Low-dose Computed Tomography Screening Program Research Articles

Pulmonary circulatory system characteristics are associated with future lung cancer risk.

Most of the subjects eligible for annual low-dose computed tomography (LDCT) lung screening will not develop lung cancer for their life. It is important to identify novel biomarkers that can help identify those at risk of developing lung cancer and improve the efficiency of LDCT screening programs. This study aims to investigate the association between the morphology of the pulmonary circulatory system (PCS) and lung cancer development using LDCT scans acquired in the screening setting. We analyzed the PLuSS cohort of 3635 lung screening patients from 2002 to 2016. Circulatory structures were segmented and quantified from LDCT scans. The time from the baseline CT scan to lung cancer diagnosis, accounting for death, was used to evaluate the prognostic ability (i.e., hazard ratio (HR)) of these structures independently and with demographic factors. Five-fold cross-validation was used to evaluate prognostic scores. Intrapulmonary vein volume had the strongest association with future lung cancer (HR=0.63, p<0.001). The joint model of intrapulmonary vein volume, age, smoking status, and clinical emphysema provided the strongest prognostic ability (HR=2.20, AUC=0.74). The addition of circulatory structures improved risk stratification, identifying the top 10% with 28% risk of lung cancer within 15 years. PCS characteristics, particularly intrapulmonary vein volume, are important predictors of lung cancer development. These factors significantly improve prognostication based on demographic factors and noncirculatory patient characteristics, particularly in the long term. Approximately 10% of the population can be identified with risk several times greater than average.

Perspective on Management of Low-Dose Computed Tomography Findings on Low-Dose Computed Tomography Examinations for Lung Cancer Screening. From the International Association for the Study of Lung Cancer Early Detection and Screening Committee

Lung cancer screening using low-dose computed tomography (LDCT) carefully implemented has been found to reduce deaths from lung cancer. Optimal management starts with selection of eligibility criteria, counseling of screenees, smoking cessation, selection of the regimen of screening which specifies the imaging protocol, and workup of LDCT findings. Coordination of clinical, radiologic, and interventional teams and ultimately treatment of diagnosed lung cancers under screening determine the benefit of LDCT screening. Ethical considerations of who should be eligible for LDCT screening programs are important to provide the benefit to as many people at risk of lung cancer as possible. Unanticipated diseases identified on LDCT may offer important benefits through early detection of leading global causes of death, such as cardiovascular diseases and chronic obstructive pulmonary disease, as the latter may result from conditions such as emphysema and bronchiectasis, which can be identified early on LDCT. This report identifies the key components of the regimen of LDCT screening for lung cancer which include the need for a management system to provide data for continuous updating of the regimen and provides quality assurance assessment of actual screenings. Multidisciplinary clinical management is needed to maximize the benefit of early detection, diagnosis, and treatment of lung cancer. Different regimens have been evolving throughout the world as the resources and needs may be different, for countries with limited resources. Sharing of results, further knowledge, and incorporation of technologic advances will continue to accelerate worldwide improvements in the diagnostic and treatment approaches.

Cytisine Therapy Improved Smoking Cessation in the Randomized Screening and Multiple Intervention on Lung Epidemics Lung Cancer Screening Trial

IntroductionCytisine, a partial agonist-binding nicotine acetylcholine receptor, is a promising cessation intervention. We conducted a single-center, randomized, controlled trial (RCT) in Italy to assess the efficacy and tolerability of cytisine as a smoking cessation therapy among lung cancer screening participants. MethodsFrom July 2019 to March 2020, the Screening and Multiple Intervention on Lung Epidemics RCT enrolled 869 current heavy tobacco users in a low-dose computed tomography screening program, with a randomized comparison of pharmacologic intervention with cytisine plus counseling (N = 470) versus counseling alone (N = 399). The primary outcome was continuous smoking abstinence at 12 months, biochemically verified through carbon monoxide measurement. ResultsAt the 12-month follow-up, the quit rate was 32.1% (151 participants) in the intervention arm and 7.3% (29 participants) in the control arm. The adjusted OR of continuous abstinence was 7.2 (95% confidence interval: 4.6–11.2). Self-reported adverse events occurred more frequently in the intervention arm (399 events among 196 participants) than in the control arm (230 events among 133 participants, p < 0.01). The most common adverse events were gastrointestinal symptoms, comprising abdominal swelling, gastritis, and constipation. ConclusionsThe efficacy and safety observed in the Screening and Multiple Intervention on Lung Epidemics RCT indicate that cytisine, a very low-cost medication, is a useful treatment option for smoking cessation and a feasible strategy to improve low-dose computed tomography screening outcomes with a potential benefit for all-cause mortality.

