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

Multidimensional biological characteristics of ground glass nodules

The detection rate of ground glass nodules (GGNs) has increased in recent years because of their malignant potential but relatively indolent biological behavior; thus, correct GGN recognition and management has become a research focus. Many scholars have explored the underlying mechanism of the indolent progression of GGNs from several perspectives, such as pathological type, genomic mutational characteristics, and immune microenvironment. GGNs have different major mutated genes at different stages of development; EGFR mutation is the most common mutation in GGNs, and p53 mutation is the most abundant mutation in the invasive stage of GGNs. Pure GGNs have fewer genomic alterations and a simpler genomic profile and exhibit a gradually evolving genomic mutation profile as the pathology progresses. Compared to advanced lung adenocarcinoma, GGN lung adenocarcinoma has a higher immune cell percentage, is under immune surveillance, and has less immune escape. However, as the pathological progression and solid component increase, negative immune regulation and immune escape increase gradually, and a suppressive immune environment is established gradually. Currently, regular computer tomography monitoring and surgery are the main treatment strategies for persistent GGNs. Stereotactic body radiotherapy and radiofrequency ablation are two local therapeutic alternatives, and systemic therapy has been progressively studied for lung cancer with GGNs. In the present review, we discuss the characterization of the multidimensional molecular evolution of GGNs that could facilitate more precise differentiation of such highly heterogeneous lesions, laying a foundation for the development of more effective individualized treatment plans.

Establishing a Pulmonary Nodule Clinic Service for Early Diagnosis of Lung Cancer - Review of International Options and Considerations for Greece

Early diagnosis of lung cancer in pulmonary nodules identified by computed tomography (CT) may be critical in reducing the epidemiological burden of the disease, particularly in countries where such a burden is considerably high and risk factors for lung cancer very prevalent. The establishment and operation of pulmonary nodule clinics (PNCs), ie, multidisciplinary services that watch and evaluate nodules found through deliberate screening efforts or as incidental findings, is increasingly becoming a key tool to implement such early-intervention, cancer-risk management policies elsewhere in the world. This review aims to research and present in a structured manner findings from published sources on options and considerations for setting up a PNC in a country such as Greece. These refer to the type of services a PNC would provide to optimize diagnosis of suspect pulmonary nodules, its structure and organization, including processes, human resources and technology infrastructure, its target audience, ie, who would be eligible to use its services, and the expected outcomes of its operation, in terms of a set of key performance indicators. Our review also revealed critical key success factors that should be considered when designing the introduction of a PNC in a health care setting, including optimal referral pathways, aligned clinical decision making and patient preferences and participation/empowerment. Our findings may inform health care systems with a high lung cancer burden and no available PNC service on options and considerations before introducing such a service in their respective settings.

CT-Based Radiomic Analysis for Preoperative Prediction of Tumor Invasiveness in Lung Adenocarcinoma Presenting as Pure Ground-Glass Nodule

It remains a challenge to preoperatively forecast whether lung pure ground-glass nodules (pGGNs) have invasive components. We aimed to construct a radiomic model using tumor characteristics to predict the histologic subtype associated with pGGNs. We retrospectively reviewed clinicopathologic features of pGGNs resected in 338 patients with lung adenocarcinoma between 2011-2016 at a single institution. A radiomic prediction model based on forward sequential selection and logistic regression was constructed to differentiate adenocarcinoma in situ (AIS)/minimally invasive adenocarcinoma (MIA) from invasive adenocarcinoma. The study cohort included 133 (39.4%), 128 (37.9%), and 77 (22.8%) patients with AIS, MIA, and invasive adenocarcinoma (acinar 55.8%, lepidic 33.8%, papillary 10.4%), respectively. The majority (83.7%) underwent sublobar resection. There were no nodal metastases or tumor recurrence during a mean follow-up period of 78 months. Three radiomic features-cluster shade, homogeneity, and run-length variance-were identified as predictors of histologic subtype and were selected to construct a prediction model to classify the AIS/MIA and invasive adenocarcinoma groups. The model achieved accuracy, sensitivity, specificity, and AUC of 70.6%, 75.0%, 70.0%, and 0.7676, respectively. Applying the developed radiomic feature model to predict the histologic subtypes of pGGNs observed on CT scans can help clinically in the treatment selection process.

