Lung Cancer Screening Criteria Research Articles

Assessing Information Available for Health Professionals and Potential Participants on Lung Cancer Screening Program Websites: Cross-sectional Study.

BackgroundLung cancer is the leading cause of cancer death worldwide. The US Preventive Services Task Force (USPSTF) updated recommendations for lung cancer screening in 2021, adjusting the age of screening to 50 years (from 55 years) and reducing the number of pack-years used to estimate total firsthand cigarette smoke exposure to 20 (from 30). With many individuals using the internet to find health care information, it is important to understand what information is available for individuals contemplating lung cancer screening.ObjectiveThis study aimed to assess the eligibility criteria and information available on lung cancer screening program websites for both health professionals and potential screening participants.MethodsA descriptive cross-sectional analysis of 151 lung cancer screening program websites of academic (n=76) and community medical centers (n=75) in the United States with information for health professionals and potential screening participants was conducted in March 2021. Presentation of eligibility criteria for potential screening participants and presence of information available specific to health professionals about lung cancer screening were the primary outcomes. Secondary outcomes included presentation of information about cost and smoking cessation, inclusion of an online risk assessment tool, mention of any clinical guidelines, and use of multimedia to present information.ResultsEligibility criteria for lung cancer screening was included in nearly all 151 websites (n=142, 94%), as well as age range (n=139, 92.1%) and smoking history (n=141, 93.4%). Age was only consistent with the latest recommendations in 14.5% (n=22) of websites, and no websites had updated smoking history. Half the websites (n=76, 50.3%) mentioned screening costs as related to the type of insurance held. A total of 23 (15.2%) websites featured an online assessment tool to determine eligibility. The same proportion (n=23, 15.2%) hosted information specifically for health professionals. In total, 44 (29.1%) websites referred to smoking cessation, and 46 (30.5%) websites used multimedia to present information, such as short videos or podcasts.ConclusionsMost websites of US lung cancer screening programs provide information about eligibility criteria, but this is not consistent and has not been updated across all websites following the latest USPSTF recommendations. Online resources require updating to present standardized information that is accessible for all.

Screening Criteria Evaluation for Expansion in Pulmonary Neoplasias (SCREEN)

The SCREEN study investigated screening eligibility and survival outcomes between heavy smokers and light-or-never-smokers with lung cancer to determine whether expanded risk factor analysis is needed to refine screening criteria. SCREEN is a retrospective study of 917 lung cancer patients diagnosed between 2005 and 2018 in Nova Scotia, Canada. Screening eligibility was determined using the National Lung Screening Trial (NSLT) criteria. Mortality risk between heavy smokers and light-or-never-smokers was compared using proportional-hazards models. The median follow-up was 2.9 years. The cohort was comprised of 179 (46.1%) female heavy smokers and 306 (57.8%) female light-or-never-smokers. Light-or-never-smokers were more likely to have a diagnosis of adenocarcinoma [n=378 (71.6%)] compared to heavy smokers [n=234 (60.5%); P< 0.001]. Heavy smokers were more frequently diagnosed with squamous cell carcinoma [n=111 (28.7%)] compared to light-or-never-smokers, [n=100 (18.9%); P< 0.001]. Overall, 36.9% (338) of patients met NLST screening criteria. There was no difference in 5-year survival between light-or-never-smokers and heavy smokers [55.2% (338) vs 58.5% (529); P = 0.408; HR 1.06, 95% CI 0.80-1.40; P = 0.704]. Multivariate analysis showed that males had an increased mortality risk [HR 2.00 (95% CI 1.57-2.54); P< 0.001]. Half of lung cancer patients were missed with the conventional screening criteria. There were more curable, stage 1 tumors among light-or-never-smokers. Smoking status and age alone may be insufficient predictors of lung cancer risk and prognosis. Expanded risk factor analysis is needed to refine lung cancer screening criteria.

Lung Cancer Screening Criteria and Cardiopulmonary Comorbidities

IntroductionLung cancer screening criteria should select candidates with minimal cardiopulmonary comorbidities who are fit for curative lung cancer resection. MethodsWe retrospectively analyzed 728 patients with lung cancer for screening eligibility using the U.S. Preventive Services Task Force (USPSTF) 2013 criteria (n = 370). If ineligible for screening, they were further assessed for eligibility using the USPSTF 2021 (n = 121) and National Comprehensive Cancer Network group 2 (NCCN gp 2) (n = 155). Comparisons of cardiopulmonary comorbidities between patients selected by the different lung cancer screening criteria were performed. Excluding missing data, a similar comparison was done between USPSTF 2013 (n = 283) and PLCOm2012 (risk threshold ≥1.51%) (n = 118). ResultsPatients eligible for USPSTF 2021 and NCCN gp 2 had lower rates of airflow obstruction (forced expiratory volume in 1 s [FEV1]/forced vital capacity <0.7) compared with those in USPSTF 2013 (55.4% and 56.8% versus 70.5%). Both USPSTF 2021 and NCCN gp 2 groups had less severe airflow obstruction; only 11.6% and 12.9% of patients, respectively, had percent-predicted FEV1 less than 50% versus 20.3% in the USPSTF 2013 group. Comparing USPSTF 2013 and PLCOm2012 revealed no significant differences in age or the rate of airflow obstruction (p = 0.06 and p = 0.09 respectively). Nevertheless, rates of percent-predicted FEV1 less than 50% and diffusing capacity of the lungs for carbon monoxide less than 50% were lower in the PLCOm2012 group compared with those in the USPSTF 2013 group (22.3% versus 10.2% and 32.6% versus 20.0%), respectively. ConclusionsThe USPSTF 2021 qualifies an additional group of screening candidates who are healthier with better lung reserve, translating to better surgical candidacy but potentially more overdiagnosis. The PLCOm2012, with its better accuracy in selecting patients at risk of cancer, selects an older group with chronic obstructive pulmonary disease but with good lung reserve and potentially less overdiagnosis.