P61.09 Feasibility of Lung Cancer Screening With Low-Dose Computed Tomography in a Rural Community Setting; An 8-Year Experience

Low-dose computed tomography (LDCT) screening guidelines per the United States Preventive Services Task Force (USPSTF) represent the most effective method to detect lung cancer at an early stage. Despite this, adoption of this practice has been mostly urban-centered and established protocols for screening in rural communities remains limited. To date, there is no published literature suggesting feasibility of an effective LDCT screening program at the rural level. Our data set contradicts this notion.

Impact of low-dose computed tomography for lung cancer screening on lung cancer surgical volume: The urgent need in health workforce education and training.

This study aimed to investigate the time trend variation in the surgical volume and prognostic outcome of patients with lung cancer after the gradual prolonged implementation of a low-dose computed tomography (LDCT) lung cancer screening program.Using the hospital-based cancer registry data on number of patients with lung cancer and deaths from 2008 to 2017, we conducted a retrospective study using a hospital-based cohort to investigate the relationship between changes in lung cancer surgical volume, the proportion of lung-sparing surgery, and prolonged prognostic outcomes after the gradual implementation of the LDCT lung cancer screening program in recent years.From 2008 to 2017, 3251 patients were diagnosed with lung cancer according to the hospital-based cancer registry. The 5-year mortality rate decreased gradually from 83.54% to 69.44% between 2008 and 2017. The volume of total lung cancer surgical procedures and proportion of lung-sparing surgery performed gradually increased significantly from 2008 to 2017, especially from 2014 to 2017 after implementation of a large volume of LDCT lung cancer screening examinations. In conclusion, our real-world data suggest that there will be an increase in cases of operable early-stage lung cancers, which in turn will increase the surgical volume and proportion of lung-sparing surgery, after the gradual implementation of the LDCT lung cancer screening program in recent years. These findings suggest the importance of a successful national policy regarding LDCT screening programs, regulation of shortage of thoracic surgeons, thoracic radiologist workforce training positions, and education programs.

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.

P41.02 Implementation Barriers In US-based Lung Cancer Screening Programs

Both the National Lung Screening Trial and the Dutch-Belgian Randomized Lung Cancer Screening Trial (NELSON) demonstrate that screening by low-dose computed tomography (LDCT) leads to a reduction in lung cancer mortality underscoring the importance of implementing effective LDCT screening programs for those at risk. To better understand implementation barriers that programs face, the GO2 Foundation for Lung Cancer’s Screening Centers of Excellence (SCOE) network was surveyed to assess barriers in US-based screening programs related to patients, workflow and reimbursement. 100 SCOE network members, representing 87753 patients screened, participated in the survey. The survey was conducted online, focused on collecting data from calendar year 2018, and was analyzed by a market research firm ZoomRx. The survey assessed program structure, implementation barriers, capacity, screening rates and workflow. The survey was designed to baseline participants by collecting both quantitative and qualitative data and will be deployed annually to allow for longitudinal analysis. Data analysis allows the comparison of different groups such as academic v community, size of program and age of program. Of the 100 SCOE participants, 22 identified as academic-based programs, 61 as community-based, and the remaining as having other program structures (such as being a stand-alone imaging center). When asked what types of barriers were most challenging to them, the top category reported by academic programs was Patient-Volume/Patient-related barriers (reported by 55% of programs) and the top category reported by community programs was Operational/workflow barriers/lack of institutional buy-in (reported by 36% of programs). In addition to indicating the general categories of barriers that presented the most challenges to them, SCOEs were also asked to indicate what specific barriers they faced. 68% of academic programs indicated patients not returning for annual screenings and 50% reported patients not returning for interval follow up screenings. 46% of academic centers reported experiencing barriers in each of the following three areas: ordering/documenting eligibility, patient tracking/data management, and insurance coding/claims difficulties. When community programs were asked about specific barriers, 64% reported staffing limitations, 61% reported patients not returning for annual screenings, and 56% reported lack of support from referring providers. The impact of barriers differs between center types with academic centers finding patient and volume related issues more challenging in 2018 while community centers found workflow and institutional issues more challenging. In terms of what specific barriers were encountered, lack of patient adherence to annual follow up screening is frequently encountered by all types of programs. However, a majority of community-based programs reported issues with staffing or lack of support from referring providers in direct contrast to academic based centers. This suggests that initiatives to improve screening implementation must address both common barriers and program-type specific issues. The SCOE program represents a unique opportunity to study screening implementation at scale and across settings and is an ideal platform for implementing potential solutions to address barriers.

