Initial Low-dose Computed Tomography Research Articles

Baseline Cell-Free DNA Can Predict Malignancy of Nodules Observed in the ITALUNG Screening Trial.

The role of total plasma cell-free DNA (cfDNA) in lung cancer (LC) screening with low-dose computed tomography (LDCT) is uncertain. We hypothesized that cfDNA could support differentiation between malignant and benign nodules observed in LDCT. The baseline cfDNA was measured in 137 subjects of the ITALUNG trial, including 29 subjects with screen-detected LC (17 prevalent and 12 incident) and 108 subjects with benign nodules. The predictive capability of baseline cfDNA to differentiate malignant and benign nodules was compared to that of Lung-RADS classification and Brock score at initial LDCT (iLDCT). Subjects with prevalent LC showed both well-discriminating radiological characteristics of the malignant nodule (16 of 17 were classified as Lung-RADS 4) and markedly increased cfDNA (mean 18.8 ng/mL). The mean diameters and Brock scores of malignant nodules at iLDCT in subjects who were diagnosed with incident LC were not different from those of benign nodules. However, 75% (9/12) of subjects with incident LC showed a baseline cfDNA ≥ 3.15 ng/mL, compared to 34% (37/108) of subjects with benign nodules (p = 0.006). Moreover, baseline cfDNA was correlated (p = 0.001) with tumor growth, measured with volume doubling time. In conclusion, increased baseline cfDNA may help to differentiate subjects with malignant and benign nodules at LDCT.

Promoting lung cancer screening of high-risk patients by primary care providers.

Lung cancer screening (LCS) with low-dose computed tomography (LDCT) of the chest of eligible patients remains low. Accordingly, augmentation of appropriate LCS referrals by primary care providers (PCPs) was sought. The quality improvement (QI) project was performed between April 2021 and June 2022. It incorporated patient education, shared decision-making (SDM) with PCPs, and tracking of initial LDCT completion. In each case, lag time (LT) to LCS and pack-years (PYs) were calculated from initial LCS eligibility. The cohort's scores were compared to national scores. Patient zip codes were used to create a geographic map of our cohort for comparison with public health data. An immediate and sustained increase in weekly LCS referrals from PCPs was recorded. Of 337 initial referrals, 95% were men, consisting of 66.2% Black, 28.4% White, and 5.4% other. Mean PY was less for minorities (45.3 vs. 37.3years; p=.0002) but mean LT was greater for Whites (7.9 vs. 6.2years; p=.03). Twenty-five percent of veterans failed to report to their scheduled screening, and two declined referrals. Notably, most no-show patients lived in transit deserts. Furthermore, Lung-RADS scores 4B/4X were more than double the expected prevalence (p=.008). The PCPs in this study successfully augmented LCS referrals. A substantial proportion of these patients were no-shows, and our data suggest complex racial and socioeconomic factors as contributing variables. In addition, a higher-than-expected number of initial Lung-RADS scores 4B/4X were reported. A large, multisite QI project is warranted to address overcoming potential transportation barriers in high-risk patient populations.

Patient perception and adherence to lung cancer screening in those who meet eligibility criteria.

e22503 Background: The US Preventive Services Task Force reported 14.2 million Americans qualify for lung cancer screening. As per the Lung Cancer Screening Trial, using low dose computed tomography (LDCT) for screening demonstrated a 20% reduction in lung cancer-related deaths. Despite that, the 2022 State of Lung Cancer Report from the American Lung Association indicates that only 5.8% of eligible patients in the U.S. undergo lung cancer screening. Indiana, where this study was conducted, is ranked 46/50 and 44/50 in the number of smokers and incidence of lung cancer, respectively. A statewide lung cancer screening effort is greatly needed. Methods: The study population was recruited between 10/2022 and 1/2023 from 2 hospitals within the Indiana University Health network. Patients were surveyed during their primary care clinic visits. Eligibility criteria included a 20-pack-year or more history of smoking, an age between 50 and 80, and were either current smokers or quit within the last 15 years. A survey was designed with open-ended questions and was standardized to all participants. The questions covered the cohort's familiarity with lung cancer screening, the associated risk with smoking, and the potential hindrances to getting screened. After discussing the benefits and risks of the screening, the patients were then asked if they would consider getting an initial LDCT. Patients' compliance with their scheduled LDCT date was recorded. Results: 175 persons met eligibility criteria, and all reported understanding the link between smoking and lung cancer; however, 147 (84%) were unfamiliar with the need for screening. The barriers to screening, as described by the cohort, included fear of cancer diagnosis (33.7%), lack of symptoms (22.2%), the stigma associated with being a smoker (12.6%), doubting the usefulness of screening (12.0%), not wanting to quit smoking (6.9%), cost of LDCT in those under 65 (4.6%), fear of exposure to radiation (4.0%), believing that cancer treatment would be worse than continuing to smoke (2.3%), and mistrust of the medical system (1.7%). When the patients were educated on LDCT’s benefits and risks, 118 patients (67.4%) perceived it as beneficial and elected to get it scheduled. Of the 118 patients, 64 (54.2%) attended their scheduled initial LDCT. Conclusions: The patient’s perceptions of screening varied, and from our data, it appears that most smokers were unaware of the need for a LDCT and had multiple concerns. Once the patients were educated about the benefits and risks of lung cancer screening, most scheduled an initial LDCT and perceived it to be beneficial.

