The Regimen of Computed Tomography Screening for Lung Cancer: Lessons Learned Over 25 Years From the International Early Lung Cancer Action Program

Calls to action on lung cancer management and research

Lung cancer, the leading cause of cancer-related deaths globally, remains a pressing health issue despite significant medical advances. The New York Lung Cancer Foundation brought together experts from academia, the pharmaceutical and biotech industries as well as organizational leaders and patient advocates, to thoroughly examine the current state of lung cancer diagnosis, treatment, and research. The goal was to identify areas where our understanding is incomplete and to develop collaborative public health and scientific strategies to generate better patient outcomes, as highlighted in our "Calls to Action." The consortium prioritized 8 different calls to action. These include (1) develop strategies to cure more patients with early-stage lung cancer, (2) investigate carcinogenesis leading to lung cancers in patients without a history of smoking, (3) harness precision medicine for disease interception and prevention, (4) implement solutions to deliver prevention measures and effective therapies to individuals in under-resourced countries, (5) facilitate collaborations with industry to collect and share data and samples, (6) create and maintain open access to big data repositories, (7) develop new immunotherapeutic agents for lung cancer treatment and prevention, and (8) invest in research in both the academic and community settings. These calls to action provide guidance to representatives from academia, the pharmaceutical and biotech industries, organizational and regulatory leaders, and patient advocates to guide ongoing and planned initiatives.

Baseline Cell-Free DNA Can Predict Malignancy of Nodules Observed in the ITALUNG Screening Trial

The role of total plasma cell-free DNA (cfDNA) in lung cancer (LC) screening with low-dose computed tomography (LDCT) is uncertain. We hypothesized that cfDNA could support differentiation between malignant and benign nodules observed in LDCT. The baseline cfDNA was measured in 137 subjects of the ITALUNG trial, including 29 subjects with screen-detected LC (17 prevalent and 12 incident) and 108 subjects with benign nodules. The predictive capability of baseline cfDNA to differentiate malignant and benign nodules was compared to that of Lung-RADS classification and Brock score at initial LDCT (iLDCT). Subjects with prevalent LC showed both well-discriminating radiological characteristics of the malignant nodule (16 of 17 were classified as Lung-RADS 4) and markedly increased cfDNA (mean 18.8 ng/mL). The mean diameters and Brock scores of malignant nodules at iLDCT in subjects who were diagnosed with incident LC were not different from those of benign nodules. However, 75% (9/12) of subjects with incident LC showed a baseline cfDNA ≥ 3.15 ng/mL, compared to 34% (37/108) of subjects with benign nodules (p = 0.006). Moreover, baseline cfDNA was correlated (p = 0.001) with tumor growth, measured with volume doubling time. In conclusion, increased baseline cfDNA may help to differentiate subjects with malignant and benign nodules at LDCT.

Morphological Predictors of Primary Lung Cancer among Part-Solid Ground-Grass Nodules on High-Resolution CT

Recent advancements in computed tomography (CT) scanning have improved the detection rates of peripheral pulmonary nodules, including those with ground-glass opacities (GGOs). This study focuses on part-solid pure ground-glass nodules (GGNs) and aims to identify imaging predictors that can reliably differentiate primary lung cancer from nodules with other diagnoses among part-solid GGNs on high-resolution CT (HRCT). A retrospective study was conducted on 609 patients who underwent surgical treatment or observation for lung nodules. Radiological findings from pre-operative HRCT scans were reviewed and several CT imaging features of part-solid GGNs were examined for their positive predictive value to identify primary lung cancer. The proportions of the nodules with a final diagnosis of primary lung cancer were significantly higher in part-solid GGNs (91.9%) compared with solid nodules (70.3%) or pure GGNs (66.7%). Among CT imaging features of part-solid GGNs that were evaluated, consolidation-to-tumor ratio (CTR) < 0.5 (98.1%), pleural indentation (96.4%), and clear tumor border (96.7%) had high positive predictive value to identify primary lung cancer. When two imaging features were combined, the combination of CTR < 0.5 and a clear tumor border was identified to have 100% positive predictive values with a sensitivity of 40.8%. Thus we conclude that part-solid GGNs with a CTR < 0.5 accompanied by a clear tumor border evaluated by HRCT are very likely to be primary lung cancers with an acceptable sensitivity. Preoperative diagnostic procedures to obtain a pathological diagnosis may potentially be omitted in patients harboring such part-solid GGNs.