Molecular biomarkers in early stage lung cancer.

Low dose computed tomography (LDCT) screening, together with the recent advances in targeted and immunotherapies, have shown to improve non-small cell lung cancer (NSCLC) survival. Furthermore, screening has increased the number of early stage-detected tumors, allowing for surgical resection and multimodality treatments when needed. The need for improved sensitivity and specificity of NSCLC screening has led to increased interest in combining clinical and radiological data with molecular data. The development of biomarkers is poised to refine inclusion criteria for LDCT screening programs. Biomarkers may also be useful to better characterize the risk of indeterminate nodules found in the course of screening or to refine prognosis and help in the management of screening detected tumors. The clinical implications of these biomarkers are still being investigated and whether or not biomarkers will be included in further decision-making algorithms in the context of screening and early lung cancer management still needs to be determined. However, it seems clear that there is much room for improvement even in early stage lung cancer disease-free survival (DFS) rates; thus, biomarkers may be the key to refine risk-stratification and treatment of these patients. Clinicians’ capacity to register, integrate, and analyze all the available data in both high risk individuals and early stage NSCLC patients will lead to a better understanding of the disease’s mechanisms, and will have a direct impact in diagnosis, treatment, and follow up of these patients. In this review, we aim to summarize all the available data regarding the role of biomarkers in LDCT screening and early stage NSCLC from a multidisciplinary perspective. We have highlighted clinical implications, the need to combine risk stratification, clinical data, radiomics, molecular information and artificial intelligence in order to improve clinical decision-making, especially regarding early diagnostics and adjuvant therapy. We also discuss current and future perspectives for biomarker implementation in routine clinical practice.

Successes and challenges of implementing a lung cancer screening program in federally qualified health centers: a qualitative analysis using the Consolidated Framework for Implementation Research.

In recent years, studies have shown that low-dose computed tomography (LDCT) is a safe and effective way to screen high-risk adults for lung cancer. Despite this, uptake remains low, especially in limited-resource settings. The American Cancer Society (ACS) partnered with two federally qualified health centers and accredited screening facilities on a 2 year pilot project to implement an LDCT screening program. Both sites attempted to develop a referral program and care coordination practices to move patients through the screening continuum and identify critical facilitators and barriers to implementation. Evaluators conducted key informant interviews (N = 46) with clinical and administrative staff, as well as regional ACS staff during annual site visits. The Consolidated Framework for Implementation Research guided our analysis of factors associated with effective implementation and improved screening outcomes. One study site established a sustainable lung screening program, while the other struggled to overcome significant implementation barriers. Increased time spent with patients, disruption to normal workflows, and Medicaid reimbursement policies presented challenges at both sites. Supportive, engaged leaders and knowledgeable champions who provided clear implementation guidance improved staff engagement and were able to train, guide, and motivate staff throughout the intervention. A slow, stepwise implementation process allowed one site’s project champions to pilot test new processes and resolve issues before scaling up. This pilot study provides critical insights into the necessary resources and steps for successful lung cancer screening program implementation in underserved settings. Future efforts can build upon these findings and identify and address possible facilitators and barriers to screening program implementation.

