Cancer-Specific Mortality, All-Cause Mortality, and Overdiagnosis in Lung Cancer Screening Trials: A Meta-Analysis

Innovations in Early Lung Cancer Detection: Tracing the Evolution and Advancements in Screening

Lung cancer mortality rates, particularly non-small cell lung cancer (NSCLC), continue to present a significant global health challenge, and the adoption of lung cancer screening remains limited, often influenced by inequities in access to healthcare. Despite clinical evidence demonstrating the efficacy of annual screening with low-dose computed tomography (LDCT) and recommendations from medical organizations including the U.S. Preventive Services Task Force (USPSTF), the national lung cancer screening uptake remains around 5% among eligible individuals. Advancements in the clinical management of NSCLC have recently become more personalized with the implementation of blood-based biomarker testing. Extensive research into tumor-derived cell-free DNA (cfDNA) through fragmentation offers a novel method for improving early lung cancer detection. This review assesses the screening landscape, explores obstacles to lung cancer screening, and discusses how a plasma whole genome fragmentome test (pWGFrag-Lung) can improve lung cancer screening participation and adherence.

The pros and cons of lung cancer screening

Several trials have shown that low-dose computed tomography-based lung cancer screening (LCS) allows a substantial reduction in lung cancer-related mortality, carrying the potential for other clinical benefits. There are, however, some uncertainties to be clarified and several aspects to be implemented to optimize advantages and minimize the potential harms of LCS. This review summarizes current evidence on LCS, discussing some of the well-established and potential benefits, including lung cancer (LC)-related mortality reduction and opportunity for smoking cessation interventions, as well as the disadvantages of LCS, such as overdiagnosis and overtreatment. CLINICAL RELEVANCE STATEMENT: Different perspectives are provided on LCS based on the updated literature. KEY POINTS: Lung cancer is a leading cancer-related cause of death and screening should reduce associated mortality. This review summarizes current evidence related to LCS. Several aspects need to be implemented to optimize benefits and minimize potential drawbacks of LCS.

Financial Interventions to Improve Screening in Primary Care: A Systematic Review

INTRODUCTION

Although health screenings offer timely detection of health conditions and enable early intervention, adoption is often poor. How might financial interventions create the necessary incentives and resources to improve screening in primary care settings? This systematic review aimed to answer this question.

METHODS

Peer-reviewed studies published between 2000 and 2023 were identified and categorized by the level of intervention (practice or individual) and type of intervention, specifically alternative payment models (APMs), fee-for-service (FFS), capitation, and capital investments. Outcomes included frequency of screening, performance/quality of care (e.g., patient satisfaction, health outcomes), and workflow changes (e.g., visit length, staffing).

RESULTS

Of 51 included studies, a majority focused on practice-level interventions (n=32), used APMs (n=41) that involved payments for achieving key performance indicators (KPIs; n=31) and were of low or very low strength of evidence based on GRADE criteria (n=42). Studies often included screenings for cancer (n=32), diabetes care (n=18), and behavioral health (n=15). KPI payments to both practices and individual providers corresponded with increased screening rates, whereas capitation and provider-level FFS models yielded mixed results. A large majority of studies assessed changes in screening rates (n=48) with less focus on quality of care (n=11) or workflow changes (n=4).

DISCUSSION

Financial mechanisms can enhance screening rates with evidence strongest for KPI payments to both practices and individual providers. Future research should explore the relationship between financial interventions and quality of care, in terms of both clinical processes and patient outcomes, as well as the role of these interventions in shaping care delivery.

Lung cancer screening provider recommendation and completion in black and White patients with a smoking history in two healthcare systems: a survey study

BACKGROUND

Annual lung cancer screening (LCS) with low dose CT reduces lung cancer mortality. LCS is underutilized. Black people who smoke tobacco have high risk of lung cancer but are less likely to be screened than are White people. This study reports provider recommendation and patient completion of LCS and colorectal cancer screening (CRCS) among patients by race to assess for utilization of LCS.

METHODS

3000 patients (oversampled for Black patients) across two healthcare systems (in Rhode Island and Minnesota) who had a chart documented age of 55 to 80 and a smoking history were invited to participate in a survey about cancer screening. Logistic regression analysis compared the rates of recommended and received cancer screenings.

