Lungenkrebsscreening: Aktuelle Entwicklungen

Screening studies on conventional chest X?rays and on sputum cytology did not show a reduction in lung cancer mortality. However, screening by low-dose computed tomography (LDCT) is more promising because it allows tumor detection in early stages at fairly low radiation levels. No reduction of lung cancer mortality was found in two small, randomized clinical studies on LDCT screening in Europe. However, in the by far largest LDCT trial, the National Lung Screening Trial (NLST) in the USA, a relative reduction of lung cancer mortality by 20.0% (95% confidence interval: 6.8–26.7%), and a relative reduction of total mortality by 6.7% (95% CI: 1.2–13.6%) was reported. According to the NLST, an important disadvantage of LDCT is the low positive predictive value of abnormal screening results: lung cancer was confirmed in only 4 of 100 abnormal screening results.In this paper, benefits and disadvantages of LDCT screening and related open questions are systematically discussed. A possible reduction of lung cancer specific and total mortality must be weighed against false positive results, overdiagnoses, and radiation exposure. In NLST, the proportion of overdiagnoses is estimated to be 11.0 to 18.5%, depending on the strategy of analysis; radiation exposure is about 1.5?mSv per scan, and thus much lower than radiation exposure in chest X?ray, which is about 8?mSv per scan. Open questions refer to who should be offered the screening, how long the time intervals between screening rounds should be, and which algorithms should be used to clarify screen-detected nodules.     

Should we screen for lung cancer? A 10-country analysis identifying key decision-making factors

The need for early detection, both early diagnosis and screening is essential for improved prognosis in lung cancer. The effectiveness of lung cancer screening using low-dose computed tomography (LDCT) for high-risk patients has been shown by extensive clinical evidence including the National Lung Cancer Screening Trial (NLST) and the Dutch-Belgian lung cancer screening trial (NELSON) which has triggered political consideration of a formal programme across countries. However, implementation of these is still limited. This study investigates how governments make decisions on the implementation of lung cancer screening, identifying key consideration factors through 10 case study countries: Australia, Canada, Croatia, France, Germany, Japan, South Korea, Switzerland, UK, and US. We identified five decision-making factors (1) recognition of the disease burden and the value of early detection, (2) strong clinical data showing mortality reduction and benefit-risk analysis relevant to the local context, (3) cost-effectiveness data and budget impact, (4) local feasibility demonstration and (5) a clear and integrated decision-making mechanism involving relevant stakeholders. The set of factors identified in this paper can help advocates address knowledge gaps, identify the key focus areas for discussions with policymakers evaluating the opportunities for lung cancer screening programmes in their local context. Ultimately, this should allow policymakers to make more informed decisions on lung cancer screening to best improve lung cancer outcomes.     

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

PURPOSEBenefit of lung cancer screening using low-dose computed tomography (LDCT) in reducing lung cancer–specific and all-cause mortality is unclear. We undertook a meta-analysis to assess its associations with outcomes.METHODSWe searched the literature and previous systematic reviews to identify randomized controlled trials comparing LDCT screening with usual care or chest radiography. We performed meta-analysis using a random effects model. The primary outcomes were lung cancer–specific mortality, all-cause mortality, and the cumulative incidence ratio of lung cancer between screened and unscreened groups as a measure of overdiagnosis.RESULTSMeta-analysis was based on 8 trials with 90,475 patients that had a low risk of bias. There was a significant reduction in lung cancer–specific mortality with LDCT screening (relative risk = 0.81; 95% CI, 0.74-0.89); the estimated absolute risk reduction was 0.4% (number needed to screen = 250). The reduction in all-cause mortality was not statistically significant (relative risk = 0.96; 95% CI, 0.92-1.01), but the absolute reduction was consistent with that for lung cancer–specific mortality (0.34%; number needed to screen = 294). In the studies with the longest duration of follow-up, the incidence of lung cancer was 25% higher in the screened group, corresponding to a 20% rate of overdiagnosis.CONCLUSIONSThis meta-analysis showing a significant reduction in lung cancer–specific mortality, albeit with a tradeoff of likely overdiagnosis, supports recommendations to screen individuals at elevated risk for lung cancer with LDCT.Key words: lung cancer, cancer screening, mass screening, low-dose computed tomography, overdiagnosis, public health, preventive medicine, health services     

