Current Evidence for a Lung Cancer Screening Program

Background

Lung cancer screening is still in an early phase compared to other cancer screening programs, despite its high lethality particularly when diagnosed late. Achieving early diagnosis is crucial to obtain optimal outcomes.

Summary

In this review, we will address the current evidence on lung cancer screening through low-dose computed tomography (LDCT) and its impact on mortality reduction, existing screening recommendations, patient eligibility criteria, screening frequency and duration, benefits and harms, cost-effectiveness and some insights on lung cancer screening implementation and adoption. Additionally, new non-imaging, noninvasive biomarkers with high diagnostic potential are also briefly highlighted.

Key Messages

LDCT screening in a prespecified population based on age and smoking history proved to reduce lung cancer mortality. Optimization of the target population and management of LDCT pitfalls can further improve lung cancer screening efficiency and cost-effectiveness. Novel screening technologies and biomarkers being studied can potentially be game-changers in lung cancer screening and diagnosis.

A methodological quality evaluation of the published guidelines and recommendations about the lung cancer screening

BACKGROUND

A project to assess the existing literature and to benchmark the quality of past guidelines and recommendations on lung cancer screening projects was developed with a particular focus on the assessment of the methodology used in producing them.

METHODS

Each guideline was assessed in the different items and domains with the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument and scored on a seven-point scale.

RESULTS

Eight guidelines matched the inclusion criteria and were assessed. A multinational collaboration produced three out of five guidelines. The multivariable analysis shows that improved scores of stakeholders' involvement were related to internationally developed guidelines. Improved methodological quality was related to the involvement of scientific societies due to the better rigor of development and editorial independence. Countries with higher expenditure on healthcare produced significantly better guidelines.

CONCLUSIONS

Assessed by the AGREE II criteria, the methodological quality of previous guidelines was relatively low. Nevertheless, the National Comprehensive Cancer Network Guidelines should be recommended as a model for the development of best methodological quality guidelines.

LUCSO-1-French pilot study of LUng Cancer Screening with low-dose computed tomography in a smokers population exposed to Occupational lung carcinogens: study protocol

INTRODUCTION

Guidelines concerning the follow-up of subjects occupationally exposed to lung carcinogens, published in France in 2015, recommended the setting up of a trial of low-dose chest CT lung cancer screening in subjects at high risk of lung cancer.

OBJECTIVE

To evaluate the organisation of low-dose chest CT lung cancer screening in subjects occupationally exposed to lung carcinogens and at high risk of lung cancer.

METHODS AND ANALYSIS

This trial will be conducted in eight French departments by six specialised reference centres (SRCs) in occupational health. In view of the exploratory nature of this trial, it is proposed to test initially the feasibility and acceptability over the first 2 years in only two SRCs then in four other SRCs to evaluate the organisation. The target population is current or former smokers with more than 30 pack-years (who have quit smoking for less than 15 years), currently or previously exposed to International Agency for Research on Cancer group 1 lung carcinogens, and between the ages of 55 and 74 years. The trial will be conducted in the following steps: (1) identification of subjects by a screening invitation letter; (2) evaluation of occupational exposure to lung carcinogens; (3) evaluation of the lung cancer risk level and verification of eligibility; (4) screening procedure: annual chest CT scans performed by specialised centres and (5) follow-up of CT scan abnormalities.

ETHICS AND DISSEMINATION

This protocol study has been approved by the French Committee for the Protection of Persons. The results from this study will be submitted to peer-reviewed journals and reported at suitable national and international meetings.

TRIAL REGISTRATION NUMBER

NCT03562052; Pre-results.

Challenges in Lung Cancer Screening in Latin America

Lung cancer is the deadliest cancer worldwide and is of particular concern for Latin America. Its rising incidence in this area of the world poses myriad challenges for the region's economies, which are already struggling with limited resources to meet the health care needs of low- and middle-income populations. In this environment, we are concerned that regional governments are relatively unaware of the pressing need to implement effective strategies for the near future. Low-dose chest computed tomography (LDCT) for screening, and routine use of minimally invasive techniques for diagnosis and staging remain uncommon. According to results of the National Lung Screening Trial, LDCT lung cancer screening provided a 20% relative reduction in mortality rates among at-risk individuals. Nevertheless, this issue is still a matter of debate, particularly in developing countries, and it is not fully embraced in developing countries. The aim of this article is to provide an overview of what the standard of care is for lung cancer computed tomography screening around the world and to aid understanding of the challenges and potential solutions that can help with the implementation of LDCT in Latin America.