Abstract PO-256: Factors determining adherence to lung cancer screening in a Hispanic urban population

Abstract Background: The National Lung Screening Trial (NLST) demonstrated that lung cancer screening reduces lung cancer mortality by 20% in high risk individuals. The rate of adherence to screening was more than 90% in the NSLT in a predominant non- Hispanic White (NHW) population, with only 1.8% Hispanics. Concerns regarding adherence in lung cancer screening have been widely reported. The goal of our study was to investigate the attributes of a Lung Cancer (LC) screening program and factors associated with screening adherence in a largely Hispanic urban population and compare with the NLST population. Methods: We performed a retrospective analysis of 421 consecutive cases who underwent LDCT screening from 2016-2019 at the University of Miami (UM), with similar inclusion criteria as the NLST. Annual adherence was defined as returning for imaging within 1 year and 90 days after an initial negative scan. Screening results, LC detection and screening adherence were examined and compared with the NLST cohort using summary statistics and X2 test for categorical variables. Association between adherence and baseline factors including age, gender, race/ethnicity, insurance, smoking history, and COPD was analyzed. Results: A total of 421 patients underwent screening from 2016-2019. UM cohort had a different racial and ethnic profile, with a higher percentage of Hispanics (47.3% vs 1.8%) and African Americans (15% vs 4.5%) in the UM than the NLST cohort respectively. Compared with NLST Low-Dose Computed Tomography (LDCT) arm, the UM cohort had fewer active smokers and a lighter smoking history. The proportion of positive LDCT screens (Lung-RADS Class 3/4) in the UM cohort (14.1%) was comparable to the NLST cohort (13.7%). Eighty-five percent of initial scans (359 of 421) were benign (Lung-RADS Class 1/2). The no-show rate for the LDCT screening shared-decision visit was 26% (228 of 891 visits). Early adherence rate to repeat annual imaging was 31.4% (81/258) Factors associated with early adherence included gender smoking, and race/ethnicity, with greater adherence in men than women, former smokers, and patients of NHW ethnicity. Despite, lower adherence to screening, the UM cohort had higher LC detection rate (3.3%) than the NLST cohort (1.1%) (p&amp;lt;0.001). Conclusion: Nonadherence to LDCT screening recommendations and non-compliance to shared decision making visits is common in a urban-based LDCT screening program. More data is needed to understand obstacles to compliance with screening in minority populations nationwide. Citation Format: Estelamari Rodriguez, Marie Jeanette Charles, Sophie Torrents, Richa Dawar, Nestor Villamizar, Dao Minh Nguyen, Kunal Gawri. Factors determining adherence to lung cancer screening in a Hispanic urban population [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-256.

Update on Lung Cancer Screening

Over the past 10 years, there has been substantial progress in the study and implementation of lung cancer screening using low-dose computed tomography (LDCT). The National Lung Screening Trial, the recently reported NELSON (NEderlands-Leuvens Longkanker Screenings ONderzoek) trial, and other European trials provide strong evidence for the efficacy of LDCT to reduce lung cancer mortality. This has resulted in the United State's Preventative Task Force and numerous professional medical societies adopting lung cancer screening recommendations. Despite the general acceptance of the positive effect of screening, low adoption and implementation rates remain nationally. In this article, the authors discuss the evolution and current state of the evidence for LDCT screening for lung cancer. The authors will also review the associated risks, cost, and challenges of implementation of an LDCT screening program.

Outcomes of a lung cancer screening program in a Hispanic urban population: The University of Miami experience.

e19011 Background: The National Lung Screening Trial (NLST) revealed a 20% reduction in lung cancer (LC) mortality when low-dose computed tomography (LDCT) was utilized for LC screening vs chest radiography. NLST participants were predominantly Non-Hispanic Whites, with only 1.8% Hispanics. The goal of our study was to investigate the attributes of a LC screening program in a largely Hispanic urban population and compare with NLST. Methods: We performed a retrospective analysis of 421 consecutive cases who underwent LDCT screening from 2016-2019 at University of Miami (UM), with similar inclusion criteria as the NLST. Demographic characteristics, smoking status, lung RADS, LC detection and compliance were examined &amp; compared with NLST cohort using summary statistics and χ2 tests for categorical variables. Results: Demographic and smoking characteristics of the UM cohort didn’t resemble those of NLST LDCT cohort. UM cohort had a different racial and ethnic profile, with a higher percentage of Hispanics (47.3% vs 1.8%) and African Americans (15% vs 4.5%) in the UM cohort vs NLST cohort respectively (p &lt; 0.001). UM cohort generally had lesser smoking intensity, and significantly fewer active smokers when compared to the NSLT cohort; 38.5% vs 48.1% respectively. The proportion of positive LDCT screens (Lung-RADS Class 3 or 4) in the UM cohort (14.1%) was almost similar to the NLST cohort (13.7%) (p = 0.81). The UM cohort had a higher LC detection rate (3.3%) than the NLST cohort (1.1%) (p &lt; 0.001). In keeping with goals of screening, both cohorts had 50% or more LC cases detected at an early curable stage. Overall patient adherence to screening guidelines was more than 90% in NLST cohort; whereas almost a quarter of referred patients in UM cohort didn’t show for their initial decision-making visit and only 45% completed two or more scans. Conclusions: Our LDCT screening program was based in a Hispanic urban location (UM) with 47.3% Hispanics. Compared to NLST LDCT arm, the UM cohort had fewer active smokers, lighter smoking history, a more diverse population, somewhat higher LC detection rate, weaker adherence to screening related visits. More data is needed to understand obstacles to compliance with screening in minority populations.

