Screening for Lung CancerUS Preventive Services Task Force Recommendation Statement

US Preventive Services Task Force

JAMA. 2021;325(10):962-970. doi:10.1001/jama.2021.1117

Abstract: Lung cancer is the second most common cancer and the leading cause of cancer death in the US. In 2020, an estimated 228 820 persons were diagnosed with lung cancer, and 135 720 persons died of the disease. The most important risk factor for lung cancer is smoking. Increasing age is also a risk factor for lung cancer. Lung cancer has a generally poor prognosis, with an overall 5-year survival rate of 20.5%. However, early-stage lung cancer has a better prognosis and is more amenable to treatment.

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New USPSTF Guidelines for Lung Cancer Screening
Yolonda L. Colson, MD, PhD; Jo-Anne O. Shepard, MD; Inga T. Lennes, MD, MPH, MBA
Summary: The updated US Preventive Services Task Force (USPSTF) guidelines1 for annual low-dose computed tomography (LDCT) screening for lung cancer in adult smokers expands the indications to include adults aged 50 to 80 years who currently smoke or have smoked within the past 15 years with an accumulated 20 packs per year or greater. Recommendations also include the discontinuation of annual screening once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery (grade: B).1 The evidence report and systematic review2 has also been updated.

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Broadened Eligibility for Lung Cancer Screening
Louise M. Henderson, PhD; M. Patricia Rivera, MD; Ethan Basch, MD
Summary: In 2013, the US Preventive Services Task Force (USPSTF) recommended annual lung cancer screening with low-dose computed tomography (CT) in US adults aged 55 to 80 years who currently smoke or formerly smoked with a 30 pack-year history, and for those who formerly smoked, quitting within the past 15 years (grade “B” recommendation).1 In this issue of JAMA, the USPSTF updates this recommendation, proposing 2 significant changes, both related to the population recommended to undergo screening. The first change reduces the age at which to initiate annual screening from 55 to 50 years. The second change reduces the smoking intensity from 30 to 20 pack-year history. Thus, the USPSTF now “recommends annual screening for lung cancer with LDCT [low-dose CT] in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. (B recommendation)”2

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Expanded Access to Lung Cancer Screening- Implementing Wisely to Optimize Health
Anne C. Melzer, MD, MS; Timothy J. Wilt, MD, MPH
Summary: Lung cancer remains the number one cause of cancer deaths in the US, with smoking accounting for approximately 90% of cases. Although smoking rates have declined to historic lows, millions of people in the US remain at elevated risk owing to a lifetime of accumulated tobacco exposure. Lung cancer screening (LCS) with annual low-dose computed tomography (LDCT) aims to reduce cancer mortality through increased lung cancer detection at a curable stage. Randomized clinical trial results, such as the National Lung Screening Trial (NLST),1 led the US Preventive Services Task Force (USPSTF) in 2014 to recommend LCS for adults in generally good health and at high lung cancer risk based on age and smoking history.

 

The Effect of Advances in Lung-Cancer Treatment on Population Mortality

Nadia Howlader, Gonçalo Forjaz, Meghan J. Mooradian, Rafael Meza, Chung Yin Kong, Kathleen A. Cronin, Angela B. Mariotto, Douglas R. Lowy, and Eric J. Feuer.

NEJM, August 2020

Summary: Using data from Surveillance, Epidemiology, and End Results (SEER) areas, the researchers assessed lung-cancer mortality and linked deaths from lung cancer to incident cases in SEER cancer registries. They found that the population-level mortality from NSCLC in the United States fell sharply from 2013 to 2016, and survival after diagnosis improved substantially. Their analysis suggests that a reduction in incidence and treatment advances — particularly approvals for and use of targeted therapies — is likely to explain the decline in mortality observed during this period.

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Utilization of Lung Cancer Screening in the Medicare Fee-for-Service Population

Tina D. Tailor, Betty C. Tong,  M.S2Junheng Gao, Louise M.Henderson, Kingshuk Roy, Choudhury Geoffrey D. Rubin

Chest June 2020.

Summary: Using Medicare data, researchers estimated the number of patients eligible for lung cancer screening and accessed how many ended up receiving lung cancer screening. They found that approximately 4% of people eligible for lung cancer screening receive it. Additionally, they report that black and Hispanic patients were screened with less frequency than white patients (p<0.001). 