Perspective on Management of Low-Dose Computed Tomography Findings on Low-Dose Computed Tomography Examinations for Lung Cancer Screening. From the International Association for the Study of Lung Cancer Early Detection and Screening Committee

Lung cancer screening using low-dose computed tomography (LDCT) carefully implemented has been found to reduce deaths from lung cancer. Optimal management starts with selection of eligibility criteria, counseling of screenees, smoking cessation, selection of the regimen of screening which specifies the imaging protocol, and workup of LDCT findings. Coordination of clinical, radiologic, and interventional teams and ultimately treatment of diagnosed lung cancers under screening determine the benefit of LDCT screening. Ethical considerations of who should be eligible for LDCT screening programs are important to provide the benefit to as many people at risk of lung cancer as possible. Unanticipated diseases identified on LDCT may offer important benefits through early detection of leading global causes of death, such as cardiovascular diseases and chronic obstructive pulmonary disease, as the latter may result from conditions such as emphysema and bronchiectasis, which can be identified early on LDCT. This report identifies the key components of the regimen of LDCT screening for lung cancer which include the need for a management system to provide data for continuous updating of the regimen and provides quality assurance assessment of actual screenings. Multidisciplinary clinical management is needed to maximize the benefit of early detection, diagnosis, and treatment of lung cancer. Different regimens have been evolving throughout the world as the resources and needs may be different, for countries with limited resources. Sharing of results, further knowledge, and incorporation of technologic advances will continue to accelerate worldwide improvements in the diagnostic and treatment approaches.

ACR Lung-RADS v2022: Assessment Categories and Management Recommendations

The ACR created the Lung CT Screening Reporting and Data System (Lung-RADS) in 2014 to standardize the reporting and management of screen-detected pulmonary nodules. Lung-RADS was updated to version 1.1 in 2019 and revised size thresholds for nonsolid nodules, added classification criteria for perifissural nodules, and allowed for short-interval follow-up of rapidly enlarging nodules that may be infectious in etiology. Lung-RADS v2022, released in November 2022, provides several updates including guidance on the classification and management of atypical pulmonary cysts, juxtapleural nodules, airway-centered nodules, and potentially infectious findings. This new release also provides clarification for determining nodule growth and introduces stepped management for nodules that are stable or decreasing in size. This article summarizes the current evidence and expert consensus supporting Lung-RADS v2022.

ACR Lung-RADS v2022: Assessment Categories and Management Recommendations

The American College of Radiology created the Lung CT Screening Reporting and Data System (Lung-RADS) in 2014 to standardize the reporting and management of screen-detected pulmonary nodules. Lung-RADS was updated to version 1.1 in 2019 and revised size thresholds for nonsolid nodules, added classification criteria for perifissural nodules, and allowed for short-interval follow-up of rapidly enlarging nodules that may be infectious in etiology. Lung-RADS v2022, released in November 2022, provides several updates including guidance on the classification and management of atypical pulmonary cysts, juxtapleural nodules, airway-centered nodules, and potentially infectious findings. This new release also provides clarification for determining nodule growth and introduces stepped management for nodules that are stable or decreasing in size. This article summarizes the current evidence and expert consensus supporting Lung-RADS v2022.

Radiologic Features of Nodules Attached to the Mediastinal or Diaphragmatic Pleura at Low-Dose CT for Lung Cancer Screening

Background Pulmonary noncalcified nodules (NCNs) attached to the fissural or costal pleura with smooth margins and triangular or lentiform, oval, or semicircular (LOS) shapes at low-dose CT are recommended for annual follow-up instead of immediate workup. Purpose To determine whether management of mediastinal or diaphragmatic pleura-attached NCNs (M/DP-NCNs) with the same features as fissural or costal pleura-attached NCNs at low-dose CT can follow the same recommendations. Materials and Methods This retrospective study reviewed chest CT examinations in participants from two databases. Group A included 1451 participants who had lung cancer that was first present as a solid nodule with an average diameter of 3.0-30.0 mm. Group B included 345 consecutive participants from a lung cancer screening program who had at least one solid nodule with a diameter of 3.0-30.0 mm at baseline CT and underwent at least three follow-up CT examinations. Radiologists reviewed CT images to identify solid M/DP-NCNs, defined as nodules 0 mm in distance from the mediastinal or diaphragmatic pleura, and recorded average diameter, margin, and shape. General descriptive statistics were used. Results Among the 1451 participants with lung cancer in group A, 163 participants (median age, 68 years [IQR, 61.5-75.0 years]; 92 male participants) had 164 malignant M/DP-NCNs 3.0-30.0 mm in average diameter. None of the 164 malignant M/DP-NCNs had smooth margins and triangular or LOS shapes (upper limit of 95% CI of proportion, 0.02). Among the 345 consecutive screening participants in group B, 146 participants (median age, 65 years [IQR, 59-71 years]; 81 female participants) had 240 M/DP-NCNs with average diameter 3.0-30.0 mm. None of the M/DP-NCNs with smooth margins and triangular or LOS shapes were malignant after a median follow-up of 57.8 months (IQR, 46.3-68.1 months). Conclusion For solid M/DP-NCNs with smooth margins and triangular or LOS shapes at low-dose CT, the risk of lung cancer is extremely low, which supports the recommendation of Lung Imaging Reporting and Data System version 2022 for annual follow-up instead of immediate workup. © RSNA, 2024 See also the editorial by Goodman and Baruah in this issue.

