Leveraging the "Teachable Moment": Impact of LDCT findings and counseling on smoking behavior.

P1.11-24 Implementation of an Organized Lung Cancer Screening Program in Korea

42O - Implementation of organized lung cancer screening program in Korea

ObjectiveTo report the radiological results of a pilot study for the Korean Lung Cancer Screening project conducted to evaluate the feasibility of lung cancer screening using low-dose chest computed tomography (LDCT) in Korea.Materials and MethodsThe National Cancer Center and three regional cancer centers participated in this study. Asymptomatic current or ex-smokers aged 55–74 years with a smoking history of at least 30 pack-years who had used tobacco within the last 15 years were considered eligible. In total, 256 participants underwent LDCT November 2016 through March 2017. The American College of Radiology Lung Imaging Reporting and Data System (Lung-RADS) was used to categorize the LDCT findings.ResultsIn total, 57%, 35.5%, 3.9%, and 3.5% participants belonged to Lung-RADS categories 1, 2, 3, and 4, respectively. Accordingly, 7.4% participants exhibited positive findings (category 3 or 4). Lung cancer was diagnosed in one participant (stage IA, small cell lung cancer). Other LDCT findings included pulmonary emphysema (32.8%), coronary artery calcification (30.9%), old pulmonary tuberculosis (11.7%), bronchiectasis (12.9%), interstitial lung disease with a usual interstitial pneumonia pattern (1.2%), and pleural effusion (0.8%).ConclusionEven though the size of our study population was small, the positive rate of 7.4% was like or lower than those in other lung cancer screening studies. Early lung cancer was detected using LDCT screening in one participant. Lung-RADS may be applicable to participants in Korea, where pulmonary tuberculosis is endemic.

Kicking the smoking habit is difficult. Although 68.8% of current adult smokers report a desire to quit and approximately 44% report attempting to stop in the last year, successful smoking cessation for more than 6 months occurs among only 4% to 7% of smokers without an intervention program (1). In a motivated population, a rigorous smoking cessation intervention with nicotine replacement therapy can have high rates (30%) of success, whereas 6-month cessation rates were halved (14%–16%) among those less motivated (2,3). Successful quitting usually requires multiple attempts, and most relapses occur within the first 90 days (4,5). The health benefits of smoking cessation are well documented and reach well beyond reducing lung cancer risk (6). The US Preventive Services Task Force recently recommended annual screening for lung cancer using low-dose computed tomography (CT) in a population at high risk for lung cancer (7). Although questions remain as to the long-term net benefits of annual low-dose CT screening (8), finding an anomaly on a chest CT may initiate a conversation between a provider and his/her patient that reinforces the desire to quit smoking (ie, a teachable moment), leading to greater cessation success. Investigators have found some evidence of a teachable moment with increased cessation when an anomaly is discovered (9,10). Some speculate that the benefit to cessation may be short-lived (11), and recent results from the Dutch lung cancer screening trial using a carbon monoxide biomarker of smoking status found no difference in smoking cessation between screened and unscreened control subjects (12). Tammemagi and colleagues examined the effects of screening results on the smoking behavior of 14 692 current smokers participating in the Lung Screening Study (LSS) portion of the National Lung Screening Trial (NLST) (13). Although smoking cessation was not an endpoint in the NLST and no systematic smoking cessation programs were initiated as part of the trial protocol, counseling for smoking cessation did occur as part of standard care. The finding of a positive screen by either low-dose CT or chest x-ray occurred in approximately 60% of current smokers. Authors divided the results of a screening CT into five categories of increasing clinical significance for suspicion of lung cancer or other diseases (eg, COPD). Except for one category between the sixth and seventh year of follow-up, smoking rates dropped across the five categories of scan results for each of the seven years. The lowest reduction in smoking rates occurred among participants with normal scans, with smoking rates of 87.4% 1 year after the initial screen and 61.8% after 7 years of follow-up. The greatest reduction occurred among current smokers whose baseline scan was suspicious for lung cancer, with smoking rates of 81.7% 1 year after the initial positive screen and 56.7% at 7 years of follow-up. The differential impact of screening results on likely smoking cessation was then estimated using a general estimating equation form of multivariable logistic regression model while controlling for other covariables. Tammemagi et al. (13) observed a strong dose–response in increased smoking cessation as screening results became more serious or suspicious for lung cancer. Their results remained consistent over the 5 years of postscreening follow-up. The strength of the results observed in this study between a positive screening CT and smoking cessation likely arises from the repeated measures of smoking cessation, incorporation of multiple annual scans, a robust model that controlled for a variety of possible confounders, and stratification of screening results. Yet, these results are in direct contrast with those from the Dutch screening trial that found no differences in smoking cessation rates (12). However, the Dutch study was one-fourth the sample size of the LSS, had no stratification of screening results, and relied on a single endpoint measurement of status at 5 years after screening. The Dutch screening trial used a biological marker of smoking status, whereas the NLST relied on self-reported status, a potential weakness of the NLST-based study (14). If the increased smoking cessation results observed in the LSS remain with implementation of a national lung cancer screening program, then the net benefit of a lung cancer screening program is likely underestimated.