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Results of Lung Cancer Screening in the Community

John R. Handy, Michael Skokan, Erika Rauch, Steven Zinck, Rachel E. Sanborn, Svetlana Kotova, and Mansen Wang

The Annals of Family Medicine May 2020, 18 (3) 243-249

Summary: The researchers investigated the ability to generalize the results of the NLST trial to a community health system. With their lung cancer screening program, they were able to screen 3,402 individuals and were able to diagnose 95 lung cancer incidences from it. Their study supported the idea that lung cancer screening programs in community health systems can be done safely and successfully. 

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Reduced Lung-Cancer Mortality with Volume CT Screening in a Randomized Trial

Harry J. de Koning, M.D., Ph.D., Carlijn M. van der Aalst, Ph.D., Pim A. de Jong, M.D., Ph.D., Ernst T. Scholten, M.D., Ph.D., et al.

New England Journal of Medicine February 2020, 382:503-513

Summary: In a randomized trial conducted in the Netherlands and Belgium, researchers randomly assigned 13,195 participants between the ages of 50-74 years to undergo either CT screening initially, year 1, year 3, and year 5.5 or were assigned no screening. All participants were followed up to a minimum of 10 years. The results showed that lung cancer mortality was 2.50 deaths per 1000 person-years in the screening group compared to 3.30 deaths per 1000 person-years in the no screening group for the male cohort, indicating a reduced mortality rate of 24% (cumulative rate ratio for lung cancer death was 0.76, 95% CI: 0.61-0.94, p=0.01). Among the women cohort, lung cancer screening reduced mortality by 33% (cumulative rate ratio for lung cancer death was 0.67, 95% CI: 0.38-1.14).

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5-year overall survival in patients with lung cancer eligible or ineligible for screening according to US Preventive Services Task Force criteria: a prospective, observational cohort study

Yung-Hung Luo, Lei Luo, Jason A Wampfler, Yi Wang, Dan Liu, Yuh-Min Chen, Alex A Adjei, David E Midthun, Ping Yang

The Lancet Oncology, August 2019

Summary: This study found that the patients with lung cancer who quit 15 or more years before diagnosis and those who are up to 5 years younger than the age cutoff recommended for screening, but otherwise meet USPSTF criteria, have a similar risk of death to those individuals who meet all USPSTF criteria. Individuals in both subgroups could benefit from screening, as the expansion of USPSTF screening criteria to include these subgroups could enable earlier detection of lung cancer and improved survival outcomes.

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Prolonged lung cancer screening reduced 10-year mortality in the MILD trial: new confirmation of lung cancer screening efficacy

U. Pastorino, M. Silva, S. Sestini, F. Sabia, M. Boeri, A. Cantarutti, N. Sverzellati, G. Sozzi, G. Corrao, A. Marchianò

Annals of Oncology, July 2019

Summary: This study evaluated the benefit of prolonged low-dose computed tomography (LDCT) screening beyond five years and its impact on overall and lung cancer (LC) specific mortality at ten years. This trial (The Multicentric Italian Lung Detection (MILD) trial) provided additional evidence that prolonged screening beyond five years can enhance the benefit of early detection and achieve a greater overall and LC mortality reduction compared with the NLST trial.

 

Evaluation of USPSTF Lung Cancer Screening Guidelines Among African American Adult Smokers

Melinda C. Aldrich, Sarah F. Mercaldo, Kim L. Sandler, William J. Blot,  Eric L. Grogan, Jeffrey D. Blume

JAMA Oncology, June 2019

Summary: This study's findings suggest that current lung cancer screening guidelines may be too conservative for African American smokers and that race-specific smoking pack-year eligibility should be considered to make screening operationally equitable.
 

POINT: Should Lung Cancer Screening Be Expanded to Persons Who Don’t Currently Meet Accepted Criteria Set Forth by the CHEST Guidelines on Lung Cancer Screening? Yes

Douglas E. Wood

CHEST, June 2018

Summary: The American College of Chest Physicians (CHEST) guidelines published in 2013 endorsed screening with low-dose CT imaging for patients aged 55 to 74 years with at least a 30 pack-year smoking history. However, they recommended against lung cancer screening for any other individuals at risk of lung cancer.  In this editorial, Dr. Wood argued for updating these guidelines, elaborating his viewpoint on how lung cancer mortality reduction attributable to annual screening with low-dose CT imaging is the most profound advance against cancer.  