Lung Cancer Screening: New Perspective and Challenges in Europe

Simple Summary

Screening for lung cancer in a high-risk population has been shown to be beneficial, with reduced mortality in large randomised trials. However, the general implementation of screening is not evident and many factors have to be considered. In this paper, we will review the current status of screening for lung cancer in Europe and the many hurdles that have to be overcome. Multidisciplinary cooperation between all specialists dealing with lung cancer is required to obtain the best outcome. Hopefully, Europe’s Beating Cancer Plan will incorporate screening for lung cancer to allow general implementation by similar programmes in every European Member State. This will also provide an opportunity for further, large-scale studies to refine the inclusion of specific risk populations, diagnosis and management of screen-detected nodules.

Abstract

Randomized-controlled trials have shown clear evidence that lung cancer screening with low-dose CT in a high-risk population of current or former smokers can significantly reduce lung-cancer-specific mortality by an inversion of stage distribution at diagnosis. This paper will review areas in which there is good or emerging evidence and areas which still require investment, research or represent implementation challenges. The implementation of population-based lung cancer screening in Europe is variable and fragmented. A number of European countries seem be on the verge of implementing lung cancer screening, mainly through the implementation of studies or trials. The cost and capacity of CT scanners and radiologists are considered to be the main hurdles for future implementation. Actions by the European Commission, related to its published Europe’s Beating Cancer Plan and the proposal to update recommendations on cancer screening, could be an incentive to help speed up its implementation.

Lung cancer screening in Europe: where are we in 2021?

This manuscript reviews the recent evidence obtained in lung cancer screening with low dose spiral CT-scan (LDSCT) and focuses on the issues associated with its implementation in Europe. After a review of the magnitude of the lung cancer toll in lives, disease and Euro’s, the recently released data of the major lung cancer screening trials are reviewed and mirrored with the results of the US National Lung Screening Trial (NLST), comparing their strengths and weaknesses and areas of future research. The specific barriers and hurdles to be addressed for widely implementing this population screening in European countries are discussed, with special emphasis on the issues of inclusion of smokers, smoking cessation interventions, radiation injury and capacity planning. The pros and cons of including current smokers will be addressed together with the issue which is the better smoking cessation intervention. A medical physicist’s view on radiation exposure and quality control will address concerns about radiation induced cancers. The downstream effects of a LDSCT screening program on the capacity of CT-scans, radiologists, thoracic surgeons and radiation oncologists will follow. An estimated roadmap for the future is sketched with the expected role of all key stakeholders. This roadmap reflects the opinion leader’s reflections as expressed in a number of discussions with European health authorities, taking place as part of the recently released European Beating Cancer plan.

Public opinion on implementing the National Lung Cancer Screening Program in Korea

Background

Lung cancer screening for high-risk population using low-dose computed tomography is a valid strategy to reduce lung cancer mortality. This study investigated public opinions toward the initiation and participation in the National Lung Cancer Screening Program (NLCSP) launched in Korea.

Methods

In this cross-sectional analysis of the 2018 Korean National Cancer Screening Survey, we analyzed the responses related to lung cancer screening. Eligible participants for NLCSP are aged 55‒74 years with at least 30 pack-years of smoking history. We compared public opinions on implementing lung cancer screening according to smoking status and eligibility for NLCSP.