Background Lung cancer is the number one cause of cancer death worldwide.(1) It is the fifth most commonly diagnosed cancer in Australia (12,741 cases diagnosed in 2018) and the leading cause of cancer death.(2) The number of years of potential life lost to lung cancer in Australia is estimated to be 58,450, similar to that of colorectal and breast cancer combined.(3) While tobacco control strategies are most effective for disease prevention in the general population, early detection via low dose computed tomography (LDCT) screening in high-risk populations is a viable option for detecting asymptomatic disease in current (13%) and former (24%) Australian smokers.(4) The purpose of this Evidence Check review is to identify and analyse existing and emerging evidence for LDCT lung cancer screening in high-risk individuals to guide future program and policy planning. Evidence Check questions This review aimed to address the following questions: 1. What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? 2. What is the evidence of potential harms from lung cancer screening for higher-risk individuals? 3. What are the main components of recent major lung cancer screening programs or trials? 4. What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Summary of methods The authors searched the peer-reviewed literature across three databases (MEDLINE, PsycINFO and Embase) for existing systematic reviews and original studies published between 1 January 2009 and 8 August 2019. Fifteen systematic reviews (of which 8 were contemporary) and 64 original publications met the inclusion criteria set across the four questions. Key findings Question 1: What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? There is sufficient evidence from systematic reviews and meta-analyses of combined (pooled) data from screening trials (of high-risk individuals) to indicate that LDCT examination is clinically effective in reducing lung cancer mortality. In 2011, the landmark National Lung Cancer Screening Trial (NLST, a large-scale randomised controlled trial [RCT] conducted in the US) reported a 20% (95% CI 6.8% – 26.7%; P=0.004) relative reduction in mortality among long-term heavy smokers over three rounds of annual screening. High-risk eligibility criteria was defined as people aged 55–74 years with a smoking history of ≥30 pack-years (years in which a smoker has consumed 20-plus cigarettes each day) and, for former smokers, ≥30 pack-years and have quit within the past 15 years.(5) All-cause mortality was reduced by 6.7% (95% CI, 1.2% – 13.6%; P=0.02). Initial data from the second landmark RCT, the NEderlands-Leuvens Longkanker Screenings ONderzoek (known as the NELSON trial), have found an even greater reduction of 26% (95% CI, 9% – 41%) in lung cancer mortality, with full trial results yet to be published.(6, 7) Pooled analyses, including several smaller-scale European LDCT screening trials insufficiently powered in their own right, collectively demonstrate a statistically significant reduction in lung cancer mortality (RR 0.82, 95% CI 0.73–0.91).(8) Despite the reduction in all-cause mortality found in the NLST, pooled analyses of seven trials found no statistically significant difference in all-cause mortality (RR 0.95, 95% CI 0.90–1.00).(8) However, cancer-specific mortality is currently the most relevant outcome in cancer screening trials. These seven trials demonstrated a significantly greater proportion of early stage cancers in LDCT groups compared with controls (RR 2.08, 95% CI 1.43–3.03). Thus, when considering results across mortality outcomes and early stage cancers diagnosed, LDCT screening is considered to be clinically effective. Question 2: What is the evidence of potential harms from lung cancer screening for higher-risk individuals? The harms of LDCT lung cancer screening include false positive tests and the consequences of unnecessary invasive follow-up procedures for conditions that are eventually diagnosed as benign. While LDCT screening leads to an increased frequency of invasive procedures, it does not result in greater mortality soon after an invasive procedure (in trial settings when compared with the control arm).