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Selecting Lung Cancer Screenees Using Risk Prediction Models - where do we go from here

Martin C Tammemägi. Translational Lung Cancer Research June 2018; 7(3) 243-253

Summary: A discussion about the variety of risk prediction models to identify people who would benefit from lung cancer screening. These models take into account risks such as age, chronic medical conditions, and race/ethnicity. Current screening guidelines use the NLST eligibility criteria as screening guidelines. However, new risk prediction models such as PLCOm2012 are showing better sensitivity and positive predictive value than the NLST criteria for identifying individuals who have lung cancer. The PLCOm2012 recommends that those with a risk greater than or equal to 2% using the PLCOm2012 risk model should get screened. However, these new risk prediction models have not been accepted for determining eligibility for lung cancer screening by the US Preventative Task Force and the Medicare/Medicaid system. Additional research and evidence are needed to move policymakers in this new direction of using risk prediction models to screen for lung cancer.

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Evaluating efficacy of current lung cancer screening guidelines

Barbara Nemesure, April Plank, Lisa Reagan, Denise Albano, Michael Reiter, Thomas V Bilfinger

J Med Screen, Dec 2017

Summary: Through this study, the researchers aimed to evaluate the efficacy of lung cancer screening criteria recommended by the United States Preventive Services Task Force, Centers for Medicare and Medicaid Services, and the National Comprehensive Cancer Network in identifying known cases of lung cancer. They found that these criteria captured less than 50% of lung cancer cases in this investigation. These findings highlight the need to reevaluate current guidelines' efficacy and may have major public health implications.

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Performance of Lung-RADS in the National Lung Screening Trial: a retrospective assessment

Paul F Pinsky, David S Gierada, William Black, Reginald Munden, Hrudaya Nath, Denise Aberle, Ella Kazerooni

Ann Intern Med., April 2015

Summary: Lung cancer screening with low-dose computed tomography (LDCT) has been recommended, based primarily on the results of the NLST (National Lung Screening Trial). In this study, the authors retrospectively applied the Lung-RADS (a classification system for LDCT lung cancer screening) criteria to the NLST. They concluded that Lung-RADS may substantially reduce the false-positive result rate; however, sensitivity is also decreased.

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Experience with a CT screening program for individuals at high risk for developing lung cancer

Brady J McKee, Jeffrey A Hashim, Robert J French, Andrea B McKee, Paul J Hesketh, Carla R Lamb, Christina Williamson, Sebastian Flacke, Christoph Wald 

J Am Coll Radiol., February 2015

Summary: This study aimed to compare the National Comprehensive Cancer Network (NCCN) high-risk group 2 with the NCCN high-risk group 1 in a clinical CT lung screening program. The authors found similar positivity and lung cancer diagnosis rates in both groups, suggesting that thousands of additional lives may be saved each year if screening eligibility is expanded to include this particular high-risk group.

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Balancing curability and unnecessary surgery in the context of computed tomography screening for lung cancer

Raja Flores, Thomas Bauer, Ralph Aye, Shahriyour Andaz, Leslie Kohman, Barry Sheppard, William Mayfield, Richard Thurer, Michael Smith, Robert Korst, Michaela Straznicka, Fred Grannis, Harvey Pass, Cliff Connery, Rowena Yip, James P Smith, David Yankelevitz, Claudia Henschke, Nasser Altorki, I-ELCAP Investigators

J Thorac Cardiovasc Surg, May 2014

Summary: The researchers identified all lung cancer patients who underwent surgical resection. They compared the results before (1993-2005) and after (2006-2011) termination of the National Lung Screening Trial to identify emerging trends. This study found that the frequency and extent of surgery for nonmalignant diseases can be minimized in a CT screening program and provide a high cure rate for those diagnosed with lung cancer and undergoing surgical resection.

