Implementation Of Lung Cancer Screening Research Articles

Deep Learning Reconstruction Shows Better Lung Nodule Detection for Ultra-Low-Dose Chest CT.

Background Ultra-low-dose (ULD) CT could facilitate the clinical implementation of large-scale lung cancer screening while minimizing the radiation dose. However, traditional image reconstruction methods are associated with image noise in low-dose acquisitions. Purpose To compare the image quality and lung nodule detectability of deep learning image reconstruction (DLIR) and adaptive statistical iterative reconstruction-V (ASIR-V) in ULD CT. Materials and Methods Patients who underwent noncontrast ULD CT (performed at 0.07 or 0.14 mSv, similar to a single chest radiograph) and contrast-enhanced chest CT (CECT) from April to June 2020 were included in this prospective study. ULD CT images were reconstructed with filtered back projection (FBP), ASIR-V, and DLIR. Three-dimensional segmentation of lung tissue was performed to evaluate image noise. Radiologists detected and measured nodules with use of a deep learning-based nodule assessment system and recognized malignancy-related imaging features. Bland-Altman analysis and repeated-measures analysis of variance were used to evaluate the differences between ULD CT images and CECT images. Results A total of 203 participants (mean age ± standard deviation, 61 years ± 12; 129 men) with 1066 nodules were included, with 100 scans at 0.07 mSv and 103 scans at 0.14 mSv. The mean lung tissue noise ± standard deviation was 46 HU ± 4 for CECT and 59 HU ± 4, 56 HU ± 4, 53 HU ± 4, 54 HU ± 4, and 51 HU ± 4 in FBP, ASIR-V level 40%, ASIR-V level 80% (ASIR-V-80%), medium-strength DLIR, and high-strength DLIR (DLIR-H), respectively, of ULD CT scans (P < .001). The nodule detection rates of FBP reconstruction, ASIR-V-80%, and DLIR-H were 62.5% (666 of 1066 nodules), 73.3% (781 of 1066 nodules), and 75.8% (808 of 1066 nodules), respectively (P < .001). Bland-Altman analysis showed the percentage difference in long diameter from that of CECT was 9.3% (95% CI of the mean: 8.0, 10.6), 9.2% (95% CI of the mean: 8.0, 10.4), and 6.2% (95% CI of the mean: 5.0, 7.4) in FBP reconstruction, ASIR-V-80%, and DLIR-H, respectively (P < .001). Conclusion Compared with adaptive statistical iterative reconstruction-V, deep learning image reconstruction reduced image noise, increased nodule detection rate, and improved measurement accuracy on ultra-low-dose chest CT images. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Lee in this issue.

Socio-Economic Inequalities in Lung Cancer Outcomes: An Overview of Systematic Reviews.

Simple SummaryLung cancer is the leading cause of cancer mortality worldwide. Research has revealed significant socio-economic inequalities in lung cancer, such that people of lower socio-economic status (SES) generally have worse outcomes. In this article, using the umbrella review methodology, we review and organize the available evidence on socio-economic inequalities in diverse lung cancer outcomes. We find that people of a lower SES have a lower chance of cancer survival, most likely due to the lower likelihood of receiving both traditional and next-generation treatments, higher rates of comorbidities, and higher likelihood of being admitted as emergency. People of a lower SES are generally not diagnosed at later stages, but this may change after broader implementation of lung cancer screening, as early evidence suggests that there are socio-economic inequalities in its use.In the past decade, evidence has accumulated about socio-economic inequalities in very diverse lung cancer outcomes. To better understand the global effects of socio-economic factors in lung cancer, we conducted an overview of systematic reviews. Four databases were searched for systematic reviews reporting on the relationship between measures of socio-economic status (SES) (individual or area-based) and diverse lung cancer outcomes, including epidemiological indicators and diagnosis- and treatment-related variables. AMSTAR-2 was used to assess the quality of the selected systematic reviews. Eight systematic reviews based on 220 original studies and 8 different indicators were identified. Compared to people with a high SES, people with a lower SES appear to be more likely to develop and die from lung cancer. People with lower SES also have lower cancer survival, most likely due to the lower likelihood of receiving both traditional and next-generation treatments, higher rates of comorbidities, and the higher likelihood of being admitted as emergency. People with a lower SES are generally not diagnosed at later stages, but this may change after broader implementation of lung cancer screening, as early evidence suggests that there may be socio-economic inequalities in its use.