Prevalence And Impact of Medical Comorbidities in A Real‐World Lung Cancer Screening Population

BackgroundLung cancer screening trials generally enroll motivated, relatively healthy, and adherent populations. We therefore evaluated the prevalence and effects of comorbidities in a real-world population undergoing low-dose computed tomography (LDCT) scans. Patients and MethodsWe calculated the Charlson Comorbidity Index (CCI) of patients for whom an initial low-dose computed tomography (LDCT) for lung cancer screening was ordered between February 2017 and February 2019 in an integrated safety-net healthcare system. We examined the association between CCI and initial LDCT completion using multivariable logistic regression, assessed the association between specific medical comorbidity and LDCT completion using Chi-square test or Fisher's exact test as appropriate, and examined the association between CCI and LDCT Lung-RADS results using Fisher's exact test. ResultsA total of 1358 patients were included in the analysis. Mean age was 63 years, 57% were women, and 50% were Black. Patients had moderate comorbidity burden (median CCI 3) with chronic pulmonary disease the most common comorbidity. Overall, 943 LDCT (70%) were completed. There was no difference in 30-day, 90-day, or 1-year completion rates of initial LDCT according to CCI. However, 30-day LDCT completion rates did increase over time (P < .001). Lung-RADS scores were not associated with CCI. ConclusionIn a real-world setting, patients undergoing lung cancer screening have moderate comorbidity burden. The degree and type of medical comorbidity are not associated with initial screening completion or results. Timeliness of LDCT completion may improve as program experience increases.

Patient Experience of Managing Adherence to Repeat Lung Cancer Screening.

Lung cancer screening (LCS) is a process involving multiple low-dose computed tomography (LDCT) scans over multiple years. While adherence to recommended follow-up is critical in reducing lung cancer mortality, little is known about factors influencing adherence following the initial LDCT scan. The purpose of this study was to examine patients’ and providers’ depictions of continued screening and their understandings of patients’ decisions to return for follow-up. Qualitative methodology involves interviews with patients about their understanding of the screening process and perceptions of lung cancer risk, including motivations to adhere to follow-up screening and surveillance. Analysis of interview transcripts followed the general procedures of grounded theory methodology. Patient adherence to LCS was influenced by their understanding of the process of screening, and their expectations for the next steps. Perceptions of lung cancer risk and associated motivation were not static and changed throughout the screening process. Recognizing that patients’ motivations may be dynamic over the course of screening and surveillance will assist providers in helping patients make decisions regarding continued engagement with LCS.

Understanding Patient and Clinical Stakeholder Perspectives to Improve Adherence to Lung Cancer Screening.

