Screening for Lung Cancer: CHEST Guideline and Expert Panel Report

Abstract

Background: Low-dose chest CT screening for lung cancer has become a standard of care in the United States, in large part because of the results of the National Lung Screening Trial (NLST). Additional evidence supporting the net benefit of low-dose chest CT screening for lung cancer, and increased experience in minimizing the potential harms, has accumulated since the prior iteration of these guidelines. Here, we update the evidence base for the benefit, harms, and implementation of low-dose chest CT screening. We use the updated evidence base to provide recommendations where the evidence allows, and statements based on experience and expert consensus where it does not.

Methods: Approved panelists reviewed previously developed key questions using the Population, Intervention, Comparator, Outcome format to address the benefit and harms of low-dose CT screening, and key areas of program implementation. A systematic literature review was conducted using MEDLINE via PubMed, Embase, and the Cochrane Library on a quarterly basis since the time of the previous guideline publication. Reference lists from relevant retrievals were searched, and additional papers were added. Retrieved references were reviewed for relevance by two panel members. The quality of the evidence was assessed for each critical or important outcome of interest using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Meta-analyses were performed when enough evidence was available. Important clinical questions were addressed based on the evidence developed from the systematic literature review. Graded recommendations and ungraded statements were drafted, voted on, and revised until consensus was reached.

Results: The systematic literature review identified 75 additional studies that informed the response to the 12 key questions that were developed. Additional clinical questions were addressed resulting in seven graded recommendations and nine ungraded consensus statements.

Conclusions: Evidence suggests that low-dose CT screening for lung cancer can result in a favorable balance of benefit and harms. The selection of screen-eligible individuals, the quality of imaging and image interpretation, the management of screen-detected findings, and the effectiveness of smoking cessation interventions can impact this balance.

Keywords: guidelines; lung cancer; screening.

Figure 1

Literature search strategies.

Figure 1

Literature search strategies.

Figure 1

Literature search strategies.

Figure 1

Literature search strategies.

Figure 2

Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram for the updated guideline.

Figure 3

Lung cancer mortality in LDCT screening programs vs usual care or CXR. CXR = chest radiograph; DANTE = Detection and Screening of Early Lung Cancer by Novel Imaging Technology and Molecular Essays Trial; DLCST = Danish Lung Cancer Screening Trial; ITALUNG = Italian Lung Cancer Screening Trial; LDCT = low-dose CT; LUSI = German Lung Cancer Screening Intervention; MILD = Multi-centric Italian Lung Detection; NELSON = Nederlands-Leuvens Longkanker Screenings Onderzoek Study.

Figure 4

Lung cancer mortality by LDCT screening protocol in LDCT screening programs vs usual care. DANTE = Detection and Screening of Early Lung Cancer by Novel Imaging Technology and Molecular Essays Trial; DLCST = Danish Lung Cancer Screening Trial; ITALUNG = Italian Lung Cancer Screening Trial; LDCT = low-dose CT; LUSI = German Lung Cancer Screening Intervention; MILD = Multi-centric Italian Lung Detection; NELSON = Nederlands-Leuvens Longkanker Screenings Onderzoek Study.

Figure 5

Lung cancer mortality by LDCT screening protocol in LDCT screening programs vs usual care or CXR. CXR = chest radiograph; DANTE = Detection and Screening of Early Lung Cancer by Novel Imaging Technology and Molecular Essays Trial; DLCST = Danish Lung Cancer Screening Trial; ITALUNG = Italian Lung Cancer Screening Trial; LDCT = low-dose CT; LSS = Lung Screening Study; LUSI = German Lung Cancer Screening Intervention; MILD = Multi-centric Italian Lung Detection; NELSON = Nederlands-Leuvens Longkanker Screenings Onderzoek Study; NLST = National Lung Screening Trial.

Figure 6

Lung cancer mortality by age of LDCT screening initiation in LDCT screening programs vs usual care. DANTE = Detection and Screening of Early Lung Cancer by Novel Imaging Technology and Molecular Essays Trial; DLCST = Danish Lung Cancer Screening Trial; ITALUNG = Italian Lung Cancer Screening Trial; LDCT = low-dose CT; LUSI = German Lung Cancer Screening Intervention; MILD = Multi-centric Italian Lung Detection; NELSON = Nederlands-Leuvens Longkanker Screenings Onderzoek Study.

Figure 7

Lung cancer mortality by age of LDCT screening initiation in LDCT screening programs vs usual care or chest radiograph. DANTE = Detection and Screening of Early Lung Cancer by Novel Imaging Technology and Molecular Essays Trial; DLCST = Danish Lung Cancer Screening Trial; ITALUNG = Italian Lung Cancer Screening Trial; LDCT = low-dose CT; LSS = Lung Screening Study; LUSI = German Lung Cancer Screening Intervention; MILD = Multi-centric Italian Lung Detection; NELSON = Nederlands-Leuvens Longkanker Screenings Onderzoek Study; NLST = National Lung Screening Trial.

Figure 8

Lung cancer mortality by sex in LDCT screening programs vs usual care. DANTE = Detection and Screening of Early Lung Cancer by Novel Imaging Technology and Molecular Essays Trial; LDCT = low-dose CT; LUSI = German Lung Cancer Screening Intervention; NELSON = Nederlands-Leuvens Longkanker Screenings Onderzoek Study.

Figure 9

Lung cancer mortality by sex in LDCT screening programs vs usual care or chest radiograph. DANTE = Detection and Screening of Early Lung Cancer by Novel Imaging Technology and Molecular Essays Trial; LDCT = low-dose CT; LUSI = German Lung Cancer Screening Intervention; NELSON = Nederlands-Leuvens Longkanker Screenings Onderzoek Study; NLST = National Lung Screening Trial.

Figure 10

Number of invasive procedures per number of screened individuals over the period of screening (low-dose CT scan). DANTE = Detection and Screening of Early Lung Cancer by Novel Imaging Technology and Molecular Essays Trial; MILD = Multi-centric Italian Lung Detection.

Figure 11

Number of deaths per invasive procedures: low-dose CT screening. RE = random effects.

Figure 12

Number of major complications per invasive procedures: low-dose CT screening.

Figure 13

Number of surgical procedures for benign disease per total procedures: low-dose CT screening. DANTE = Detection and Screening of Early Lung Cancer by Novel Imaging Technology and Molecular Essays Trial; MILD = Multi-centric Italian Lung Detection.

Figure 14

Number of nonsurgical procedures for benign disease per total procedures: low-dose CT screening.

Figure 15

Continuum of net benefit of lung cancer screening for different patients.

Figure 16

Risk of smoking cessation in patients enrolled in LDCT screening programs vs usual care. LDCT = low-dose CT.