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Mascalchi M, Picozzi G, Puliti D, Diciotti S, Deliperi A, Romei C, Falaschi F, Pistelli F, Grazzini M, Vannucchi L, Bisanzi S, Zappa M, Gorini G, Carozzi FM, Carrozzi L, Paci E. Lung Cancer Screening with Low-Dose CT: What We Have Learned in Two Decades of ITALUNG and What Is Yet to Be Addressed. Diagnostics (Basel) 2023; 13:2197. [PMID: 37443590 DOI: 10.3390/diagnostics13132197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/15/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
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.
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Affiliation(s)
- Mario Mascalchi
- Department of Clinical and Experimental Biomedical Sciences "Mario Serio", University of Florence, 50121 Florence, Italy
- Division of Epidemiology and Clinical Governance, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), 50100 Florence, Italy
| | - Giulia Picozzi
- Division of Epidemiology and Clinical Governance, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), 50100 Florence, Italy
| | - Donella Puliti
- Division of Epidemiology and Clinical Governance, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), 50100 Florence, Italy
| | - Stefano Diciotti
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, 47521 Cesena, Italy
| | - Annalisa Deliperi
- Radiodiagnostic Unit 2, Department of Diagnostic Imaging, Cisanello University Hospital of Pisa, 56124 Pisa, Italy
| | - Chiara Romei
- Radiodiagnostic Unit 2, Department of Diagnostic Imaging, Cisanello University Hospital of Pisa, 56124 Pisa, Italy
| | - Fabio Falaschi
- Radiodiagnostic Unit 2, Department of Diagnostic Imaging, Cisanello University Hospital of Pisa, 56124 Pisa, Italy
| | - Francesco Pistelli
- Pulmonary Unit, Cardiothoracic and Vascular Department, University Hospital of Pisa, 56124 Pisa, Italy
| | - Michela Grazzini
- Division of Pneumonology, San Jacopo Hospital Pistoia, 51100 Pistoia, Italy
| | - Letizia Vannucchi
- Division of Radiology, San Jacopo Hospital Pistoia, 51100 Pistoia, Italy
| | - Simonetta Bisanzi
- Regional Laboratory of Cancer Prevention, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), 50100 Florence, Italy
| | - Marco Zappa
- Division of Epidemiology and Clinical Governance, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), 50100 Florence, Italy
| | - Giuseppe Gorini
- Division of Epidemiology and Clinical Governance, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), 50100 Florence, Italy
| | - Francesca Maria Carozzi
- Regional Laboratory of Cancer Prevention, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), 50100 Florence, Italy
| | - Laura Carrozzi
- Pulmonary Unit, Cardiothoracic and Vascular Department, University Hospital of Pisa, 56124 Pisa, Italy
| | - Eugenio Paci
- Division of Epidemiology and Clinical Governance, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), 50100 Florence, Italy
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Puliti D, Picozzi G, Gorini G, Carrozzi L, Mascalchi M. Gender effect in the ITALUNG screening trial. A comparison with UKLS and other trials. THE LANCET REGIONAL HEALTH. EUROPE 2022; 13:100300. [PMID: 35024679 PMCID: PMC8733174 DOI: 10.1016/j.lanepe.2021.100300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Donella Puliti
- Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
| | - Giulia Picozzi
- Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
| | - Giuseppe Gorini
- Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
| | - Laura Carrozzi
- Pulmonary Unit, Cardiothoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Mario Mascalchi
- Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
- Department of Clinical and Experimental Biomedical Sciences, University of Florence
- Corresponding author.
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Abstract
A recent position statement by a group of European experts reviewed the current evidence for low-dose computed tomography (LDCT) lung cancer screening, based on the outcomes and screening performance of the published randomized trials and identified actions needed for eventual future implementation. After the National Lung Screening Trial (NLST) outcome publication, guidelines changed in USA and Canada, but there are still problems in real-world screening practice. In Europe any decision was postponed to the publication of the European randomized trial outcomes and recommendations continue to discourage screening for lung cancer in all member countries. The NELSON randomized controlled trial (RCT), the largest one in Europe, outcome results are still waited, whereas the MILD, DANTE, DLSCT and ITALUNG (all with small sample size) RCTs have published mortality and incidence data with adequate follow up. The implementation of an organized screening in Europe is conditioned by a health technology assessment process at European level. According with the European policy, confirmed in the recent European Cancer Code [2015], screening is transferred in current public-health practice according with evidence-based recommendations and based on organized, usually population-based, programs. Guidelines, standard indicators of performance, training of dedicated radiologists and professionals and a comprehensive quality assurance system is requested in European countries to implement nationally a public health screening program. Waiting the NELSON randomized trial results, key issues as modality for selection of high risk subjects and recruitment, integration of screening and smoking cessation, optimal screening regimen and related research on biomarkers should be assessed, discussed and reviewed. Informed decision making, promotion of primary prevention and integration of screening and smoking cessation are all essential components of a comprehensive risk reduction policy. The path to an Evidence-based screening practice is narrow and, in the absence of a well-established decision-making process, the risk of a spontaneous, uncontrolled use of LDCT screening or, on the other side, an oversight of the screening opportunity is high.
