Implementation of lung cancer screening: promises and hurdles

the ONA take:

Sparked by the publication of the data from the national lung screening trial (NLST), considerable interest has been shown in lung cancer screening. The NLST enrolled more than 50,000 participants to demonstrate that screening with low-dose computed tomography (LDCT) could improve lung mortality, and overall mortality in the screened population. Based on these results, many US institutions are implementing such programs.

However, some potential hurdles exist that can affect implementing a screening program. Questions still remain about who should be screened, at what intervals should screenings be planned, how should detected nodules be managed, and what are the risks of overdiagnosis and cumulative radiation dose.

Lastly, the cost-effectiveness of lung cancer screening is a significant question. An actuarial analysis demonstrated that lung cancer screening would cost less per life-year saved than colorectal, breast, or cervical cancer screening in the United States in high-risk populations.

Lung cancer screening in Europe lags behind the United States; although many studies are still ongoing, those studies are statistically underpowered. A pooling of data may strengthen the evidence. Currently, the NLST is the single study that produced the data; the pooled data of the European trials could confirm the results seen in the US trial.

Translational Lung Cancer Research
Translational Lung Cancer Research

Abstract: Lung cancer screening is a subject of considerable interest in the medical community and the general population. Since the publication of the data from the national lung screening trial (NLST) in 2011, the interest in lung cancer screening has increased even more. Data from many sources provide evidence that low-dose computed tomography (LD-CT) lung cancer screening can be performed with even greater efficacy if inclusion criteria as well as nodule management are optimized. There are, however, also a number of potential hurdles for the implementation of lung cancer screening. Among these are, in particular, the high prevalence of screen-detected pulmonary nodules, the unknown extent of over-diagnosis, the potential harms of the cumulative radiation dose and the insufficient data on cost-efficiency of lung cancer screening. In this article, the most recent insights into some of the most imminent questions are reviewed to provide an understanding of the challenges we still face in lung cancer screening.


Keywords: Lung cancer screening; pulmonary nodules; lung cancer

Submitted Aug 27, 2014. Accepted for publication Sep 28, 2014.
doi: 10.3978/j.issn.2218-6751.2014.09.11 


Introduction

Lung cancer screening has gained considerable interest in the medical community, as well as in the general population, over the last two decades. Since the publication of the data from the national lung screening trial (NLST) in 2011, the interest in lung cancer screening has increased even more. With more than 50,000 enrolled persons, the NLST could prove, for the first time, that by using lung cancer screening with low-dose computed tomography (LD-CT)—compared to screening with chest radiographs—lung cancer mortality could be improved by 20% (1). In addition to lung cancer mortality, overall mortality could also be improved in the LD-CT screening group by 6.7% (1). The promising data from the NLST encouraged several major American medical societies to recommend offering LD-CT screening for high-risk patients (2-4). In a current survey among members of the Society of Thoracic Radiology, 65.9% of the responding institutions indicated that they had an active LDCT screening program (5). Of the institutions without an active screening program, 89.3% indicated that they were considering such a program in the future (5). The results of this survey indicate that lung cancer screening has finally arrived in many centers in the US.

While LD-CT lung cancer screening is implemented in more and more US centers, there are only a few LD-CT screening projects in Europe outside screening trials. The reservation about the implementation of screening projects in Europe can, in part, be explained by the ongoing screening in many countries where results are expected to be published within the next few years. Initial data from two Italian screening trials (the MILD trial and the DANTE trial) and one Danish trial (the DLCST trial) could not confirm the positive effect of LD-CT lung cancer screening on mortality (6-8). The number of participants in all of the three trials, however, is too small to reach statistical significance.

Although the majority of the ongoing European screening trials are statistically underpowered, a pooling of the data is expected to strengthen the evidence and to provide insights into many open questions.

Promising data from the NLST and other trials provide evidence that LD-CT lung cancer screening can be performed with even greater efficacy if inclusion criteria, as well as nodule management, are optimized. There are, however, also a number of potential hurdles for the implementation of lung cancer screening. Among these are, in particular, the high prevalence of screen-detected pulmonary nodules, the unknown extent of over-diagnosis, the potential harms of the cumulative radiation dose and the insufficient data on cost-efficiency of lung cancer screening. A broad implementation of LD-CT screening largely depends on answering most, if not all, of these questions. In this article, the most recent insights into some of the most imminent questions are reviewed to provide an understanding of the challenges we still face in lung cancer screening.  

Page 1 of 3
Loading links....
You must be a registered member of ONA to post a comment.

Sign Up for Free e-newsletters

Regimen and Drug Listings

GET FULL LISTINGS OF TREATMENT Regimens and Drug INFORMATION

Bone Cancer Regimens Drugs
Brain Cancer Regimens Drugs
Breast Cancer Regimens Drugs
Endocrine Cancer Regimens Drugs
Gastrointestinal Cancer Regimens Drugs
Genitourinary Cancer Regimens Drugs
Gynecologic Cancer Regimens Drugs
Head and Neck Cancer Regimens Drugs
Hematologic Cancer Regimens Drugs
Lung Cancer Regimens Drugs
Other Cancers Regimens
Rare Cancers Regimens
Skin Cancer Regimens Drugs