RESULTS

1177 participants responded (42% response rate; 45% White, 39% Black). 24% of respondents were eligible for LCS based on USPSTF2013 criteria. One-third of patients eligible for LCS reported that a doctor had recommended screening, compared to 90% of patients reporting a doctor recommended CRCS. Of those recommended screening, 88% reported completing LCS vs. 83% who reported completion of a sigmoidoscopy/colonoscopy. Black patients were equally likely to receive LCS recommendations but less likely to complete LCS when referred compared to White patients. There was no difference in completion of CRCS between Black and White patients.

CONCLUSIONS

Primary care providers rarely recommend lung cancer screening to patients with a smoking history. Systemic changes are needed to improve provider referral for LCS and to facilitate eligible Black people to complete LCS.

Survival Outcomes in Older Women with Oestrogen-Receptor-Positive Early-Stage Breast Cancer: Primary Endocrine Therapy vs. Surgery by Comorbidity and Frailty Levels

Primary endocrine therapy (PET) offers non-surgical treatment for older women with early-stage breast cancer who are unsuitable for surgery due to frailty or comorbidity. This research assessed all-cause and breast cancer-specific mortality of PET vs. surgery in older women (≥70 years) with oestrogen-receptor-positive early-stage breast cancer by frailty and comorbidity levels. This study used UK secondary data to analyse older female patients from 2000 to 2016. Patients were censored until 31 May 2019 and grouped by the Charlson comorbidity index (CCI) and hospital frailty risk score (HFRS). Cox regression models compared all-cause and breast cancer-specific mortality between PET and surgery within each group, adjusting for patient preferences and covariates. Sensitivity analyses accounted for competing risks. There were 23,109 patients included. The hazard ratio (HR) comparing PET to surgery for overall survival decreased significantly from 2.1 (95%CI: 2.0, 2.2) to 1.2 (95%CI: 1.1, 1.5) with increasing HFRS and from 2.1 (95%CI: 2.0, 2.2) to 1.4 (95%CI 1.2, 1.7) with rising CCI. However, there was no difference in BCSM for frail older women (HR: 1.2; 0.9, 1.9). There were no differences in competing risk profiles between other causes of death and breast cancer-specific mortality with PET versus surgery, with a subdistribution hazard ratio of 1.1 (0.9, 1.4) for high-level HFRS (p = 0.261) and CCI (p = 0.093). Given limited survival gains from surgery for older patients, PET shows potential as an effective option for frail older women with early-stage breast cancer. Despite surgery outperforming PET, surgery loses its edge as frailty increases, with negligible differences in the very frail.

Overdiagnosis and overtreatment of ground-glass nodule-like lung cancer

Lung cancer has had one of the highest incidences and mortality in the world over the last few decades, which has aided in the promotion and popularization of screening for lung ground-glass nodules (GGNs). People have great psychological anxiety about GGN because of the chance that it will develop into lung cancer, which makes clinical treatment of GGN a generally excessive phenomenon. Overdiagnosis in screening has recently been mentioned in the literature. An important research emphasis of screening is how to reduce the incidence of overdiagnosis and overtreatment. This paper discusses from different aspects how to characterize the occurrence of overdiagnosis and overtreatment, how to reduce overdiagnosis and overtreatment, and future screening, follow-up, and treatment approaches.

Data-driven overdiagnosis definitions: A scoping review

INTRODUCTION

Adequate methods to promptly translate digital health innovations for improved patient care are essential. Advances in Artificial Intelligence (AI) and Machine Learning (ML) have been sources of digital innovation and hold the promise to revolutionize the way we treat, manage and diagnose patients. Understanding the benefits but also the potential adverse effects of digital health innovations, particularly when these are made available or applied on healthier segments of the population is essential. One of such adverse effects is overdiagnosis.

OBJECTIVE

to comprehensively analyze quantification strategies and data-driven definitions for overdiagnosis reported in the literature.

METHODS

we conducted a scoping systematic review of manuscripts describing quantitative methods to estimate the proportion of overdiagnosed patients.

RESULTS

we identified 46 studies that met our inclusion criteria. They covered a variety of clinical conditions, primarily breast and prostate cancer. Methods to quantify overdiagnosis included both prospective and retrospective methods including randomized clinical trials, and simulations.

