Screening for lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

Abstract

Background: Lung cancer is by far the major cause of cancer deaths largely because in the majority of patients it is at an advanced stage at the time it is discovered, when curative treatment is no longer feasible. This article examines the data regarding the ability of screening to decrease the number of lung cancer deaths.

Methods: A systematic review was conducted of controlled studies that address the effectiveness of methods of screening for lung cancer.

Results: Several large randomized controlled trials (RCTs), including a recent one, have demonstrated that screening for lung cancer using a chest radiograph does not reduce the number of deaths from lung cancer. One large RCT involving low-dose CT (LDCT) screening demonstrated a significant reduction in lung cancer deaths, with few harms to individuals at elevated risk when done in the context of a structured program of selection, screening, evaluation, and management of the relatively high number of benign abnormalities. Whether other RCTs involving LDCT screening are consistent is unclear because data are limited or not yet mature.

Conclusions: Screening is a complex interplay of selection (a population with sufficient risk and few serious comorbidities), the value of the screening test, the interval between screening tests, the availability of effective treatment, the risk of complications or harms as a result of screening, and the degree with which the screened individuals comply with screening and treatment recommendations. Screening with LDCT of appropriate individuals in the context of a structured process is associated with a significant reduction in the number of lung cancer deaths in the screened population. Given the complex interplay of factors inherent in screening, many questions remain on how to effectively implement screening on a broader scale.

Figure 1.

[Section 3.1] Rate ratios of lung cancer mortality. Lung cancer mortality rate ratios for chest radiograph-screened vs usual care participants in the PLCO. NLST = National Lung Screening Trial; PLCO = Prostate, Lung, Colorectal and Ovarian trial.

Figure 2.

[Section 3.3] Frequency of screening participants with a nodule detected on baseline LDCT scan and percentage of nodules eventually proven to be benign in LDCT studies. A, Percentage of all participants screened with LDCT imaging who had a nodule detected at baseline screening. B, Percentage of patients with a lesion identified at baseline LDCT screening that was eventually found to be benign. Cohort = single-arm cohort studies of LDCT; DANTE = Detection and Screening of Early Lung Cancer by Novel Imaging Technology and Molecular Essays Trial; DLST = Danish Lung Cancer Screening Trial; LDCT = low-dose CT; LSS = Lung Screening Study; NELSON = Dutch Belgian Randomised Lung Cancer Screening Trial; RCT = randomized controlled trial. See Figure 1 legend for expansion of other abbreviation.

Figure 3.

[Sections 3.3, 4.2] Frequency of patients undergoing a surgical biopsy or procedure and percentage of such surgical biopsies or procedures done for a benign lesion in LDCT studies. A, Percentage of all participants screened with LDCT imaging who underwent a surgical biopsy or procedure to evaluate a detected nodule at baseline screening. B, Percentage of patients who underwent a surgical biopsy or procedure for a lesion identified at baseline LDCT screening that was found to be benign. *Both surgical and nonsurgical (ie, needle aspiration) biopsies were reported together. See Figure 1 and 2 legends for expansion of abbreviations.

Figure 4.

[Sections 4.2, 4.3] Components of a CT scan screening program as proposed by major organizations.