Abstract IA-49: Facilitators and barriers to implementing low-dose CT screening for lung cancer in a tribal health system

Abstract Lung cancer is the leading cause of cancer mortality among American Indians and Alaska Natives (AI/AN), and many AI/AN communities have worse lung cancer incidence rates, survival, and death compared to the general population. Although lung cancer screening (LCS) with low-dose computed tomography is a grade-B USPSTF recommendation, uptake of LCS has been slow in most healthcare systems. LCS implementation among AI/AN has not been studied before in detail. To address this knowledge and implementation gap, a multi-phase, 5-year “Tribally Engaged Approaches to Lung Screening" (TEALS) study was launched in 2019 in partnership with the Choctaw Nation of Oklahoma. The overarching goal of this project is to co-design and test an LCS implementation program. This presentation will discuss what is being learned about potential facilitators and barriers to implementing LCS in a tribal health care setting. Findings may be pertinent to other health systems serving tribal, rural or underserved populations. Citation Format: Zsolt J. Nagykáldi. Facilitators and barriers to implementing low-dose CT screening for lung cancer in a tribal health system [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 IA-49.

Access to Care Limits Lung Cancer Screening Eligibility in an Urban Safety Net Hospital.

Purpose:Lung cancer screening (LCS) results in earlier detection of malignancy and decreases mortality but requires access to care to benefit. We assessed factors associated with timing of lung cancer diagnosis in the absence of systematic LCS in an urban safety net hospital.Patients and Methods:Retrospective chart review was performed of patients with pathologic diagnosis and/or staging of lung cancer at our institution between 2015 and 2018. Patient socio-demographics, disease characteristics, factors associated with access to medical care, and time point and process by which the patient accessed care were collected and analyzed.Results:In total, 223 patients were identified with median age of 63 years and 57.8% male predominance. Racial distribution was 22.9%, 20.2%, 17.1%, and 9.4% for Black, White, Asian, and Hispanic, respectively. Stage at diagnosis was 8.1%, 4.5%, 17.0%, and 60.5% for stages I, II, III, and IV, respectively. Medicaid (59.6%) and Medicare/Medicaid (17.1%) were the most common insurance types, while 16.1% had no insurance. A majority (54.3%) had no established primary care provider (PCP), and only 17.9% had an in-network PCP. Patients without PCPs were more likely to have diagnostic evaluation initiated from Emergency Department or Urgent Care settings (95.0% vs 50.1%, P < .01) and present with later stage disease (92.7% vs 77.8%, P < .01). Of the 83 patients that met age and smoking history LCS criteria, only 33.7% (12.6% of total) also had an in-network PCP.Conclusion:Absence of established PCPs is associated with later stage presentation of lung cancer and may limit system- level benefits of LCS implementation.

Engaging veteran stakeholders to identify patient-centred research priorities for optimizing implementation of lung cancer screening.

