDCT) that can detect the smallest nodules in lung parenchyma. Up-to-date detection approaches, such as computer aided detection systems, have been increasingly employed for lung nodule automatic identification and are largely used in most LCS programs as a complementary tool to visual reading. Solid nodules of any size are represented in the vast majority of subjects undergoing LDCT. However, less than 1% of solid nodules will be diagnosed lung cancer. This fact calls for specific characterization of nodules to avoid false positives, overinvestigation, and reduce the risks associated with nodule work up. Recent research has been exploring the potential of artificial intelligence, including deep learning techniques, to enhance the accuracy of both detection and characterisation of lung nodule. Computer aided detection and diagnosis algorithms based on artificial intelligence approaches have demonstrated the ability to accurately detect and characterize parenchymal nodules, reducing the number of false positives, and to outperform some of the currently used risk models for prediction of lung cancer risk, potentially reducing the proportion of surveillance CT scans. These forthcoming approaches will eventually integrate a new reasoning for development of future guidelines, which are expected to evolve into precision and personalized stratification of lung cancer risk stratification by continuous fashion, as opposed to the current format with a limited number of risk classes within fixed thresholds of nodule size. This review aims to detail the standard of reference for optimal management of solid nodules by low-dose computed and its projection into the fine selection of candidates for work up.

Lung Cancer Screening: Evidence, Risks, and Opportunities for Implementation

BACKGROUND

 Lung cancer is the most common cause of cancer death worldwide. Several trials with different screening approaches have recognized the role of lung cancer screening with low-dose CT for reducing lung cancer mortality. The efficacy of lung cancer screening depends on many factors and implementation is still pending in most European countries.

METHODS

 This review aims to portray current evidence on lung cancer screening with a focus on the potential for opportunities for implementation strategies. Pillars of lung cancer screening practice will be discussed according to the most updated literature (PubMed search until November 16, 2020).

RESULTS AND CONCLUSION

 The NELSON trial showed reduction of lung cancer mortality, thus confirming previous results of independent European studies, notably by volume of lung nodules. Heterogeneity in patient recruitment could influence screening efficacy, hence the importance of risk models and community-based screening. Recruitment strategies develop and adapt continuously to address the specific needs of the heterogeneous population of potential participants, the most updated evidence comes from the UK. The future of lung cancer screening is a tailored approach with personalized continuous stratification of risk, aimed at reducing costs and risks.

KEY POINTS

  · Secondary prevention of lung cancer by low-dose computed tomography showed a reduction of lung cancer mortality.. · Semi-automated volume measurement and use of volume doubling time should be the reference method for optimization of risks, namely controlling measurement variability and the false-positive rate.. · A conservative approach with surveillance of subsolid nodules can be one of the strategies to reduce the risk of overdiagnosis and overtreatment.. · The goal of a tailored approach with personalized risk stratification aims to reduce costs and risks. A longer interval between rounds is one option for participants at lower risk..

CITATION FORMAT

· Tringali G, Milanese G, Ledda RE et al. Lung Cancer Screening: Evidence, Risks, and Opportunities for Implementation. Fortschr Röntgenstr 2021; 193: 1153 - 1161.

False-Negative Results in Lung Cancer Screening-Evidence and Controversies

Identifying false-negative cases is an important quality metric in lung cancer screening, but it has been infrequently and variably reported in previous studies. Although as a proportion of all screening participants, false-negative cases are uncommon, such cases may constitute a substantial proportion of all lung cancers diagnosed (up to 15%) within a screening program. This article reviews the impact and causes of false-negative lung cancer screening tests, including those related to radiologic evaluation, nodule management protocols, and management decisions made by multidisciplinary teams. Following a review of data from international screening studies, this article discusses the controversies within the screening literature surrounding the definition and classification of a false-negative lung cancer screening test and how data on false-negative rates should be captured and recorded. Challenges, such as avoiding overly cautious surveillance of lung nodules while minimizing overdiagnosis and investigation of indolent or benign lesions, are considered. Finally, the advantages and disadvantages of different approaches to dealing with false-negative results in lung cancer screening are discussed.

Cone-Beam CT Image Guidance With and Without Electromagnetic Navigation Bronchoscopy for Biopsy of Peripheral Pulmonary Lesions

BACKGROUND

Bronchoscopic diagnosis of small peripheral lung lesions suspected of lung cancer remains a challenge. A successful endobronchial diagnosis comprises navigation, confirmation, and tissue acquisition. In all steps, 3-dimensional information is essential. Cone-beam computed tomography (CBCT) imaging can provide computed tomography information and 3-dimensional augmented fluoroscopy imaging. We assessed whether CBCT imaging can improve navigation and diagnosis of peripheral lesions by 2 clinical workflows with a cross-over design: (1) a primary CBCT and radial endobronchial ultrasound mini probe imaging-based approach and (2) a primary electromagnetic navigation (EMN) and radial endobronchial ultrasound mini probe imaging-based approach.

METHODS

All patients with a peripheral lung lesion biopsy indication were eligible for study inclusion and randomly assigned to study arms. Commercially available equipment was used. The main study goals were to assess CBCT-confirmed navigation success and diagnostic accuracy. Surgery or unambiguous clinical follow-up served as the gold standard.

