ESR/ERS statement paper on lung cancer screening

2020

Eur J Epidemiol

As randomized trials in the USA and Europe have convincingly demonstrated efficacy of lung cancer screening by computed tomography (CT), European countries are discussing the introduction of screening programs. To maintain acceptable cost-benefit and clinical benefit-to-harm ratios, screening should be offered to individuals at sufficiently elevated risk of having lung cancer. Using federal-wide survey and lung cancer incidence data (2008–2013), we examined the performance of four well-established risk models from the USA (PLCOM2012, LCRAT, Bach) and the UK (LLP2008) in the German population, comparing with standard eligibility criteria based on age limits, minimal pack years of smoking (or combination of total duration with average intensity) and maximum years since smoking cessation. The eligibility criterion recommended by the United States Preventive Services Taskforce (USPSTF) would select about 3.2 million individuals, a group equal in size to the upper fifth of ever smokers age 50–79 at highest risk, and to 11% of all adults aged 50–79. According to PLCOM2012, the model showing best concordance between numbers of lung cancer cases predicted and reported in registries, persons with 5-year risk ≥ 1.7% included about half of all lung cancer incidence in the full German population. Compared to eligibility criteria (e.g. USPSTF), risk models elected individuals in higher age groups, including ex-smokers with longer average quitting times. Further studies should address how in Germany these shifts may affect expected benefits of CT screening in terms of life-years gained versus the potential harm of age-specific increasing risk of over-diagnosis.

Section: Discussionmentioning

confidence: 99%

Risk prediction models versus simplified selection criteria to determine eligibility for lung cancer screening: an analysis of German federal-wide survey and incidence data

Hüsing

2020

Eur J Epidemiol

“…Clearly, numerous factors must be taken into account to ensure that the benefit of screening will outweigh the risks of potential harms. European [29,38,39] and German [40] medical societies and expert panels have recommended that screening should be performed exclusively in context of a systematically organized and quality-assured program, regionally organized around expert oncological centers, similar to the key elements outlined above. The German Federal Office for Radiation Protection (Bundesamt für Strahlenschutz, BfS) is currently performing a scientific evaluation of LDCT screening for the reduction of lung cancer mortality, including the systematic modalities required for it to be sufficiently safe and overall beneficial.…”

Section: Discussionmentioning

confidence: 99%

“…Nodules meeting neither criterion will, as indeterminate lesions, be followed up by interim follow-up LDCT, and so will be non-solid lesions. Minimal size limits for follow-up examinations diverge widely in the published recommendations (see also [29]). ▪ Growth rate: When two or more examinations over time are available for comparison, nodule growth rates or volume doubling times (VDT) can be calculated.…”

Section: Well-specified Criteria For Screening Detection and Further mentioning

confidence: 99%

Lung Cancer Screening by Low-Dose Computed Tomography: Part 2 – Key Elements for Programmatic Implementation of Lung Cancer Screening

Delorme

2020

Rofo

Purpose For screening with low-dose CT (LDCT) to be effective, the benefits must outweigh the potential risks. In large lung cancer screening studies, a mortality reduction of approx. 20 % has been reported, which requires several organizational elements to be achieved in practice. Materials and Methods The elements to be set up are an effective invitation strategy, uniform and quality-assured assessment criteria, and computer-assisted evaluation tools resulting in a nodule management algorithm to assign each nodule the needed workup intensity. For patients with confirmed lung cancer, immediate counseling and guideline-compliant treatment in tightly integrated regional expert centers with expert skills are required. First, pulmonology contacts as well as CT facilities should be available in the participant’s neighborhood. IT infrastructure, linkage to clinical cancer registries, quality management as well as epidemiologic surveillance are also required. Results An effective organization of screening will result in an articulated structure of both widely distributed pulmonology offices as the participants’ primary contacts and CT facilities as well as central expert facilities for supervision of screening activities, individual clarification of suspicious findings, and treatment of proven cancer. Conclusion In order to ensure that the benefits of screening more than outweigh the potential harms and that it will be accepted by the public, a tightly organized structure is needed to ensure wide availability of pulmonologists as first contacts and CT facilities with expert skills and high-level equipment concentrated in central facilities. Key Points: Citation Format

“…Based on quantitative simulation models (see below), judging by the good overall balance between the projected reduction in lung cancer mortality and the gain in life years (LYG) versus expected biopsies or surgeries for benign lesions and cases of overdiagnosis, the US Preventive Services Task Force (USPSTF) recommends annual screening for men and women age 55 to 80 (stopping age) with a minimum of 30 pack years of cumulative lifetime smoking exposure and who have not quit smoking for more than 15 years (coded: A-55-80-30-15)a scenario similar to that of the NLST trial (A-55-75-30-15) but with a stopping age of 80 instead of 75 years [37,45]. Other US organizations as well as expert organizations in Canada and Europe followed the original NLST criteria, i. e., with a stopping age of 75 [49][50][51].…”

Section: To Whom Should Screening Be Targeted?mentioning

confidence: 99%

Lung Cancer Screening by Low-Dose Computed Tomography – Part 1: Expected Benefits, Possible Harms, and Criteria for Eligibility and Population Targeting

Delorme

2020

Rofo

Background Trials in the USA and Europe have convincingly demonstrated the efficacy of screening by low-dose computed tomography (LDCT) as a means to lower lung cancer mortality, but also document potential harms related to radiation, psychosocial stress, and invasive examinations triggered by false-positive screening tests and overdiagnosis. To ensure that benefits (lung cancer deaths averted; life years gained) outweigh the risk of harm, lung cancer screening should be targeted exclusively to individuals who have an elevated risk of lung cancer, plus sufficient residual life expectancy. Methods and Conclusions Overall, randomized screening trials show an approximate 20 % reduction in lung cancer mortality by LDCT screening. In view of declining residual life expectancy, especially among continuing long-term smokers, risk of being over-diagnosed is likely to increase rapidly above the age of 75. In contrast, before age 50, the incidence of LC may be generally too low for screening to provide a positive balance of benefits to harms and financial costs. Concise criteria as used in the NLST or NELSON trials may provide a basic guideline for screening eligibility. An alternative would be the use of risk prediction models based on smoking history, sex, and age as a continuous risk factor. Compared to concise criteria, such models have been found to identify a 10 % to 20 % larger number of LC patients for an equivalent number of individuals to be screened, and additionally may help provide security that screening participants will all have a high-enough LC risk to balance out harm potentially caused by radiation or false-positive screening tests. Key Points: Citation Format