(8) Overdiagnosis, exposure to radiation, psychological distress and an impact on quality of life are other known harms. Systematic review evidence indicates the benefits of LDCT screening are likely to outweigh the harms. The potential harms are likely to be reduced as refinements are made to LDCT screening protocols through: i) the application of risk predication models (e.g. the PLCOm2012), which enable a more accurate selection of the high-risk population through the use of specific criteria (beyond age and smoking history); ii) the use of nodule management algorithms (e.g. Lung-RADS, PanCan), which assist in the diagnostic evaluation of screen-detected nodules and cancers (e.g. more precise volumetric assessment of nodules); and, iii) more judicious selection of patients for invasive procedures. Recent evidence suggests a positive LDCT result may transiently increase psychological distress but does not have long-term adverse effects on psychological distress or health-related quality of life (HRQoL). With regards to smoking cessation, there is no evidence to suggest screening participation invokes a false sense of assurance in smokers, nor a reduction in motivation to quit. The NELSON and Danish trials found no difference in smoking cessation rates between LDCT screening and control groups. Higher net cessation rates, compared with general population, suggest those who participate in screening trials may already be motivated to quit. Question 3: What are the main components of recent major lung cancer screening programs or trials? There are no systematic reviews that capture the main components of recent major lung cancer screening trials and programs. We extracted evidence from original studies and clinical guidance documents and organised this into key groups to form a concise set of components for potential implementation of a national lung cancer screening program in Australia: 1. Identifying the high-risk population: recruitment, eligibility, selection and referral 2. Educating the public, people at high risk and healthcare providers; this includes creating awareness of lung cancer, the benefits and harms of LDCT screening, and shared decision-making 3. Components necessary for health services to deliver a screening program: a. Planning phase: e.g. human resources to coordinate the program, electronic data systems that integrate medical records information and link to an established national registry b. Implementation phase: e.g. human and technological resources required to conduct LDCT examinations, interpretation of reports and communication of results to participants c. Monitoring and evaluation phase: e.g. monitoring outcomes across patients, radiological reporting, compliance with established standards and a quality assurance program 4. Data reporting and research, e.g. audit and feedback to multidisciplinary teams, reporting outcomes to enhance international research into LDCT screening 5. Incorporation of smoking cessation interventions, e.g. specific programs designed for LDCT screening or referral to existing community or hospital-based services that deliver cessation interventions. Most original studies are single-institution evaluations that contain descriptive data about the processes required to establish and implement a high-risk population-based screening program. Across all studies there is a consistent message as to the challenges and complexities of establishing LDCT screening programs to attract people at high risk who will receive the greatest benefits from participation. With regards to smoking cessation, evidence from one systematic review indicates the optimal strategy for incorporating smoking cessation interventions into a LDCT screening program is unclear. There is widespread agreement that LDCT screening attendance presents a ‘teachable moment’ for cessation advice, especially among those people who receive a positive scan result. Smoking cessation is an area of significant research investment; for instance, eight US-based clinical trials are now underway that aim to address how best to design and deliver cessation programs within large-scale LDCT screening programs.(9) Question 4: What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Assessing the value or cost-effectiveness of LDCT screening involves a complex interplay of factors including data on effectiveness and costs, and institutional context. A key input is data about the effectiveness of potential and current screening programs with respect to case detection, and the likely outcomes of treating those cases sooner (in the presence of LDCT screening) as opposed to later (in the absence of LDCT screening). Evidence about the cost-effectiveness of LDCT screening programs has been summarised in two systematic reviews. We identified a further 13 studies—five modelling studies, one discrete choice experiment and seven articles—that used a variety of methods to assess cost-effectiveness. Three modelling studies indicated LDCT screening was cost-effective in the settings of the US and Europe. Two studies—one from Australia and one from New Zealand—reported LDCT screening would not be cost-effective using NLST-like protocols. We anticipate that, following the full publication of the NELSON trial, cost-effectiveness studies will likely be updated with new data that reduce uncertainty about factors that influence modelling outcomes, including the findings of indeterminate nodules. Gaps in the evidence There is a large and accessible body of evidence as to the effectiveness (Q1) and harms (Q2) of LDCT screening for lung cancer. N