RESULTS

Eighty-seven patients with 107 lesions were included. Lesion mean longest axis size in the CBCT arm was 16.6 mm (n=47) and 14.2 mm in the EMN arm (n=40). The primary CBCT approach and primary EMN approach had 76.3% and 52.2% navigation success, respectively. Addition of EMN to the CBCT approach increased navigation success to 89.9%. Addition of CBCT imaging to the EMN approach significantly increased navigation success to 87.5% per lesion. The overall diagnostic accuracy per patient was significantly lower than the navigation success, being 72.4%.

CONCLUSION

CBCT imaging is a valuable addition to navigation bronchoscopy. Although overall navigation success was high, the diagnostic accuracy remains to be improved. Future research should focus on improving the tissue acquisition methodology.

Artificial Intelligence Tools for Refining Lung Cancer Screening

Nearly one-quarter of all cancer deaths worldwide are due to lung cancer, making this disease the leading cause of cancer death among both men and women. The most important determinant of survival in lung cancer is the disease stage at diagnosis, thus developing an effective screening method for early diagnosis has been a long-term goal in lung cancer care. In the last decade, and based on the results of large clinical trials, lung cancer screening programs using low-dose computer tomography (LDCT) in high-risk individuals have been implemented in some clinical settings, however, this method has various limitations, especially a high false-positive rate which eventually results in a number of unnecessary diagnostic and therapeutic interventions among the screened subjects. By using complex algorithms and software, artificial intelligence (AI) is capable to emulate human cognition in the analysis, interpretation, and comprehension of complicated data and currently, it is being successfully applied in various healthcare settings. Taking advantage of the ability of AI to quantify information from images, and its superior capability in recognizing complex patterns in images compared to humans, AI has the potential to aid clinicians in the interpretation of LDCT images obtained in the setting of lung cancer screening. In the last decade, several AI models aimed to improve lung cancer detection have been reported. Some algorithms performed equal or even outperformed experienced radiologists in distinguishing benign from malign lung nodules and some of those models improved diagnostic accuracy and decreased the false-positive rate. Here, we discuss recent publications in which AI algorithms are utilized to assess chest computer tomography (CT) scans imaging obtaining in the setting of lung cancer screening.

Lung cancer LDCT screening and mortality reduction - evidence, pitfalls and future perspectives

In the past decade, the introduction of molecularly targeted agents and immune-checkpoint inhibitors has led to improved survival outcomes for patients with advanced-stage lung cancer; however, this disease remains the leading cause of cancer-related mortality worldwide. Two large randomized controlled trials of low-dose CT (LDCT)-based lung cancer screening in high-risk populations - the US National Lung Screening Trial (NLST) and NELSON - have provided evidence of a statistically significant mortality reduction in patients. LDCT-based screening programmes for individuals at a high risk of lung cancer have already been implemented in the USA. Furthermore, implementation programmes are currently underway in the UK following the success of the UK Lung Cancer Screening (UKLS) trial, which included the Liverpool Health Lung Project, Manchester Lung Health Check, the Lung Screen Uptake Trial, the West London Lung Cancer Screening pilot and the Yorkshire Lung Screening trial. In this Review, we focus on the current evidence on LDCT-based lung cancer screening and discuss the clinical developments in high-risk populations worldwide; additionally, we address aspects such as cost-effectiveness. We present a framework to define the scope of future implementation research on lung cancer screening programmes referred to as Screening Planning and Implementation RAtionale for Lung cancer (SPIRAL).

Predictive value of suvmax changes between two sequential post-therapeutic FDG-pet in head and neck squamous cell carcinomas

18-flurodesoxyglucose position emission tomography (FDG-PET) with computed tomography (CT) or magnetic resonance imaging (MRI) is a broadly accepted tool for pretherapeutic staging and post-therapeutic assessment of response. The prognostic value of sequential post-therapeutic FDG-PETs and the impact of change in metabolic activity has been scarcely reported so far. We hypothesized that an increase in metabolic activity (as measured by maximum standardized uptake value, SUVmax) would be predictive for recurrence. We retrospectively assessed all oral, oropharyngeal, laryngeal, and hypopharyngeal squamous cell carcinoma patients treated at the Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital Zurich between April 1st, 2010 and September 30th, 2018 (N = 337). After a negative post-treatment FDG-PET at 3 months, we measured the SUVmax of the local tumor area and the regional lymph nodes on follow-up FDG-PET at 9 months. We then correlated SUVmax difference between 9 and 3 months with tumor recurrence using Kaplan Meier analysis. During follow-up, 68 patients (20.2%) had local recurrence and 53 had regional recurrence (15.7%) at a median time of 9.0 (IQR 4.25-14) and 7.0 (IQR 5.25-23) months, respectively. An increase in local and/or regional SUVmax from the 3 months to the 9 months post-therapeutic FDG-PET resulted in a poorer recurrence-free survival (Log rank, P = 0.001, for both). An increase in local SUVmax between 3 and 9 months was associated with a hazard ratio of 4.17 for recurrence (95%CI 1.89-9.2, P = 0.0003). In conclusion, an increase in metabolic activity/SUVmax between two post-therapeutic FDG-PETs requires a histological examination as it is associated with tumor recurrence.

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

BACKGROUND

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

OBJECTIVE

Meta-analyze LDCT lung cancer screening trials.

METHODS

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

RESULTS

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

DISCUSSION

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