Screening for high frequency malignant disease (SHIELD).

TPS1602 Background: Implementation of asymptomatic cancer screening has yielded positive impacts on global cancer mortality rates. However, significant screening adherence gaps exist. A blood-based multi-cancer screening test with clinically significant performance in cancers where early detection and intervention can save lives, can address adherence gaps, especially by reducing access barriers inherent to current screening options. Effective evaluation of such a test in screen relevant populations requires studies designed to enroll individuals across multiple cancer types, taking into account prevalence rates for the cancers being evaluated, allowing for overlapping screen-eligible populations, and ensuring representation of individuals from diverse ethnicities and geographies. Methods: SHIELD (Screening for High Frequency Malignant Disease; NCT# 05117840) is a prospective, observational, multi-center basket study ongoing in the United States and Europe uniquely designed to recruit individuals across multiple cancer types. The study’s primary objective is to evaluate the performance of a blood-based multi-cancer screening test (GuardantLUNAR-2, Guardant Health, USA) to detect cancer in screen-relevant individuals as compared to the reference standard cancer screening modality. The study will recruit eligible individuals into multiple separate cohorts with specified pathways for cancer screening. Within each cohort, eligible individuals consent to whole blood collection within 90-days of the standard of care screening method. Clinical diagnoses, including the diagnosis of cancer, are made per standard of care. Primary outcomes are sensitivity, specificity, negative predictive value, and positive predictive value of the test as compared to the standard of care screening modality. Secondary outcome is the number of screen-detected cancers, early- (stage I/II) and late-stage (stage III/IV), per 1000 screened individuals. Follow-up continues for 24 months with outcomes collected at one and two-years to investigate the possibility of incidental non-screen relevant cancer cases and interval screen-relevant cancer cases that had not reached clinical threshold for detection at initial screening. Additional cancer specific follow-up is designed per cohort. The first cohort to enroll screen-eligible individuals, cohort A, is focused on those who meet guideline criteria for lung cancer screening with low dose CT. Additional cancer-risk cohorts will begin enrolling as the study expands and are designated cohort B, C, etc. Cohort A: Eligibility criteria are aligned with lung cancer screening guidelines – age 50-80 years with &gt; 20 pack-year smoking history who are current smokers or have quit &lt; 15 years prior, without a cancer history, preinvasive lung lesions, or current treatment for pneumonia. Cohort A enrollment, targeting 9,000 subjects over 24 months at up to 120 global sites, began in January 2022. Clinical trial information: NCT05117840.

Health utilities for participants in a population-based sample who meet eligibility criteria for lung cancer screening

IntroductionTrial-based, risk-targeted lung cancer screening with low-dose computed tomography has been shown to reduce lung cancer mortality but implementation may depend on favourable cost-effectiveness evaluations where quality-adjusted life-years are a key metric. Baseline health utility values for a screening population at high risk of lung cancer are not likely to match age-specific population norms, and utilities derived from screening trials may not be representative of real-world screening populations. We estimated utility values for screening-eligible individuals in a population-based cohort study in Australia. MethodsCancer-free participants aged 50–80 years in the New South Wales 45 and Up Study completed the 12-Item Short Form Survey (2010–2011). Mean SF-6D utility values were calculated for 19,991 participants and compared across screening criteria defined by the US Preventive Services Task Force (USPSTF-2021/2013), NELSON trial eligibility, and the PLCOm2012 risk tool. ResultsMean SF-6D utility values were comparable across screening criteria: USPSTF-2021, 0.772 (95%CI, 0.768–0.776); USPSTF-2013, 0.764 (95%CI, 0.759–0.770); NELSON, 0.768 (95%CI, 0.763–0.774), and were each lower than among ineligible participants (0.810–0.814). While there was a decline in utilities with increasing risk of lung cancer as measured with the PLCOm2012 risk tool, mean utility values for those with ≥ 1.51% 6-year risk did not differ to other criteria (0.772, 95%CI, 0.767–0.776). ConclusionRisk criteria are necessary for the efficiency of lung cancer screening programs, but they select populations with lower mean health utilities than population norms. We provide baseline values that can be used in cost-effectiveness evaluations of risk-targeted lung cancer screening.

Characteristics of Singapore lung cancer patients who miss out on lung cancer screening recommendations.