Opportunistic Screening With Low-Dose Computed Tomography and Lung Cancer Mortality in China

Importance

Despite the recommendations of lung cancer screening guidelines and the evidence supporting the effectiveness of population-based lung screening, a common barrier to effective lung cancer screening is that the participation rates of low-dose computed tomography (LDCT) screening among individuals with the highest risk are not large. There are limited data from clinical practice regarding whether opportunistic LDCT screening is associated with reduced lung-cancer mortality.

Objective

To evaluate whether opportunistic LDCT screening is associated with improved prognosis among adults with lung cancer in mainland China.

Design, Setting, and Participants

This cohort study included patients diagnosed with lung cancer at Weihai Municipal Hospital Healthcare Group, Weihai City, China, from 2016 to 2021. Data were analyzed from January 2022 to February 2023.

Exposures

Data collected included demographic indicators, tumor characteristics, comorbidities, blood indexes, and treatment information. Patients were classified into screened and nonscreened groups on the basis of whether or not their lung cancer diagnosis occurred through opportunistic screening.

Main Outcomes and Measures

Follow-up outcome indicators included lung cancer-specific mortality and all-cause mortality. Propensity score matching (PSM) was adopted to account for potential imbalanced factors between groups. The associations between LDCT screening and outcomes were analyzed using Cox regression models based on the matched data. Propensity score regression adjustment and inverse probability treatment weighting were used for sensitivity analysis.

Results

A total of 5234 patients (mean [SD] baseline age, 61.8 [9.8] years; 2518 [48.1%] female) with complete opportunistic screening information were included in the analytical sample, with 2251 patients (42.91%) receiving their lung cancer diagnosis through opportunistic screening. After 1:1 PSM, 2788 patients (1394 in each group) were finally included. The baseline characteristics of the matched patients were balanced between groups. Opportunistic screening with LDCT was associated with a 49% lower risk of lung cancer death (HR, 0.51; 95% CI, 0.42-0.62) and 46% lower risk of all-cause death (HR, 0.54; 95% CI, 0.45-0.64).

Conclusions and Relevance

In this cohort study of patients with lung cancer, opportunistic lung cancer screening with LDCT was associated with lower lung cancer mortality and all-cause mortality. These findings suggest that opportunistic screening is an important supplement to population screening to improve prognosis of adults with lung cancer.

A 20-year Follow-up of the International Early Lung Cancer Action Program (I-ELCAP)

Background The low-dose CT (≤3 mGy) screening report of 1000 Early Lung Cancer Action Program (ELCAP) participants in 1999 led to the International ELCAP (I-ELCAP) collaboration, which enrolled 31 567 participants in annual low-dose CT screening between 1992 and 2005. In 2006, I-ELCAP investigators reported the 10-year lung cancer-specific survival of 80% for 484 participants diagnosed with a first primary lung cancer through annual screening, with a high frequency of clinical stage I lung cancer (85%). Purpose To update the cure rate by determining the 20-year lung cancer-specific survival of participants diagnosed with first primary lung cancer through annual low-dose CT screening in the expanded I-ELCAP cohort. Materials and Methods For participants enrolled in the HIPAA-compliant prospective I-ELCAP cohort between 1992 and 2022 and observed until December 30, 2022, Kaplan-Meier survival analysis was used to determine the 10- and 20-year lung cancer-specific survival of participants diagnosed with first primary lung cancer through annual low-dose CT screening. Eligible participants were aged at least 40 years and had current or former cigarette use or had never smoked but had been exposed to secondhand tobacco smoke. Results Among 89 404 I-ELCAP participants, 1257 (1.4%) were diagnosed with a first primary lung cancer (684 male, 573 female; median age, 66 years; IQR, 61-72), with a median smoking history of 43.0 pack-years (IQR, 29.0-60.0). Median follow-up duration was 105 months (IQR, 41-182). The frequency of clinical stage I at pretreatment CT was 81% (1017 of 1257). The 10-year lung cancer-specific survival of 1257 participants was 81% (95% CI: 79, 84) and the 20-year lung cancer-specific survival was 81% (95% CI: 78, 83), and it was 95% (95% CI: 91, 98) for 181 participants with pathologic T1aN0M0 lung cancer. Conclusion The 10-year lung cancer-specific survival of 80% reported in 2006 for I-ELCAP participants enrolled in annual low-dose CT screening and diagnosed with a first primary lung cancer has persisted, as shown by the updated 20-year lung cancer-specific survival for the expanded I-ELCAP cohort. © RSNA, 2023 See also the editorials by Grenier and by Sequist and Olazagasti in this issue.