Results

Among 3,495 respondents, 205 (5.9%) were eligible for screening. Most of the respondents (71.2%) agreed with implementing NLCSP. Agreement rates were relatively lower in never smokers (66.2%) and higher in former (80.8%) and current smokers (82.3%). Factors associated with agreement included the presence of private health insurance [odds ratio (OR) 1.36, 95% confidence interval (CI), 1.04–1.78], regular health checkup (OR 2.10, 95% CI, 1.72–2.57), and smoking history (former, OR 1.66, 95% CI, 1.09–2.55; current, OR 1.97, 95% CI, 1.45–2.67). Preference of the screening facilities showed that quality was considered more important than accessibility (46.9% vs. 31.9%). Furthermore, people were more affirmative (75.5%) towards receiving mandatory smoking cessation counseling included in NLCSP.

Conclusions

Public agreement and active participation of the eligible population are key factors in the successful implementation of NLCSP. Our data would be a valuable resource in building appropriate strategies to maximize the benefits of nationwide lung cancer screening.

GalNAc-T3 and MUC1, a combined predictor of prognosis and recurrence in solitary pulmonary adenocarcinoma initially diagnosed as malignant solitary pulmonary nodule (≤ 3 cm)

The significance of the polypeptide N-acetyl-galactosaminyl transferase-3 (GalNAc-T3) and mucin 1 (MUC1) in solitary pulmonary adenocarcinoma (SPA) initially diagnosed as malignant solitary pulmonary nodule (≤ 3 cm), especially as a combined predictor of prognosis and recurrence, was explored in this study. A retrospective analysis of 83 patients with SPA (≤ 3 cm), which revealed postoperative pathological diagnosis was lung adenocarcinoma after complete resection. Immunohistochemical staining was used to detect the expression of GalNAc-T3 and MUC1 in primary tumor specimens. The relationship between expression and various clinicopathological factors was analyzed, as well as the effects of patients' overall survival (OS) and disease-free survival (DFS). In all patients, GalNAc-T3 was highly expressed in 53 (63.9%) cases; MUC1 was highly expressed in 31 (37.3%) cases. The GalNAc-T3 expression was correlated with differentiation, pathological risk group, N stage, and TNM stage. The group with high GalNAc-T3 expression and low MUC1 expression (GalNAc-T3Hig/MUC1Low) is correlated to pathological differentiation and has a trend related to the TNM stage. The patients with better differentiation, lower pathological risk group, lower N stage, and GalNAc-T3 high expression had better overall survival, especially the GalNAc-T3Hig/MUC1Low group. Moreover, the moderate differentiation, N3 stage, and GalNAc-T3Hig/MUC1Low group were independent predictive factors for OS. Besides, patients with lower N stage, lower TNM stage, higher GalNAc-T3 expression got better disease-free survival (DFS), especially the GalNAc-T3Hig/MUC1Low group. The GalNAc-T3Hig/MUC1Low group was an independent predictive factor for DFS. In conclusion, GalNAc-T3 and MUC1 were combined predictors of prognosis and recurrence in SPA (≤ 3 cm).

Examining the effect of underlying individual preferences for present over future on lung cancer screening participation: a cross-sectional analysis of a Korean National Cancer Screening Survey

OBJECTIVES

This study aimed to examine the effect of underlying individual preferences for the present over that for the future on lung cancer screening participation.

SETTING

We analysed the data from the Korean National Cancer Screening Survey in 2018.

PARTICIPANTS

4500 adults aged 20-74 years old participated in the study.

DESIGN

In this cross-sectional survey, multivariate logistic regression analysis was carried out to examine the association between subjects' intention to participate in lung cancer screening and individual preferences. The underlying individual preferences were measured on the basis of the self-reported general willingness to spend money now in order to save money in the future and general preferences with regard to financial planning.

PRIMARY OUTCOME MEASURE

Intention to participate in lung cancer screening.

RESULTS

Individuals eligible for lung cancer screening who place less value on their future were around four times less likely to report an intention to participate in lung cancer screening than were those who valued their future (OR 3.86, 95% CI 1.89 to 7.90). A present-biassed individual (one with a tendency for immediate gratification) was also about four times less likely to report an intention to participate in screening than an individual with no present bias (OR 0.26, 95% CI 0.12 to 0.57).