The National Lung Screening Trial (NLST) identified individuals at high risk for lung cancer and showed that serial low-dose helical computed tomography could identify lung cancer at an earlier stage, leading to mortality reduction. However, there is little evidence regarding the effectiveness of the NLST criteria for the Asian population. We performed a retrospective audit in our hospital from January 2018 to December 2018, with the aim to describe the characteristics of patients diagnosed with lung cancer and to identify patients who would miss out on lung cancer screening when the NLST criteria was applied. We found that only 38.1% of our cohort who were diagnosed with lung cancer met the NLST criteria strictly by age and smoking status. Patients who met the screening criteria would have derived significant benefits from it, as 85.4% of our patients had presented at an advanced stage and 54.6% died within 1 year. When the United States Preventive Services Task Force criteria was applied, it increased the sensitivity of lung cancer diagnosis to 58.7%. Only 15.5% of the female patients with lung cancer met the NLST criteria; their low smoking quantity was a significant contributing factor for exclusion. The majority of Singapore patients diagnosed with lung cancer, especially females, would not have been identified with the NLST criteria. However, those who met the inclusion criteria would have benefited greatly from screening. Extending the screening age upper limit may yield benefits and improved sensitivity in the Singapore context.

AHRR (cg05575921) Methylation Safely Improves Specificity of Lung Cancer Screening Eligibility Criteria: A Cohort Study.

Screening reduces lung cancer mortality, but specificities of eligibility criteria are low. We tested if leukocyte AHRR(cg05575921) methylation improves specificity of lung cancer screening eligibility criteria. A total of 9,206 and 5,370 individuals of the 1991 to 1994 and 2001 to 2003 examinations of the Copenhagen City Heart Study, Denmark, were followed for lung cancer within 5 years after examination and mortality. Screening eligibility criteria (DANTE, DLCST, ITALUNG, LUSI, NELSON, NLST, and PLCOM2012) were evaluated, and AHRR (cg05575921) methylation extent at different methylation cut points was added. The model with the lowest number of eligible individuals per 5-year lung cancer was validated within the 2001 to 2003 examination. Eligibility criteria identified risk-groups ranging from 3,182 (DANTE) to 1,641 (ITALUNG) individuals. The positive predictive value was highest for PLCOM2012 (3.2%), while DANTE showed the highest negative predictive value (99.7%). Adding AHRR (cg05575921) methylation led to higher specificities for all criteria. Number of eligible individuals per 5-year lung cancer varied from 38 (NELSON) to 27 (NLST) with AHRR (cg05575921) methylation <55%. This last model led to a 21.9% lower screening burden and increased (P < 0.05) specificity of 84.0%. Findings were reproduced among the 5,334 individuals of the 2001 to 2003 examination. Adding AHRR (cg05575921) methylation on top of current eligibility criteria for lung cancer screening improves specificity by excluding those individuals with the lowest risk. The results point toward a potential clinical use of AHRR (cg05575921) methylation, which is a cost-effective measurement compared with lung CT scanning, to provide additional predictive risk information to identify eligible smokers for lung cancer screening. See related commentary by Hung, p. 698.

Comparison Between the 2021 USPSTF Lung Cancer Screening Criteria and Other Lung Cancer Screening Criteria for Racial Disparity in Eligibility

In 2021, the US Preventive Services Task Force (USPSTF) broadened its age and smoking pack-year requirement for lung cancer screening. To compare the 2021 USPSTF lung cancer screening criteria with other lung cancer screening criteria and evaluate whether the sensitivity and specificity of these criteria differ by race. This study included 912 patients with lung cancer and 1457 controls without lung cancer enrolled in an epidemiology study (INHALE [Inflammation, Health, Ancestry, and Lung Epidemiology]) in the Detroit metropolitan area between May 15, 2012, and March 31, 2018. Patients with lung cancer and controls were 21 to 89 years of age; patients with lung cancer who were never smokers and controls who were never smokers were not included in these analyses. Statistical analysis was performed from August 31, 2020, to April 13, 2021. The study assessed whether patients with lung cancer and controls would have qualified for lung cancer screening using the 2013 USPSTF, 2021 USPSTF, and 2012 modification of the model from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCOm2012) screening criteria. Sensitivity was defined as the percentage of patients with lung cancer who qualified for screening, while specificity was defined as the percentage of controls who did not qualify for lung cancer screening. Participants included 912 patients with a lung cancer diagnosis (493 women [54%]; mean [SD] age, 63.7 [9.5] years) and 1457 control participants without lung cancer at enrollment (795 women [55%]; mean [SD] age, 60.4 [9.6] years). With the use of 2021 USPSTF criteria, 590 patients with lung cancer (65%) were eligible for screening compared with 619 patients (68%) per the PLCOm2012 criteria and 445 patients (49%) per the 2013 USPSTF criteria. With the use of 2013 USPSTF criteria, significantly more White patients than African American patients with lung cancer (324 of 625 [52%] vs 121 of 287 [42%]) would have been eligible for screening. This racial disparity was absent when using 2021 USPSTF criteria (408 of 625 [65%] White patients vs 182 of 287 [63%] African American patients) and PLCOm2012 criteria (427 of 625 [68%] White patients vs 192 of 287 [67%] African American patients). The 2013 USPSTF criteria excluded 950 control participants (65%), while the PLCOm2012 criteria excluded 843 control participants (58%), and the 2021 USPSTF criteria excluded 709 control participants (49%). The 2013 USPSTF criteria excluded fewer White control participants than African American control participants (514 of 838 [61%] vs 436 of 619 [70%]). This racial disparity is again absent when using 2021 USPSTF criteria (401 of 838 [48%] White patients vs 308 of 619 [50%] African American patients) and PLCOm2012 guidelines (475 of 838 [57%] White patients vs 368 of 619 [60%] African American patients). This study suggests that the USPSTF 2021 guideline changes improve on earlier, fixed screening criteria for lung cancer, broadening eligibility and reducing the racial disparity in access to screening.