Lung Cancer Screening with Low-Dose CT: What We Have Learned in Two Decades of ITALUNG and What Is Yet to Be Addressed

The ITALUNG trial started in 2004 and compared lung cancer (LC) and other-causes mortality in 55-69 years-aged smokers and ex-smokers who were randomized to four annual chest low-dose CT (LDCT) or usual care. ITALUNG showed a lower LC and cardiovascular mortality in the screened subjects after 13 years of follow-up, especially in women, and produced many ancillary studies. They included recruitment results of a population-based mimicking approach, development of software for computer-aided diagnosis (CAD) and lung nodules volumetry, LDCT assessment of pulmonary emphysema and coronary artery calcifications (CAC) and their relevance to long-term mortality, results of a smoking-cessation intervention, assessment of the radiations dose associated with screening LDCT, and the results of biomarkers assays. Moreover, ITALUNG data indicated that screen-detected LCs are mostly already present at baseline LDCT, can present as lung cancer associated with cystic airspaces, and can be multiple. However, several issues of LC screening are still unaddressed. They include the annual vs. biennial pace of LDCT, choice between opportunistic or population-based recruitment. and between uni or multi-centre screening, implementation of CAD-assisted reading, containment of false positive and negative LDCT results, incorporation of emphysema. and CAC quantification in models of personalized LC and mortality risk, validation of ultra-LDCT acquisitions, optimization of the smoking-cessation intervention. and prospective validation of the biomarkers.

Initial low-dose computed tomography screening results and summary of participant characteristics: based on the latest Chinese guideline

Background

Low-dose computed tomography (LDCT) has been promoted as a promising screening strategy for early detection of lung cancer. China released the latest lung cancer screening guideline in 2021. The compliance of the individuals who received LDCT for lung cancer screening with the guideline is unknown yet. It is necessary to summarize the distribution of guideline-defined lung cancer-related risk factors in the Chinese population so as to inform the selection of target population for the future lung cancer screening.

Methods

A single-center, cross-sectional study design was adopted. All participants were individuals who underwent LDCT at a tertiary teaching hospital in Hunan, China, between 1 January and 31 December 2021. LDCT results were derived along with guideline-based characteristics for descriptive analysis.

Results

A total of 5,486 participants were included. Over one-quarter (1,426, 26.0%) of the participants who received screening did not meet the guideline-defined high-risk population, even among non-smokers (36.4%). Most of the participants (4,622, 84.3%) were found to have lung nodules, while no clinical intervention was required basically. The detection rate of positive nodules varied from 46.8% to 71.2% when using different cut-off values for positive nodules. Among non-smoking women, ground glass opacity appeared to be more significantly common compared with non-smoking men (26.7% vs. 21.8%).

Conclusion

Over one-quarter of individuals who received LDCT screening did not meet the guideline-defined high-risk populations. Appropriate cut-off values for positive nodules need to be continuously explored. More precise and localized criteria for high-risk individuals are needed, especially for non-smoking women.

Artificial intelligence in lung cancer diagnosis and prognosis: Current application and future perspective

Lung cancer is one of the malignant tumors with the highest incidence and mortality in the world. The overall five-year survival rate of lung cancer is relatively lower than many leading cancers. Early diagnosis and prognosis of lung cancer are essential to improve the patient's survival rate. With artificial intelligence (AI) approaches widely applied in lung cancer, early diagnosis and prediction have achieved excellent performance in recent years. This review summarizes various types of AI algorithm applications in lung cancer, including natural language processing (NLP), machine learning and deep learning, and reinforcement learning. In addition, we provides evidence regarding the application of AI in lung cancer diagnostic and clinical prognosis. This review aims to elucidate the value of AI in lung cancer diagnosis and prognosis as the novel screening decision-making for the precise treatment of lung cancer patients.