Integrating effective smoking cessation strategies for individuals undergoing lung cancer screening stands to significantly increase the impact of lung screening programmes. We assessed the impact of low-dose computed tomography (LDCT) findings on smoking cessation among high-risk adults who currently smoked. 13 035 individuals, aged 55-77 years, attended a lung health check appointment, as part of a prospective observational cohort study (the SUMMIT Study), prior to undergoing a baseline LDCT scan. Logistic regressions examined the likelihood of smoking cessation at a 1-year follow-up appointment and its association with LDCT findings. 12.6% (n = 647/5135) of individuals self-reported smoking cessation at 1-year follow-up. Higher odds of quitting were found in those receiving indeterminate pulmonary nodule findings requiring a 3-month interval LDCT (aOR = 1.27; 1.01, 1.61), those with urgent findings requiring referral to secondary care (aOR = 1.55; 1.05, 2.32), and those with a possible new chronic obstructive pulmonary disease diagnosis (aOR = 1.60; 1.23, 2.06), compared to those receiving no actionable LDCT findings. Older age, Asian ethnic background, current high smoking intensity, motivation and number of quit attempts, and low nicotine dependence were associated with increased odds of quitting. Individuals currently smoking, at high lung cancer risk, participating in LDCT screening, and receiving incidental findings requiring a 1-year interval LDCT or primary care follow-up might therefore need additional behavioral support to quit. Tailored communication strategies depending on the severity of the LDCT findings, including additional behavioral support for those with less clinical concerning or negative findings, could increase quit rates and reduce smoking-related morbidity. This study reports high odds of self-reported complete smoking cessation in adults who currently smoked after receiving their LDCT findings. Though the impact of specific types of LDCT findings on smoking cessation was positive for high lung cancer risk individuals, reception of incidental findings could potentially be perceived as less severe to encourage individuals who currently smoked to quit. Clearly communicating the severity of LDCT findings along with the delivery of behavioral smoking cessation support targeted to high-risk individuals may increase their chances of complete smoking cessation and reduce lung cancer mortality.