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Clinical characteristics and survival in never smokers with lung cancer

Isaura Parente Lamelas , José Abal Arca , Nagore Blanco Cid , María Teresa Alves Pérez, Raquel Dacal Quintas, Hugo Gómez Márquez, Rogelio Alejandro García Montenegro, Pedro Marcos Velázquez

Arch Bronconeumologia, February 2014

Summary: In this retrospective study, the authors analyzed the frequency, clinical characteristics, and survival of patients with lung cancer (LC) who have never smoked compared to patients who smoke. They found that of the patients diagnosed with LC, 18.3% had never smoked. It was diagnosed mainly in women at advanced stages, and the most common histological type was adenocarcinoma. There were no survival differences compared to the group of smokers.

 

Annual number of lung cancer deaths potentially avertable by screening in the United States

Jiemin Ma, Elizabeth M Ward, Robert Smith, Ahmedin Jemal

Cancer, April 2013

Summary:  In this article, the authors provided an estimate of the annual number of lung cancer deaths that can be averted by screening, assuming the screening regimens adopted in the NLST are fully implemented in the United States. The current study's data indicate that LDCT screening could potentially avert approximately 12,000 lung cancer deaths per year in the United States.

 

Previous Lung Diseases and Lung Cancer Risk: A Pooled Analysis From the International Lung Cancer Consortium

Darren R. Brenner, Paolo Boffetta, Eric J. Duell, Heike Bickeböller, Albert Rosenberger, Valerie McCormack, Joshua E. Muscat, Ping Yang, H.-Erich Wichmann, Irene Brueske-Hohlfeld, Ann G. Schwartz, Michele L. Cote, Anne Tjønneland, Søren Friis, Loic Le Marchand, Zuo-Feng Zhang, Hal Morgenstern, Neonila Szeszenia-Dabrowska, Jolanta Lissowska, David Zaridze, Peter Rudnai, Eleonora Fabianova, Lenka Foretova, Vladimir Janout, Vladimir Bencko, Miriam Schejbalova, Paul Brennan, Ioan N. Mates, Philip Lazarus, John K. Field, Olaide Raji, John R. McLaughlin, Geoffrey Liu, John Wiencke, Monica Neri, Donatella Ugolini, Angeline S. Andrew, Qing Lan, Wei Hu, Irene Orlow, Bernard J. Park, and Rayjean J. Hung

American Journal of Epidemiology, October 2012

Summary: To clarify the role of previous lung diseases (chronic bronchitis, emphysema, pneumonia, and tuberculosis) in the development of lung cancer, the authors conducted a pooled analysis of studies in the International Lung Cancer Consortium. Among never smokers, elevated risks were observed for emphysema, pneumonia, and tuberculosis. These results suggest that previous lung diseases influence lung cancer risk independently of tobacco use and that these diseases are essential for assessing individual risk.
 

Applying the National Lung Screening Trial eligibility criteria to the US population: what percent of the population and of incident lung cancers would be covered?

Paul F Pinsky, Christine D Berg

J Med Screen, September 2012

Summary: In this study, the authors used previously available data to estimate the proportion of the total US population and those currently diagnosed with lung cancer covered by the NLST and other suggested eligibility criteria.  They found that, for the NLST criteria, 26.7% of lung cancers and 6.2% of the population (over 40) were covered. Also, they estimated that a criterion of ever smokers aged 50-79 would cover 68% of the cancers while screening 30% of the (over 40) population.

 

Lung Cancer Screening

Douglas E. Wood, George A. Eapen, David S. Ettinger, Lifang Hou, David Jackman, Ella Kazerooni, Donald Klippenstein, Rudy P. Lackner, Lorriana Leard, Ann N. C. Leung, Pierre P. Massion, Bryan F. Meyers, Reginald F. Munden, Gregory A. Otterson, Kimberly Peairs, Sudhakar Pipavath, Christie Pratt-Pozo, Chakravarthy Reddy, Mary E. Reid, Arnold J. Rotter, Matthew B. Schabath, Lecia V. Sequist, Betty C. Tong, William D. Travis, Michael Unger, and Stephen C. Yang

JNCCN, February 2012

Summary: This article gives a set of clinically oriented guidelines for lung cancer screening

 

Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening

The National Lung Screening Trial Research Team 

NEJM, August 2011

Summary: The National Lung Screening Trial (NLST) was conducted to determine whether screening with low-dose CT could reduce lung cancer mortality. Through this, it was found that screening using low-dose CT reduces mortality from lung cancer.

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