Limited evidence-based implementation strategies exist for maintaining lung cancer screening. We evaluated the Lung Cancer Screening Program at Kaiser Permanente Washington (KPWA) to develop multilevel interventions to improve screening adherence. We conducted a concurrent mixed-methods study 1) to measure adherence to repeat screening with low-dose computed tomography (LDCT); 2) to interview KPWA stakeholders to understand the Lung Cancer Screening Program; and 3) to conduct codesign workshops with KPWA members and researchers. We used descriptive statistics to describe adherence, and rapid qualitative data analysis for stakeholder interviews and workshops. Between 2015 and 2019, 2089 KPWA members had initial LDCT scans with negative, benign or short-interval follow-up results. Among those with sufficient follow-up, the proportion with on-time repeat screening after a negative LDCT was 26.4% after the initial scan, and increased to 43.1% on subsequent scans. Opportunities for health-care system improvement included clarification of clinical roles and responsibilities, care coordination across providers, ongoing training in lung cancer screening, and revising electronic health record tools. From patient perspectives, facilitators to repeat screening were making screening personalized and convenient; offering consistent messages and reminders in different modes; increasing patient knowledge about benefits, harms, and expectations of LDCT; and providing nonfinancial and financial incentives for adherence. From a storyboard exercise, we identified 10 design features for lung cancer screening interventions, including versatility of communication, social support, and knowledge. We identified clear gaps in adherence to lung cancer screenings, organizational and clinical barriers to care, and design features for patient-centered interventions to improve lung cancer screening in US settings.

Patient Adherence in an Academic Medical Center's Low-dose Computed Tomography Screening Program.

Low-dose computed tomography (LDCT) screening is an important tool for reducing lung cancer mortality. This study describes a single center's experience with LDCT and attempts to identify any barriers to compliance with standard guidelines. This is a retrospective review of a single university-based hospital system from 2015 to 2019. All individuals who met eligibility for lung cancer screening were entered into a database. The definition of adherence with the screening program was determined by the recommended timeline for the follow-up LDCT. Cohorts were split by adherence and demographics were compared. A total of 203 LDCTs were performed in 121 patients who met eligibility for LDCT and had appropriate surveillance from 2015 to 2019. The average age was 64 years old. The overall adherence rate for prescribed LDCTs was 59.1%. Patients with Lung-RADS score 2 had 2.43 times higher odds of adherence relative to patients with Lung-RADS score 1 (odds ratio [OR]=2.43; 95% confidence interval [CI]: 1.23-4.83; P=0.011). African American patients had 42% lower odds of adherence relative to white patients (OR=0.58; 95% CI: 0.32-1.06; P=0.076). Patients with non-District of Columbia zip codes had 57% higher odds of adherence relative to those with District of Columbia zip codes, although this did not reach statistical significance (OR=1.57; 95% CI: 0.87-2.82; P=0.136). Despite the implementation of a multidisciplinary, academic LDCT screening program, overall adherence rate to prescribed follow-up scans was suboptimal. Socioeconomic disparities and African American race may negatively affect adherence to lung cancer screening LDCT guidelines. Patients with concerning findings on initial LDCT had a higher association of adherence to guidelines.

Abstract PO-264: Examining factors of adherence to low-dose computed tomography lung cancer screenings among high-risk patients

Abstract Background: Low-dose computed tomography (LDCT) scans have reported a significant reduction in lung cancer mortality among high-risk patients. However, there are low adherence rates to annual LDCT screenings among patients who initially screen negative. This descriptive study seeks to understand the factors that influence adherence to annual screenings. Methods: A survey was conducted among patients with initial negative LDCT screenings from 2016-2019 at Temple University Hospital. Patients were between ages 55-80, have at least 30 pack-year smoking history, who are current smokers or quit within the past 15 years. Surveys assessed participants’ health literacy, beliefs, psychosocial factors, patient-provider relationship, and knowledge of lung cancer screenings. The outcome measure is adherence to LDCT, which is defined as following up with 15 months after initial screenings. These attributes were measured on various-point Likert scales. The Fagerstrom test was used to measure cigarette dependence and International Physical Activities Questionnaire was used to measure physical activity. Results: Bivariable analysis results indicate lung cancer screening knowledge varied across racial groups. Caucasians had the highest score of lung cancer knowledge followed by African Americans. Lung cancer screening knowledge also varied among education attainment levels. Those who graduated high school or have higher education had higher scores of lung cancer screening knowledge compared to those who did not graduate high school. Results also showed that participants who were cigarette dependent had a higher perceived risk of lung cancer. Overall, participants demonstrated a strong patient-provider relationship with an average score of 4.49 out of 5. Conclusion: This study demonstrated that factors such as low lung cancer screening knowledge, race, low perceived risk, and cigarette dependence may be factors that influence nonadherence to annual screenings. Furthermore, findings suggest that strong patient-provider relationship and shared decision making models may be the key to increasing annual adherence rates. Citation Format: Cherie P. Erkmen, Mark Lee, Lin Zhu, Ra'Ann Merceir, Timmy R. Lin, Freda Patterson. Examining factors of adherence to low-dose computed tomography lung cancer screenings among high-risk patients [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-264.