BackgroundPatient engagement in research agenda setting is increasingly being seen as a strategy to improve the responsiveness of healthcare to patient priorities. Implementation of low‐dose computed tomography (LDCT) screening for lung cancer is suboptimal, suggesting that research is needed.ObjectivesThis study aimed to describe an approach by which a Veteran patient group worked with other stakeholders to develop a research agenda for LDCT screening and to describe the research questions that they prioritized.MethodsWe worked with Veterans organizations to identify 12 Veterans or family members at risk for or having experience with lung cancer to form a Patient Advisory Council (PAC). The PAC met repeatedly from June 2018 to December 2020, both independently and jointly, with stakeholders representing clinicians, health administrators and researchers to identify relevant research topics. The PAC prioritized these topics and then identified questions within these areas where research was needed using an iterative process. Finally, they ranked the importance of obtaining answers to these questions.ResultsPAC members valued the co‐learning generated by interactions with stakeholders, but emphasized the importance of facilitation to avoid stakeholders dominating the discussion. The PAC prioritized three broad research areas—(1) the impact of insurance on uptake of LDCT; (2) how best to inform Veterans about LDCT; and (3) follow‐up and impact of screening results. Using these areas as guides, PAC members identified 20 specific questions, ranking as most important (1) innovative outreach methods, (2) the impact of screening on psychological health, and (3) the impact of outsourcing scans from VA to non‐VA providers on completion of recommended follow‐up of screening results. The latter two were not identified as high priority by the stakeholder group.ConclusionsWe present an approach that facilitates co‐learning between Veteran patients and providers, researchers and health system administrators to increase patient confidence in their ability to contribute important information to a research agenda. The research questions prioritized by the Veterans who participated in this project illustrate that for this new screening technology, patients are concerned about the practical details of implementation (e.g., follow‐up) and the technology's impact on quality of life.Patient or Public ContributionVeterans and Veteran advocates contributed to our research team throughout the entire research process, including conceiving and co‐authoring this manuscript.

Impact of the National Lung Screening Trial (NLST) publication and Medicare Lung cancer screening payment on lung cancer incidence rates: An interrupted time series analysis

IntroductionExplore the impact of the Lung Cancer Screening Trial (NLST-September-2011) and the Medicare approval for CT-screening (CT-LCS-AP-February-2015) on lung cancer incidence rates, mortality, and the percentage of early-stage lung cancer diagnosis (ESLCD-T1-T2N0M0). MethodsRetrospective interrupted time series analysis using SEER-18 database. All individuals with lung cancer (LC) diagnosis from 2006 to 2016 were included. The effect of NLST and CT-AP-2015 on the monthly percentage of early-stage ESLCD was the primary outcome, additionally LC incidence and mortality rates were calculated. The analysis was performed by age, sex, race, marital status, insurance status, and household income. Bivariate and multivariate models were used to identify predictors of ESLCD. ResultsThe study cohort was composed by 388,207 individuals, 69 years old in average, 46.6 % female, and 81.1 % white. LC incidence and mortality rates declined from 2006 to 2016 without association with NLST-September-2011 and CT-LCS-AP-February-2015. The percentage of ESLCD increased over time for all groups. Overall rates of ESLCD started at 18 % in January-2006 and increased to 25 % by December-2016. The intervention NLST-2011 did not show an impact in the ESLCD while the CT-AP-2015 showed a significant impact in the ESLCD trend (p < 0.001). ESLCD was associated with female, white, insurance, and household incomes above median. Medicare expansion was a significant factor for insured group, married patients and those from households under the median income level. ConclusionMedicare approval for CT screening was found to have a statistically significant effect on the diagnosis of early-stage lung cancer and neither NLST-September-2011 nor CT-AP-2015-February-2015 impacted the incidence nor mortality rates. Policy summaryTo improve early-stage lung cancer diagnosis, it is vital to invest in health policies to increase Lung Cancer Screening implementation and to reduce disparities in access to diagnosis. Furthermore, policies that facilitate access to diagnosis and treatment are crucial to reduce lung cancer mortality.

Lung Cancer Screening Considerations During Respiratory Infection Outbreaks, Epidemics or Pandemics: An International Association for the Study of Lung Cancer Early Detection and Screening Committee Report

After the results of two large, randomized trials, the global implementation of lung cancer screening is of utmost importance. However, coronavirus disease 2019 infections occurring at heightened levels during the current global pandemic and also other respiratory infections can influence scan interpretation and screening safety and uptake. Several respiratory infections can lead to lesions that mimic malignant nodules and other imaging changes suggesting malignancy, leading to an increased level of follow-up procedures or even invasive diagnostic procedures. In periods of increased rates of respiratory infections from severe acute respiratory syndrome coronavirus 2 and others, there is also a risk of transmission of these infections to the health care providers, the screenees, and patients. This became evident with the severe acute respiratory syndrome coronavirus 2 pandemic that led to a temporary global stoppage of lung cancer and other cancer screening programs. Data on the optimal management of these situations are not available. The pandemic is still ongoing and further periods of increased respiratory infections will come, in which practical guidance would be helpful.The aims of this report were: (1) to summarize the data available for possible false-positive results owing to respiratory infections; (2) to evaluate the safety concerns for screening during times of increased respiratory infections, especially during a regional outbreak or an epidemic or pandemic event; (3) to provide guidance on these situations; and (4) to stimulate research and discussions about these scenarios.