Abstract PO-064: Health literacy as a tool to drive equitable action for lung cancer screening in high-risk communities

Abstract In the United States, communities at risk of developing lung cancer include rural populations, low socioeconomic status (SES) and the under-insured, immigrants, aged populations, racial and ethnic minority groups, and LGBTQIA communities. Many of these high-risk communities are diagnosed at much later stages than high SES whites. When lung cancer is detected early, survival rates are higher due to the possibility of curative surgery. Lung cancer screening (LCS) using low-density computed tomography (LDCT) has been recommended by the USPSTF since 2013. Guidelines for those who meet the USPSTF LCS criteria were expanded in 2021. A major barrier to accessing screening by vulnerable populations is the lack of health literate LCS education materials that can be used to engage and empower these groups and motivate them to seek screening. Research Question: How do we develop health literate (HL), culturally sensitive, and linguistically appropriate health information about LCS to high-risk communities and make them available through trusted community partners? Methods: A multi-phased approach that included material creation, testing, and dissemination was conceptualized by LUNGevity Foundation in partnership with Health Literacy Media (HLM) and a leading expert in accessible patient education. Using an IRB-approved protocol, the study team identified a representative population of persons (N=40 in 15 states) with online recruitment facilitated by NCI community cancer center outreach leaders in high-risk geographies. The participants gave extensive quantitative and qualitative feedback via virtual focus groups or in-depth interviews to obtain opinions and insights into how easily LUNGevity Foundation's Screening and Early Detection Booklet was understood. Revised materials were created using HL best practices, and re-tested with new community members to ensure acceptability, accessibility, and HL. Then, additional materials with relevant health topics were developed consistent with HL principles for extensive testing with communities. An additional 24 people in 11 states took part in 1 of 4, 1 ½ hour focus groups for final review. New HL lung cancer screening materials were made available to NCI community outreach leaders via LUNGevity Foundation's trusted national community engagement network. Results: The participants raised important insights about eligibility for and accessibility to screening. Based on their insights and recommendations, HLM transformed one large booklet into 4 fact sheets and 6 mini booklets. Final materials were disseminated to vulnerable populations via LUNGevity Foundation's trusted community engagement network. Conclusions: The feasibility of creating patient-centered health literate materials that also incorporate community engagement is established. Using LCS as an example, we were able to successfully create materials that were acceptable to high-risk communities. We recommend offering understandable and accessible information to all communities regardless of their literacy or education levels. Citation Format: Jeanne M. Regnante, Upal Basu Roy, Catina O'Leary, Linda M. Fleisher, Diane W. Webb, Linda Wenger, Andrea Ferris, Robert Winn. Health literacy as a tool to drive equitable action for lung cancer screening in high-risk communities [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-064.

Patient navigation to promote lung cancer screening in a community health center for people experiencing homelessness: Protocol for a pragmatic randomized controlled trial

BackgroundLung cancer is a major cause of death among people experiencing homelessness, with mortality rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) could reduce lung cancer deaths in this population, although the circumstances of homelessness present multiple barriers to LCS LDCT completion. Patient navigation is a promising strategy for overcoming these barriers. MethodsThe Investigating Navigation to Help Advance Lung Equity (INHALE) Study is a pragmatic randomized controlled trial of patient navigation for LCS among individuals receiving primary care at Boston Health Care for the Homeless Program (BHCHP). Three hundred BHCHP patients who meet Medicare/Medicaid criteria for LCS will be randomized 2:1 to usual care with (n = 200) or without (n = 100) LCS navigation. Following a structured, theory-based protocol, the patient navigator assists with each step in the LCS process, providing lung cancer education, facilitating shared decision-making visits with primary care providers (PCPs), assisting in making and attending LCS LDCT appointments, arranging follow-up when needed, and offering tobacco cessation support for smokers. The primary outcome is receipt of LCS LDCT at 6 months. Using a sequential explanatory mixed methods approach, qualitative interviews with participants and PCPs will aid in interpreting and contextualizing the trial results. DiscussionThis trial will produce the first experimental evidence on patient navigation for cancer screening in a homeless health care setting. Results could inform cancer health equity efforts at the 299 Health Care for the Homeless programs that serve over 900,000 patients annually in the US.

Lung cancer screening primer: Key information for primary care providers.