National Lung Cancer Screening Utilization Trends in the Veterans Health Administration.

Many Veterans are high risk for lung cancer. Low-dose computed tomography (LDCT) is an effective strategy for lung cancer early detection in a high-risk population. Our objective was to describe and compare annual and geographic utilization trends for LDCT screening in the Veteran's Health Administration (VHA). A national retrospective cohort of screened Veterans from January 1, 2011 to May 31, 2018 was used to calculate annual and regional rates of initial LDCT utilization per 1000 eligible Veterans. We identified Veterans with a first LDCT exam using common procedure terminology codes G0297 or 71250 and described as "lung cancer screening," "screening," or "LCS." The number of screen-eligible Veterans per year was calculated as unique Veterans aged 55 to 80 years seen at a Veterans Affairs medical center (VAMC) in that year, multiplied by 32% (estimated proportion with eligible smoking history). We present 95% confidence intervals (CI) for rates. Screened Veterans had a mean age of 66.1 years (standard deviation [SD] = 5.6); 95.5% male; 77.4% Caucasian. There were 119300 LDCT exams, of which 80819 (67.7%) were initial. Nationally, initial screens increased from 0 (95% CI = 0.00 to 0.00) in 2011 to 29.6 (95% CI = 29.26 to 29.88) scans per 1000 eligible Veterans in 2018 (Ptrend < .001). Initial screens increased over time within all geographic regions, most prominently in northeastern and Florida VAMCs. VHA LDCT utilization increased from 2011 to 2018. However, overall utilization remained low. Future interventions are needed to increase lung cancer screening utilization among eligible Veterans.

Review of annual compliance of low-dose CT for lung cancer screening among internal medicine resident physicians in a university teaching program.

e19187 Background: Lung cancer remains the leading cause of morbidity and mortality, with an estimated 2.1 million newly diagnosed cases each year. A large percentage of cases are detected at an advanced stage, making treatment recalcitrant. Only about 15% are diagnosed at an early stage, highlighting the significance of timely screening. USPSTF recommends annual screening with low-dose computed tomography (LDCT) in adults aged 55-80, who have a 30 pack-year smoking history and are current smokers, or former smokers who have quit within the last 15 years. The National Comprehensive Cancer Network (NCCN) guidelines, as well as the National Lung Screening Trial (NLST), recommend annual screening with LDCT until a person is no longer a candidate for definitive treatment. This study aimed to evaluate the compliance with annual LDCT based on USPSTF guidelines among internal medicine residents from the University of Connecticut residency program at a Clinic in Hartford, Connecticut, USA. Methods: Patients who were under the care of internal medicine residents and who had undergone an initial LDCT for lung cancer screening were included. A total of 61 medical charts were reviewed. Three patients were diagnosed with lung cancer and nineteen patients had their initial LDCT in 2019, and therefore excluded. Results: Out of the 39 patients, 10 patients (25.64%) had a follow-up annual LDCT performed, 2 patients before the annual mark due to various clinical concerns, and 9 patients (23%) in the following 24-48 months. 6 patients (15.38%) had a repeat LDCT ordered but was not done or it was canceled. 12 patients (30.77%) had no repeat LDCT ordered at 12 months. Overall, 69.23% had no follow-up CT at 12 months, and 46.15% with no follow up CT at all at the time of chart review. Conclusions: Based on our analysis, follow-up annual LDCT scans for lung cancer screening on patients under the care of residents-in-training are not being ordered frequently enough. The failure to order annual LDCT could be due to a false sense of relief with a normal initial LDCT, the lack of provider’s awareness of USPSTF guidelines, or insurance issues. Educating primary care providers on the importance of follow-up annual LDCT will ensure early detection and decrease mortality from lung cancer in high risk patient population.