Screening for lung cancer: A systematic review and meta-analysis

ObjectivesTo examine evidence on benefits and harms of screening average to high-risk adults for lung cancer using chest radiology (CXR), sputum cytology (SC) and low-dose computed tomography (LDCT).MethodsThis systematic review was conducted to provide up to date evidence for Canadian Task Force on Preventive Health Care (CTFPHC) lung cancer screening guidelines. Four databases were searched to March 31, 2015 along with utilizing a previous Cochrane review search. Randomized trials reporting benefits were included; any design was included for harms. Meta-analyses were performed if possible. PROSPERO #CRD42014009984.ResultsThirty-four studies were included. For lung cancer mortality there was no benefit of CXR screening, with or without SC. Pooled results from three small trials comparing LDCT to usual care found no significant benefits for lung cancer mortality. One large high quality trial showed statistically significant reductions of 20% in lung cancer mortality over a follow-up of 6.5 years, for LDCT compared with CXR. LDCT screening was associated with: overdiagnosis of 10.99–25.83%; 11.18 deaths and 52.03 patients with major complications per 1000 undergoing invasive follow-up procedures; median estimate for false positives of 25.53% for baseline/once-only screening and 23.28% for multiple rounds; and 9.74 and 5.28 individuals per 1000 screened, with benign conditions underwent minor and major invasive follow-up procedures.ConclusionThe evidence does not support CXR screening with or without sputum cytology for lung cancer. High quality evidence showed that in selected high-risk individuals, LDCT screening significantly reduced lung cancer mortality and all-cause mortality. However, for its implementation at a population level, the current evidence warrants the development of standardized practices for screening with LDCT and follow-up invasive testing to maximize accuracy and reduce potential associated harms.     

Should we screen for occupational lung cancer with low-dose computed tomography?

OBJECTIVE: The objective of this study was to assess the potential value of screening for occupational lung cancer through the use of low-dose computed tomography (LDCT). METHODS: A literature review of Medline was conducted to assess: 1) screening studies of occupational lung cancer that used LDCT; 2) screening studies of nonoccupational lung cancer that used LDCT; and 3) position papers of medical professional societies and nongovernmental health organizations that have addressed the value of screening for lung cancer with LDCT. RESULTS: No screening studies of occupational lung cancer with LDCT were uncovered; however, numerous observational and population-based studies have addressed the value of screening for lung cancer among cigarette smokers. Results of these studies are difficult to interpret in light of numerous biases associated with these types of studies. No randomized, controlled studies on screening for lung cancer have been published at this time. No professional, governmental, or nonprofit health organization recommends screening asymptomatic people at risk of lung cancer with LDCT at this time. CONCLUSION: In the absence of randomized, controlled studies that can address biases commonly encountered in observational and population-based studies, it is unclear whether LDCT reduces mortality from lung cancer. The National Cancer Institute is sponsoring a randomized, controlled study of over 50,000 current and former smokers with the results expected in 2009.     

Offering Lung Cancer Screening to High-Risk Medicare Beneficiaries Saves Lives and Is Cost-Effective: An Actuarial Analysis

Background

By a wide margin, lung cancer is the most significant cause of cancer death in the United States and worldwide. The incidence of lung cancer increases with age, and Medicare beneficiaries are often at increased risk. Because of its demonstrated effectiveness in reducing mortality, lung cancer screening with low-dose computed tomography (LDCT) imaging will be covered without cost-sharing starting January 1, 2015, by nongrandfathered commercial plans. Medicare is considering coverage for lung cancer screening.

Objective

To estimate the cost and cost-effectiveness (ie, cost per life-year saved) of LDCT lung cancer screening of the Medicare population at high risk for lung cancer.

