Implementation of an Integrated Lung Cancer Prevention and Screening Program Using a Mobile Computed Tomography (CT) Unit in Brazil

Data-driven risk stratification and precision management of pulmonary nodules detected on chest computed tomography

The widespread implementation of low-dose computed tomography (LDCT) in lung cancer screening has led to the increasing detection of pulmonary nodules. However, precisely evaluating the malignancy risk of pulmonary nodules remains a formidable challenge. Here we propose a triage-driven Chinese Lung Nodules Reporting and Data System (C-Lung-RADS) utilizing a medical checkup cohort of 45,064 cases. The system was operated in a stepwise fashion, initially distinguishing low-, mid-, high- and extremely high-risk nodules based on their size and density. Subsequently, it progressively integrated imaging information, demographic characteristics and follow-up data to pinpoint suspicious malignant nodules and refine the risk scale. The multidimensional system achieved a state-of-the-art performance with an area under the curve (AUC) of 0.918 (95% confidence interval (CI) 0.918-0.919) on the internal testing dataset, outperforming the single-dimensional approach (AUC of 0.881, 95% CI 0.880-0.882). Moreover, C-Lung-RADS exhibited a superior sensitivity compared with Lung-RADS v2022 (87.1% versus 63.3%) in an independent cohort, which was screened using mobile computed tomography scanners to broaden screening accessibility in resource-constrained settings. With its foundation in precise risk stratification and tailored management, this system has minimized unnecessary invasive procedures for low-risk cases and recommended prompt intervention for extremely high-risk nodules to avert diagnostic delays. This approach has the potential to enhance the decision-making paradigm and facilitate a more efficient diagnosis of lung cancer during routine checkups as well as screening scenarios.

An oral cancer screening program in Brazil: Analysis of seven years of outcome after its implementation in the suburban cities of São Paulo

OBJECTIVE

To describe the implementation of an oral cancer screening program at the Barretos Cancer Hospital (BCH) and present the outcome based on data obtained from 2014 to 2020.

MATERIALS AND METHODS

The residents of the Regional Health District of Barretos (DRS-V) were personally invited by community health agents or nurses, and among 13,973 people, 15,222 oral examinations were carried out over the years in 18 of its municipalities. Oral examinations were performed at the Mobile Dental Unit and at the Prevention Department of the BCH. Inclusion criteria were being 35 years of age or older, having a personal history of tobacco or alcohol consumption, or having a lesion in the oral cavity found by community health agent or self-reported, regardless of age or risk factors.

RESULTS AND CONCLUSION

The main result of our study was the stages of oral cancer among screen detected cases were smaller compared to cases in the hospital registry, in the state and in Brazil. Oral cancer detection rate per 1,000 oral examinations was 10.7.The early stages of oral cancer found by screening in primary care facilities or using mobile units suggest that, when organized, screening may improve the prognosis of oral cancer.

Telemedicine-Enhanced Lung Cancer Screening Using Mobile Computed Tomography Unit with Remote Artificial Intelligence Assistance in Underserved Communities: Initial Results of a Population Cohort Study in Western China

Introduction: Lung cancer is a leading cause of cancer deaths globally. Despite favorable recommendations, low-dose computed tomography (LDCT) lung screening adoption remains low in China. Barriers such as limited infrastructure, costs, distance, and personnel shortages restrict screening access in disadvantaged regions. We initiated a telemedicine-enabled lung cancer screening (LCS) program in a medical consortium to serve people at risk in underserved communities. The objective of this study was to describe the implementation and initial results of the program. Methods: From 2020 to 2021, individuals aged 40-80 years were invited to take LCS by mobile computed tomography (CT) units in three underserved areas in Western China. Numerous CT scans were remotely reported by radiologists aided by artificial intelligence (AI) diagnostic systems. Abnormal cases were tracked through an integrated hospital network for follow-up. A retrospective cohort study documented participant demographics, health history, LDCT results, and outcomes. Descriptive analysis was conducted to report baseline characteristics and first-year follow-up results. Results: Of the 28,728 individuals registered in the program, 19,517 (67.94%) participated in the screening. The study identified 2.68% of participants with high-risk pulmonary nodules and diagnosed 0.55% with lung cancer after a 1-year follow-up. The majority of high-risk participants received timely treatment in hospitals. Conclusions: This study demonstrated mobile CT units with remote AI assistance improved access to LCS in underserved areas, with high participation and early detection rates. Our implementation supports the feasibility of deploying telemedicine-enabled LCS to increase access to a large scale of basic radiology and diagnostic services in resource-limited settings. Clinical Trial Registration Number: ChiCTR1900024623.