CONCLUSION

a variety of methods to quantify overdiagnosis have been published, producing widely diverging results. A standard method to quantify overdiagnosis is needed to allow its mitigation during the rapidly increasing development of new digital diagnostic tools.

Unknown Causes of Death in Cancer Patients

OBJECTIVES

Deaths from an unknown cause are difficult to adjudicate and oncologic studies of comparative effectiveness often demonstrate inconsistencies in incorporating these deaths and competing events (eg, heart disease and stroke) in their analyses. In this study, we identify cancer patients most at risk for death of an unknown cause.

METHODS

This retrospective, population-based study used cancer registry data from the Surveillance, Epidemiology, and End Results database (1992-2015). The absolute rate of unknown causes of death (COD) cases stratified by sex, marital status, race, treatment, and cancer site were calculated and a multivariable logistic regression model was applied to obtain adjusted odds ratios with 95% CIs.

RESULTS

Out of 7,154,779 cancer patients across 22 cancer subtypes extracted from Surveillance, Epidemiology, and End Results, 3,448,927 died during follow-up and 276,068 (7.4%) of these deaths were from unknown causes. Patients with an unknown COD had a shorter mean survival time compared with patients with known COD (36.3 vs 65.7 mo, P < 0.001). The contribution of unknown COD to total mortality was highest in patients with more indolent cancers (eg, prostate [12.7%], thyroid [12.3%], breast [10.7%]) and longer follow-up (eg, >5 to 10 y). One, 3, and 5-year cancer-specific survival (CSS) calculations including unknown COD were significantly decreased compared with CSS estimates excluding cancer patients with unknown COD.

CONCLUSION

Of the patients, 7.4% died of unknown causes during follow-up and the proportion of death was higher with longer follow-up and among more indolent cancers. The attribution of high percentages of unknown COD to cancer or non-cancer causes could impact population-based cancer registry studies or clinical trial outcomes with respect to measures involving CSS and mortality.

Benign-malignant classification of pulmonary nodules by low-dose spiral computerized tomography and clinical data with machine learning in opportunistic screening

BACKGROUND

Many people were found with pulmonary nodules during physical examinations. It is of great practical significance to discriminate benign and malignant nodules by using data mining technology.

METHODS

The subjects' demographic data, baseline examination results, and annual follow-up low-dose spiral computerized tomography (LDCT) results were recorded. The findings from annual physical examinations of positive nodules, including highly suspicious nodules and clinically tentative benign nodules, was analyzed. The extreme gradient boosting (XGBoost) model was constructed and the Grid Search CV method was used to select the super parameters. External unit data were used as an external validation set to evaluate the generalization performance of the model.

RESULTS

A total of 135,503 physical examinees were enrolled. Baseline testing found that 27,636 (20.40%) participants had clinically tentative benign nodules and 611 (0.45%) participants had highly suspicious nodules. The proportion of highly suspicious nodules in participants with negative baseline was about 0.12%-0.46%, which was lower than the baseline level except the follow-up of >5 years. In the 27,636 participants with clinically tentative benign nodules, only in the first year of LDCT re-examination was the proportion of highly suspicious nodules (1.40%) significantly greater than that of baseline screening (0.45%) (p < 0.001), and the proportion of highly suspicious nodules was not different between the baseline screening and other follow-up years (p > 0.05). Furthermore, 322 cases with benign nodules and 196 patients with malignant nodules confirmed by surgery and pathology were compared. A model and the top 15 most important clinical variables were determined by XGBoost algorithm. The area under the curve (AUC) of the model was 0.76 [95% CI: 0.67-0.84], and the accuracy was 0.75. The sensitivity and specificity of the model under this threshold were 0.78 and 0.73, respectively. In the validation of model using external data, the AUC was 0.87 and the accuracy was 0.80. The sensitivity and specificity were 0.83 and 0.77, respectively.

CONCLUSIONS

It is important that pulmonary nodules could be more accurately identified at the first LDCT examination. A model with 15 variables which are routinely measured in the clinic could be helpful to distinguish benign and malignant nodules. It could help the radiological team issue a more accurate report; and it may guide the clinical team regarding LDCT follow-up.