To review new evidence reported since the 2016 publication of the Canadian Task Force on Preventive Health Care recommendations and to summarize key facets of lung cancer screening to better equip primary care providers (PCPs) in anticipation of wider implementation of the recommendations. A new, large randomized controlled trial has been published since 2016, as have updates from 4 other trials. PubMed was searched for studies published between January 1, 2004, and December 31, 2020, using search words including lung cancer screening eligibility, lung cancer screening criteria, and lung cancer screening guidelines. All information from peer-reviewed articles, reference lists, books, and websites was considered. Lung cancers diagnosed at stage 4 have a 5-year survival rate of only 5% and have a disproportionate impact on those with lower socioeconomic status, rural populations, and Indigenous populations. By downstaging, or diagnosing lung cancers at an earlier and more treatable stage, lung cancer screening reduces mortality with a number needed to screen of 250 to prevent 1 death. Practical aspects of lung cancer screening are reviewed, including criteria to screen, appropriate low-dose computed tomography screening, and management of findings. Harms of screening, such as overdiagnosis and incidental findings, are discussed to allow PCPs to appropriately counsel their patients in the face of ongoing implementation of new lung cancer screening programs. Lung cancer screening, with its embedded emphasis on smoking cessation, is an excellent addition to PCPs' preventive health care tools. The implementation of formal and pilot lung cancer screening programs across Canada means that PCPs will be increasingly required to counsel their patients around the uptake of lung cancer screening.

Association between biomarkers of tobacco consumption and lung cancer risk among daily smokers

ABSTRACT Background Biomarkers of tobacco consumption may play a role in the lung cancer risk assessment. However, the role of salivary biomarkers has not been well studied. The aim of this study is to assess the use of salivary biomarkers of tobacco consumption as lung cancer screening criterion. Research design and methods Data came from the Determinants of cotinine phase 3 project (Barcelona, 2013–2014). We compared the concentrations of TSNAs, including NNAL, NNN and NNK, and cotinine, in saliva samples of 142 daily smokers from the general population according to their risk of lung cancer. High risk of lung cancer was defined as per the inclusion criteria in the US National Lung Screening Trial (NLST) and in the Dutch-Belgian lung cancer screening trial (NELSON). Results Among daily smokers accomplishing the age criterion for lung cancer screening, salivary concentrations of cotinine, NNAL and NNK adjusted for sex were significantly higher (p-value < 0.05) in daily smokers at high risk of lung cancer compared to smokers not at high risk according to both NELSON and NLST criteria. Conclusions Saliva concentrations of cotinine, NNAL and NNK may be used as additional criteria for lung cancer screening. Further research on this topic is guaranteed.

QUANTITATIVE CT ASSESSMENT IN THE CT LUNG CANCER SCREENING POPULATION: A POTENTIAL TOOL FOR SCREENING CANDIDATES FOR BRONCHOSCOPIC LUNG VOLUME REDUCTION