Cribado de cáncer de pulmón: Supervivencia en un amplio programa de detección precoz en España (I-ELCAP)

IntroductionLung cancer (LC) is usually diagnosed at advanced stages with only a 12% 5-year survival. Trials as NLST and NELSON show a mortality decrease, which justifies implementation of lung cancer screening in risk population. Our objective was to show survival results of the largest LC screening program in Spain with low dosage computed tomography (LDCT). MethodsClinical records from International Early Lung Cancer Detection Program (IELCAP) at Valencia, Spain were analysed. This program recruited volunteers, ever-smokers aged 40-80 years, since 2008. Results are compared to those from other similar sizeable programs. ResultsA total of 8278 participants were screened with at least two-rounds until November 2020. A mean of 6 annual screening rounds were performed. We detected 239 tumours along 12-year follow-up. Adenocarcinoma was the most common histology, being 61.3% at stage I. The lung cancer prevalence and incidence proportion was 1.5% and 1.4%, respectively with an annual detection rate of 0.17. One-year survival and 10-year survival were 90% and 80.1%, respectively. Adherence was 96.84%. ConclusionLargest lung cancer screening in Spain shows that survival is improved when is performed in multidisciplinary team experienced in management of LC, and is comparable to similar screening programs.

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.

A modeling analysis to compare eligibility strategies for lung cancer screening in Brazil.

BackgroundCountry-specific evidence is needed to guide decisions regarding whether and how to implement lung cancer screening in different settings. For this study, we estimated the potential numbers of individuals screened and lung cancer deaths prevented in Brazil after applying different strategies to define screening eligibility.MethodsWe applied the Lung Cancer Death Risk Assessment Tool (LCDRAT) to survey data on current and former smokers (ever-smokers) in 15 Brazilian state capital cities that comprise 18% of the Brazilian population. We evaluated three strategies to define eligibility for screening: (1) pack-years and cessation time (≥30 pack-years and <15 years since cessation); (2) the LCDRAT risk model with a fixed risk threshold; and (3) LCDRAT with age-specific risk thresholds.FindingsAmong 2.3 million Brazilian ever-smokers aged 55–79 years, 21,459 (95%CI 20,532–22,387) lung cancer deaths were predicted over 5 years without screening. Applying the fixed risk-based eligibility definition would prevent more lung cancer deaths than the pack-years definition [2,939 (95%CI 2751–3127) vs. 2,500 (95%CI 2318–2681) lung cancer deaths], and with higher screening efficiency [NNS=177 (95%CI 170–183) vs. 205 (95%CI 194–216)], but would tend to screen older individuals [mean age 67.8 (95%CI 67.5–68.2) vs. 63.4 (95%CI 63.0–63.9) years]. Applying age-specific risk thresholds would allow younger ever-smokers to be screened, although these individuals would be at lower risk. The age-specific thresholds strategy would avert three-fifths (60.1%) of preventable lung cancer deaths [N = 2629 (95%CI 2448–2810)] by screening 21.9% of ever-smokers.InterpretationThe definition of eligibility impacts the efficiency of lung cancer screening and the mean age of the eligible population. As implementation of lung screening proceeds in different countries, our analytical framework can be used to guide similar analyses in other contexts. Due to limitations of our models, more research would be needed.

Lung cancer screening: a critical appraisal.