CONCLUSIONS

Underlying individual preferences regarding the present and future significantly affect individuals' intention to participate in lung cancer screening. Hence, provision of incentives may be necessary to encourage the targeted heavy smokers who may have a strong preferences for the present over future.

The European experience

Traditionally, pulmonary lobectomy has always been considered as the gold standard for the treatment of early stage non-small cell lung cancer (NSCLC); limited resections have been proposed in case of "compromised" patients, with relevant comorbidities. In the last years, the interest in anatomical segmentectomies among surgeons has been progressively growing, even for patients fit for lobectomy, in selected cases. In this article we debate the current trends in the treatment of early stage NSCLC around Europe.

Recommendations for Implementing Lung Cancer Screening with Low-Dose Computed Tomography in Europe

Lung cancer screening (LCS) with low-dose computed tomography (LDCT) was demonstrated in the National Lung Screening Trial (NLST) to reduce mortality from the disease. European mortality data has recently become available from the Nelson randomised controlled trial, which confirmed lung cancer mortality reductions by 26% in men and 39-61% in women. Recent studies in Europe and the USA also showed positive results in screening workers exposed to asbestos. All European experts attending the "Initiative for European Lung Screening (IELS)"-a large international group of physicians and other experts concerned with lung cancer-agreed that LDCT-LCS should be implemented in Europe. However, the economic impact of LDCT-LCS and guidelines for its effective and safe implementation still need to be formulated. To this purpose, the IELS was asked to prepare recommendations to implement LCS and examine outstanding issues. A subgroup carried out a comprehensive literature review on LDCT-LCS and presented findings at a meeting held in Milan in November 2018. The present recommendations reflect that consensus was reached.

Recommendations for Implementing Lung Cancer Screening with Low-Dose Computed Tomography in Europe

Lung cancer screening (LCS) with low-dose computed tomography (LDCT) was demonstrated in the National Lung Screening Trial (NLST) to reduce mortality from the disease. European mortality data has recently become available from the Nelson randomised controlled trial, which confirmed lung cancer mortality reductions by 26% in men and 39-61% in women. Recent studies in Europe and the USA also showed positive results in screening workers exposed to asbestos. All European experts attending the "Initiative for European Lung Screening (IELS)"-a large international group of physicians and other experts concerned with lung cancer-agreed that LDCT-LCS should be implemented in Europe. However, the economic impact of LDCT-LCS and guidelines for its effective and safe implementation still need to be formulated. To this purpose, the IELS was asked to prepare recommendations to implement LCS and examine outstanding issues. A subgroup carried out a comprehensive literature review on LDCT-LCS and presented findings at a meeting held in Milan in November 2018. The present recommendations reflect that consensus was reached.

Uptake of minimally invasive surgery and stereotactic body radiation therapy for early stage non-small cell lung cancer in the USA: an ecological study of secular trends using the National Cancer Database

BACKGROUND

We aimed to assess the uptake of minimally invasive surgery (MIS) and stereotactic body radiation therapy (SBRT) among early stage (stage IA-IIB) non-small cell lung cancer (NSCLC) cases in the USA, and the rate of conversions from MIS to open surgery.

MATERIALS AND METHODS

Data were obtained from the US National Cancer Database, a nationwide facility-based cancer registry capturing up to 70% of incident cancer cases in the USA. We included cases diagnosed with early stage (clinical stages IA-IIB) NSCLC between 2010 and 2014. In an ecological analysis, we assessed changes in treatment by year of diagnosis. Among surgically treated cases, we assessed the uptake of MIS and whether conversion to open surgery took place. For cases that received thoracic radiotherapy, we assessed the uptake of SBRT.