Methods

Medicare costs, enrollment, and demographics were used for this study; they were derived from the 2012 Centers for Medicare & Medicaid Services (CMS) beneficiary files and were forecast to 2014 based on CMS and US Census Bureau projections. Standard life and health actuarial techniques were used to calculate the cost and cost-effectiveness of lung cancer screening. The cost, incidence rates, mortality rates, and other parameters chosen by the authors were taken from actual Medicare data, and the modeled screenings are consistent with Medicare processes and procedures.

Results

Approximately 4.9 million high-risk Medicare beneficiaries would meet criteria for lung cancer screening in 2014. Without screening, Medicare patients newly diagnosed with lung cancer have an average life expectancy of approximately 3 years. Based on our analysis, the average annual cost of LDCT lung cancer screening in Medicare is estimated to be $241 per person screened. LDCT screening for lung cancer in Medicare beneficiaries aged 55 to 80 years with a history of ≥30 pack-years of smoking and who had smoked within 15 years is low cost, at approximately $1 per member per month. This assumes that 50% of these patients were screened. Such screening is also highly cost-effective, at <$19,000 per life-year saved.

Conclusion

If all eligible Medicare beneficiaries had been screened and treated consistently from age 55 years, approximately 358,134 additional individuals with current or past lung cancer would be alive in 2014. LDCT screening is a low-cost and cost-effective strategy that fits well within the standard Medicare benefit, including its claims payment and quality monitoring.Lung cancer is a lethal disease that claims the lives of more people in the United States annually than the next 4 most lethal cancers combined, which are, in order, colon, breast, pancreas, and prostate cancers.1,2 In the United States, an estimated 224,210 people will be diagnosed with lung cancer, and an estimated 159,260 people will die of the disease in 2014.3 The incidence of lung cancer increases with age,4 and the risk increases with the cumulative effects of past smoking. Millions of Medicare beneficiaries are at significant risk.5On December 31, 2013, lung cancer screening using low-dose computed tomography (LDCT) was rated as a level “B” recommendation by the US Preventive Services Task Force (USPSTF),6 a panel of independent experts convened by the Agency for Healthcare Research and Quality to evaluate the strength of evidence and the balance of benefits and harms of preventive services.7 The USPSTF recommendation applies to people aged 55 to 80 years with a history of heavy smoking.6 LDCT is an imaging technology that enables 3-dimensional visualization of internal body structures, including the lungs, using low doses of radiation.Under the Affordable Care Act, the “B” recommendation means that LDCT lung cancer screening must be covered without cost-sharing by qualified health plans starting January 1, 2015.6,8 Qualified health plans include commercial insurance and self-insured benefit plans, with the exclusion of grandfathered plans. Several private insurers have initiated LDCT screening coverage in advance of the 2015 requirement.9 Furthermore, versions of the USPSTF recommendations have been adopted essentially by every major academic body with an interest in lung cancer, including the National Comprehensive Cancer Network, American Association for Thoracic Surgery, American College of Radiology, Society of Thoracic Surgeons, International Association for the Study of Lung Cancer, American College of Chest Physicians, and the American Cancer Society.Medicare has begun a national coverage analysis to determine whether LDCT lung cancer screening meets its criteria for coverage, which includes whether screening is reasonable and necessary for early detection, whether the service has an “A” or a “B” recommendation by the USPSTF, and whether screening is appropriate for Medicare beneficiaries.High doses of radiation can be harmful. LDCT can be performed at very low doses of <0.7 mSv per procedure10 by comparison, the annual natural background radiation in New York City (sea level) is 3 mSv. LDCT technology refinements and protocol optimization have translated into patient benefits, supporting the detection of ever-smaller lung cancers, reducing the rate of surgical procedures, and providing higher cure rates.11–14Advances in LDCT technology, promising results from nonrandomized trials,14 and unchanged survival statistics over the previous 30 years, led to the implementation of the National Lung Screening Trial (NLST), the most expensive and one of the largest randomized screening trials ever sponsored by the National Cancer Institute.13 The trial of 53,454 people aged 55 to 74 years at high risk for lung cancer was conducted to determine whether LDCT screening could reduce mortality from lung cancer. Participants in this 2-arm US study received 3 annual screenings with either an LDCT or a chest x-ray. Based on the study protocol, the trial was stopped when findings demonstrated a relative reduction of 20% in lung cancer mortality in the LDCT arm versus the chest x-ray arm.13Observational data and epidemiologic arguments for breast cancer also suggest that additional rounds of screening would reduce lung cancer mortality by much more than 20%.15–22 Other large studies have shown that computed tomography (CT) screening is associated with a high proportion (much higher than 70%) of the lung cancer diagnoses being early stage15–17,21 compared with 15% in the national data.23 Long-term survival rates of approximately 80% have been reported for patients with lung cancer who are diagnosed by CT screening12,15,16 compared with a 16.8% 5-year survival rate from the national data.23