The recently published large-scale NELSON trial showed a reduction in lung cancer (LC) mortality with the use of low-dose computed tomography (LDCT) in high-risk patients. This is the first such European-based trial to mirror the results of the US National Lung Screening Trial (NLST). The NLST was responsible for nationwide implementation of LC screening protocols which has shown a decrease in LC mortality. However, the implementation of such screening in Europe has been challenging. With the findings from the NELSON trial, implementation of LC screening throughout Europe should once again be evaluated. This review article further elaborates on the advantages of LDCT in LC screening. It also discusses promising future approaches that can supplement the current LC screening guidelines. Implementation of LC screening with LDCT should again be evaluated throughout Europe as it could substantially decrease LC-related mortality.

P61.10 Swiss Pilot Low-Dose Computed Tomography Lung Cancer Screening Study

Low-dose computed tomography (LDCT) lung cancer screening is endorsed by United States guidelines and has recently been shown effective in a large European randomized controlled trial. Nevertheless, the actual realization of a lung cancer screening program is challenging and depends on country-specific factors. This pilot study aimed to evaluate implementation, execution and performance of LDCT lung cancer screening in Switzerland. Starting from October 2018, asymptomatic participants aged 55-74 years with more than 30 pack-years smoking history were enrolled at a tertiary hospital in Switzerland. Participants with history of lung cancer, major (palliative) health problems or those that had a thorax CT scan 18 months prior to enrollment were excluded. First line we evaluated lung cancer risk according NLST guidelines. Secondly, we estimated lung cancer risk using the PLCOm2012 model risk calculater with a threshold of 5%. Lung nodules were assessed according Lung-RADS 1.1 {ACoR. Lung-Screening Reporting and Data System (LungRADS) Version 1.1. 2019}. Participants were predominantly recruited through flyers, a newspaper article and pulmonary specialists. Screening consisted of one LDCT-scan and follow-up was recommended for suspicious nodules only. LDCT assessment was performed by two radiologists, one of them a board certified chest radiologist. Enrollment and follow-up are currently ongoing. To date, 75 participants with a median age of 62 years (interquartile range [IQR] 56-67 years) were included. The median number of pack years smoked was 49 (IQR 41-58 pack years) and 25 (33%) were female. The median PLCOm2012 6-year lung cancer probability was 2.7% (IQR 2.6-2.9%) and 19 (26%) participants had stopped smoking before enrollment. Of the 75 participants, 61 (81%) were found to have calcified or non-calcified lung nodules. 6 participants required follow up imaging of suspect nodules which resulted in a recall rate of 8%. At baseline, lung cancer was found in 2 (2.7%) participants. The lung cancers were one squamous cell carcinoma (stage IIIA) and one adenocarcinoma (stage IV). In this Swiss LDCT lung cancer screening pilot study using modified inclusion criteria, lung nodules were found in a significant number of participants of whom 2.7 % were diagnosed with lung cancer to date. To date, the recall rate for follow-up imaging is 8%.

Implementing lung cancer screening in primary care: needs assessment and implementation strategy design.

Lung cancer screening with low-dose computed tomography (CT) could help avert thousands of deaths each year. Since the implementation of screening is complex and underspecified, there is a need for systematic and theory-based strategies. Explore the implementation of lung cancer screening in primary care, in the context of integrating a decision aid into the electronic health record. Design implementation strategies that target hypothesized mechanisms of change and context-specific barriers. The study had two phases. The Qualitative Analysis phase included semi-structured interviews with primary care physicians to elicit key task behaviors (e.g., ordering a low-dose CT) and understand the underlying behavioral determinants (e.g., social influence). The Implementation Strategy Design phase consisted of defining implementation strategies and hypothesizing causal pathways to improve screening with a decision aid. Three key task behaviors and four behavioral determinants emerged from 14 interviews. Implementation strategies were designed to target multiple levels of influence. Strategies included increasing provider self-efficacy toward performing shared decision making and using the decision aid, improving provider performance expectancy toward ordering a low-dose CT, increasing social influence toward performing shared decision making and using the decision aid, and addressing key facilitators to using the decision aid. This study contributes knowledge about theoretical determinants of key task behaviors associated with lung cancer screening. We designed implementation strategies according to causal pathways that can be replicated and tested at other institutions. Future research is needed to evaluate the effectiveness of these strategies and to determine the contexts in which they can be effectively applied.