Participation in lung cancer screening programs: are there gender and social differences? A systematic review

Lung cancer remains the leading cause of cancer mortality worldwide. A number of screening trials for early detection of lung cancer exist, using chest X-ray, low-dose computed tomography, or both. However, little is known about the socio-demographic characteristics of participants in lung cancer screening programs. As gender and socio-economic determinants are important variables to consider for successful program implementation, this review aims to characterize the participants in such programs and to investigate whether differences in representation exist across screening programs. Systematic methods were used to identify relevant studies. A search was undertaken to locate all studies published up to August 2017 assessing the socio-demographic profile of participants in lung cancer screening programs. A search strategy was developed, refined, and implemented to search in two different online databases (MEDLINE and Web of Sciences). A total of 1588 references were retrieved of which 14 were eligible for review. The results highlight differences in gender and social characteristics of participants across programs, while noting that differences may be partly explained by the various epidemiological contexts, program inclusion criteria, and socio-economic status (SES) measures collected. Most importantly, despite a well-recognized predominance of low SES among heavy smokers, people with high SES are seemingly over-represented among participants. Male participants also seem to be over-represented. These findings are important to help inform the development and implementation processes of future lung cancer screening programs, which should likely include strategies for engaging women as well as individuals with low SES and, of course, those most at risk for developing lung cancer.

Implementation of lung cancer CT screening in the Nordic countries

INTRODUCTION

We review the current knowledge of CT screening for lung cancer and present an expert-based, joint protocol for the proper implementation of screening in the Nordic countries.

MATERIALS AND METHODS

Experts representing all the Nordic countries performed literature review and concensus for a joint protocol for lung cancer screening.

RESULTS AND DISCUSSION

Areas of concern and caution are presented and discussed. We suggest to perform CT screening pilot studies in the Nordic countries in order to gain experience and develop specific and safe protocols for the implementation of such a program.

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

In order to provide recommendations regarding implementation of computed tomography (CT) screening in Europe the ESTS established a working group with eight experts in the field. On a background of the current situation regarding CT screening in Europe and the available evidence, ten recommendations have been prepared that cover the essential aspects to be taken into account when considering implementation of CT screening in Europe. These issues are: (i) Implementation of CT screening in Europe, (ii) Participation of thoracic surgeons in CT screening programs, (iii) Training and clinical profile for surgeons participating in screening programs, (iv) the use of minimally invasive thoracic surgery and other relevant surgical issues and (v) Associated elements of CT screening programs (i.e. smoking cessation programs, radiological interpretation, nodule evaluation algorithms and pathology reports). Thoracic Surgeons will play a key role in this process and therefore the ESTS is committed to providing guidance and facilitating this process for the benefit of patients and surgeons.

Medical follow-up of workers exposed to lung carcinogens: French evidence-based and pragmatic recommendations

Background

The aim of this work was to establish recommendations for the medical follow-up of workers currently or previously exposed to lung carcinogens.

Methods

A critical synthesis of the literature was conducted. Occupational lung carcinogenic substances were listed and classified according to their level of lung cancer risk. A targeted screening protocol was defined.

Results

A clinical trial, National Lung Screnning Trial (NLST), showed the efficacy of chest CAT scan (CT) screening for populations of smokers aged 55–74 years with over 30 pack-years of exposure who had stopped smoking for less than 15 years. To propose screening in accordance with NLST criteria, and to account for occupational risk factors, screening among smokers and former smokers needs to consider the types of occupational exposure for which the risk level is at least equivalent to the risk of the subjects included in the NLST. The working group proposes an algorithm that estimates the relative risk of each occupational lung carcinogen, taking into account exposure to tobacco, based on available data from the literature.