KEY POINTS

• ▸ Lung cancer is the leading cause of cancer death in the United States and worldwide.
• ▸ Because the risk increases with age and with a history of smoking, some Medicare beneficiaries are at high risk for this type of cancer.
• ▸ Low-dose computed tomography (LDCT) has been shown to reduce mortality from lung cancer by more than 20%.
• ▸ Under healthcare reform, LDCT must be covered without cost-sharing by nongrandfathered commercial health plans beginning in 2015.
• ▸ Based on this new analysis, LDCT screening of high-risk Medicare beneficiaries is cost-effective and will cost approximately $1 per member per month.
• ▸ The average annual cost of such a screening policy is estimated to be $241 for a Medicare beneficiary screened.
• ▸ Given all causes of mortality, without screening, Medicare patients newly diagnosed with lung cancer have an average of 3 years life expectancy.
• ▸ With screening, these patients would have an additional 4 years of additional life expectancy incremental to the life expectancy without screening.
• ▸ If all eligible beneficiaries had been screened and treated consistently from age 55 years, approximately 358,134 additional individuals with current or past lung cancer would be alive in 2014.

One of the coauthors of this article was the lead author of an actuarial analysis of LDCT lung cancer screening for the commercially insured population.24 This report used similar methodology, types of structures, and data to examine lung cancer screening for the Medicare program. The Medicare program faces significant budget limitations, and any new coverage benefit will face scrutiny regarding its costs and benefits.The purpose of the present study was to estimate the hypothetical 2014 costs and benefits associated with the responsible implementation of widespread lung cancer screening in the high-risk US population covered by Medicare.     

2014-2019年北京城市癌症早诊早治项目人群肺癌筛查结果分析

目的分析2014—2019年北京城市癌症早诊早治项目肺癌筛查结果。方法基于国家城市癌症早诊早治项目,以北京市东城、西城、朝阳、海淀、丰台和石景山区的80个筛查项目实施街道为研究现场,采用整群抽样的方法,将街道/居委会所辖的88044名40~69岁北京市户籍居民纳入研究。对问卷初筛肺癌阳性的人群,采用低剂量螺旋CT(LDCT)进行筛查,同时每年通过主动和被动随访相结合的方式对募集的全部人群进行随访,获取其健康结局信息(确诊肺癌/未确诊肺癌)。计算不同特征人群经问卷初筛的肺癌高危率、LDCT筛查参与率、肺部阳性结节检出率、肺癌发病密度(率)、累积发病率以及早诊率;采用Cox比例回归模型计算不同筛查模式下肺癌发生的风险。结果88044名研究对象年龄为(57.4±7.4)岁,其中男性占38.76%(34128例)。问卷初筛肺癌高危率为23.14%,临床筛查参与率为52.26%,肺部阳性结节检出率为10.99%。平均随访3年后,40~69岁男性肺癌发病密度为172.82/10万人年,女性肺癌发病密度为133.52/10万人年;肺癌发生风险随年龄升高而上升(P_趋势<0.001)。问卷初筛阳性人群发病密度为259.22/10万人年;与问卷初筛阴性人群相比,问卷初筛阳性人群肺癌发病风险HR(95%CI)值为2.27(1.83~2.81)。接受LDCT筛查且被判定为阳性结节人群的肺癌发病密度为1825.03/10万人年,3年内的累积发病率为4615.38/10万;与结节阴性人群相比,结节阳性人群肺癌发病风险HR(95%CI)值为13.80(8.91~21.36)。接受LDCT筛查者三年内确诊肺癌的早诊率为70.21%,高于未接受临床筛查者确诊肺癌时的早期比例(45.45%,P=0.016)。结论北京城市癌症早诊早治项目肺癌临床筛查依从性较好;在高危人群中应用LDCT筛查肺癌,能够提高肺癌患者检出率和早诊率。     