TOPIC: Obstructive Lung Diseases TYPE: Original Investigations PURPOSE: 15 million Americans are estimated to be eligible for CT lung cancer screening (CTLS) based on the U.S. Preventive Services Task Force guidelines. Patients who qualify for CTLS are at high-risk for numerous cardio-pulmonary co-morbidities including emphysema.Lung volume reduction surgery (LVRS) has been shown to provide a mortality benefit in a subset of subjects with upper-lobe emphysema and reduced exercise capacity. Due to the morbidity of the surgical procedure it has not achieved widespread use. Now minimally-invasive forms of LVR (bronchoscopic lung volume reduction, BLVR) with endobronchial valves (EBV) wiht placement of one-way EBVs induces atelectasis of emphysematous areas blocked by the valve and redirects airflow to more normal lung. BLVR has been shown to provide benefit in both upper and lower lobe disease in both heterogenous and homogeneous emphysema, provided there is no collateral ventilation (CV) in the target lobe. Qualifying criteria for BLVR includes FEV1 <45% pred., DLCO > 20% pred., TLC > 100% pred., RV > 175% pred. ( in some cases RV > 150%), (≥200% pred. for homogeneous) and BMI < 35. Fissure integrity of approximately 80% on CT predicts the likelihood of absence of CV and likely clinical benefit of BLVR, although CV should be ruled out through a physiological assessment. CTLS may help identify patients who could clinically benefit from BLVR or LVRS. METHODS: This restrospective, single-center study assessed all baseline CTLS exams performed from January 1, 2012 through September 30, 2017. All patients met the National Comprehensive Cancer Network Guidelines Lung Cancer Screening Version 1.2012 high-risk criteria for lung cancer screening. All analysis was performed utilizing a lung analysis software on IntelliSpace Portal 9.0 (CT COPD, Phillips Healthcare, Cleveland, OH USA). Four research assistants blinded to outcomes data performed the analysis and reviewed the multiplanar images and corrected any errors in interlobar segmentation. Attenuation of each voxel within segmented lungs was calculated automatically. Emphysema destruction was calculated as the sum of voxels with attenuation below -950 Hounsfield units (HU). RESULTS: A total of 4673 patients were included in the study. Quantitative global and lobar emphysema scores were obtained on 4495 patients ( 96.2%). A majority of patients 2845 ( 60.9%) had less than 1% emphysema destruction, 1207 ( 25.8%) had between 1-5%, 235 ( 5.0%) between 5-10% and 208 (4.5%) greater than 10%. In our cohort 124 patients (59.6%) with global % LAA ( low attenuation area) -950> 10% had heterogeneous disease defined as a delta of 15% LAA between ipsilateral lobes. There were 182 patients ( 3.9%) who had at least one lobe with at least 20% lung destruction ( %LAA -950> 20%). CONCLUSIONS: Systematic use of quantitative emphysema CT assessment in a lung cancer screening population was able to identify approximately 4% of the lung screening population who may benefit from further evaluation for candidacy for bronchoscopic or surgical lung volume reduction. Further work is needed to compare and standardize the various commercially available quantitative CT algorithms with low dose CT to better incorporate this information with clinical selection pathways for lung volume reduction. CLINICAL IMPLICATIONS: Quantitative CT Assessment may be a potential screening tool in the lung screening CT population for candidacy of bronchoscopic or surgical lung volume reduction. DISCLOSURES: No relevant relationships by Effie Adjei, source=Web Response Grant funding relationship with Genentech Please note: 9/10/2020 Added 04/23/2021 by Lee Gazourian, source=Web Response, value=Grant/Research Support No relevant relationships by Susan Kim, source=Web Response Consultant relationship with Veracyte Please note: 2019-2021 Added 06/23/2021 by Carla Lamb, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Covidien Please note: $1001 - $5000 by andrea mckee, source=Web Response, value=Salary Speaker/Speaker's Bureau relationship with Covidien Please note: $1-$1000 by andrea mckee, source=Web Response, value=Travel Advisor relationship with AstraZeneca Please note: 2019-2021 Added 04/22/2021 by Brady McKee, source=Web Response, value=Advisor Fee No relevant relationships by Timothy MD, source=Web Response No relevant relationships by Elizabeth Pagura, source=Web Response No relevant relationships by Julia Rabazzi, source=Web Response No relevant relationships by Shawn Regis, source=Web Responseresearch relationship with Veracyte Please note: 1/1/18-present Added 06/23/2021 by Kimberly Rieger-Christ, source=Web Response, value=Grant/Research Support No relevant relationships by William Thedinger, source=Web Response No relevant relationships by Christoph Wald, source=Web Response, value=Honoraria Removed 04/22/2021 by Christoph Wald, source=Web Response

Improving lung cancer screening: An equitable strategy through a tobacco treatment clinic

Annual screening with low dose chest tomography has been adopted for those at high risk to aid in the early detection of lung cancer. In addition to screening, it is recommended that such persons receive evidence-based smoking-cessation. However, both lung cancer screening and evidence-based smoking-cessation strategies are underutilized in the US. We review the impact of a dedicated Tobacco Treatment Clinic (TTC), delivering evidence-based smoking cessation strategies, on lung cancer screening enrollment. Patients of the TTC, aged 50 years or older, having a minimum 20-pack-year smoking history were included. All patients had records reviewed to see if they had received lung cancer screening; if their lung cancer screening was achieved through the TTC, this was documented as “initial screening” versus “continued screening or surveillance”. Sociodemographic variables were collected as well. As for results, between January 2019 to February 2020, 92 patients enrolled in the TTC and fulfilled criteria for lung cancer screening. The mean age was 65.7 ± 8.3 years old, with 58 (63.0%) of the patients being female. Seventy-five (81.5%) patients were African American. Of the 92, 68 (73.9%) patients had lung cancer screening, with 51 patients receiving their first lung cancer screening scan through the TTC. In conclusion, through enrollment in a dedicated TTC, a significant proportion of patients were able to access lung cancer screening for the first time. Further, many of these patients were of minority status. Having a dedicated TTC may improve current health equity gaps in lung cancer screenings in certain US populations.

Characterizing phenotypic abnormalities associated with high-risk individuals developing lung cancer using electronic health records from the All of Us researcher workbench.

The study sought to test the feasibility of conducting a phenome-wide association study to characterize phenotypic abnormalities associated with individuals at high risk for lung cancer using electronic health records. We used the beta release of the All of Us Researcher Workbench with clinical and survey data from a population of 225 000 subjects. We identified 3 cohorts of individuals at high risk to develop lung cancer based on (1) the 2013 U.S. Preventive Services Task Force criteria, (2) the long-term quitters of cigarette smoking criteria, and (3) the younger age of onset criteria. We applied the logistic regression analysis to identify the significant associations between individuals' phenotypes and their risk categories. We validated our findings against a lung cancer cohort from the same population and conducted an expert review to understand whether these associations are known or potentially novel. We found a total of 214 statistically significant associations (P < .05 with a Bonferroni correction and odds ratio > 1.5) enriched in the high-risk individuals from 3 cohorts, and 15 enriched in the low-risk individuals. Forty significant associations enriched in the high-risk individuals and 13 enriched in the low-risk individuals were validated in the cancer cohort. Expert review identified 15 potentially new associations enriched in the high-risk individuals. It is feasible to conduct a phenome-wide association study to characterize phenotypic abnormalities associated in high-risk individuals developing lung cancer using electronic health records. The All of Us Research Workbench is a promising resource for the research studies to evaluate and optimize lung cancer screening criteria.