The article by Westmaas et al that accompanies this editorial demonstrated an increased rate of smoking cessation among Cancer Prevention Study II participants who were diagnosed with cancer as compared with those without cancer diagnoses. The authors concluded that cancer diagnosis provides a teachable moment for smoking cessation (teachable moment is described by McBride et al as “life transitions or health events thought to motivate individuals to spontaneously adopt risk-reducing health behaviors”). The clinical relevance of cessation at diagnosis is suggested by meta-analyses demonstrating that the relative risk of cancer-specific mortality among current smokers is 1.6 relative to never-smokers; by comparison, the relative risk for former smokers is 1.03 relative to never-smokers. One may conclude that cessation at diagnosis will decrease the relative risk of an individual. However, the improvement in prognosis as a result of cessation at diagnosis is subject to variation as a result of longitudinal smoking status, lifetime exposure, and other important variables. Definitive population-level conclusions are difficult, in part because randomized trials of cessation among patients with newly diagnosed cancer are challenging to conduct, and many observational studies have not collected or adjusted for smoking status or other variables during follow-up. One reason that follow-up assessment is important is the finding by Westmaas et al of a 12% rate of smoking resumption among cancer patients who quit smoking at diagnosis. Thus, although Westmaas et al provide robust evidence that cessation is more likely after diagnosis, important research remains to be conducted regarding the impact on long-term outcomes of smoking and smoking cessation at the time of diagnosis. Data are sufficient, however, to conclude broadly that quitting smoking improves the prognosis of patients with cancer. It is notable that this increase in cessation was evident despite the exclusion of several of those cancer sites most strongly related to smoking. The authors excluded cancers of the esophagus, head, neck, and lung, based on the idea that those cancers would more likely produce symptoms that might lead to cessation, whereas the aim was to measure the spontaneous cessation attributable to patients being told that they had cancer. One might argue whether that exclusion is appropriate. Many cancers and many cancer therapies produce symptoms that might make smoking more difficult or less palatable. Furthermore, a tobacco-related cancer diagnosis would arguably be more likely to motivate cessation, even in the absence of symptoms. In any case, diagnosis may provide a teachable moment even if the cancer or treatment symptoms are the cause of increased motivation to quit. The Westmaas et al finding of higher cessation rates among individuals diagnosed with cancer raises the question of whether cessation rates are also higher after cancer screening. This question is timely, given the current rapid expansion of low-dose computed tomography (LDCT) screening for lung cancer. In 2011, the National Lung Screening Trial found that LDCT screening was associated with a reduction of lung cancer mortality of approximately 20% among long-term cigarette smokers. In 2013, the US Preventive Services Task Force recommended LDCT lung cancer screening for high-risk individuals. Recently, the Centers for Medicare and Medicaid Services announced the decision to provide Medicare coverage for lung cancer screening. There is a large potential for growth in both the number of patients who will receive LDCT lung cancer screening and the number of clinics that will offer the service when Medicare and private insurance plans begin to cover this service (as required by the Affordable Care Act). An estimated 8.6 million Americans were eligible for LDCT screening as of 2010. In lung cancer screening studies, approximately 50% of participants were current smokers. As of October 2014, the American College of Radiology had designated only 280 sites as lung cancer screening centers of roughly 6,700 sites that had been accredited in the chest computed tomography module, which indicates that there may be a large number of centers that are developing the facilities to provide LDCT. LDCT screening for lung cancer provides a crucial opportunity for smoking cessation intervention. The Public Health Service–sponsored “Treating Tobacco Use Guideline” states: “It is essential that clinicians and health care delivery systems consistently treat every tobacco user seen in a health care setting.” There is support from professional organizations and insurers for LDCT sites to provide cessation. The American College of Radiology designation as a lung cancer screening center requires an attestation that “a mechanism [. . .] be in place to refer patients for smoking cessation counseling or to provide smoking cessation materials.” Medicare coverage will require that patients receive a written order from a clinician after a shared decision-making visit. That visit must include brief cessation counseling and furnishing of information about tobacco cessation interventions. Within 5 years after cessation, the reduction in lung cancer mortality (compared with continuing smokers) is similar to that associated with LDCT screening; after 20 years, the reduction in lung cancer mortality is much larger (eg, 87% reduced risk among women in the Nurses’ Health Study). JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 33 NUMBER 15 MAY 2