肺癌社区高危人群队列研究进展

肺癌社区高危人群队列是2017年启动的国家重点研发计划精准医学专项"肺癌专病队列研究"的一部分，其主要目标是在全国7个大区的7个城市，收集5万例以上社区人群肺癌危险因素暴露信息，识别肺癌高危人群，开展低剂量螺旋CT筛查，并进一步追踪肺癌确诊和死亡信息；同时采集生物样本，建立以社区人群为基础、涵盖危险因素暴露、人群危险评估、低剂量螺旋CT筛查、生物样本以及结局随访信息的肺癌社区高危人群队列，为后续开展肺癌精准医学研究提供数据和样本支持。     

Screening for lung cancer in the Netherlands: the role of spiral CT scan

The very poor prognosis of lung cancer has barely changed in the last two decades despite all efforts. However, prognosis is better when the disease is detected earlier, so that curative surgery or radiotherapy can be applied. Lung cancer screening in the past by chest X-ray did not lead to a decrease in lung cancer mortality, because the chest X-ray has low sensitivity for early invasive stages. With the advent of the low-dose spiral CT scan it has become feasible to detect early invasive stage I lung cancer in 80-90%. Modern screening for lung cancer by spiral CT scan could possibly decrease lung cancer mortality. Despite the first favourable results of screening the question remains whether lung cancer screening will be cost-effective. These questions can only be resolved in a randomised controlled trial with lung cancer mortality as unbiased end-point. Such a study should be initiated in the Netherlands, a country with large experience in screening trials and a good health care system. Only after lung cancer screening has proven to be cost-effective can appropriate implementation be recommended to prevent uncontrolled and opportunistic diffusion of this new screening technique into clinical practice in the near future.     

Evidence of a healthy volunteer effect in the prostate, lung, colorectal, and ovarian cancer screening trial

Volunteers for prevention or screening trials are generally healthier and have lower mortality than the general population. The Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) is an ongoing, multicenter, randomized trial that randomized 155,000 men and women aged 55-74 years to a screening or control arm between 1993 and 2001. The authors compared demographics, mortality rates, and cancer incidence and survival rates of PLCO subjects during the early phase of the trial with those of the US population. Incidence and mortality from PLCO cancers (prostate, lung, colorectal, and ovarian) were excluded because they are the subject of the ongoing trial. Standardized mortality ratios for all-cause mortality were 46 for men, 38 for women, and 43 overall (100 = standard). Cause-specific standardized mortality ratios were 56 for cancer, 37 for cardiovascular disease, and 34 for both respiratory and digestive diseases. Standardized mortality ratios for all-cause mortality increased with time on study from 31 at year 1 to 48 at year 7. Adjusting the PLCO population to a standardized demographic distribution would increase the standardized mortality ratio only modestly to 54 for women and 55 for men. Standardized incidence ratios for all cancer were 84 in women and 73 in men, with a large range of standardized incidence ratios observed for specific cancers.     

Cost-Effectiveness of Baseline Low-Dose Computed Tomography Screening for Lung Cancer: The Israeli Experience

