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New Guideline Advises Yearly Lung Cancer Screening With CT

Barbara Boughton

May 24, 2012 (San Francisco, California) — The recommendation that older smokers and former smokers be screened yearly for lung cancer with low-dose computed tomography (LDCT) was discussed here at the American Thoracic Society (ATS) 2012 International Conference. A review of the benefits and harms of screening with LDCT was published online May 20 in JAMA.

The new guideline was issued last week by the American College of Chest Physicians and the American Society of Clinical Oncology (ASCO), and was endorsed by the ATS. It recommends yearly LDCT screening for smokers and former smokers 55 years and older with heavy smoking habits — but there are some caveats, Peter Bach, MD, from Memorial Sloan-Kettering Cancer Center in New York City, and colleagues note in their review.

The guideline is the result of the collaboration of ASCO, the American College of Chest Physicians (ACCP), the American Cancer Society, and the National Cancer Comprehensive Network (NCCN).

In the guideline, the ACCP and ASCO recommend that smokers and former smokers 55 to 74 years of age with a smoking history of more than 30 pack-year — and who have continued to smoke or who have quit in the previous 15 years — be screened annually with LDCT rather than chest x-ray. For smokers younger than 55 years, those older than 75 years and/or those with significant comorbidities, and those with a smoking history of less than 30 pack-years, the ACCP and ASCO do not recommend screening.

However, even the recommendation for older smokers with 30 or more pack-years was tempered by the advice that screening take place “only in settings that can deliver the comprehensive care provided to National Lung Screening Trial (NLST) participants.”

The NLST, a randomized trial of LDCT with 53,454 participants, has been the chief large randomized trial to find a benefit to screening; it found a 20% relative decrease in deaths from lung cancer, compared with chest x-ray, over 6.5 years (P = .004).

In their review, Dr. Bach and colleagues considered evidence from 8 randomized trials and 13 cohort studies of LDCT.

The primary end points they used were lung cancer mortality and all-cause mortality, Dr. Bach explained. Other considerations were the percentages of nodule detection, invasive procedures, and follow-up tests after LDCT, and smoking cessation rates, he noted.

“Lung cancer kills 150,000 people per year, so we felt the need to put the guideline out there,” Dr. Bach said at the meeting.

The panel that developed the guideline found that the evidence of benefit from LDCT was most convincing in the NSLT trial. However, the findings on the harms of LDCT screening in the NSLT trial were not uniformly collected, particularly in follow-up investigations, biopsies, and surgical procedures, the panel writes. These potential harms of LDCT might be outweighed by the benefit of yearly LDCT screening for older smokers with a longer and heavier smoking habit, but not for lighter smokers, nonsmokers, or those 42 years and younger, they say.

Dr. Bach acknowledged that if the guideline is followed by physicians and clinicians in the community who are not affiliated with NCCN centers, there could be a potential for harm, no matter the smoker’s age or established habit. “We do know that false positives accumulate over time, so for someone who is being screened year after year in the community, the benefit/harm balance of LDCT screening might shift toward harm,” he said.

“There is always a struggle when you take a screening approach that’s worked within the confines of an experimental trial and move it into widespread practice,” said Howard Bauchner, MD, editor-in-chief of JAMA. “Because research trials have been done within highly specialized CT groups that have a lot of experience with scans and their follow-up, the authors wanted to establish that these scans be done in the setting of select academic centers.”

“There is concern that [medical] groups that don’t have enough sophistication in interpreting LDCT may end up misleading patients,” Dr. Bauchner said. Clinicians and radiologists who do not have expertise in LDCT should not be performing it or following patients screened using this method, he added.

Dr. Bach reports receiving speaking fees from Genentech. Dr. Bauchner has disclosed no relevant financial relationships.

JAMA. Published online May 20, 2012. Abstract

American Thoracic Society (ATS) 2012 International Conference. Session A12. Presented May 20, 2012.

Medscape Medical News © 2012 WebMD, LLC