Lung cancer screening in Brazil: recommendations from the Brazilian Society of Thoracic Surgery, Brazilian Thoracic Association, and Brazilian College of Radiology and Diagnostic Imaging

Although lung cancer (LC) is one of the most common and lethal tumors, only 15% of patients are diagnosed at an early stage. Smoking is still responsible for more than 85% of cases. Lung cancer screening (LCS) with low-dose CT (LDCT) reduces LC-related mortality by 20%, and that reduction reaches 38% when LCS by LDCT is combined with smoking cessation. In the last decade, a number of countries have adopted population-based LCS as a public health recommendation. Albeit still incipient, discussion on this topic in Brazil is becoming increasingly broad and necessary. With the aim of increasing knowledge and stimulating debate on LCS, the Brazilian Society of Thoracic Surgery, the Brazilian Thoracic Association, and the Brazilian College of Radiology and Diagnostic Imaging convened a panel of experts to prepare recommendations for LCS in Brazil. The recommendations presented here were based on a narrative review of the literature, with an emphasis on large population-based studies, systematic reviews, and the recommendations of international guidelines, and were developed after extensive discussion by the panel of experts. The following topics were reviewed: reasons for screening; general considerations about smoking; epidemiology of LC; eligibility criteria; incidental findings; granulomatous lesions; probabilistic models; minimum requirements for LDCT; volumetric acquisition; risks of screening; minimum structure and role of the multidisciplinary team; practice according to the Lung CT Screening Reporting and Data System; costs versus benefits of screening; and future perspectives for LCS.

Lung Cancer Screening in Brazil Comparing the 2013 and 2021 USPSTF Guidelines

Importance

It is estimated that, from 2023 to 2025, lung cancer (LC) will be the second most frequent cancer in Brazil, but the country does not have an LC screening (LCS) policy.

Objective

To compare the number of individuals eligible for screening, 5-year preventable LC deaths, and years of life gained (YLG) if LC death is averted by LCS, considering 3 eligibility strategies by sociodemographic characteristics.

Design, Setting, and Participants

This comparative effectiveness research study assessed 3 LCS criteria by applying a modified version of the LC-Death Risk Assessment Tool (LCDRAT) and the LC-Risk Assessment Tool (LCRAT). Data are from the 2019 Brazilian National Household Survey. Participants included ever-smokers aged 50 to 80 years. Data analysis was performed from February to May 2023.

Exposures

Exposures included ever-smokers aged 50 to 80 years, US Preventive Services Task Force (USPSTF) 2013 guidelines (ever-smokers aged 55 to 80 years with ≥30 pack-years and <15 years since cessation), and USPSTF 2021 guidelines (ever-smokers aged 50 to 80 years with 20 pack-years and <15 years since cessation).

Main Outcomes and Measures

The primary outcomes were the numbers of individuals eligible for LCS, the 5-year preventable deaths attributable to LC, and the number of YLGs if death due to LC was averted by LCS.

Results

In Brazil, the eligible population for LCS was 27 280 920 ever-smokers aged 50 to 80 years (13 387 552 female [49.1%]; 13 249 531 [48.6%] aged 50-60 years; 394 994 Asian or Indigenous [1.4%]; 3 111 676 Black [11.4%]; 10 942 640 Pardo [40.1%]; 12 830 904 White [47.0%]; 12 428 536 [45.6%] with an incomplete middle school education; and 12 860 132 [47.1%] living in the Southeast region); 5 144 322 individuals met the USPSTF 2013 criteria for LCS (2 090 636 female [40.6%]; 2 290 219 [44.5%] aged 61-70 years; 66 430 Asian or Indigenous [1.3%]; 491 527 Black [9.6%]; 2 073 836 Pardo [40.3%]; 2 512 529 [48.8%] White; 2 436 221 [47.4%] with an incomplete middle school education; and 2 577 300 [50.1%] living in the Southeast region), and 8 380 279 individuals met the USPSTF 2021 LCS criteria (3 507 760 female [41.9%]; 4 352 740 [51.9%] aged 50-60 years; 119 925 Asian or Indigenous [1.4%]; 839 171 Black [10.0%]; 3 330 497 Pardo [39.7%]; 4 090 687 [48.8%] White; 4 022 784 [48.0%] with an incomplete middle school education; and 4 162 070 [49.7%] living in the Southeast region). The number needed to screen to prevent 1 death was 177 individuals according to the USPSTF 2013 criteria and 242 individuals according to the USPSTF 2021 criteria. The YLG was 23 for all ever-smokers, 19 for the USPSTF 2013 criteria, and 21 for the USPSTF 2021 criteria. Being Black, having less than a high school education, and living in the North and Northeast regions were associated with increased 5-year risk of LC death.