ObjectiveReduced mortality with low-dose computed tomography (LDCT) lung cancer screening was demonstrated in a large randomized controlled study of high-risk individuals. Cost-effectiveness must be assessed before routine LDCT screening is considered. We aimed to evaluate the cost-effectiveness of LDCT lung cancer screening in Israel.MethodsA decision analytic framework was used to evaluate the decision to screen or not screen from the health system perspective. The screening arm included 842 moderate-to-heavy smokers aged 45 years or older, screened at Hadassah-Hebrew University Medical Center from 1998 to 2004. In the usual-care arm, stage distribution and stage-specific life expectancy were obtained from the Israel National Cancer Registry data for 1994 to 2006. Lifetime stage-specific costs were estimated from medical records of patients diagnosed and treated at Hadassah Medical Center in the period 2003 to 2004. The analysis considered possible biases—lead time, overdiagnosis, and self-selection. Cost per quality-adjusted-life-year (QALY) gained by screening was estimated.ResultsBase-case incremental cost per QALY gained was $1464 (2011 prices). Extensive sensitivity analysis affirmed the low cost per QALY gained. The cost per QALY gained is lower than $10,000 with probability 0.937 and is lower than $20,000 with probability 0.978.ConclusionsOur analysis suggests that baseline LDCT lung cancer screening in Israel presents a good value for the money and should be considered for inclusion in the National List of Health Services financed publicly.     

Annals Journal Club: Cumulative Incidence of False-Positive Results in Repeated,Multimodal Cancer Screening

PURPOSE Multiple cancer screening tests have been advocated for the general population; however, clinicians and patients are not always well-informed of screening burdens. We sought to determine the cumulative risk of a false-positive screening result and the resulting risk of a diagnostic procedure for an individual participating in a multimodal cancer screening program.METHODS Data were analyzed from the intervention arm of the ongoing Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, a randomized controlled trial to determine the effects of prostate, lung, colorectal, and ovarian cancer screening on disease-specific mortality. The 68,436 participants, aged 55 to 74 years, were randomized to screening or usual care. Women received serial serum tests to detect cancer antigen 125 (CA-125), transvaginal sonograms, posteroanterior-view chest radiographs, and flexible sigmoidoscopies. Men received serial chest radiographs, flexible sigmoidoscopies, digital rectal examinations, and serum prostate-specific antigen tests. Fourteen screening examinations for each sex were possible during the 3-year screening period.RESULTS After 14 tests, the cumulative risk of having at least 1 false-positive screening test is 60.4% (95% CI, 59.8%–61.0%) for men, and 48.8% (95% CI, 48.1%–49.4%) for women. The cumulative risk after 14 tests of undergoing an invasive diagnostic procedure prompted by a false-positive test is 28.5% (CI, 27.8%–29.3%) for men and 22.1% (95% CI, 21.4%–22.7%) for women.CONCLUSIONS For an individual in a multimodal cancer screening trial, the risk of a false-positive finding is about 50% or greater by the 14th test. Physicians should educate patients about the likelihood of false positives and resulting diagnostic interventions when counseling about cancer screening.     

低剂量螺旋CT和痰液基薄层细胞学联合筛查社区肺癌高危人群的研究

目的 评价低剂量螺旋CT（low-dose computed tomography, LDCT）和痰液基薄层细胞学检测（thinprep cytologic test, TCT）对社区肺癌高危人群的联合筛查效果。方法 对2013年8月~2014年9月在社区招募符合本研究高危人群定义的3 708名东莞本地居民进行肺癌筛查。肺癌高危人群定义为符合下列任何一项的40岁以上者:20包年以上的吸烟史,肺癌家族史,肺部既往病史,职业接触史或被动吸烟史。发现至少一个直径≥4 mm 非钙化结节为LDCT筛查的阳性结果;细胞学重度不典型增生或镜检可见癌细胞为TCT检查的阳性结果。结果 LDCT肺部结节的检出率为12.59%（467/3 708）。经病理证实,LDCT筛查阳性人群中共确诊肺癌56例,检出率为1.51%（56/3 708）。TCT的阳性检出率为1.91%（71/3 708）。TCT阳性人群中共确诊肺癌36例,肺癌检出率为0.97%（36/3 708）。本次联合筛查共确诊肺癌58例,非小细胞肺癌41例,其中0～Ⅰ 期22例,早期诊断率为53.66%（22/41）。结论 LDCT和TCT联合筛查肺癌高危人群有助于提高肺癌的早期诊断率和检出率,降低筛查的假阳性比例。     

Cost-Effectiveness Analyses of Lung Cancer Screening Strategies Using Low-Dose Computed Tomography: a Systematic Review

Background

Lung cancer screening with low-dose computed tomography (LDCT) has been shown to deliver appreciable reductions in mortality in high-risk patients. However, in an era of constrained medical resources, the cost-effectiveness of such a program needs to be demonstrated.