A stepped-wedge randomized trial protocol of a community intervention for increasing lung screening through engaging primary care providers (I-STEP)

Lung cancer screening with low-dose computed tomography (LDCT) reduces lung cancer mortality, yet few eligible high-risk patients receive it annually. This protocol describes a community-partnered intervention (Toolkit) designed to support primary care practices in making referrals for lung screening and guiding patients into appropriate screening pathways.This study uses a stepped-wedge implementation design. Screening centers are randomized by readiness level to enter the intervention phase in three-month “steps” with pre-intervention data serving as the control. The primary outcome is whether delivery of the Toolkit to primary care practices results in a monthly increase in number of initial LDCT screenings. Six participating centers will identify 10 practices and reach 2–3 providers per practice to train them to use the Toolkit. The Toolkit will address known barriers to screening and referral at the patient and provider levels and provide support for required elements of screening. Toolkit components include adaptable evidence-based interventions to maximize compatibility with workflows. We hypothesize that after nine months of intervention delivery, the number of initial screening per center will double. Involving 60 practices achieves 80% power at 5% level of significance. Implementation outcomes such as adoption, acceptability, feasibility, adaptation, and sustainability will be assessed through field-notes and activity logs.LDCT for lung cancer screening currently reaches a small fraction of eligible adults. To reach the full potential to reduce mortality, primary care practices are an important venue for increasing appropriate referrals. This multidisciplinary trial will encourage acceptability and sustainability by using local knowledge and promoting partnership between providers and patients.Trial registration: ClinicalTrials.gov, NCT03958253

Impact of Significant Coronary Artery Calcification Reported on Low-Dose Computed Tomography Lung Cancer Screening.

Coronary artery calcification (CAC) is a common and important incidental finding in low-dose computed tomography (LDCT) performed for lung cancer screening (LCS). The impact of these incidental findings on patient management is unclear. The goals of our study were to determine the impact of reporting CAC on patient management and to determine whether standardized reporting of CAC affects the likelihood of future interventions. In this IRB-approved retrospective study, we queried our LCS database for reports of LDCT performed between January 2016 and September 2018. All reports with significant findings of CAC designated with the letter "S" for any Lung-RADS category were selected. The grading of CAC was extracted from the reports. Medical records were reviewed for each patient to determine demographics, clinical history, medications, and cardiac-related diagnostic and interventional procedures. The changes in management after the report of significant CAC on LDCT were documented. Statistical analysis with Student t test and Pearson χ test was performed. A total of 756/3110 patients (mean age: 67±6.4 y; M=466, 61.6%: F=290, 38.4%) were reported to have significant CAC on LDCT for LCS. Of them, 236/756 patients (31.2%) had established coronary artery disease (CAD) at baseline, before the initial LDCT. A change in management was observed in 155/756 patients (20.5%). The most common changes in management included the following: alteration in medication regimen (n=114/155, 73.5%), stress testing (n=65/155, 41.9%), and referral to a cardiologist (36/155, 23.2%). Percutaneous coronary intervention (4, 2.6%) and surgery (3, 1.9%) were uncommon. Changes in management were more common in those without established CAD and in those whose CAC was semiquantitatively graded (35% vs. 25%, P=0.02). CAC is a common significant finding in LDCT for LCS. Reporting of CAC in patients with nonestablished CAD and semiquantitative assessment resulted in changes in management.