Using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to study adaptations in lung cancer screening delivery in the Veterans Health Administration: a cohort study

BACKGROUND

Lung cancer screening is a complex clinical process that includes identification of eligible individuals, shared decision-making, tobacco cessation, and management of screening results. Adaptations to the delivery process for lung cancer screening in situ are understudied and underreported, with the potential loss of important considerations for improved implementation. The Framework for Reporting Adaptations and Modifications-Expanded (FRAME) allows for a systematic enumeration of adaptations to implementation of evidence-based practices. We applied FRAME to study adaptations in lung cancer screening delivery processes implemented by lung cancer screening programs in a Veterans Health Administration (VHA) Enterprise-Wide Initiative.

METHODS

We prospectively conducted semi-structured interviews at baseline and 1-year intervals with lung cancer screening program navigators at 10 Veterans Affairs Medical Centers (VAMCs) between 2019 and 2021. Using this data, we developed baseline (1st) process maps for each program. In subsequent years (year 1 and year 2), each program navigator reviewed the process maps. Adaptations in screening processes were identified, documented, and mapped to FRAME categories.

RESULTS

We conducted a total of 16 interviews across 10 VHA lung cancer screening programs (n=6 in year 1, n=10 in year 2) to collect adaptations. In year 1 (2020), six programs were operational and eligible. Of these, three reported adaptations to their screening process that were planned or in response to COVID-19. In year 2 (2021), all 10 programs were operational and eligible. Programs reported 14 adaptations in year 2. These adaptations were planned and unplanned and often triggered by increased workload; 57% of year 2 adaptations were related to the identification and eligibility of Veterans and 43% were related to follow-up with Veterans for screening results. Throughout the 2 years, adaptations related to data management and patient tracking occurred in 60% of programs to improve the data collection and tracking of Veterans in the screening process.

CONCLUSIONS

Using FRAME, we found that adaptations occurred primarily in the areas of patient identification and communication of results due to increased workload. These findings highlight navigator time and resource considerations for sustainability and scalability of existing and future lung cancer screening programs as well as potential areas for future intervention.

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.

Non-small cell lung cancer in China

In China, lung cancer is a primary cancer type with high incidence and mortality. Risk factors for lung cancer include tobacco use, family history, radiation exposure, and the presence of chronic lung diseases. Most early-stage non-small cell lung cancer (NSCLC) patients miss the optimal timing for treatment due to the lack of clinical presentations. Population-based nationwide screening programs are of significant help in increasing the early detection and survival rates of NSCLC in China. The understanding of molecular carcinogenesis and the identification of oncogenic drivers dramatically facilitate the development of targeted therapy for NSCLC, thus prolonging survival in patients with positive drivers. In the exploration of immune escape mechanisms, programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitor monotherapy and PD-1/PD-L1 inhibitor plus chemotherapy have become a standard of care for advanced NSCLC in China. In the Chinese Society of Clinical Oncology's guidelines for NSCLC, maintenance immunotherapy is recommended for locally advanced NSCLC after chemoradiotherapy. Adjuvant immunotherapy and neoadjuvant chemoimmunotherapy will be approved for resectable NSCLC. In this review, we summarized recent advances in NSCLC in China in terms of epidemiology, biology, molecular pathology, pathogenesis, screening, diagnosis, targeted therapy, and immunotherapy.

The Association of Health Care System Resources With Lung Cancer Screening Implementation

Background

The Veterans Health Administration issued policy for lung cancer screening resources at eight Veterans Affairs Medical Centers (VAMCs) in a demonstration project (DP) from 2013 through 2015.

Research Question

Do policies that provide resources increase lung cancer screening rates?

Study Design and Methods

Data from eight DP VAMCs (DP group) and 20 comparable VAMCs (comparison group) were divided into before DP (January 2011-June 2013), DP (July 2013-June 2015), and after DP (July 2015-December 2018) periods. Coprimary outcomes were unique veterans screened per 1,000 eligible per month and those with 1-year (9-15 months) follow-up screening. Eligible veterans were estimated using yearly counts and the percentage of those with eligible smoking histories. Controlled interrupted time series and difference-in-differences analyses were performed.

Results

Of 27,746 veterans screened, the median age was 66.5 years and most were White (77.7%), male (95.6%), and urban dwelling (67.3%). During the DP, the average rate of unique veterans screened at DP VAMCs was 17.7 per 1,000 eligible per month, compared with 0.3 at comparison VAMCs. Adjusted analyses found a higher rate increase at DP VAMCs by 0.93 screening per 1,000 eligible per month (95% CI, 0.25-1.61) during this time, with an average facility-level difference of 17.4 screenings per 1,000 eligible per month (95% CI, 12.6-22.3). Veterans with 1-year follow-up screening also increased more rapidly at DP VAMCs during the DP, by 0.39 screening per 1,000 eligible per month (95% CI, 0.18-0.60), for an average facility-level difference of 7.2 more screenings per 1,000 eligible per month (95% CI, 5.2-9.2). Gains were not maintained after the DP.