RESULTS

Among 117 370 selected cases, radiotherapy use increased 3.4 percentage points between 2010 and 2014 (p<0.0001). Surgical treatments decreased 3.5 percentage points (p<0.0001). Rates of non-treatment remained stable (range: 10.0%-10.6% (p=0.4066)). Among surgically treated stage IA cases, uptake of MIS increased from 28.7% (95% CI 27.8% to 29.7%) in 2010 to 48.6% (95% CI 47.6% to 49.6%) in 2014 (p<0.0001), while conversions decreased from 17.0% (95% CI 15.6% to 18.6%) in 2010 to 9.1% (95% CI 8.3% to 10.0%) in 2014 (p<0.0001). MIS uptake among stages IB-IIB was lower and conversion rates were higher, but time trends were similar. Uptake of SBRT among stage IA receiving thoracic radiotherapy increased from 53.4% (95% CI 51.2% to 55.6%) in 2010 to 73.0% (95% CI 71.4% to 74.6%) in 2014 (p<0.0001). SBRT uptake among stage IB increased from 32.5% (95% CI 29.9% to 35.2%) in 2010 to 48.2% (95% CI 45.6% to 50.8%) in 2014 (p<0.0001).

CONCLUSION

Between 2010 and 2014, uptake of MIS and SBRT among early stage NSCLC significantly increased, while the rate of conversions to open surgery significantly decreased. Continuing these trends may contribute to improving patient care, in particular with the expected increase in early stages due to the implementation of lung cancer screening.

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

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

[The health economics of cancer screening in Germany: Which population-based interventions are cost-effective?]

Only a small proportion of German health expenditure is spent on prevention and early detection (screening). The rationale for screening is to identify persons with disease precursors or at the early stage of diseases when they are still asymptomatic, in order to decrease disease-specific morbidity and mortality. In Germany, the economic evidence is one of the evaluation criteria for screening measures, which, among other things, takes into account the additional cost per additional case detected or per case-related event avoided, as well as a cost-benefit balance.For this purpose, cost-effectiveness analyses, which report marginal or incremental cost effectiveness ratios, comparing a measure with its appropriate alternatives, may be a useful tool. Their application requires a defensible benchmark (threshold) for cost effectiveness and a supplementary analysis of the necessary infrastructure and the budgetary impact associated with program implementation. Also (albeit not only) because of the usually long time required to observe the clinical outcomes of a screening measure, the economic evaluation of such programs regularly involves the application of decision analytic simulation models. With regard to cancer screening programs, the available models indicate an excellent cost-benefit ratio for the fecal occult blood test and colonoscopy for colorectal cancer screening and, similarly, for the use of mammography for breast cancer screening. On the other hand, the economic evidence in favor of low-dose computed tomography for lung cancer screening does not yet appear sufficiently strong, and the currently available health economic evidence does not support the use of PSA testing for prostate screening.

Treatment capacity required for full-scale implementation of lung cancer screening in the United States

BACKGROUND

Full-scale implementation of lung cancer screening in the United States will increase detection of early stages. This study was aimed at assessing the capacity required for treating those cancers.

METHODS

A well-established microsimulation model was extended with treatment data from the National Cancer Database. We assessed how treatment demand would change when implementing lung cancer screening in 2018. Three policies were assessed: 1) annual screening of current smokers and former smokers who quit fewer than 15 years ago, aged 55 to 80 years, with a smoking history of at least 30 pack-years (US Preventive Services Task Force [USPSTF] recommendations); 2) annual screening of current smokers and former smokers who quit fewer than 15 years ago, aged 55 to 77 years, with a smoking history of at least 30 pack-years (Centers for Medicare and Medicaid Services [CMS] recommendations); and 3) annual screening of current smokers and former smokers who quit fewer than 10 years ago, aged 55 to 75 years, with a smoking history of at least 40 pack-years (the most cost-effective policy in Ontario [Ontario]). The base-case screening adherence was a constant 50%. Sensitivity analyses assessed other adherence levels, including a linear buildup to 50% between 2018 and 2027.

