Treatment capacity required for full‐scale implementation of lung cancer screening in the United States

Blom, Erik F.; Haaf, Kevin ten; Arenberg, Douglas A.; Koning, Harry J. de

doi:10.1002/cncr.32026

Cited by 24 publications

(31 citation statements)

References 27 publications

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“…Assessing and planning the health infrastructure capacity for the resources required is needed to ensure that implementation is feasible. 163 Lessons learned from implementation of other national screening programmes such as breast, colorectal and cervical screening can be utilized. Ad hoc or opportunistic screening outside an accredited programme may result in screening of low-risk patients, incorrect LDCT technique and incorrect nodule management resulting in unnecessary downstream investigations and/or surgery and the potential for harm.…”

Section: Program Coordination and Developmentmentioning

confidence: 99%

Lung cancer screening implementation: Complexities and priorities

2020

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Lung cancer is the number one cause of cancer death worldwide. The benefits of lung cancer screening to reduce mortality and detect early‐stage disease are no longer in any doubt based on the results of two landmark trials using LDCT. Lung cancer screening has been implemented in the US and South Korea and is under consideration by other communities. Successful translation of demonstrated research outcomes into the routine clinical setting requires careful implementation and co‐ordinated input from multiple stakeholders. Implementation aspects may be specific to different healthcare settings. Important knowledge gaps remain, which must be addressed in order to optimize screening benefits and minimize screening harms. Lung cancer screening differs from all other cancer screening programmes as lung cancer risk is driven by smoking, a highly stigmatized behaviour. Stigma, along with other factors, can impact smokers' engagement with screening, meaning that smokers are generally ‘hard to reach’. This review considers critical points along the patient journey. The first steps include selecting a risk threshold at which to screen, successfully engaging the target population and maximizing screening uptake. We review barriers to smoker engagement in lung and other cancer screening programmes. Recruitment strategies used in trials and real‐world (clinical) programmes and associated screening uptake are reviewed. To aid cross‐study comparisons, we propose a standardized nomenclature for recording and calculating recruitment outcomes. Once participants have engaged with the screening programme, we discuss programme components that are critical to maximize net benefit. A whole‐of‐programme approach is required including a standardized and multidisciplinary approach to pulmonary nodule management, incorporating probabilistic nodule risk assessment and longitudinal volumetric analysis, to reduce unnecessary downstream investigations and surgery; the integration of smoking cessation; and identification and intervention for other tobacco related diseases, such as coronary artery calcification and chronic obstructive pulmonary disease. National support, integrated with tobacco control programmes, and with appropriate funding, accreditation, data collection, quality assurance and reporting mechanisms will enhance lung cancer screening programme success and reduce the risks associated with opportunistic, ad hoc screening. Finally, implementation research must play a greater role in informing policy change about targeted LDCT screening programmes.

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Section: Program Coordination and Developmentmentioning

confidence: 99%

Lung cancer screening implementation: Complexities and priorities

2020

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“…both the peak and drop) would be much larger for older cohorts than for younger cohorts. This can be explained by reductions in smoking trends [8], due to which younger birth-cohorts 1) have a lower background risk of getting lung cancer, and 2) are less often eligible for screening [20,21].…”

Section: Modeling Incidencementioning

confidence: 99%

Trends in lung cancer risk and screening eligibility affect overdiagnosis estimates

2020

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The degree of overdiagnosis due to lung cancer screening in the general US population remains unknown. Estimates may be influenced by the method used and by decreasing smoking trends, which reduce lung cancer risk and screening eligibility over time. Therefore, we aimed to estimate the degree of overdiagnosis due to lung cancer screening in the general US population, using three distinct methods. Material and methods: The MISCAN-Lung model was used to project lung cancer incidence and overdiagnosis in the general US population between 2018-2040, assuming perfect adherence to the United States Preventive Task Force recommendations. MISCAN-Lung was calibrated to the NLST and PLCO trials and incorporates birthcohort-specific smoking trends and life expectancies. We estimated overdiagnosis using the cumulative excessincidence approach, the annual excess-incidence approach, and the microsimulation approach. Results: Using the cumulative excess-incidence approach, 10.5 % of screen-detected cases were overdiagnosed in the 1950 birth-cohort compared to 5.9 % in the 1990 birth-cohort. Incidence peaks and drops due to screening were larger for older birth-cohorts than younger birth-cohorts. In the general US population, these differing incidence peaks and drops across birth-cohorts overlap. Therefore, annual excess-incidence would be absent between 2029-2040, suggesting no overdiagnosis occurs. Using the microsimulation approach, overdiagnosis among screen-detected cases increased from 7.1 % to 9.5 % between 2018-2040, while overdiagnosis among all lung cancer cases decreased from 3.7 % to 1.4 %. Conclusion: Overdiagnosis studies should use appropriate methods to account for trends in background risk and screening eligibility in the general population. Estimates from randomized trials, based on the cumulative excess-incidence approach, are not generalizable to the general population. The annual excess-incidence approach does not account for trends in background risk and screening eligibility, and falsely suggests no overdiagnosis occurs in the general population. Using the microsimulation approach, overdiagnosis was limited but not nil. Overdiagnosis increased among screen-detected cases, while overdiagnosis among all cases decreased.

