Chest
Volume 143, Issue 5, Supplement, May 2013, Pages e78S-e92S
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Screening for Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.12-2350Get rights and content

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.

Section snippets

Summary of Recommendations

3.2.1. In patients at risk for developing lung cancer, screening for lung cancer with chest radiograph (CXR) once or at regular intervals is not recommended (Grade 1A).

Remark: These results should not be interpreted as diminishing the role of CXR in evaluating patients with pulmonary symptoms (an entirely different situation than screening asymptomatic individuals).

3.2.2. In patients at risk for developing lung cancer, screening for lung cancer with sputum cytology at regular intervals is not

Methods

The following questions were selected as being most relevant. All pertain to asymptomatic, otherwise healthy adults with no history of lung cancer who are at an elevated risk for lung cancer (see also Table 1S):

  • What is the rate of death from lung cancer (ie, lung cancer mortality) among individuals at elevated risk of lung cancer who undergo screening with LDCT compared with either no screening or screening with another modality?

  • What is the rate of death or complications resulting from biopsies

Background—General Issues Related to Screening

There are several aspects about screening for a disease that make assessment of this intervention different from assessment of treatment of a disease. Screening is applied to an asymptomatic healthy population. Because the majority of screened individuals are likely not to have the disease and would go on to live their lives normally if screening were not done, any potential harms resulting from screening are seen in a different light than potential complications of evaluation or treatment in

Screening With CXR or Sputum Analysis

The first edition of the ACCP Lung Cancer Guidelines summarized the data from RCTs using CXR or sputum analysis to screen for lung cancer.7, 8 The present search yielded one new RCT that assessed the value of screening with CXR or sputum,9 three systematic reviews,10, 11, 12 and two repeat publications with updated data.13, 14 These were combined with studies identified in the first edition and in the following analysis.

Two studies analyzed the addition of sputum analysis every 4 months to

Participant Selection

At present, the only population for which there is a demonstrated benefit is that defined by the NLST: smokers with at least 30 pack-years of exposure, who are aged 55 to 74 years, and who quit < 15 years ago. It is important to note that there is demonstration of benefit only for the entire NLST population; the risk of developing lung cancer ranges from about 2% to > 20% over 10 years for individuals at the low or high end of the NLST inclusion criteria, as estimated from risk prediction

Conclusion

Lung cancer is by far the leading cause of cancer deaths mainly because of the high proportion of lung cancers diagnosed in an advanced stage. CXR and sputum analysis have not been of benefit as screening tools for lung cancer. However, there is a great deal of excitement and enthusiasm about LDCT screening, and emerging data from maturing studies show promise for a substantial reduction in advanced stage cancers and, thereby, the reduced number of people dying of lung cancer. A systematic

Acknowledgments

Author contributions: Dr Detterbeck had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Detterbeck: contributed to planning the overall process for development of the article, data analysis, formulation of recommendations, writing, and oversight of the revision of the manuscript during its development.

Dr Naidich: contributed to the review and revisions of the manuscript and recommendations.

Dr Mazzone:

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    COI grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.

    Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://dx.doi.org/10.1378/chest.1435S1.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

    Funding/Sponsors: The overall process for the development of these guidelines, including matters pertaining to funding and conflicts of interest, are described in the methodology article.1 The development of this guideline was supported primarily by the American College of Chest Physicians. The lung cancer guidelines conference was supported in part by a grant from the Lung Cancer Research Foundation. The publication and dissemination of the guidelines was supported in part by a 2009 independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.

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