Conclusion

Given the lack of data on bronchopulmonary cancer (BPC) screening in occupationally exposed workers, the working group proposed implementing a screening experiment for bronchopulmonary cancer in subjects occupationally exposed or having been occupationally exposed to lung carcinogens who are confirmed as having high risk factors for BPC. A specific algorithm is proposed to determine the level of risk of BPC, taking into account the different occupational lung carcinogens and tobacco smoking at the individual level.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4114-1) contains supplementary material, which is available to authorized users.

Lung Cancer Screening Using Low Dose CT Scanning in Germany. Extrapolation of results from the National Lung Screening Trial

BACKGROUND

It is now debated whether the screening of heavy smokers for lung cancer with low dose computed tomography (low dose CT) might lower their mortality due to lung cancer. We use data from the National Lung Screening Trial (NLST) in the USA to predict the likely effects of such screening in Germany.

METHODS

The number of heavy smokers aged 55-74 in Germany was extrapolated from survey data obtained by the Robert Koch Institute. Published data from the NLST were then used to estimate the likely effects of low dose CT screening of heavy smokers in Germany.

RESULTS

If low dose CT screening were performed on 50% of the heavy smokers in Germany aged 55-74, an estimated 1 329 506 persons would undergo such screening. If the screening were repeated annually, then, over three years, 916 918 screening CTs would reveal suspect lesions, and the diagnosis of lung cancer would be confirmed thereafter in 32 826 persons. At least one positive test result in three years would be obtained in 39.1% of the participants (519 837 persons). 4155 deaths from lung cancer would be prevented over 6.5 years, and the number of persons aged 55-74 who die of lung cancer in Germany would fall by 2.6%. 12 449 persons would have at least one complication, and 1074 persons would die in the 60 days following screening.

CONCLUSION

The screening of heavy smokers for lung cancer can lower their risk of dying of lung cancer by 20% in relative terms, corresponding to an absolute risk reduction of 0.3 percentage points. These figures can provide the background for a critical discussion of the putative utility of this type of screening in Germany.

Clinicopathologic Features of Advanced Squamous NSCLC

Lung cancer remains the leading cause of cancer-related death worldwide. NSCLC accounts for more than 85% of all lung cancers, and the prognosis for advanced-stage disease is typically poor. In recent years, the importance of histologic subtypes of NSCLC has been recognized, and the distinction between squamous and other NSCLC histologic subtypes is now critical to patient management. Squamous cell lung cancer (sqCLC) represents approximately 25% to 30% of NSCLC. The prognosis for patients with advanced NSCLC is poorer for those with sqCLC than for those with adenocarcinoma. This is partly due to a number of clinical characteristics that distinguish sqCLC from other NSCLC histologic subtypes, such as smoking history, comorbid diseases, age, and molecular profile. Together, these factors make sqCLC an especially challenging disease to manage. Herein, we review some of the key clinicopathologic features of sqCLC. Understanding these features to optimally address many of the unique therapeutic challenges of this disease is likely to be central to ultimately improving outcomes for patients with squamous NSCLC.

Induction of G2/M phase arrest and apoptosis by ZGDHU-1 in A549 and RERF-LC-MA lung cancer cells

Lung cancer is a major public health issue worldwide and is associated with high mortality and poor prognosis. Chemotherapy has the potential to reduce tumor size, increase operability and eradicate micrometastases; therefore, novel chemicals to treat lung cancer are urgently required. In the present study, the effects of N, N'-di-(m-methylphenyi)-3,6-dimethyl-1,4-dihydro-1,2,4, 5-tetrazine-1,4-dicarboamide (ZGDHu-1), a novel tetrazine derivative, were investigated in A549 and RERF-LC-MA lung cancer cells, and the underlying molecular mechanism of ZGDHu in treating lung cancer was determined. Following incubation with different concentrations of ZGDHu-1, flow cytometry analysis results indicated that ZGDHu-1 could induce G₂/mitotic (M) cell cycle arrest and apoptosis in A549 and RERF-LC-MA cells in a dose-dependent manner. Furthermore, western blot analysis demonstrated that the expression levels of G₂/M regulatory molecules, including cyclin B1, Cdc2 and cell division cycle 25c, decreased following treatment with ZGDHu-1, whilst p53 expression increased. In addition, A549 and RERF-LC-MA cell apoptosis was induced by cell cycle arrest at the G₂/M phase and through the downregulation of nuclear factor-κB. These results suggest that ZGDHu-1 may induce G₂/M phase arrest and apoptosis of lung cancer cells, and may serve as a potential therapeutic drug for the treatment of lung cancer.