RESULTS

The USPSTF policy would require 37.0% more lung cancer surgeries in 2015-2040 than no screening, 2.2% less radiotherapy, and 5.4% less chemotherapy; 5.7% more patients would require any therapy. The increase in surgical demand would be 96.1% in 2018, 46.0% in 2023, 38.3% in 2028, and 24.9% in 2040. Adherence strongly influenced results. By 2018, surgical demand would range from 52,619 (20% adherence) to 96,121 (80%). With a gradual buildup of adherence, the increase in surgical demand would be 9.6% in 2018, 38.3% in 2023, 42.0% in 2028, and 24.4% in 2040. Results for the CMS and Ontario policies were similar, although the changes in comparison with no screening were smaller.

CONCLUSIONS

Full-scale implementation of lung cancer screening causes a major increase in surgical demand, with a peak within the first 5 years. A gradual buildup of adherence can spread this peak over time. Careful surgical capacity planning is essential for successfully implementing screening.

Implementation of lung cancer screening at the national level: Polish example

In Poland the national demonstration lung cancer screening program is about to be started in 2019. We share our concerns and discussing most important topics to be resolved while preparing such a program. The decisions made are virtually based on available scientific data and the results of two randomized controlled trials but also on the personal experience gained during the lung cancer screening studies performed in Poland. The most important and comprehensive guidelines and statements, both European and American, have been searched to find an optimal solution adjusted to the Polish national circumstances-as we assume that should be done in each country implementing such a program.

The 8th TNM edition for lung cancer: a critical analysis

The 8^th edition of the tumor, node and metastasis (TNM) classification provides several new categories and for the first time, some prospective data are included. The T (tumor) descriptor is further subdivided with 1 cm increments for T1 and T2 disease. For metastatic disease (M descriptor) the new M1b category comprises patients with only one metastasis in one distant organ, whereas M1c implies multiple distant metastases in one or several organs. There are no changes regarding the nodal map and N component but new categories are suggested for further analysis, subdividing the N1 and N2 descriptors into involvement of single or multiple lymph node stations. The residual tumor (R) classification, related to completeness of resection, was revised in the 7^th edition specifically for lung cancer resection and has been maintained in its revised form in the 8th edition. For the first time, a thorough analysis has been made of patients with multiple lung lesions distinguishing four distinct categories. Although prospective data were used for this edition, their overall number is low and more good-quality prospective data collection coming from all continents is certainly required. Main challenge for subsequent editions is the combination of specific anatomical factors with detailed immunohistochemical data and information from biomarkers and mutational changes inside the primary tumor as well as those occurring in lymph node and distant metastases. In this way not only prognosis of our patients with lung cancer will be better determined, but more specific diagnostic and therapeutic algorithms may be applied.

A national survey of lung cancer specialists' views on low-dose CT screening for lung cancer in Korea

Lung cancer specialists play an important role in designing and implementing lung cancer screening. We aimed to describe their 1) attitudes toward low-dose lung computed tomography (LDCT) screening, 2) current practices and experiences of LDCT screening and 3) attitudes and opinions towards national lung cancer screening program (NLCSP). We conducted a national web-based survey of pulmonologists, thoracic surgeons, medical oncologists, and radiological oncologists who are members of Korean Association for Lung Cancer (N = 183). Almost all respondents agreed that LDCT screening increases early detection (100%), improves survival (95.1%), and gives a good smoking cessation counseling opportunity (88.6%). Most were concerned about its high false positive results (79.8%) and the subsequent negative effects. Less than half were concerned about radiation hazard (37.2%). Overall, most (89.1%) believed that the benefits outweigh the risks and harms. Most (79.2%) stated that they proactively recommend LDCT screening to those who are eligible for the current guidelines, but the screening propensity varied considerably. The majority (77.6%) agreed with the idea of NLCSP and its beneficial effect, but had concerns about the quality control of CT devices (74.9%), quality assurance of radiologic interpretation (63.3%), poor access to LDCT (56.3%), and difficulties in selecting eligible population using self-report history (66.7%). Most (79.2%) thought that program need to be funded by a specialized fund rather than by the National Health Insurance. The opinions on the level of copayment for screening varied. Our findings would be an important source for health policy decision when considering for NLCSP in Korea.