Clinical validation of a ctDNA-Based Assay for Multi-Cancer Detection: An Interim Report from a Vietnamese Longitudinal Prospective Cohort Study of 2795 Participants

The SPOT-MAS assay "Screening for the Presence Of Tumor by Methylation And Size" detects the five most common cancers in Vietnam by evaluating circulating tumor DNA in the blood. Here, we validated its performance in a prospective multi-center clinical trial, K-DETEK. Our analysis of 2795 participants from 14 sites across Vietnam demonstrates its ability to detect cancers in asymptomatic individuals with a positive predictive value of 60%, with 83.3% accuracy in detecting tumor location. We present a case report to support further using SPOT-MAS as a complementary method to achieve early cancer detection and provide the opportunity for early treatment.

CircRNA circ-PDCD11 is highly expressed in lung large-cell carcinoma and predicts poor survival

BACKGROUND

Circ-PDCD11 (hsa_circ_0019853, 461 bp) has been characterized as an oncogenic circRNA in breast cancer, while its function in other cancers is unclear. In this study, we explored the role of circ-PDCD11 in lung cancer.

METHODS

Plasma samples were obtained from patients with lung large-cell carcinoma (LLCC, n = 40), lung squamous cell carcinoma (LSCC, n = 40), lung adenocarcinoma (LA, n = 40) and small-cell lung cancer (SCLC, n = 40) as well as healthy controls (Control, n = 40). Paired tumor and nontumor tissue samples were obtained from all patients. Expression of circ-PDCD11 in these samples was determined by RT-qPCR. The role of plasma circ-PDCD11 in the diagnosis of LLCC was analyzed with ROC curve. A five-year follow-up was performed to analyze the role of plasma circ-PDCD11 in the prognosis of LLCC.

RESULTS

Plasma circ-PDCD11 was specifically upregulated in LLCC but not in other lung cancer types, compared to the controls. Increased circ-PDCD11 expression in tumor tissues compared to nontumor tissues was only observed in LLCC patients but not in other lung cancer types. Increased plasma circ-PDCD11 levels effectively separated LLCC patients from patients with other types of cancers. High plasma circ-PDCD11 levels were closely correlated with poor survival of LLCC patients. Plasma circ-PDCD11 levels were closely correlated with tumor metastasis, but not tumor size of LLCC.

CONCLUSION

CircRNA circ-PDCD11 is highly expressed specifically in LLCC and predicts poor survival.

The 50-Year Journey of Lung Cancer Screening: A Narrative Review

Early diagnosis and treatment are associated with better outcomes in oncology. We reviewed the existing literature using the search terms “low dose computed tomography” and “lung cancer screening” for systematic reviews, metanalyses, and randomized as well as non-randomized clinical trials in PubMed from January 1, 1963 to April 30, 2022. The studies were heterogeneous and included people with different age groups, smoking histories, and other specific risk scores for lung cancer screening. Based on the available evidence, almost all the guidelines recommend screening for lung cancer by annual low dose CT (LDCT) in populations over 50 to 55 years of age, who are either current smokers or have left smoking less than 15 years back with more than 20 to 30 pack-years of smoking. “LDCT screening” can reduce lung cancer mortality if carried out judiciously in countries with adequate resources and infrastructure.

Racial Disparities in Adherence to Annual Lung Cancer Screening and Recommended Follow-Up Care: A Multicenter Cohort Study