Objective

The aim of this study was to systematically review the literature analyzing the cost-effectiveness of lung cancer screening using LDCT.

Methods

We searched MEDLINE, EMBASE, EBM Reviews—Health Technology Assessment, the National Health Service Economic Evaluation Database (NHS-EED), and the Cochrane Database of Systematic Reviews. Due to technological progress in CT, we limited our search to studies published between January 2000 and December 2014. Our search returned 393 unique results. After removing studies that did not meet our inclusion criteria, 13 studies remained. Costs are presented in 2014 US dollars (US$).

Results

The results from the economic evaluations identified in this review were varied. All identified studies reported outcomes using either additional survival (life-years gained) or quality-adjusted life-years (QALYs gained). Results ranged from US$18,452 to US$66,480 per LYG and US$27,756 to US$243,077 per QALY gained for repeated screening. The results of cost-effectiveness analyses were sensitive to several key model parameters, including the prevalence of lung cancer, cost of LDCT for screening, the proportion of lung cancer detected as localized disease, lead time bias, and, if included, the characteristics of a smoking cessation program.

Conclusions

The cost-effectiveness of a lung cancer screening program using LDCT remains to be conclusively resolved. It is expected that its cost-effectiveness will largely depend on identifying an appropriate group of high-risk subjects.

     

Lung cancer screening practices of primary care physicians: results from a national survey

PURPOSE

Although current practice guidelines do not recommend screening asymptomatic patients for lung cancer, physicians may still order lung cancer screening tests. No recent national survey of health care professionals has focused on lung cancer screening. In this study, we examined the lung cancer screening practices of US primary care physicians and characteristics of those who order lung cancer screening tests.

METHODS

We conducted a nationally representative survey of practicing primary care physicians in 2006–2007. Mailed questionnaires assessed the physicians’ knowledge of lung cancer screening guidelines, beliefs about the effectiveness of screening tests, and ordering of screening chest radiograph, low-dose spiral computed tomography, or sputum cytology in the past 12 months. Clinical vignettes were used to assess the physicians’ intentions to screen asymptomatic 50-year-old patients with varying smoking histories for lung cancer.

RESULTS

A total of 962 family physicians, general practitioners, and general internists completed questionnaires (cooperation rate = 76.8%). Overall, 38% had ordered no lung cancer screening tests; 55% had ordered chest radiograph, 22% low-dose spiral computed tomography, and less than 5% sputum cytology. In multivariate modeling, physicians were more likely to have ordered lung cancer screening tests if they believed that expert groups recommend lung cancer screening or that screening tests are effective; if they would recommend screening for asymptomatic patients, including patients without substantial smoking exposure; and if their patients had asked them about screening.

CONCLUSIONS

Primary care physicians in the United States frequently order lung cancer screening tests for asymptomatic patients, even though expert groups do not recommend it. Primary care physicians and patients need more information about lung cancer screening’s evidence base, guidelines, potential harms, and costs to avert inappropriate ordering.     

Assessing Lung Cancer Screening Programs under Uncertainty in a Heterogeneous Population

Background

Lung cancer screening can reduce cancer mortality. Most implementation studies focus only on low-dose computed tomography (LDCT) and clinical attributes of screening and do not include preferences of potential participants. In this study we evaluated the perceived value of screening programs based on LDCT, breath analysis (BA), or blood biomarkers (BB) according to the perspective of the target population.