Conclusions and Relevance

In this comparative effectiveness study, USPSTF 2021 criteria were better than USPSTF 2013 in reducing disparities in LC death rates. Nonetheless, the risk of LC death remained unequal, and these results underscore the importance of identifying an appropriate approach for high-risk populations for LCS, considering the local epidemiological context.

Barriers to Lung Cancer Screening Access from the Perspective of the Patient and Current Interventions

In the context of the Conceptual Model for Lung Cancer Screening Participation, this article describes patient barriers to lung cancer screening highlighting current interventions. Patient barriers include cognitive factors (lack of awareness, limited information/misinformation, and low perceived risk), factors related to access (logistical issues, no provider recommendation, cost, and other financial/social factors), and psychological factors (fear, fatalism, lung cancer worry, and stigma). Current interventions include the use of educational materials/presentations to address cognitive barriers, use of direct outreach and structural change to address factors related to access, and use of educational material focused on psychological barriers to address psychological barriers.

Geographic variations in cancer incidence and mortality in the State of São Paulo, Brazil 2001-17

BACKGROUND

Cancer is a leading cause of morbidity and mortality in Brazil and the burden is rising. To better inform tailored cancer actions, we compare incidence and mortality profiles according to small areas in the capital and northeast region of the State of São Paulo for the leading cancer types.

METHODS

New cancer cases were obtained from cancer registries covering the department of Barretos (2003-2017) and the municipality of São Paulo (2001-2015). Cancer deaths for the same period were obtained from a Brazilian public government database. Age-standardized rates per 100,000 persons-years by cancer and sex are presented as thematic maps, by municipality for Barretos region, and by district for São Paulo.

RESULTS

Prostate and breast cancer were the leading forms of cancer incidence in Barretos, with lung cancer leading in terms of cancer mortality in both regions. The highest incidence and mortality rates were seen in municipalities from the northeast of Barretos region in both sexes, while elevated incidence rates were mainly found in São Paulo districts with high and very high socioeconomic status (SES), with mortality rates more dispersed. Breast cancer incidence rates in São Paulo were 30 % higher than Barretos, notably in high and very high SES districts, while corresponding rates of cervical cancer conveyed the opposite profile, with elevated rates in low and medium SES districts.

CONCLUSIONS

There is substantial diversity in the cancer profiles in the two regions, by cancer type and sex, with a clear relation between the cancer incidence and mortality patterns observed at the district level and corresponding SES in the capital.

Liquid Biopsy for Lung Cancer: Up-to-Date and Perspectives for Screening Programs

Lung cancer is the deadliest cancer worldwide. Tissue biopsy is currently employed for the diagnosis and molecular stratification of lung cancer. Liquid biopsy is a minimally invasive approach to determine biomarkers from body fluids, such as blood, urine, sputum, and saliva. Tumor cells release cfDNA, ctDNA, exosomes, miRNAs, circRNAs, CTCs, and DNA methylated fragments, among others, which can be successfully used as biomarkers for diagnosis, prognosis, and prediction of treatment response. Predictive biomarkers are well-established for managing lung cancer, and liquid biopsy options have emerged in the last few years. Currently, detecting EGFR p.(Tyr790Met) mutation in plasma samples from lung cancer patients has been used for predicting response and monitoring tyrosine kinase inhibitors (TKi)-treated patients with lung cancer. In addition, many efforts continue to bring more sensitive technologies to improve the detection of clinically relevant biomarkers for lung cancer. Moreover, liquid biopsy can dramatically decrease the turnaround time for laboratory reports, accelerating the beginning of treatment and improving the overall survival of lung cancer patients. Herein, we summarized all available and emerging approaches of liquid biopsy-techniques, molecules, and sample type-for lung cancer.