IMPACT OF CURRENT SMOKING STATUS ON UPTAKE OF LUNG CANCER SCREENING REFERRAL IN A COHORT OF RACIALLY DIVERSE PATIENTS

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: In 2013, the US Preventive Services Task Force (USPSTF) recommended lung cancer screening by low-dose computed tomography (LDCT) for individuals ages 55-80 with a smoking history of 30 pack-years or more. Factors that affect uptake of screening recommendations are of utmost importance, particularly in marginalized groups, in order to prevent the disparity typically seen with new screening regimens. In this study, we assess factors that may affect the uptake of a referral to lung cancer screening at Henry Ford Health System. Particularly of interest were race and smoking status at the time of the first screening recommendation. METHODS: Using a cohort of patients referred for lung cancer screening between March 1, 2015 and February 28, 2018 (N=4,097), we used multivariable logistic regression to determine whether race or smoking status were associated with completion of an initial lung screening exam. Data were captured using the health system’s electronic medical record. RESULTS: Of all patients referred for screening, 932 (22.7%) were black and 2,747 (67.0%) were white. Current smokers represented 60.7%, 57.3%, and 70.2% of all, white, and black patients, respectively. Overall, 2,791 (68.1%) patients completed an initial LDCT screen. Of these, 614 (22.0%) were black and 1,902 (68.1%) were white. In multivariable analyses, race was not associated with completion of LDCT screen. Former smokers were more likely to complete a screening exam than current smokers (aOR 1.170, 95% CI 1.01-1.36). However, this finding differed by racial group; among whites, the adjusted odds ratio for lung cancer screening uptake comparing former smokers to current smokers was 1.32 (95% CI 1.10-1.59). Among blacks, smoking status was not significantly associated with screening (aOR 0.84 [95% CI 0.60-1.16]). CONCLUSIONS: These findings have implications for promoting uptake of lung screening among diverse patient populations. CLINICAL IMPLICATIONS: Racially diverse patient groups may require tailored shared decision making in lung cancer screening. DISCLOSURES: No relevant relationships Added 03/14/2019 by Elizabeth Alleman, source=Web Response, value=Ownership interest Removed 03/14/2019 by Elizabeth Alleman, source=Web Response No relevant relationships Added 03/14/2019 by Elizabeth Alleman, source=Web Response, value=Ownership interest Removed 03/14/2019 by Elizabeth Alleman, source=Web Response No relevant relationships by Amanda Holm, source=Web Response No relevant relationships by Christine Neslund-Dudas, source=Web Response No relevant relationships by Angel Rolando Peralta, source=Web Response No relevant relationships by Michael Sheehan, source=Web Response Consultant relationship with Auris Health Please note: $1001 - $5000 Added 03/15/2019 by Michael Simoff, source=Web Response, value=Consulting fee Board Member relationship with Intuitive Surgical Please note: $1001 - $5000 Added 03/15/2019 by Michael Simoff, source=Web Response, value=Consulting fee Principle Investigator relationship with Gongwin Biopharm Please note: $5001 - $20000 Added 03/15/2019 by Michael Simoff, source=Web Response, value=Grant/Research Support No relevant relationships by Amy Tang, source=Web Response

Improved discrimination between benign and malignant LDCT screening-detected lung nodules with dynamic over static 18F-FDG PET as a function of injected dose

Lung cancer mortality rate can be significantly reduced by up to 20% through routine low-dose computed tomography (LDCT) screening, which, however, has high sensitivity but low specificity, resulting in a high rate of false-positive nodules. Combining PET with CT may provide more accurate diagnosis for indeterminate screening-detected nodules. In this work, we investigated low-dose dynamic 18F-FDG PET in discrimination between benign and malignant nodules using a virtual clinical trial based on patient study with ground truth. Six patients with initial LDCT screening-detected lung nodules received 90 min single-bed PET scans following a 10 mCi FDG injection. Low-dose static and dynamic images were generated from under-sampled list-mode data at various count levels (100%, 50%, 10%, 5%, and 1%). A virtual clinical trial was performed by adding nodule population variability, measurement noise, and static PET acquisition start time variability to the time activity curves (TACs) of the patient data. We used receiver operating characteristic (ROC) analysis to estimate the classification capability of standardized uptake value (SUV) and net uptake constant Ki from their simulated benign and malignant distributions. Various scan durations and start times (t*) were investigated in dynamic Patlak analysis to optimize simplified acquisition protocols with a population-based input function (PBIF). The area under curve (AUC) of ROC analysis was higher with increased scan duration and earlier t*. Highly similar results were obtained using PBIF to those using image-derived input function (IDIF). The AUC value for Ki using optimized t* and scan duration with 10% dose was higher than that for SUV with 100% dose. Our results suggest that dynamic PET with as little as 1 mCi FDG could provide discrimination between benign and malignant lung nodules with higher than 90% sensitivity and specificity for patients similar to the pilot and simulated population in this study, with LDCT screening-detected indeterminate lung nodules.

Lung Cancer Screening, Version 3.2018, NCCN Clinical Practice Guidelines in Oncology.

Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. Early detection of lung cancer is an important opportunity for decreasing mortality. Data support using low-dose computed tomography (LDCT) of the chest to screen select patients who are at high risk for lung cancer. Lung screening is covered under the Affordable Care Act for individuals with high-risk factors. The Centers for Medicare & Medicaid Services (CMS) covers annual screening LDCT for appropriate Medicare beneficiaries at high risk for lung cancer if they also receive counseling and participate in shared decision-making before screening. The complete version of the NCCN Guidelines for Lung Cancer Screening provides recommendations for initial and subsequent LDCT screening and provides more detail about LDCT screening. This manuscript focuses on identifying patients at high risk for lung cancer who are candidates for LDCT of the chest and on evaluating initial screening findings.

Low-dose Lung Cancer Screening at an Academic Medical Center: Initial Experience and Dose Reduction Strategies

Implementation of low dose computed tomography (LDCT) lung cancer screening programs has followed the demonstration of reduced lung cancer mortality in the National Lung Screening Trial and subsequent consensus screening recommendations. Here we aim to assess the initial results of a screening program at an academic medical center, to discuss the challenges of implementing such a program, and suggest strategies for reducing patient dose. Retrospective review of all patients who underwent LDCT lung cancer screening at our institution between March 2015 and July 2016 was performed to assess the lung cancer detection rate, the spectrum of imaging findings (nodule or mass characteristics, degree of emphysema, etc.), and patient radiation dose indices. A total of 272 patients were screened during the study period. Approximately 50% (n = 135) were women. The lung cancer detection rate was 2.2% (n = 6). One patient underwent chemoradiation therapy, whereas the remainder underwent uneventful thoracoscopic resection. Approximately, 80% of screened patients met United States Preventative Services Task Force criteria for LDCT screening. The median pack-years of smoking was 42 pack-years. The mean volume CT dose index for the screening CTs was 3.12 mGy. Utilizing tube current modulation and iterative reconstruction, where available, resulted in lower patient doses. Initial LDCT lung cancer screening at our institution yielded results similar to those of the National Lung Screening Trial. Thorough prescreening evaluation, joint decision-making, centralized coordination of screening-related care, and patient size conscious scanning protocols are critical elements of a safe and successful lung cancer screening program.

Lung Cancer Screening with Low-Dose CT in Female Never Smokers: Retrospective Cohort Study with Long-term National Data Follow-up.

PurposeBecause of growing concerns about lung cancer in female never smokers, chest low-dose computed tomography (LDCT) screening is often performed although it has never shown clinical benefits. We examinewhether or not female never smokers really need annual LDCT screening when the initial LDCT showed negative findings.Materials and MethodsThis retrospective cohort study included 4,365 female never smokers aged 40 to 79 years who performed initial LDCT from Aug 2002 to Dec 2007. Lung cancer diagnosis was identified from the Korea Central Cancer Registry Database registered until December 31, 2013. We calculated the incidence, cumulative probability, and standardized incidence ratio (SIR) of lung cancer by Lung Imaging Reporting and Data System (Lung-RADS) categories showed on initial LDCT.ResultsAfter median follow-up of 9.69 years, 22 (0.5%) had lung cancer. Lung cancer incidence for Lung-RADS category 4 was 1,848.4 (95% confidence interval [CI], 1,132.4 to 3,017.2) per 100,000 person-years and 16.4 (95% CI, 7.4 to 36.4) for categories 1, 2, and 3 combined. The cumulative probability of lung cancer for category 4 was 10.6% at 5 years and 14.8% at 10 years while they were 0.07% and 0.17% when categories 1, 2, and 3 were combined. The SIR for subjects with category 4 was 43.80 (95% CI, 25.03 to 71.14), which was much higher than 0.47 (95% CI, 0.17 to 1.02) for categories 1, 2, and 3 combined.ConclusionConsidering the low risk of lung cancer development in female never smokers, it seems unnecessary to repeat annual LDCT screening for at least 5 years or even longer unless the initial LDCT showed Lung-RADS category 4 findings.