Contemporary issues in the implementation of lung cancer screening.

Lung cancer screening with low-dose computed tomography can reduce death from lung cancer by 20-24% in high-risk smokers. National lung cancer screening programmes have been implemented in the USA and Korea and are being implemented in Europe, Canada and other countries. Lung cancer screening is a process, not a test. It requires an organised programmatic approach to replicate the lung cancer mortality reduction and safety of pivotal clinical trials. Cost-effectiveness of a screening programme is strongly influenced by screening sensitivity and specificity, age to stop screening, integration of smoking cessation intervention for current smokers, screening uptake, nodule management and treatment costs. Appropriate management of screen-detected lung nodules has significant implications for healthcare resource utilisation and minimising harm from radiation exposure related to imaging studies, invasive procedures and clinically significant distress. This review focuses on selected contemporary issues in the path to implement a cost-effective lung cancer screening at the population level. The future impact of emerging technologies such as deep learning and biomarkers are also discussed.

Imaging Administrators: The Overlooked Barrier to Lung Cancer Screening Implementation

Imaging Administrators: The Overlooked Barrier to Lung Cancer Screening Implementation

Perspectives of stereotactic radiotherapy in primary and oligo-metastatic pulmonary tumors

Lung cancer (LC) is a common malignant neoplasm (MN) with high lethality, often detected at late stages. The implementation of lung cancer screening can change the ratio in favor of the early stages. Screening could help diagnose early-stage LC in 60% of patients. Multiple primary LCs occur in 4–10% of patients within five years after treatment. The presence of oligo-metastatic disease only in the lungs (up to 5 nodules) occurs in 6-40% of patients with malignant tumors, and complete resection could increase 5-year survival to 20-40%. Due to functional limitations, surgical treatment can be performed only in 65-70% of patients. Stereotactic radiation therapy gives an opportunity to accurately deliver a high dose of radiation to the tumor with minimal damage to the surrounding healthy tissues. Local control is possible in 85–95% of cases, and 3-year overall survival is about 60–80%. New algorithms for fractionation and dose determination (BED10 ≥ 100 Gy) could improve the treatment results for early-stage lung cancer and oligometastatic lesions. In this non-systematic review, we analyze a recent publication and our own experience. We consider the effectiveness and safety of stereotactic radiotherapy and planning, modeling, fractionation, dose restrictions on critical organs, radiation reactions, and adverse events. We conclude that randomized controlled trials can reveal the stereotactic radiation therapy's potential in patients with primary and oligo-metastatic pulmonary tumors.

"It's Really Like Any Other Study": Rural Radiology Facilities Performing Low-Dose Computed Tomography for Lung Cancer Screening.

Rationale: The majority of eligible people have not been screened for lung cancer. There is emerging evidence that there are location-based disparities applicable to lung cancer screening (LCS). Objectives: To describe LCS radiologic services in rural Oregon and understand the barriers and facilitators to implementation of LCS using low-dose computed tomography (LDCT). Methods: This was a mixed-method descriptive study using surveys and semistructured interviews of key informants. We approached representatives from all 37 small and rural hospitals in Oregon. We purposively interviewed key informants from a subset based on LDCT implementation outcomes. Results: We surveyed representatives from 29 radiology facilities and qualitatively interviewed 18 key informants from 19 facilities (representing 12 healthcare systems). Among the surveyed radiology facilities, 59% were performing LDCT for LCS. Key informants reported that facilities that performed this service were often motivated by community needs and were less motivated by financial gain or evidence strength, and all described the importance of having a champion. Key informants described that LCS programmatic components that were within their normal scope of practice (e.g., specifying the LDCT parameters) were burdensome to establish but that barriers were surmountable. Most informants reported they did not perform other components of high-quality programs (e.g., ensuring adherence to recommended follow-up testing) and suggested that these steps were important but were the responsibility of primary care providers. Conclusions: Many rural hospital facilities in Oregon offer LDCT for LCS but do not perform all the recommended components of a screening program. Disparities in LCS use and adherence are unlikely to be solved by an exclusive focus at the radiology facility level and may require additional interventions at the primary care level.