Interpretation

In this cohort, provision of resources for lung cancer screening implementation was associated with an increase in veterans screened and those with 1-year follow-up screening. Screening gains associated with the DP were not maintained.

Using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to study lung cancer screening adaptations in the Veterans Health Administration

Background: Lung cancer screening includes identification of eligible individuals, shared decision-making inclusive of tobacco cessation, and management of screening results. Adaptations to the implemented processes for lung cancer screening in situ are understudied and underreported, with potential loss of important considerations for improved implementation. The Framework for Reporting Adaptations and Modifications-Expanded (FRAME) allows for systematic enumeration of adaptations to implementations of evidence-based practices. We used FRAME to study adaptations in lung cancer screening processes that were implemented as part of a Veterans Health Administration (VHA) Enterprise-Wide Initiative. Methods: We conducted semi-structured interviews at baseline and 1-year intervals with lung cancer screening program navigators at 10 Veterans Affairs Medical Centers (VAMC) between 2019-2021. Using this data, we developed baseline (1st) process maps for each program. In subsequent years (year 1 and year 2), each program navigator reviewed the process maps. Adaptations in screening processes were identified, recorded and mapped to FRAME categories. Results: A total of 14 program navigators across 10 VHA lung cancer screening programs participated in 20 interviews. In year 1 (2019-2020), seven programs were operational and of these, three reported adaptations to their screening process that were either planned and in response to COVID-19. In year 2 (2020-2021), all 10 programs were operational. Programs reported 14 adaptations in year 2. These adaptations were both planned and unplanned and often triggered by increased workload; 57% of year 2 adaptations were related to identification and eligibility of Veterans and 43% were related to follow-up with Veterans for screening results. Throughout the 2 years, adaptations related to data management and patient tracking occurred in 6 of 10 programs to improve the data collection and tracking of Veterans in the screening process. Conclusions: Using FRAME, we found that adaptations occurred throughout the lung cancer screening process but primarily in the areas of patient identification and communication of results. These findings highlight considerations for lung cancer screening implementation and potential areas for future intervention.

Contemporary Concise Review 2021: Pulmonary nodules from detection to intervention

The US Preventive Task Force (USPSTF) has updated screening criteria by expanding age range and reducing smoking history required for eligibility; the International Lung Screen Trial (ILST) data have shown that PLCOM2012 performs better for eligibility than USPSTF criteria. Screening adherence is low (4%-6% of potential eligible candidates in the United States) and depends upon multiple system and patient/candidate-related factors. Smoking cessation in lung cancer improves survival (past prospective trial data, updated meta-analysis data); smoking cessation is an essential component of lung cancer screening. Circulating biomarkers are emerging to optimize screening and early diagnosis. COVID-19 continues to affect lung cancer treatment and screening through delays and disruptions; specific operational challenges need to be met. Over 70% of suspected malignant lesions develop in the periphery of the lungs. Bronchoscopic navigational techniques have been steadily improving to allow greater accuracy with target lesion approximation and therefore diagnostic yield. Fibre-based imaging techniques provide real-time microscopic tumour visualization, with potential diagnostic benefits. With significant advances in peripheral lung cancer localization, bronchoscopically delivered ablative therapies are an emerging field in limited stage primary and oligometastatic disease. In advanced stage lung cancer, small-volume samples acquired through bronchoscopic techniques yield material of sufficient quantity and quality to support clinically relevant biomarker assessment.

The impact of cardiopulmonary hemodynamic factors in volumetry for pulmonary nodule management

BACKGROUND

The acceptance of coronary CT angiogram (CCTA) scans in the management of stable angina has led to an exponential increase in studies performed and reported incidental findings, including pulmonary nodules (PN). Using low-dose CT scans, volumetry tools are used in growth assessment and risk stratification of PN between 5 and 8 mm in diameter. Volumetry of PN could also benefit from the increased temporal resolution of CCTA scans, potentially expediting clinical decisions when an incidental PN is first detected on a CCTA scan, and allow for better resource management and planning in a Radiology department. This study aims to investigate how cardiopulmonary hemodynamic factors impact the volumetry of PN using CCTA scans. These factors include the cardiac phase, vascular distance from the main pulmonary artery (MPA) to the nodule, difference of the MPA diameter between systole and diastole, nodule location, and cardiomegaly presence.

