From the Guidelines
Lung cancer screening is recommended for high-risk individuals using low-dose computed tomography (LDCT) annually, as it has been shown to reduce lung cancer mortality by 20-24% compared to chest X-rays or no screening 1.
High-Risk Individuals
High-risk individuals include adults aged 55-80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. The screening should continue annually until the person has not smoked for 15 years, reaches 80 years of age, or develops a health problem that substantially limits life expectancy or the ability to have curative lung surgery.
Screening Guidelines
The American Cancer Society recommends that clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about screening with apparently healthy patients who meet the high-risk criteria 2. The U.S. Preventive Services Task Force also recommends annual screening for lung cancer by LDCT in asymptomatic individuals who meet the high-risk criteria 3.
Benefits and Harms
Before beginning screening, patients should have a thorough discussion with their healthcare provider about the benefits, limitations, and potential harms of screening, including false positives that may lead to unnecessary procedures. Smoking cessation remains the most effective way to reduce lung cancer risk, so current smokers should be offered cessation support alongside screening.
Insurance Coverage
Insurance coverage for eligible individuals is generally available through Medicare, Medicaid, and most private insurance plans with no cost-sharing. Some key points to consider when implementing lung cancer screening include:
- The age to begin and end screening
- The optimal screening interval
- The performance characteristics of screening
- The potential benefits and harms of screening
- The importance of shared decision-making between clinicians and patients
- The need for smoking cessation counseling and support for current smokers.
From the Research
Screening Methods for Lung Cancer
- Low-dose computed tomography (LDCT) is a commonly used method for lung cancer screening, as it can reduce lung cancer mortality 4, 5.
- The National Lung Screening Trial (NLST) found a reduction in lung cancer mortality with 3 rounds of annual LDCT screening compared to chest radiograph for high-risk current and former smokers aged 55 to 74 years 5.
- The Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON) study found a reduction in lung cancer mortality with 4 rounds of LDCT screening with increasing intervals compared to no screening for high-risk current and former smokers aged 50 to 74 years 5.
Effectiveness and Risks of LDCT Screening
- LDCT screening can detect lung cancer early, but it also causes false-positive results leading to unnecessary tests and invasive procedures, overdiagnosis, incidental findings, increases in distress, and rarely, radiation-induced cancers 5, 6.
- The lifetime attributable risk of lung cancer and major cancers after 10 years of CT screening ranged from 5.5 to 1.4 per 10,000 people screened, and from 8.1 to 2.6 per 10,000 people screened, respectively 6.
- The numbers of lung cancer and major cancer cases induced by 10 years of screening were 1.5 and 2.4, respectively, which corresponded to an additional risk of induced major cancers of 0.05% 6.
Cost-Effectiveness of LDCT Screening
- LDCT screening may be clinically effective in reducing lung cancer mortality, but there is considerable uncertainty 7.
- Screening programs are predicted to be more effective than no screening, reduce lung cancer mortality, and result in more lung cancer diagnoses, but also increase costs 7.
- The incremental cost-effectiveness ratio for a single screen in smokers aged 60-75 years with at least a 3% risk of lung cancer is £28,169 per quality-adjusted life-year (QALY) 7.
Role of Positron Emission Tomography (PET) in Lung Cancer Screening
- PET may be used as a useful tool for early detection of lung cancer in high-risk populations, especially when combined with LDCT 8.
- The sensitivity of 18F-FDG-PET for the detection of T1 lung cancers ranged between 68% and 95% 8.
- FDG-PET using SUV level can predict the outcome of the screening detected lung cancer 8.