Initial LDCT appearance of incident lung cancers in the ITALUNG trial

ObjectivesTo characterize early features of lung cancers detected with low-dose computed tomography (LDCT) screening. Materials and methodsTwo radiologists reviewed prior LDCTs in 20 incident cancers diagnosed at annual repeat screening rounds and 83 benign nodules observed in the ITALUNG trial. ResultsNo abnormality was observed in 3 cancers. Focal abnormalities in prior LDCT were identified in 17(85%) cancers (14 adenocarcinomas; 14 stage I). Initial abnormalities were intra-pulmonary in 10, subpleural in 4 and perifissural in 3. Average mean diameter was 9mm (range 4.5–18mm). Nine exhibited solid, 4 part-solid and 4 non-solid density. The margins were smooth and regular in 5 cases, lobulated in 6, irregular with spiculations in 3 and blurred in 3. Ten (59%) initial focal abnormalities had a round or oval nodular shape, but 7(41%) had a non-nodular complex (n=5) or “stripe-like” (n=2) shape. Bronchus sign was observed in 3 cases and association with cystic airspace in 2 cases. Non-solid density, complex or “stripe-like” shape, bronchus sign and association with cystic airspace had a specificity higher than 90%, but positive predictive value of every feature of incident lung cancers was low (range 10.4–50%). ConclusionsThe vast majority of cancers diagnosed at annual repeat show corresponding focal lung abnormalities in prior LDCTs. Perifissural location and non-nodular shape do not exclude the possibility of early lung cancer. Since specificity of the early features of incident lung cancer is incomplete and their positive predictive value is low, all focal pulmonary abnormalities detected in screened subjects should be re-evaluated in subsequent LDCTs.

Changes in Volume-corrected Whole-lung Density in Smokers and Former Smokers During the ITALUNG Screening Trial

To evaluate with a volume-corrected whole-lung approach changes in lung density over 2 years consistent with progression of pulmonary emphysema in smokers and former smokers enrolled in the ITALUNG trial of lung cancer screening using low-dose computed tomography (LDCT). A total of 103 subjects (mean age 63±4 y with a pack-year history of at least 20) underwent 2 whole-lung LDCT examinations 2 years apart. Visual assessment was made independently by 2 experienced observers on the initial LDCT examination with a 0 to 4 grading system for each of 6 regions (right and left upper, mid, and lower lung). The whole-lung 15th percentile of attenuation coefficient and relative area (RA) at -910 HU, both corrected to the individual lung volume (Perc15v and RA910v), were measured on the 2 LDCT examinations. The intrasubject variability of Perc15v and RA910v was previously determined in 32 other subjects of the trial examined using the same scanner and technique twice over a 3-month interval for suspicious nodules. The 2 operators agreed on the presence of mild to severe emphysema (visual score ≥1 in at least 1 region) at initial LDCT examination in 24 (23%) of the 103 subjects. Fifteen subjects (15%) showed a Perc15v change between the 2 examinations exceeding the lower 95% limit of agreement, indicating progression of emphysema with a mean difference in lung density of -14.7%±2.6%. Ten of the 15 were identified as showing emphysema progression by RA910v as well. No association was observed between progression of emphysema and visual evidence of emphysema at initial LDCT examination, smoking status, or pack-years at baseline, or intervening changes in smoking habits. Once variations in inspiratory lung volumes are taken into account, changes in lung density over 2 years consistent with progression of pulmonary emphysema in elderly smokers and former smokers are uncommon.

Transient Pulmonary Eosinophilia Incidentally Found on Low-Dose Computed Tomography

To describe computed tomography (CT) findings of transient pulmonary eosinophilia (TPE) incidentally found on low-dose CT (LDCT) and to identify suggestive CT features helpful in initial diagnosis. We retrospectively reviewed LDCT scans in 40 individuals who met criteria for having TPE. There were 35 men and 5 women (age range, 32-62 years; mean, 48.5 +/- 9 years). Initial LDCT scans were assessed as either (a) nodules, further characterized as either solid, solid associated with a halo of ground-glass attenuation, or pure ground-glass lesions as well as by number, size, and location or (b) ill-defined foci of parenchymal consolidation. A range of focal parenchymal abnormalities (n = 78) were identified-both single (48%) and multiple (52%). Most of these proved to be either solid nodules with discrete ground-glass halos (72%), or poorly defined solid nodules exhibiting a variety of differing morphologies (24%). Ill-defined foci of consolidation were noted in 3 cases (4%). The lesions were predominantly located in the lower lung zone (73%) with peripheral distribution (92%). Transient pulmonary eosinophilia most often manifests as solid nodules with associated ground-glass halos. Awareness of TPE should serve to limit the number of mistaken diagnoses of early lung cancer.