Predictors of lung cancer among asbestos-exposed men in the {beta}-carotene and retinol efficacy trial

Despite numerous published studies, debate continues regarding the risk of developing lung cancer among men exposed occupationally to asbestos, particularly those without radiographic or functional evidence of asbestosis. The beta-Carotene and Retinol Efficacy Trial (CARET), a study of vitamin supplementation for chemoprevention of lung cancer, has followed 4,060 heavily exposed US men for 9-17 years. Lung cancer incidence for 1989-2002 was analyzed using a stratified proportional hazards model. The study confirmed excessive rates of lung cancer among men with radiographic asbestosis. Comparison of study arms revealed a strong, unanticipated synergy between radiographic profusion category and the active intervention. In the large subgroup of men with normal lung parenchyma on chest radiograph at baseline, there was evidence of exposure-related lung cancer risk: Men with more than 40 years' exposure in high-risk trades had a risk approximately fivefold higher than men with 5-10 years, after adjustment for covariates. The effect in these men was independent of study intervention arm, but pleural plaques on the baseline radiograph and abnormal baseline flow rate were strong independent predictors of subsequent lung cancer. Residual confounding by subclinical asbestosis, exposure to unmeasured lung carcinogens, or differences in smoking are unlikely to explain these observations better than a carcinogenic effect of asbestos per se.     

Is routine mammography screening appropriate for women 40-49 years of age?

This article reviews the evidence about screening for breast cancer. Results are now available from four randomized trials--one quasi-experimental study and three case control studies. Only the oldest, the Health Insurance Plan (HIP) Trial, shows any evidence of mortality reduction in women from 40 to 49 years of age. However, the evidence from the HIP trial is weak and somewhat contradictory. Preliminary data from a further trial in Sweden and the National Breast Screening Study in Canada confirm my conclusion that the scientific evidence is insufficient at present to recommend mammography screening for women 40-49 years of age. This conclusion reinforces the decision of the U.S. Preventive Services Task Force, but contradicts the guidelines of the American Cancer Society and the National Cancer Institute.     

An Enhanced Shared Decision Making Model to Address Willingness and Ability to Undergo Lung Cancer Screening and Follow-Up Treatment in Minority Underserved Populations

Failure to address willingness and ability to undergo lung cancer treatment before lung cancer screening could cause patients unnecessary anxiety, cost and care. We employed an enhanced shared decision making (SDM) model to address willingness and ability to undergo lung cancer screening of low dose CT (LDCT) scanning. We hypothesized that enhanced SDM was feasible and did not discourage patients from undergoing lung cancer screening. We performed a prospective study of patients referred for lung cancer screening. We measured adherence to the LCS protocol, including consent to discuss lung cancer treatment if cancer is found and direct questions to patients about willingness and ability to undergo lung cancer treatment. We measured race, gender, adherence to the consent process and questions regarding willingness and ability to undergo lung cancer treatment and subsequent uptake of LDCT. All 190 patients have a documented SDM visit addressing the risks and benefits of lung cancer screening and consented to discuss lung cancer treatment if lung cancer is diagnosed. One hundred and seventy-nine (179) of 190 (94%) answered yes to being willing and able to undergo lung cancer treatment. One hundred and eighty-seven (187) patients underwent LDCT (98.4%). Discussion about willingness and ability to undergo lung cancer treatment should be an essential component of a SDM discussion prior to LDCT. This study demonstrated that an enhanced SDM experience is feasible in a clinical setting. Furthermore, patients proceeded with LDCT following the enhanced SDM process.     

Generalizability of results from the National Lung Screening Trial

Lung cancer is the major cause of cancer-related death worldwide, with a 5-year survival of only 16?%. Most lung cancer cases are diagnosed at an advanced incurable stage. As earlier stages have a better prognosis, the key to reducing mortality could be early diagnosis of the disease. At present, low-dose computed tomographic (CT) screening has shown promising data. Lung cancer death rates were reduced by 20?% when CT screening is compared to chest radiography in a high-risk group. There are many advantages of CT screening in lung cancer, however there are also some important issues that should be taken into account. Therefore, the applicability of the results to clinical practice is not clear yet. In this Commentary we discuss different aspects that play important roles in the balance between harms and benefits of screening, including overdiagnosis, availability of treatment options worldwide, ethical considerations, costs, and prolonged life expectancy. We conclude that clinicians should be cautious in generalizing findings to the total population of smokers and take into account that the use of lung cancer screening in clinical practice may have limitations.