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“…7 It has been estimated that the full-scale implementation of lung cancer screening in the USA will shift the percentage of stage I diagnoses in the general population (which includes individuals that are not eligible for screening) from 22.2% to 30.6%. 6 This will increase demand for lung cancer surgery in the USA by up to 37.0%. 6 If screening is to be effective, these cases should receive optimal treatment by MIS resection in a high-volume hospital.…”

Section: Open Accessmentioning

confidence: 99%

“…6 This will increase demand for lung cancer surgery in the USA by up to 37.0%. 6 If screening is to be effective, these cases should receive optimal treatment by MIS resection in a high-volume hospital. 24 25 Therefore, we expect that the uptake of MIS in the USA will continue to increase in coming years.…”

Section: Open Accessmentioning

confidence: 99%

“…3 Currently, most NSCLC cases are diagnosed with metastatic disease, 4 in which case curative treatment is usually not possible. 5 However, the number of cases diagnosed with potentially curative early stage disease is expected to increase in upcoming years 6 due to the ongoing (USA) and considered (EU and UK) implementation of lung cancer screening. [7][8][9] Open access While surgical resection is still standard of care for early stage NSCLC, the preferred surgical approach has shifted from thoracotomy to minimally invasive surgery (MIS).…”

Section: Introductionmentioning

confidence: 99%

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Uptake of minimally invasive surgery and stereotactic body radiation therapy for early stage non-small cell lung cancer in the USA: an ecological study of secular trends using the National Cancer Database

2020

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BackgroundWe aimed to assess the uptake of minimally invasive surgery (MIS) and stereotactic body radiation therapy (SBRT) among early stage (stage IA–IIB) non-small cell lung cancer (NSCLC) cases in the USA, and the rate of conversions from MIS to open surgery.Materials and methodsData were obtained from the US National Cancer Database, a nationwide facility-based cancer registry capturing up to 70% of incident cancer cases in the USA. We included cases diagnosed with early stage (clinical stages IA–IIB) NSCLC between 2010 and 2014. In an ecological analysis, we assessed changes in treatment by year of diagnosis. Among surgically treated cases, we assessed the uptake of MIS and whether conversion to open surgery took place. For cases that received thoracic radiotherapy, we assessed the uptake of SBRT.ResultsAmong 117 370 selected cases, radiotherapy use increased 3.4 percentage points between 2010 and 2014 (p<0.0001). Surgical treatments decreased 3.5 percentage points (p<0.0001). Rates of non-treatment remained stable (range: 10.0%–10.6% (p=0.4066)). Among surgically treated stage IA cases, uptake of MIS increased from 28.7% (95% CI 27.8% to 29.7%) in 2010 to 48.6% (95% CI 47.6% to 49.6%) in 2014 (p<0.0001), while conversions decreased from 17.0% (95% CI 15.6% to 18.6%) in 2010 to 9.1% (95% CI 8.3% to 10.0%) in 2014 (p<0.0001). MIS uptake among stages IB–IIB was lower and conversion rates were higher, but time trends were similar. Uptake of SBRT among stage IA receiving thoracic radiotherapy increased from 53.4% (95% CI 51.2% to 55.6%) in 2010 to 73.0% (95% CI 71.4% to 74.6%) in 2014 (p<0.0001). SBRT uptake among stage IB increased from 32.5% (95% CI 29.9% to 35.2%) in 2010 to 48.2% (95% CI 45.6% to 50.8%) in 2014 (p<0.0001).ConclusionBetween 2010 and 2014, uptake of MIS and SBRT among early stage NSCLC significantly increased, while the rate of conversions to open surgery significantly decreased. Continuing these trends may contribute to improving patient care, in particular with the expected increase in early stages due to the implementation of lung cancer screening.

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Treatment capacity required for full‐scale implementation of lung cancer screening in the United States

Cited by 24 publications

References 27 publications

Lung cancer screening implementation: Complexities and priorities

Lung cancer screening implementation: Complexities and priorities

Trends in lung cancer risk and screening eligibility affect overdiagnosis estimates

Uptake of minimally invasive surgery and stereotactic body radiation therapy for early stage non-small cell lung cancer in the USA: an ecological study of secular trends using the National Cancer Database

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