Rationale: Black patients receive recommended lung cancer screening (LCS) follow-up care less frequently than White patients, but it is unknown if this racial disparity persists across both decentralized and centralized LCS programs. Objectives: To determine adherence to American College of Radiology Lung Imaging Reporting and Data System (Lung-RADS) recommendations among individuals undergoing LCS at either decentralized or centralized programs and to evaluate the association of race with LCS adherence. Methods: We performed a multicenter retrospective cohort study of patients receiving LCS at five heterogeneous U.S. healthcare systems. We calculated adherence to annual LCS among patients with a negative baseline screen (Lung-RADS 1 or 2) and recommended follow-up care among those with a positive baseline screen (Lung-RADS 3, 4A, 4B, or 4X) stratified by type of LCS program and evaluated the association between race and adherence using multivariable modified Poisson regression. Results: Of the 6,134 total individuals receiving LCS, 5,142 (83.8%) had negative baseline screens, and 992 (16.2%) had positive baseline screens. Adherence to both annual LCS (34.8% vs. 76.1%; P < 0.001) and recommended follow-up care (63.9% vs. 74.6%; P < 0.001) was lower at decentralized compared with centralized programs. Among individuals with negative baseline screens, a racial disparity in adherence was observed only at decentralized screening programs (interaction term, P < 0.001). At decentralized programs, Black race was associated with 27% reduced adherence to annual LCS (adjusted relative risk [aRR], 0.73; 95% confidence interval [CI], 0.63-0.84), whereas at centralized programs, no effect by race was observed (aRR, 0.98; 95% CI, 0.91-1.05). In contrast, among those with positive baseline screens, there was no significant difference by race for adherence to recommended follow-up care by type of LCS program (decentralized aRR, 0.95; 95% CI, 0.81-1.11; centralized aRR, 0.81; 95% CI, 0.71-0.93; interaction term, P = 0.176). Conclusions: In this large multicenter study of individuals screened for lung cancer, adherence to both annual LCS and recommended follow-up care was greater at centralized screening programs. Black patients were less likely to receive annual LCS than White patients at decentralized compared with centralized LCS programs. Our results highlight the need for further study of healthcare system-level mechanisms to optimize longitudinal LCS care.

The Beneficial Effects of Physical Activity in Lung Cancer Prevention and/or Treatment

Lung cancer is the most lethal cancer: it has a significant incidence and low survival rates. Lifestyle has an important influence on cancer onset and its progression, indeed environmental factors and smoke are involved in cancer establishment, and in lung cancer. Physical activity is a determinant in inhibiting or slowing lung cancer. Certainly, the inflammation is a major factor responsible for lung cancer establishment. In this scenario, regular physical activity can induce anti-inflammatory effects, reducing ROS production and stimulating immune cell system activity. On lung function, physical activity improves lung muscle strength, FEV1 and forced vital capacity. In lung cancer patients, it reduces dyspnea, fatigue and pain. Data in the literature has shown the effects of physical activity both in in vivo and in vitro studies, reporting that its anti-inflammatory action is determinant in the onset of human diseases such as lung cancer. It has a beneficial effect not only in the prevention of lung cancer, but also on treatment and prognosis. For these reasons, it is retained as an adjuvant in lung cancer treatment both for the administration and prognosis of this type of cancer. The purpose of this review is to analyze the role of physical activity in lung cancer and to recommend regular physical activity and lifestyle changes to prevent or treat this pathology.

The value of supplemental prone imaging in low-dose CT lung cancer screening. A technical note

This technical note presents our experience with the additional prone examination of patients during low dose CT lung cancer screening. The prone examination adds only a minor amount of radiation and time to the study and can reduce false positive findings that are gravity-dependent.

The Potential Role of Nutrition in Lung Cancer Establishment and Progression

Lung cancer is a devastating disease with a high incidence and low survival rates, so recent studies have focused on analyzing the risk factors that might prevent this disease from developing or have protective/therapeutic effects. Nutrition is an important key factor in the prevention and treatment of lung cancer. Various factors appear to be involved in the development of the latter, such as cigarette smoking or certain external environmental factors. The increase in oxidative stress is therefore an integral part of the carcinogenesis process. The biological role of bioactive factors derived from adipose tissue, mainly adipokines, is implicated in various cancers, and an increasing body of evidence has shown that certain adipocytokines contribute to the development, progression and prognosis of lung cancer. Not all adipokines stimulate tumor growth; in fact, adiponectin inhibits carcinogenesis by regulating both cell growth and the levels of inflammatory cytokines. Adiponectin expression is deregulated in several cancer types. Many nutritional factors have been shown to increase adiponectin levels and therefore could be used as a new therapeutic strategy for combating lung cancer. In addition, foods with antioxidant and anti-inflammatory properties play a key role in the prevention of many human diseases, including lung cancer. The purpose of this review is to analyze the role of diet in lung cancer in order to recommend dietary habit and lifestyle changes to prevent or treat this pathology.

Lung cancer screening primer: Key information for primary care providers

OBJECTIVE

To review new evidence reported since the 2016 publication of the Canadian Task Force on Preventive Health Care recommendations and to summarize key facets of lung cancer screening to better equip primary care providers (PCPs) in anticipation of wider implementation of the recommendations.