MATERIALS AND METHODS

Two readers reviewed all CCTA scans performed from 2016 to 2019 in a tertiary hospital and detected PN measuring between 5 and 8 mm in diameter. Each observer measured each nodule using two different software packages and in systole and diastole. A multiple linear regression model was applied, and inter-observer and inter-software agreement were assessed using intraclass correlation.

RESULTS

A total of 195 nodules from 107 patients were included in this retrospective, cross-sectional and observational study. The regression model identified the vascular distance (p < 0.001), the difference of the MPA diameter between systole and diastole (p < 0.001), and the location within the lower or posterior thirds of the field of view (p < 0.001 each) as affecting the volume measurement. The cardiac phase was not significant in the model. There was a very high inter-observer agreement but no reasonable inter-software agreement between measurements.

CONCLUSIONS

PN volumetry using CCTA scans seems to be sensitive to cardiopulmonary hemodynamic changes independently of the cardiac phase. These might also be relevant to non-gated scans, such as during PN follow-up. The cardiopulmonary hemodynamic changes are a new limiting factor to PN volumetry. In addition, when a patient experiences an acute or deteriorating cardiopulmonary disease during PN follow-up, these hemodynamic changes could affect the PN growth estimation.

Application Value of PET/CT and MRI in the Diagnosis and Treatment of Patients With Synchronous Multiple Pulmonary Ground-Glass Nodules

Background

Synchronous multiple ground-glass nodules (SMGGNs) in synchronous multiple lung cancers are associated with specific imaging findings. It is difficult to distinguish whether multiple nodules are primary tumors or metastatic lesions in the lungs. The need for PET/CT and contrast-enhanced brain MRI for these patients remains unclear. This study investigated the necessity of these two imaging examinations for SMGGN patients by means of retrospective analysis.

Methods

SMGGN patients who were diagnosed and treated in our hospital from October 2017 to May 2020 and underwent whole-body PET/CT(Cranial excepted) and/or contrast-enhanced brain MRI+DWI were enrolled in this study. We analyzed the imaging and clinical characteristics of these patients to evaluate SMGGN patients’ need to undergo whole-body PET/CT and brain MRI examination.

Results

A total of 87 SMGGN patients were enrolled. 51 patients underwent whole-body PET/CT examinations and did not show signs of primary tumors in other organs, metastatic foci in other organs, or metastasis to surrounding lymph nodes. 87 patients underwent whole-brain MRI, which did not reveal brain metastases but did detect an old cerebral infarction in 23 patients and a new cerebral infarction in one patient. 87 patients underwent surgical treatment in which 219 nodules were removed. All nodules were diagnosed as adenocarcinoma or atypical adenomatous hyperplasia. No lymph node metastasis was noted.

Conclusion

For SMGGN patients, PET/CT and enhanced cranial MRI are unnecessary for SMGGNs patients, but from the perspective of perioperative patient safety, preoperative MRI+DWI examination is recommended for SMGGNs patients.

Association of Rurality With Annual Repeat Lung Cancer Screening in the Veterans Health Administration

PURPOSE

Lung cancer causes the largest number of cancer-related deaths in the United States. Lung cancer incidence rates, mortality rates, and rates of advanced stage disease are higher among those who live in rural areas. Known disparities in lung cancer outcomes between rural and nonrural populations may be in part because of barriers faced by rural populations. The authors tested the hypothesis that among Veterans who receive initial lung cancer screening, rural Veterans would be less likely to complete annual repeat screening than nonrural Veterans.

METHODS

A retrospective cohort study was conducted of 10 Veterans Affairs medical centers from 2015 to 2019. Rural and nonrural Veterans undergoing lung cancer screening were identified. Rural status was defined using the rural-urban commuting area codes. The primary outcome was annual repeat lung cancer screening in the 9- to 15-month window (primary analysis) and 31-day to 18-month window (sensitivity analysis) after the first documented lung cancer screening. To examine rurality as a predictor of annual repeat lung cancer screening, multivariable logistic regression models were used.

RESULTS

In the final analytic sample of 11,402 Veterans, annual repeat lung cancer screening occurred in 27.7% of rural Veterans (641 of 2,316) and 31.8% of nonrural Veterans (2,891 of 9,086) (adjusted odds ratio: 0.86; 95% confidence interval: 0.73-1.03). Similar results were seen in the sensitivity analysis, with 41.6% of rural Veterans (963 of 2,316) versus 45.2% of nonrural Veterans (4,110 of 9,086) (adjusted odds ratio: 0.88; 95% confidence interval: 0.73-1.04) having annual repeat screening in the expanded 31-day to 18-month window.