SMOKING HISTORY DOCUMENTATION IN THE ELECTRONIC HEALTH RECORD: AN IMPORTANT CONTRIBUTOR TO RATES OF LUNG CANCER SCREENING

BackgroundLung cancer screening conducted in high-risk group using low-dose computer tomography (LDCT) has been reported as an effective method to reduce lung cancer mortality in two large randomized-control trials. However, the effectiveness is uncertain when lung cancer screening is expanded to a nationwide population-based program.MethodsThe Korean Lung Cancer Screening Project (K-LUCAS) is a single-arm cohort study that was conducted from February 2017 to evaluate the feasibility of implementing an organized national lung cancer screening program in Korea. High-risk population aged 55–74 years with more than a 30-pack-year smoking history was recruited. Smoking history was obtained from administering questionnaires at national health screening programs or public smoking cessation programs which are already established programs in Korea. The screening results were reported using the Lung Imaging Reporting and Data System (Lung-RADS), suggested by the American College of Radiology. K-LUCAS was performed by a network-based diagnosis supporting system using a computer-aided detection (CAD) program to maintain screening quality. Current smokers were provided with mandatory smoking counseling.ResultsAmong 71,829 participants aged 50 years or older in the national health screening program, 5,975 (8.3%) were eligible for lung cancer screening. Among them, 1,062 (17.8%) refused to participate in K-LUCAS. Additionally, 779 participants were recruited in the smoking cessation program. Thus, a total of 5,692 eligible high-risk participants were recruited in this study. Among them, 865 (15.2%) had positive screening results, which requires a further examination; 529 (9.3%) had Lung-RADS category 3 (indeterminate), and 336 (5.9%) had category 4 (suspicious of lung cancer); 42 (0.7%) had confirmed lung cancer. Approximately 66.7% had early-stage lung cancer: 24 (57.1%), stage I and 4 (9.5%), stage II. Six (1.1%) patients developed complications at the time of diagnosis, including one death. The anxiety level related to cancer screening was low. Participation in screening encouraged motivation to quit smoking.ConclusionsK-LUCAS provided promising evidence supporting the implementation of a national lung cancer screening program to detect early stage lung cancer and promote smoking cessation for participants in Asian population.

LUNG CANCER SCREENING PARTICIPATION IN COMMUNITY-BASED HEALTH SYSTEMS FROM THE PROSPR-LUNG CONSORTIUM

Background: The USPSTF currently recommends lung cancer screening (LCS) by low-dose CT (LDCT) in those 50 to 80 years of age with 20+ pack-years of smoking who are currently smoking or quit smoking within the last 15 years. LCS LDCT often detects non-cancer related incidental findings, most commonly coronary artery calcifications (CAC). CAC is a measure of subclinical coronary atherosclerosis, is higher in those with tobacco use, and may require additional clinical assessment after LCS. In the National Lung Screening Trial, reductions in all-cause mortality were stronger among Black than White participants undergoing LDCT. It was hypothesized that this may have been due to follow-up and treatment of incidental findings such as CAC during the trial. Methods: In this on-going observational study, we are evaluating clinical follow-up of moderate or severe CAC within 12 months of LCS among individuals undergoing baseline LCS at two Michigan health systems, one urban and one rural. We report here our initial findings for individuals with a baseline LCS LDCT at Henry Ford Health in 2018. Pearson Chi Square and McNemar’s tests were used to determine differences between race and sex groups and in change in statin use and cardiology visits (yes/no) pre- to post-screening. Results: Of 1,630 individuals (18% Black) with a baseline LDCT in 2018, moderate or severe CAC was documented in 154 (9.4%). Moderate or severe CAC prevalence was significantly higher among Black versus Non-Black ( 17.7 % vs 7.1%; p= <0.001) individuals and men versus women ( 11.7% vs 7.1%; p=0.002 ). Pre- to post-LCS increases in statin use (68.2% vs. 76.0%; p=0.02) and cardiology visits (25.9% vs. 50.7%; p<0.01) were observed, overall. Statin use did not differ by race, sex, or race-sex group in the pre- or post- periods. Cardiology visits were less common among Blacks (18.2% vs. 28.9%; p=0.14) and women ( 18.2% vs. 28.9%; p= 0.14) in the pre-LCS period with Black women (8.3%) being the least likely to have a cardiology visit before LCS. Post-LCS, the cardiology gap between Black and Non-Black individuals (43.6% vs. 55.6%: p=0.16) narrowed and was eliminated between women and men (53.6 % vs. 50%; p=0.67). This was due in part to a substantial uptick of cardiology visits post-LCS in Black females. However, Black men, were significantly less likely than Non-Black men (32.3 % vs 56.7% ; p=0.024 ) and Black women (32.2% vs. 62.5%; p=0.024) to have a cardiology visit post-LCS . Conclusions: Our study is on-going; however, preliminary results suggest that in addition to reducing lung cancer mortality, LCS provides an opportunity for CAC detection and its related management. LCS, if implemented equitably with comprehensive follow-up of incidental findings, may help to close gaps in cardiac care for Black individuals and women. Further investigation is needed to assess whether appropriate follow-up of CAC decreases cardiovascular risks for those undergoing screening. Citation Format: Christine Neslund-Dudas, Katie R. Zarins, Punith Shetty, Andrea E. Cassidy-Bushrow, Nada Al-Antary, Katie A. Latack, Vritti Gupta, Michael Simoff, Riley Draper, Samuel Wilcox, Kendra Worden, Kathy LaRaia, Kelly Hirko. Follow-up of moderate and severe coronary artery calcifications identified on lung cancer screening CT scans: An opportunity to improve cardiac health outcomes in Black men and women [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C121.