QUALITY OF EVIDENCE

A new, large randomized controlled trial has been published since 2016, as have updates from 4 other trials. PubMed was searched for studies published between January 1, 2004, and December 31, 2020, using search words including lung cancer screening eligibility, lung cancer screening criteria, and lung cancer screening guidelines. All information from peer-reviewed articles, reference lists, books, and websites was considered.

MAIN MESSAGE

Lung cancers diagnosed at stage 4 have a 5-year survival rate of only 5% and have a disproportionate impact on those with lower socioeconomic status, rural populations, and Indigenous populations. By downstaging, or diagnosing lung cancers at an earlier and more treatable stage, lung cancer screening reduces mortality with a number needed to screen of 250 to prevent 1 death. Practical aspects of lung cancer screening are reviewed, including criteria to screen, appropriate low-dose computed tomography screening, and management of findings. Harms of screening, such as overdiagnosis and incidental findings, are discussed to allow PCPs to appropriately counsel their patients in the face of ongoing implementation of new lung cancer screening programs.

CONCLUSION

Lung cancer screening, with its embedded emphasis on smoking cessation, is an excellent addition to PCPs' preventive health care tools. The implementation of formal and pilot lung cancer screening programs across Canada means that PCPs will be increasingly required to counsel their patients around the uptake of lung cancer screening.

ABC du dépistage du cancer du poumon

Objectif

Examiner les nouvelles données probantes rapportées depuis la publication, en 2016, des recommandations du Groupe d’étude canadien sur les soins de santé préventifs et résumer les facettes clés du dépistage du cancer du poumon afin de mieux équiper les médecins de première ligne avant la mise en œuvre généralisée des recommandations.

Qualité des données

Depuis 2016, une vaste nouvelle étude randomisée et contrôlée, de même que la mise à jour de 4 autres études ont été publiées. Une recherche d’études publiées entre le 1er janvier 2004 et le 31 décembre 2020 a été effectuée dans PubMed à l’aide des mots-clés anglais lung cancer screening eligibility, lung cancer screening criteria et lung cancer screening guidelines . On a tenu compte de toute l’information trouvée dans les articles revus par les pairs, les listes de références, les manuels et les sites Web.

Message principal

Le cancer du poumon diagnostiqué au stade 4 a un taux de survie à 5 ans d’à peine 5 %, et son impact est disproportionné dans les populations à faible statut socio-économique, rurales et autochtones. En déstadifiant , c’est-à-dire en diagnostiquant le cancer du poumon à un stade plus précoce et plus facilement traitable, le dépistage du cancer du poumon réduit la mortalité, le nombre de sujets à soumettre au dépistage étant de 250 pour prévenir 1 décès. Nous examinons les aspects pratiques du dépistage du cancer du poumon, y compris les critères de dépistage, le dépistage approprié par tomodensitométrie à faible dose et la prise en charge des trouvailles. On parle des préjudices liés au dépistage, comme le surdiagnostic et les trouvailles fortuites, afin de permettre aux médecins de première ligne de bien conseiller leurs patients devant l’adoption de nouveaux programmes de dépistage du cancer du poumon.

Conclusion

Le dépistage du cancer du poumon, qui met l’accent sur l’abandon du tabac, est un excellent ajout à la boîte à outils de prévention du médecin de première ligne. La mise en œuvre de programmes formels et de programmes pilotes de dépistage du cancer du poumon partout au Canada signifie que les médecins de première ligne devront de plus en plus conseiller à leurs patients d’accepter le dépistage du cancer du poumon.

Lung cancer mortality reduction by LDCT screening: UKLS randomised trial results and international meta-analysis

BACKGROUND

The NLST reported a significant 20% reduction in lung cancer mortality with three annual low-dose CT (LDCT) screens and the Dutch-Belgian NELSON trial indicates a similar reduction. We present the results of the UKLS trial.

METHODS

From October 2011 to February 2013, we randomly allocated 4 055 participants to either a single invitation to screening with LDCT or to no screening (usual care). Eligible participants (aged 50-75) had a risk score (LLPv2) ≥ 4.5% of developing lung cancer over five years. Data were collected on lung cancer cases to 31 December 2019 and deaths to 29 February 2020 through linkage to national registries. The primary outcome was mortality due to lung cancer. We included our results in a random-effects meta-analysis to provide a synthesis of the latest randomised trial evidence.