Recent advances in the management of non-small cell lung cancer

Lung cancer is the number one cause of cancer-related death in both men and women. However, over the last few years, we have witnessed improved outcomes that are largely attributable to early detection, increased efforts in tobacco control, improved surgical approaches, and the development of novel targeted therapies. Currently, there are several novel therapies in clinical practice, including those targeting actionable mutations and more recently immunotherapeutic agents. Immunotherapy represents the most significant step forward in eradicating this deadly disease. Given the ever-changing landscape of lung cancer management, here we present an overview of the most recent advances in the management of non-small cell lung cancer.

Quality assurance and quantitative imaging biomarkers in low-dose CT lung cancer screening

After years of assessment through controlled clinical trials, low-dose CT screening for lung cancer is becoming part of clinical practice. As with any cancer screening test, those undergoing lung cancer screening are not being evaluated for concerning signs or symptoms, but are generally in good health and proactively trying to prevent premature death. Given the resultant obligation to achieve the screening aim of early diagnosis while also minimizing the potential for morbidity from workup of indeterminate but ultimately benign screening abnormalities, careful implementation of screening with conformance to currently recognized best practices and a focus on quality assurance is essential. In this review, we address the importance of each component of the screening process to optimize the effectiveness of CT screening, discussing options for quality assurance at each step. We also discuss the potential added advantages, quality assurance requirements and current status of quantitative imaging biomarkers related to lung cancer screening. Finally, we highlight suggestions for improvements and needs for further evidence in evaluating the performance of CT screening as it transitions from the research trial setting into daily clinical practice.

Geographical Variation and Factors Associated with Non-Small Cell Lung Cancer in Manitoba

Background

Screening decreases non-small cell lung cancer (NSCLC) deaths and is recommended by the Canadian Task Force on Preventive Health Care. We investigated risk factor prevalence and NSCLC incidence at a small region level to inform resource allocation for lung cancer screening.

Methods

NSCLC diagnoses were obtained from the Canadian Cancer Registry, then geocoded to 283 small geographic areas (SGAs) in Manitoba. Sociodemographic characteristics of SGAs were obtained from the 2006 Canadian Census and Canadian Community Health Survey. Geographical variation was modelled using a Bayesian spatial Poisson model.

Results

NSCLC incidence in SGAs ranged from 1 to 343 cases per 100,000 population per year. The highest incidence rates were in the Southeastern, Southwestern, and Central regions of Manitoba, while most of Northern Manitoba had lower rates. Poisson regression suggested areas with higher proportions of Aboriginal people and higher average income, and immigrants had lower NSCLC incidence whereas areas with higher proportions of smokers had higher incidence.

Conclusion

On an SGA level, smoking rates remain the most significant factor driving NSCLC incidence. Socioeconomic status and proportions of immigrants or Aboriginal peoples independently impact NSCLC rates. We have identified SGAs in Manitoba to target in policy and infrastructure planning for lung cancer screening.

Non-small cell lung cancer: the new T1 categories

Recently, major changes have occurred in the staging, diagnosis, and treatment of early stage lung cancer. By screening high-risk populations, we are now able to detect lung cancers at an early stage, but the false-positive rate is high. A new pathological classification was published in 2011 and fully incorporated in the 2015 World Health Organisation (WHO) Classification of Tumours of the Lung, Pleura, Thymus, and Heart. The new eighth edition of the tumour-node-metastasis (TNM) staging system has been fully published and will be in use from January 2017. T1 lesions are subdivided into T1a, T1b, and T1c lesions corresponding to lung cancers up to 10 mm, between 11 and 20 mm, and between 21 and 30 mm, respectively. To determine the size, only the solid part on computed tomographic scanning of the chest and the invasive part on pathological examination will be considered. Prognosis is significantly better for the smallest lesions. For some specific subgroups, sublobar resection may be oncologically valid and yield good long-term outcome, but the results of recently performed randomised trials are awaited.