Maximum-Intensity-Projection and Computer-Aided-Detection Algorithms as Stand-Alone Reader Devices in Lung Cancer Screening Using Different Dose Levels and Reconstruction Kernels

OBJECTIVE

The objective of our study was to evaluate lung nodule detection rates on standard and microdose chest CT with two different computer-aided detection systems (SyngoCT-CAD, VA 20, Siemens Healthcare [CAD1]; Lung CAD, IntelliSpace Portal DX Server, Philips Healthcare [CAD2]) as well as maximum-intensity-projection (MIP) images. We also assessed the impact of different reconstruction kernels.

MATERIALS AND METHODS

Standard and microdose CT using three reconstruction kernels (i30, i50, i70) was performed with an anthropomorphic chest phantom. We placed 133 ground-glass and 133 solid nodules (diameters of 5 mm, 8 mm, 10 mm, and 12 mm) in 55 phantoms. Four blinded readers evaluated the MIP images; one recorded the results of CAD1 and CAD2. Sensitivities for CAD and MIP nodule detection on standard dose and microdose CT were calculated for each reconstruction kernel.

RESULTS

Dose for microdose CT was significantly less than that for standard-dose CT (0.1323 mSv vs 1.65 mSv; p < 0.0001). CAD1 delivered superior results compared with CAD2 for standard-dose and microdose CT (p < 0.0001). At microdose level, the best stand-alone sensitivity (97.6%) was comparable with CAD1 sensitivity (96.0%; p = 0.36; both with i30 reconstruction kernel). Pooled sensitivities for all nodules, doses, and reconstruction kernels on CAD1 ranged from 88.9% to 97.3% versus 49.6% to 73.9% for CAD2. The best sensitivity was achieved with standard-dose CT, i50 kernel, and CAD1 (97.3%) versus 96% with microdose CT, i30 or i50 kernel, and CAD1. MIP images and CAD1 had similar performance at both dose levels (p = 0.1313 and p = 0.48).

CONCLUSION

Submillisievert CT is feasible for detecting solid and ground-glass nodules that require soft-tissue kernels for MIP and CAD systems to achieve acceptable sensitivities. MIP reconstructions remain a valuable adjunct to the interpretation of chest CT for increasing sensitivity and have the advantage of significantly lower false-positive rates.

Implementation and organization of lung cancer screening

CT screening for lung cancer is now being implemented in the US and China on a widespread national scale but not in Europe so far. The review gives a status for the implementation process and the hurdles to overcome in the future. It also describes the guidelines and requirements for the structure and components of high quality CT screening programs. These are essential in order to achieve a successful program with the fewest possible harms and a possible mortality benefit like that documented in the American National Lung Screening Trial (NLST). In addition the importance of continued research in CT screening methods is described and discussed with focus on the great potential to further improve this method in the future for the benefit of patients and society.

The Clinical Dilemma of Incidental Findings on the Low-Resolution CT Images from SPECT/CT MPI Studies

Incidental findings are common in medical imaging. There is a particularly high prevalence of incidental findings within the thorax, the most frequent being pulmonary nodules. Although pulmonary nodules have the potential to be malignant, most are benign, resulting in a high number of false-positive findings. Low-resolution CT images produced for attenuation correction of SPECT images are essentially a by-product of the imaging process. The high number of false-positive incidental findings detected on these attenuation-correction images causes a reporting dilemma. Early detection of cancer can be beneficial, but false-positive findings and overdiagnosis can be detrimental to the patient. Attenuation-correction CT images are not of diagnostic quality, and further diagnostic tests are usually necessary for a definitive diagnosis to be reached. Given the high number of false-positive findings, the psychologic effect on the patient should be considered. This review recommends caution when the findings on attenuation-correction CT images are routinely reported.