Germline mutations and age at onset of lung adenocarcinoma.

To identify additional at-risk groups for lung cancer screening, which targets persons with a long history of smoking and thereby misses younger or nonsmoking cases, the authors evaluated germline pathogenic variants (PVs) in patients with lung adenocarcinoma for an association with an accelerated onset. The authors assembled a retrospective cohort (1999-2018) of oncogenetic clinic patients with lung adenocarcinoma. Eligibility required a family history of cancer, data on smoking, and a germline biospecimen to screen via a multigene panel. Germline PVs (TP53/EGFR, BRCA2, other Fanconi anemia [FA] pathway genes, and non-FA DNA repair genes) were interrogated for associations with the age at diagnosis via an accelerated failure time model. Subjects (n = 187; age, 28-89 years; female, 72.7%; Hispanic, 11.8%) included smokers (minimum of 5 pack-years; n = 65) and nonsmokers (lighter ever smokers [n = 18] and never smokers [n = 104]). Overall, 26.7% of the subjects carried 1 to 2 germline PVs: TP53 (n = 5), EGFR (n = 2), BRCA2 (n = 6), another FA gene (n = 11), or another DNA repair gene (n = 28). After adjustment for smoking, sex, and ethnicity, the diagnosis of lung adenocarcinoma was accelerated 12.2 years (95% confidence interval [CI], 2.5-20.6 years) by BRCA2 PVs, 9.0 years (95% CI, 0.5-16.5 years) by TP53/EGFR PVs, and 6.1 years (95% CI, -1.0 to 12.6 years) by PVs in other FA genes. PVs in other DNA repair genes showed no association. Germline associations did not vary by smoking. Among lung adenocarcinoma cases, germline PVs (TP53, EGFR, BRCA2, and possibly other FA genes) may be associated with an earlier onset. With further study, the criteria for lung cancer screening may need to include carriers of high-risk PVs, and findings could influence precision therapy and reduce lung cancer mortality by earlier stage diagnosis.

Machine Learning for Early Lung Cancer Identification Using Routine Clinical and Laboratory Data.

Rationale: Most lung cancers are diagnosed at an advanced stage. Presymptomatic identification of high-risk individuals can prompt earlier intervention and improve long-term outcomes. Objectives: To develop a model to predict a future diagnosis of lung cancer on the basis of routine clinical and laboratory data by using machine learning. Methods: We assembled data from 6,505 case patients with non-small cell lung cancer (NSCLC) and 189,597 contemporaneous control subjects and compared the accuracy of a novel machine learning model with a modified version of the well-validated 2012 Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial risk model (mPLCOm2012), by using the area under the receiver operating characteristic curve (AUC), sensitivity, and diagnostic odds ratio (OR) as measures of model performance. Measurements and Main Results: Among ever-smokers in the test set, a machine learning model was more accurate than the mPLCOm2012 for identifying NSCLC 9-12 months before clinical diagnosis (P < 0.00001) and demonstrated an AUC of 0.86, a diagnostic OR of 12.3, and a sensitivity of 40.1% at a predefined specificity of 95%. In comparison, the mPLCOm2012 demonstrated an AUC of 0.79, an OR of 7.4, and a sensitivity of 27.9% at the same specificity. The machine learning model was more accurate than standard eligibility criteria for lung cancer screening and more accurate than the mPLCOm2012 when applied to a screening-eligible population. Influential model variables included known risk factors and novel predictors such as white blood cell and platelet counts. Conclusions: A machine learning model was more accurate for early diagnosis of NSCLC than either standard eligibility criteria for screening or the mPLCOm2012, demonstrating the potential to help prevent lung cancer deaths through early detection.

Brief Report: Risk Prediction Model Versus United States Preventive Services Task Force 2020 Draft Lung Cancer Screening Eligibility Criteria—Reducing Race Disparities

IntroductionEligibility criteria for lung cancer screening based solely on age and smoking history are less sensitive than validated risk prediction models. The U.S. Preventive Services Task Force (USPSTF) has proposed new guidelines to improve the sensitivity for selecting high-risk individuals and to decrease race disparity. In this retrospective study, termed the Chicago Race Eligibility for Screening Cohort, we compare the sensitivity of the proposed USPSTF2020 criteria versus the PLCOm2012 risk prediction model for selecting a racially diverse lung cancer population with a smoking history for lung cancer screening. MethodsThis Chicago Race Eligibility for Screening Cohort study applies the PLCOm2012 model with a risk threshold of 1.0%/6 years and the USPSTF2020 criteria (age 50–80 y, pack-years ≥ 20 y, quit-years ≤ 15 y) to 883 individuals with a smoking history diagnosed with having lung cancer. ResultsThe PLCOm2012 was more sensitive than the USPSTF2020 overall (79.1% versus 68.6%, p < 0.0001) in White (81.5% versus 75.4%, p = 0.029) and in African American (82.8% versus 70.6% p < 0.0001) individuals. Of the total cohort, 254 (28.8%) would not have qualified owing to less than 20 pack-years, quit-time of more than 15 years, and age less than 50 years. Of these 254 cases, 40% would have qualified by the PLCOm2012 model. For the 20 pack-year criterion, of the 497 African American individuals, 19.3% did not meet this criterion, and of these, an additional 31.3% would have qualified by the PLCOm2012 model (p = 0.002). ConclusionsAlthough more sensitive than USPSTF2013, the proposed USPSTF2020 draft guidelines still have a race disparity in eligibility for screening. This study provides “real world” evidence that use of the PLCOm2012 risk prediction model eliminates this race disparity.