Characteristics and Outcomes of Lung Cancers Detected on Low-Dose Lung Cancer Screening CT.

Lung cancer screening (LCS) with low-dose CT (LDCT) was implemented in the United States following the National Lung Screening Trial (NLST). The real-world benefits of implementing LCS are yet to be determined with outcome-oriented data. The study objective is to investigate the characteristics and outcomes of screening-detected lung cancers. This single-institution retrospective study included LCS patients between June 2014 and December 2019. Patient demographics, number of screening rounds, imaging features, clinical workup, disease extent, histopathology, treatment, complications, and mortality outcomes of screening-detected lung cancers were extracted and compared with NLST data. LCS LDCTs (7,480) were performed on 4,176 patients. The cancer detection rate was 3.8%, higher than reported by NLST (2.4%, P < 0.0001), and cancers were most often found in patients ≥65 years (62%), older than those in NLST (41%, P < 0.0001). The patients' ethnicity was similar to NLST, P = 0.87. Most LCS-detected cancers were early stage I tumors (71% vs. 54% in NLST, P < 0.0001). Two thirds of cancers were detected in the first round of screening (67.1%) and were multifocal lung cancers in 15%. As in NLST, the complication rate after invasive workup or surgery was low (24% vs. 28% in NLST, P = 0.32). Over a median follow-up of 3.3 years, the mortality rate was 0.45%, lower than NLST (1.33%, P < 0.0001). LCS implementation achieved a higher cancer detection rate, detection of early-stage cancers, and more multifocal lung cancers compared with the NLST, with low complications and mortality. The real-world implementation of LCS has been successful for detection of lung cancer with favorable outcomes.

Personalising lung cancer screening: An overview of risk-stratification opportunities and challenges.

Randomised clinical trials have shown the efficacy of computed tomography lung cancer screening, initiating discussions on whether and how to implement population‐based screening programs. Due to smoking behaviour being the primary risk‐factor for lung cancer and part of the criteria for determining screening eligibility, lung cancer screening is inherently risk‐based. In fact, the selection of high‐risk individuals has been shown to be essential in implementing lung cancer screening in a cost‐effective manner. Furthermore, studies have shown that further risk‐stratification may improve screening efficiency, allow personalisation of the screening interval and reduce health disparities. However, implementing risk‐based lung cancer screening programs also requires overcoming a number of challenges. There are indications that risk‐based approaches can negatively influence the trade‐off between individual benefits and harms if not applied thoughtfully. Large‐scale implementation of targeted, risk‐based screening programs has been limited thus far. Consequently, questions remain on how to efficiently identify and invite high‐risk individuals from the general population. Finally, while risk‐based approaches may increase screening program efficiency, efficiency should be balanced with the overall impact of the screening program. In this review, we will address the opportunities and challenges in applying risk‐stratification in different aspects of lung cancer screening programs, as well as the balance between screening program efficiency and impact.

Ongoing challenges in implementation of lung cancer screening.

Lung cancer is the leading cause of cancer deaths in Europe and around the world. Although available therapies have undergone considerable development in the past decades, the five-year survival rate for lung cancer remains low. This sobering outlook results mainly from the advanced stages of cancer most patients are diagnosed with. As the population at risk is relatively well defined and early stage disease is potentially curable, lung cancer outcomes may be improved by screening. Several studies already show that lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality. However, for a successful implementation of LCS programmes, several challenges have to be overcome: selection of high-risk individuals, standardization of nodule classification and measurement, specific training of radiologists, optimization of screening intervals and screening duration, handling of ancillary findings are some of the major points which should be addressed. Last but not least, the psychological impact of screening on screened individuals and the impact of potential false positive findings should not be neglected. The aim of this review is to discuss the different challenges of implementing LCS programmes and to give some hints on how to overcome them. Finally, we will also discuss the psychological impact of screening on quality of life and the importance of smoking cessation.