Clinical parameters predicting development of pulmonary malignancies in patients treated for head and neck squamous cell carcinoma

BACKGROUND

As the locoregional control rates in head and neck squamous cell carcinoma (HNSCC) have increased, these patients may suffer distant metastasis in a higher proportion of cases. Clinicopathological characteristics allowing prediction of high-risk profile would allow adapting posttreatment surveillance to individual risk.

METHODS

A retrospective review of all patients with HNSCC treated at the Jewish General Hospital, McGill University, Montreal, Quebec, Canada, between 1999 and 2008 was conducted for this study.

RESULTS

The study included 428 patients with a mean follow-up of 65 months (±SEM 1.7). Eighty patients (18.6%) developed pulmonary malignancy during follow-up. In multivariate Cox-regression analysis, locoregional failure and current smoking were associated with higher risk of pulmonary malignancy (p < .001 and p = .008, respectively).

CONCLUSION

Locoregional failure and smoking persistence are predictors of pulmonary malignancy in patients with HNSCC. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1277-E1280, 2016.

Surgeons and lung cancer screening: rules of engagement

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

[Quantization Methodology of Autofluorescence Bronchoscopy Image in the YUV System]

背景与目的

通过对不同病理类型的自荧光气管镜（autofluorescence bronchoscope, AFB）图像目标区域的YUV定量分析，确定区分不同疾病类型的最佳判别指标，探讨AFB在中央型支气管肺癌诊断中的价值。

方法

对研究对象进行白光气管镜+AFB检查，二者在镜下存在异常者行活检。并对荧光图像显示病变部位通过MATLAB图像测量软件进行YUV定量分析。根据正常支气管粘膜、炎症、低级别上皮样瘤变、高级别上皮样瘤变、浸润性癌的病理结果分组。研究各组与YUV值间的关系，所得数据采用SPSS 11.5软件进行统计学处理。

结果

Y值在浸润性癌和LGD组间存在统计学差异（P=0.040），在浸润性癌和炎症组也存在明显统计学差异（P < 0.001）。其他的各组间无统计学差异。U值在浸润性癌和HGD、LGD、炎症、正常支气管粘膜组之间存在统计学差异（P < 0.050），能较好鉴别正常粘膜及恶性病变。V值在浸润性癌和LGD组（P=0.003）、炎症组（P < 0.001）、正常支气管粘膜组（P < 0.001）存在统计学差异，能有效鉴别浸润性癌及良性疾病。V值在正常支气管粘膜组与HGD组（P=0.001）、炎症组（P=0.004）间比较也具有统计学差异。

结论

利用YUV色彩空间系统针对支气管和肺良恶性疾病鉴别有一定临床应用价值，为临床气管镜诊断肺癌及癌前病变提供有效科学依据。

Lung cancer incidence and mortality in China, 2010

BACKGROUND

The National Central Cancer Registry of China (NCCR) is responsible for cancer surveillance. Local cancer registries in each province submit data for annual publication. The incidence and mortality of lung cancer in China in 2010 by age, gender, and area is reported in this article.

METHODS

In 2013, 145 of 219 population-based cancer registries' 2010 data were selected after quality evaluation. Classification included Western, Middle, and Eastern areas, and the crude incidence and mortality rates of lung cancer were calculated by age, gender, and urban and rural. Age-standardized rates were determined by China and World standard population data. The 6th National Population Census data of China was used, combined with the registries' data to estimate the lung cancer burden in China in 2010.

RESULTS

Lung cancer had the highest incidence and mortality in China for men and women. It was estimated that 605 946 lung cancer cases were diagnosed in China in 2010, with a crude incidence rate of 46.08/100 000, and 486 555 patients died from lung cancer, with a crude mortality rate of 37.00/100 000. Age-standardized rates for incidence were 35.23/100 000 and 35.04/100 000, respectively. Incidence and mortality rates for lung cancer were higher in men and urban areas than those in women and rural areas, reaching a peak for subjects of 80-84 years old.

CONCLUSION

Lung cancer has the highest incidence and mortality of all cancers in China, especially for males in urban areas. Our findings justify the need to plan and develop effective interventions, such as air pollution control and smoking deterrents, to control and prevent the spread of lung cancer in China.