FINDINGS

1 987 participants in the intervention and 1 981 in the usual care arms were followed for a median of 7.3 years (IQR 7.1-7.6), 86 cancers were diagnosed in the LDCT arm and 75 in the control arm. 30 lung cancer deaths were reported in the screening arm, 46 in the control arm, (relative rate 0.65 [95% CI 0.41-1.02]; p=0.062). The meta-analysis indicated a significant reduction in lung cancer mortality with a pooled overall relative rate of 0.84 (95% CI 0.76-0.92) from nine eligible trials.

INTERPRETATION

The UKLS trial of single LDCT indicates a reduction of lung cancer death of similar magnitude to the NELSON and NLST trials and was included in a meta-analysis of nine randomised trials which provides unequivocal support for lung cancer screening in identified risk groups.

FUNDING

NIHR Health Technology Assessment programme; NIHR Policy Research programme; Roy Castle Lung Cancer Foundation.

Association Between the 5As and Stage of Change Among African American Smokers Eligible for Low-Dose Computed Tomography Screening

We investigated the association between the 5As (Ask, Advise, Assess, Assist, and Arrange) clinical protocol and stage of change among African American smokers who are eligible for low-dose computed tomography screening. In 2019, 60 African American daily smokers aged 55 years or older were recruited in a large hospital in New Orleans, Louisiana. Smokers who received assistance for smoking cessation were more likely to be in the preparation stage than those who did not receive any assistance. Assistance from health professionals is an essential form of support and may substantially enhance smokers’ motivation to quit smoking in this population that is at higher risk for mortality from lung cancer.

Lung Cancer Screening with Low-Dose CT in Smokers: A Systematic Review and Meta-Analysis

Lung cancer continues to be one of the main causes of cancer death in Europe. Low-dose computed tomography (LDCT) has shown high potential for screening of lung cancer in smokers, most recently in two European trials. The aim of this review was to assess lung cancer screening of smokers by LDCT with respect to clinical effectiveness, radiological procedures, quality of life, and changes in smoking behavior. We searched electronic databases in April 2020 for publications of randomized controlled trials (RCT) reporting on lung cancer and overall mortality, lung cancer morbidity, and harms of LDCT screening. A meta-analysis was performed to estimate effects on mortality. Forty-three publications on 10 RCTs were included. The meta-analysis of eight studies showed a statistically significant relative reduction of lung cancer mortality of 12% in the screening group (risk ratio = 0.88; 95% CI: 0.79-0.97). Between 4% and 24% of screening-LDCT scans were classified as positive, and 84-96% of them turned out to be false positive. The risk of overdiagnosis was estimated between 19% and 69% of diagnosed lung cancers. Lung cancer screening can reduce disease-specific mortality in (former) smokers when stringent requirements and quality standards for performance are met.

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

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

Food, Nutrition, Physical Activity and Microbiota: Which Impact on Lung Cancer?

Lung cancer still represents the leading cause of cancer-related death, globally. Likewise, malnutrition and inactivity represent a major risk for loss of functional pulmonary capacities influencing overall lung cancer severity. Therefore, the adhesion to an appropriate health lifestyle is crucial in the management of lung cancer patients despite the subtype of cancer. This review aims to summarize the available knowledge about dietary approaches as well as physical activity as the major factors that decrease the risk towards lung cancer, and improve the response to therapies. We discuss the most significant dietary schemes positively associated to body composition and prognosis of lung cancer and the main molecular processes regulated by specific diet schemes, functional foods and physical activity, i.e., inflammation and oxidative stress. Finally, we report evidence demonstrating that dysbiosis of lung and/or gut microbiome, as well as their interconnection (the gut–lung axis), are strictly related to dietary patterns and regular physical activity playing a key role in lung cancer formation and progression, opening to the avenue of modulating the microbiome as coadjuvant therapy. Altogether, the evidence reported in this review highlights the necessity to consider non-pharmacological interventions (nutrition and physical activity) as effective adjunctive strategies in the management of lung cancer.