CONCLUSIONS

Among a national cohort of Veterans, rural residence was associated with numerically lower odds of annual repeat lung cancer screening than nonrural residence. Continued, intentional outreach efforts to increase annual repeat lung cancer screening among rural Veterans may offer an opportunity to decrease deaths from lung cancer.

Protocol to evaluate an enterprise-wide initiative to increase access to lung cancer screening in the Veterans Health Administration

INTRODUCTION

The Veterans Affairs Partnership to increase Access to Lung Screening (VA-PALS) is an enterprise-wide initiative to implement lung cancer screening programs at VA medical centers (VAMCs). VA-PALS will be using implementation strategies that include program navigators to coordinate screening activities, trainings for navigators and radiologists, an open-source software management system, tools to standardize low-dose computed tomography image quality, and access to a support network. VAMCs can utilize strategies according to their local needs. In this protocol, we describe the planned program evaluation for the initial 10 VAMCs participating in VA-PALS.

MATERIALS AND METHODS

The implementation of programs will be evaluated using the Consolidated Framework for Implementation Research to ensure broad contextual guidance. Program evaluation measures have been developed using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. Adaptations of screening processes will be assessed using the Framework for Reporting Adaptations and Modifications to Evidence Based Interventions. Measures collected will reflect the inner settings, estimate and describe the population reached, adoption by providers, implementation of the programs, report clinical outcomes and maintenance of programs. Analyses will include descriptive statistics and regression to evaluate predictors and assess implementation over time.

DISCUSSION

This theory-based protocol will evaluate the implementation of lung cancer screening programs across the Veterans Health Administration using scientific frameworks. The findings will inform plans to expand the VA-PALS initiative beyond the original sites and can guide implementation of lung cancer screening programs more broadly.

Added benefits of early detection of other diseases on low-dose CT screening

Low-dose CT screening for lung cancer provides images of the entire chest and upper abdomen. While the focus of screening is on finding early lung cancer, radiology leadership has embraced the fact that the information contained in the images presents a new challenge to the radiology profession. Other findings in the chest and upper abdomen were not the reason for obtaining the screening CT scan, nor symptom-prompted, but still need to be reported. Reporting these findings and making recommendations for further workup requires careful consideration to avoid unnecessary workup or interventions while still maximizing the benefit that early identification of these other diseases provided. Other potential findings, such as cardiovascular disease and chronic pulmonary obstructive diseases actually cause more deaths than lung cancer. Existing recommendations for workup of abnormal CT findings are based on symptom-prompted indications for imaging. These recommendations may be different when the abnormalities are identified in asymptomatic people undergoing CT screening for lung cancer. I-ELCAP, a large prospectively collected multi-institutional and multi-national database of screenings, was used to analyze CT findings identified in screening for lung cancer. These analyses and recommendations were made by radiologists in collaboration with clinicians in different medical specialties.

Implementation of low-dose CT screening in two different health care systems: Mount Sinai Healthcare System and Phoenix VA Health Care System

Implementation of lung screening (LS) programs is challenging even among health care organizations that have the motivation, the resources, and more importantly, the goal of providing for life-saving early detection, diagnosis, and treatment of lung cancer. We provide a case study of LS implementation in different healthcare systems, at the Mount Sinai Healthcare System (MSHS) in New York City, and at the Phoenix Veterans Affairs Health Care System (PVAHCS) in Phoenix, Arizona. This will illustrate the commonalities and differences of the LS implementation process in two very different health care systems in very different parts of the United States. Underlying the successful implementation of these LS programs was the use of a comprehensive management system, the Early Lung Cancer Action Program (ELCAP) Management System^TM. The collaboration between MSHS and PVAHCS over the past decade led to the ELCAP Management System^TM being gifted by the Early Diagnosis and Treatment Research Foundation to the PVAHCS, to develop a “VA-ELCAP” version. While there remain challenges and opportunities to continue improving LS and its implementation, there is an increasing realization that most patients who are diagnosed with lung cancer as a result of annual LS can be cured, and that of all the possible risks associated with LS, the greater risk of all is for heavy cigarette smokers not to be screened. We identified 10 critical components in implementing a LS program. We provided the details of each of these components for the two healthcare systems. Most importantly, is that continual re-evaluation of the screening program is needed based on the ongoing quality assurance program and database of the actual screenings. At minimum, there should be an annual review and updating. As early diagnosis of lung cancer must be followed by optimal treatment to be effective, treatment advances for small, early lung cancers diagnosed as a result of screening also need to be assessed and incorporated into the entire screening and treatment program.