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Affiliation(s)
- Eugenio Paci
- Epidemiologist, ISPO - Cancer Prevention and Research Institute, Florence, Italy
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Carozzi FM, Bisanzi S, Carrozzi L, Falaschi F, Lopes Pegna A, Mascalchi M, Picozzi G, Peluso M, Sani C, Greco L, Ocello C, Paci E. Multimodal lung cancer screening using the ITALUNG biomarker panel and low dose computed tomography. Results of the ITALUNG biomarker study. Int J Cancer 2017; 141:94-101. [PMID: 28387927 DOI: 10.1002/ijc.30727] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 03/31/2017] [Indexed: 12/19/2022]
Abstract
Asymptomatic high-risk subjects, randomized in the intervention arm of the ITALUNG trial (1,406 screened for lung cancer), were enrolled for the ITALUNG biomarker study (n = 1,356), in which samples of blood and sputum were analyzed for plasma DNA quantification (cut off 5 ng/ml), loss of heterozygosity and microsatellite instability. The ITALUNG biomarker panel (IBP) was considered positive if at least one of the two biomarkers included in the panel was positive. Subjects with and without lung cancer diagnosis at the end of the screening cycle with LDCT (n = 517) were evaluated. Out of 18 baseline screen detected lung cancer cases, 17 were IBP positive (94%). Repeat screen-detected lung cancer cases were 18 and 12 of them positive at baseline IBP test (66%). Interval cancer cases (2-years) and biomarker tests after a suspect Non Calcific Nodule follow-up were investigated. The single test versus multimodal screening measures of accuracy were compared in a simulation within the screened ITALUNG intervention arm, considering screen-detected and interval cancer cases. Sensitivity was 90% at baseline screening. Specificity was 71 and 61% for LDCT and IBP as baseline single test, and improved at 89% with multimodal, combined screening. The positive predictive value was 4.3% for LDCT at baseline and 10.6% for multimodal screening. Multimodal screening could improve the screening efficiency at baseline and strategies for future implementation are discussed. If IBP was used as primary screening test, the LDCT burden might decrease of about 60%.
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Affiliation(s)
- Francesca Maria Carozzi
- Regional Cancer Prevention Laboratory, ISPO-Cancer Prevention and Research Institute, Florence, Italy
| | - Simonetta Bisanzi
- Regional Cancer Prevention Laboratory, ISPO-Cancer Prevention and Research Institute, Florence, Italy
| | - Laura Carrozzi
- Cardiopulmonary Department, University Hospital of Pisa, Pisa, Italy
| | - Fabio Falaschi
- Radiology Department, University Hospital of Pisa, Pisa, Italy
| | | | - Mario Mascalchi
- Radiodiagnostic Section, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Giulia Picozzi
- Radiodiagnostic Unit, ISPO-Cancer Prevention and Research Institute, Florence, Italy
| | - Marco Peluso
- Regional Cancer Prevention Laboratory, ISPO-Cancer Prevention and Research Institute, Florence, Italy
| | - Cristina Sani
- Regional Cancer Prevention Laboratory, ISPO-Cancer Prevention and Research Institute, Florence, Italy
| | - Luana Greco
- Biologist, formerly at ISPO-Cancer Prevention and Research Institute, Florence, Italy
| | | | - Eugenio Paci
- Retired, formerly at ISPO-Cancer Prevention and Research Institute, Florence, Italy
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Paci E, Puliti D, Lopes Pegna A, Carrozzi L, Picozzi G, Falaschi F, Pistelli F, Aquilini F, Ocello C, Zappa M, Carozzi FM, Mascalchi M. Mortality, survival and incidence rates in the ITALUNG randomised lung cancer screening trial. Thorax 2017; 72:825-831. [DOI: 10.1136/thoraxjnl-2016-209825] [Citation(s) in RCA: 150] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 02/06/2017] [Accepted: 03/09/2017] [Indexed: 11/04/2022]
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Silva M, Pastorino U, Sverzellati N. Lung cancer screening with low-dose CT in Europe: strength and weakness of diverse independent screening trials. Clin Radiol 2017; 72:389-400. [PMID: 28168954 DOI: 10.1016/j.crad.2016.12.021] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/27/2016] [Accepted: 12/29/2016] [Indexed: 12/17/2022]
Abstract
A North American trial reported a significant reduction of lung cancer mortality and overall mortality as a result of annual screening using low-dose computed tomography (LDCT). European trials prospectively tested a variety of possible screening strategies. The main topics of current discussion regarding the optimal screening strategy are pre-test selection of the high-risk population, interval length of LDCT rounds, definition of positive finding, and post-test apportioning of lung cancer risk based on LDCT findings. Despite the current lack of statistical evidence regarding mortality reduction, the European independent diverse strategies offer a multi-perspective view on screening complexity, with remarkable indications for improvements in cost-effectiveness and harm-benefit balance. The UKLS trial reported the advantage of a comprehensive and simple risk model for selection of patients with 5% risk of lung cancer in 5 years. Subjective risk prediction by biological sampling is under investigation. The MILD trial reported equal efficiency for biennial and annual screening rounds, with a significant reduction in the total number of LDCT examinations. The NELSON trial introduced volumetric quantification of nodules at baseline and volume-doubling time (VDT) for assessment of progression. Post-test risk refinement based on LDCT findings (qualitative or quantitative) is under investigation. Smoking cessation remains the most appropriate strategy for mortality reduction, and it must therefore remain an integral component of any lung cancer screening programme.
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Affiliation(s)
- M Silva
- Section of Radiology, Department of Surgical Sciences, University Hospital of Parma, Parma, Italy
| | - U Pastorino
- Thoracic Surgery Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - N Sverzellati
- Section of Radiology, Department of Surgical Sciences, University Hospital of Parma, Parma, Italy.
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