Abstract
Most patients with lung cancer are diagnosed when they present with symptoms, they have advanced stage disease, and curative treatment is no longer an option. An effective screening test has long been desired for early detection with the goal of reducing mortality from lung cancer. Sputum cytology, chest radiography, and computed tomography (CT) scan have been studied as potential screening tests. The National Lung Screening Trial (NLST) demonstrated a 20% reduction in mortality with low-dose CT (LDCT) screening, and guidelines now endorse annual LDCT for those at high risk. Implementation of screening is underway with the desire that the benefits be seen in clinical practice outside of a research study format. Concerns include management of false positives, cost, incidental findings, radiation exposure, and overdiagnosis. Studies continue to evaluate LDCT screening and use of biomarkers in risk assessment and diagnosis in attempt to further improve outcomes for patients with lung cancer.
Highlights
The American Cancer Society estimates that there will be approximately 224,000 new cases and 158,000 deaths from lung cancer in 2016; the current 5-year survival is about 18%1
The US Preventive Services Task Force (USPSTF) recommendation includes a shared decision making process[17]; this is mandated by Center for Medicare and Medicaid Services (CMS) as an identifiable visit with specific components: eligibility, absence of signs or symptoms of lung cancer, discussion of benefits and harms of screening, follow-up diagnostic testing, overdiagnosis, false positive rate, radiation exposure, importance of adherence to annual screening, impact of comorbidities, willingness to undergo treatment, and the importance of cigarette smoking abstinence or cessation[30]
An analysis of data from the National Lung Screening Trial (NLST) showed the percentages of lung cancer diagnoses that would have been missed or delayed and false positives that would have been avoided increased from 1.0% and 15.8% at a 5 mm threshold to 10.5% and 65.8% at an 8 mm threshold, respectively (Figure 1)[44]
Summary
The American Cancer Society estimates that there will be approximately 224,000 new cases and 158,000 deaths from lung cancer in 2016; the current 5-year survival is about 18%1. The USPSTF recommendation includes a shared decision making process (not required for breast cancer screening)[17]; this is mandated by CMS as an identifiable visit with specific components: eligibility, absence of signs or symptoms of lung cancer, discussion of benefits and harms of screening, follow-up diagnostic testing, overdiagnosis, false positive rate, radiation exposure, importance of adherence to annual screening, impact of comorbidities, willingness to undergo treatment, and the importance of cigarette smoking abstinence or cessation[30]. The authors of the NLST estimated that the radiation risk from screening smokers aged 55 years results in one to three lung cancer deaths per 10,000 people screened and 0.3 new breast cancers per 10,000 females[8] This potential harm from screening highlights the importance of having proven mortality reduction through a randomized controlled trial. The diagnostic performance of bronchoscopy was improved with the addition of the gene-expression classifier
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