Lung cancer screening using low-dose computed tomography (LDCT) is now widely recommended for adults who are current or former heavy smokers. It is important to evaluate the impact of screening on smoking abstinence rates. Among current and former smokers eligible for lung cancer screening, we sought to determine the consequence of screening with LDCT, as well as subsequent results, on smoking cessation and relapse rates. We searched the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the fourth quarter, 2012), MEDLINE (2000 to May 31, 2013), reference lists of papers, and Scopus for relevant English-language studies and systematic reviews. To evaluate the effect of LDCT screening on smoking abstinence, we included only randomized controlled trials (RCTs) involving asymptomatic adults. To evaluate the association of particular results and/or recommendations from a screening CT with smoking behaviors, we included results from RCTs as well as cohort studies. A total of 8,215 abstracts were reviewed. Three publications from two European RCTs and five publications from three cohort studies conducted in the United States met inclusion criteria. The process of LDCT lung cancer screening did not influence smoking behaviors. LDCT recipients with results concerning for lung cancer had higher abstinence rates than those with scans without such findings. This association may have a dose-response relationship in terms of the number of abnormal CT scans as well as the seriousness of the finding. Limited evidence suggests LDCT lung cancer screening itself does not influence smoking behaviors, but positive results are associated with increased abstinence. As lung cancer screening is implemented in the general population, it is very important to evaluate its association with smoking behaviors to maximize its potential as a teachable moment to encourage long-term abstinence. Clinicians should consider tailoring LDCT result communication to emphasize the importance of smoking abstinence.

The purpose of this article is to review clinical computed tomography (CT) lung screening program elements essential to safely and effectively manage the millions of Americans at high risk for lung cancer expected to enroll in lung cancer screening programs over the next 3 to 5 years. To optimize the potential net benefit of CT lung screening and facilitate medical audits benchmarked to national quality standards, radiologists should interpret these examinations using a validated structured reporting system such as Lung-RADS. Patient and physician educational outreach should be enacted to support an informed and shared decision-making process without creating barriers to screening access. Programs must integrate smoking cessation interventions to maximize the clinical efficacy and cost-effectiveness of screening. At an institutional level, budgets should account for the necessary expense of hiring and/or training qualified support staff and equipping them with information technology resources adequate to enroll and track patients accurately over decades of future screening evaluation. At a national level, planning should begin on ways to accommodate the upcoming increased demand for physician services in fields critical to the success of CT lung screening such as diagnostic radiology and thoracic surgery. Institutions with programs that follow these specifications will be well equipped to meet the significant oncoming demand for CT lung screening services and bestow clinical benefits on their patients equal to or beyond what was observed in the National Lung Screening Trial.