Closing the gap in health care disparities by improving the rate of lung cancer screening in an intercity hospital.

195 Background: The National Lung Cancer Screening Trial showed reduced lung cancer mortality with low-dose computed tomography (LDCT) screening. Although LDCT is generally covered by private and government insurance, the rate of LDCT screening has been reported to be very low (2-3%) in previous studies. One of the main barriers in adequate screening was assessment of smoking history to identify eligible populations. Purpose: To increase the rate of lung cancer screening in Medstar Washington Hospital Center Internal Medicine (WHCIM) clinics from a baseline rate of 2.88% by 50% over a 3-month period. Methods: Retrospective baseline data was collected over a 2-week period 01/06/2020–01/17/2020 from patients visits at WHCIM to assess the rate of lung cancer screening. A session was held with physicians and nursing staff to find the barriers in identifying eligible patients for lung cancer screening and to create a fishbone diagram. The first plan-do-study act cycle (PDSA) was initiated from 02/24/2020–03/13/2020 where we piloted a clinical reminder in the form of a print-out filled out by the medical assistants at check in and then given to physicians. The form included the patient's age and simple smoking questionnaire according to the lung cancer screening guidelines. Data was collected during this time period which included documentation of patient’s smoking history, lung cancer screening eligibility and referral to LDCT. Results: By retrospective analysis from the time period of 01/06/2020-01/17/2020 providers documented a smoking history in only 16% of patients seen and only 2.88% of all patients seen over the age of 55 were referred for lung cancer screening. Post intervention for the time period of 02/24/2020-03/13/2020 increased the amount of documented smoking history by providers to 26% and number of patients sent for lung cancer screening to 6.0%. Of patients who met the criteria for lung cancer screening, prior to the intervention only 42% of patients were referred. However, after the clinical reminder has been initiated, 86% of patients who did meet the criteria were sent for screening. Conclusions: The clinical reminder has increased documentation of smoking history by 62% and lung cancer screening for those who meet the criteria according to the guidelines by a relative increase of 105%. We are currently working on PDSA cycle 2 to incorporate education materials in the encounter room and PDSA cycle 3 to incorporate this clinical reminder into the electronic medical record and to implement hospital wide.

IMPROVING RATE OF LUNG CANCER SCREENING IN PRIMARY CARE CLINIC

SESSION TITLE: Lung Cancer Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: The National Lung Cancer Screening Trial showed reduced lung cancer mortality with low-dose computed tomography (LDCT) screening. Although LDCT is generally covered by private and government insurance, the rate of LDCT screening is reported to be about 2-3% in previous studies. One of the main barrier in adequate screening was assessment of smoking history to identify eligible populations. Our study aims to address this barrier and improve the rate of lung cancer screening in Medstar Washington Hospital Center Internal Medicine (WHCIM) clinics. We aim to achieve an improvement from a baseline rate of 2.88% by 50% over a 3-month period. METHODS: Data from cumulative patient visits at WHCIM clinic was collected over a 2 week period to assess the baseline rate of LDCT screening. After multidisciplinary team meeting to assess the barriers in adequate screening, we piloted a clinical reminder in the form of print-out form given to physicians from the medical assistants. This served to remind physicians to take detailed smoking histories and included the current lung cancer screening guidelines. This reminder is being given to providers for each patient seen in the clinic and the results will be followed for the next 3 months. For this study post-intervention data was collected over a 2 week period. RESULTS: Preceding the intervention, providers documented a smoking history in 16% of patients seen where post-intervention was 26%. Prior to the clinical reminder 2.88% of all patients seen over the age of 55 were referred for lung cancer screening which has now increased to 6.0%. Of patients who met the criteria for lung cancer screening, prior to the intervention only 42% of patients were referred for LDCT. However, after the clinical reminder has been initiated, 86% of patients who did meet the criteria were sent for screening. CONCLUSIONS: Our intervention has increased documentation of smoking history by 62% and lung cancer screening, for those who meet the criteria according to the guidelines, by a relative increase of 105%. We are currently working on further interventions to incorporate this clinical reminder into the electronic medical record and to implement this across the Medstar Health Hospitals. CLINICAL IMPLICATIONS: Lung cancer is the leading cause of death not only in the United States, but throughout the world. Improving the rate of lung cancer screening by addressing barriers is a simple and cost-effective method that would go a long way in lowering lung cancer mortality. Furthermore, multidisciplinary team involvement helps address gaps in patient care in a holistic manner. DISCLOSURES: No relevant relationships by Anika Bhargava, source=Web Response No relevant relationships by Akshay Kohli, source=Web Response no disclosure on file for Irina Veytsman