e23341 Background: Coronary artery calcification (CAC) is a known risk factor for coronary heart disease. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) can detect lung cancer at earlier stages and reduce mortality. Additionally, CAC are common incidental findings among patients undergoing LDCT for LCS. However, racial differences in incidental findings of CAC among LCS patients have not been thoroughly investigated. We examined the association between race and presence of moderate to severe CAC among patients undergoing LDCT for LCS. Methods: We conducted a retrospective analysis of electronic health records (EHR) from Henry Ford Health (2016-2023) among patients undergoing LDCT for LCS. CAC was classified as moderate or severe (vs. none or mild). Race was categorized as Black, White, Asian, American Indian/Alaskan Native, Other and Unknown. We focused on Black and White patients, owing to the small sample size in the other groups. Multivariable logistic regression was used to examine the association between race and presence of moderate to severe CAC, adjusting for age, sex, and tobacco smoking status. Results: A total of 15,911 patients who were eligible for LCS and completed at least one screen during our study period were included. Of these, 79.6% were White and 20.4% were Black. The mean age of patients was 63.8±5.8 years; 50.4% were male and 61.4% reported current tobacco smoking. Demographic comparisons show that White patients were more frequently male compared to Black patients (50.9% vs 47.9%, p = 0.002). In addition, Black patients were slightly older (64.3±5.7 vs 63.6±5.8 years) and reported a higher current tobacco smoking status (67.9% vs 59.7%, p < 0.0001) compared to White patients. The prevalence of moderate to severe CAC was 10.9% overall and was higher among Black vs White patients (16.1% vs 9.6%, p < 0.0001). After covariate adjustment, Black patients had significantly higher odds of moderate to severe CAC compared to White patients (odds ratio [OR] = 1.8, 95% CI 1.6–1.9, p < 0.0001). Conclusions: The study findings suggest significant racial differences in the prevalence of CAC among patients undergoing LCS. Race may be an important factor when assessing cardiovascular risk in patients undergoing LCS and may have implications for screening protocols and preventive strategies. Future research is needed to explore the impact of these differences on risk and mortality from cardiovascular diseases.

BackgroundLung cancer screening may provide a “teachable moment” for the smoking cessation and relapse prevention. However, the impact of lung cancer screening on smoking initiation in non‐smokers has not been reported.MethodsA baseline smoking behavior survey was conducted in 2000 participants who were screened by low‐dose computed tomography (LDCT) from 2014 to 2018. All participants were re‐surveyed on their smoking behavior in 2019. Of these, 312 participants were excluded, leaving 1688 participants in the final analysis. The smoking initiation rate in baseline non‐smokers, the relapse rate in baseline former smokers, and the abstinence rate in baseline current smokers were calculated, respectively. The associations between screening results, demographic characteristics, and smoking behavior change were analyzed using multivariable logistic regression.ResultsFrom 2014 to 2019, smoking prevalence significantly decreased from 52.6% to 49.1%. The prevalence of smoking initiation, relapse, and abstinence in baseline non‐smokers, former, and current smokers was 16.8%, 22.9%, and 23.7%, respectively. The risk of smoking initiation in baseline non‐smokers was significantly higher in those with negative screening result (adjusted OR = 2.97, 95% CI: 1.27–6.94). Compared to smokers who only received baseline screening, the chance of smoking abstinence in baseline current smokers was reduced by over 80% in those who attended 5 rounds of screening (adjusted OR = 0.15, 95% CI:0.08–0.27). No significant associations were found between smoking relapse and prior screening frequency, with at least one positive screening result. Age, gender, occupational exposure, income, and smoking pack years were also associated with smoking behavior changes.ConclusionsThe overall decreased smoking prevalence indicated an overwhelming effect of “teachable moment” on “license to smoke.” A tailored smoking cessation strategy should be integrated into lung cancer screening.