Feasibility of electromagnetic navigation bronchoscopy-guided lung resection for pulmonary ground-glass opacity nodules.

BackgroundRecent advances in imaging modalities and recommended low-dose computed tomography screening programs have made it easier to diagnose early lung cancer. However, the diagnosis of small ground-glass nodules (GGNs) has been problematic due to inappropriate specimen procurement and failure of conventional percutaneous core needle biopsy. Thus, we aimed to evaluate the usefulness of electromagnetic navigation bronchoscopy (ENB)-guided video-assisted lung resection for not only the diagnosis but also treatment of GGNs.MethodsFrom 2017 to 2019, 110 patients with suspicious lung cancer lesions that were not diagnosed by conventional procedure underwent ENB-guided lung resection. Among 35 cases of GGNs, 33 cases of localization were included in this study (two cup biopsy cases were excluded). We used SuperDimension™ for the ENB procedure. After general anesthesia, indigo carmine (0.3–0.5 mL) was injected, and GGNs were resected through video-assisted thoracoscopic surgery.ResultsOf the 33 GGNs, 16 were pure (2 adenocarcinomas in situ, 5 minimally invasive adenocarcinomas (MIAs), 3 adenocarcinomas, and 6 benign lesions) and 17 were mixed (1 MIA, 11 adenocarcinomas, and 5 benign lesions). The mean size of all lesions was 11.2±7.78 mm, mean distance to the pleura was 11.2±14.2 mm, and mean ENB procedure time was 18.8±8.88 minutes. Dye localization and surgical resection of GGN were successful in all cases. There was no procedure-related complication.ConclusionsENB is a feasible and highly accurate localization method for minimally invasive lung resection of small GGNs.

MS12.04 The International Lung Cancer Consortium (ILCCO), an International Study to Identify Risk Factors for Lung Cancer Development

The International Lung Cancer Consortium (ILCCO) was established in 2004 to maximize research efficiency for lung cancer and to share comparable epidemiological and clinical data, and biological samples across studies. Since its establishment, over 70 studies have participated in the ILCCO and shared comparable clinico-epidemiological data and a subset with biological samples and genomic data. The data harmonization was conducted at the Sinai Health System in Toronto, and genomic data is managed at the Dartmouth College of Medicine/Baylor College of Medicine. In total, the ILCCO Data Repository now has epidemiological data for over 1.2 million study participants, including 100,000 lung cancer patients, and genomic data on approximately 50,000 study participants. The large-scale epidemiological and genomic data allow us to extensively study and characterize the etiological factors, including lifestyle risk factors, medical history and genomic architectures for lung cancer development. Data submitted from all studies are systematically checked for missing values, outliers, inadmissible values, aberrant distributions and internal inconsistencies before harmonization. Common variable definitions were developed. For lifestyle risk factors and medical history, we conducted meta-analysis based on study-specific estimates, when applicable. If heterogeneities were present, random effects models were employed to account for the heterogeneity across studies. For subgroup of interests or when sample size is limited, pooled-analyses based on individual-level data were applied. When applicable, the non-linearity relationship was assessed. For genetic susceptibility of lung cancer, we investigated the genetic loci associated with lung cancer risk using log-additive model adjusted for population ancestry and account for multiple comparisons. To assess the causality of specific exposures and lung cancer risk, we applied Mendelian Randomization and mediation analytical approaches. To estimate 5-year lung cancer absolute risk, we incorporated risk factors, medical history and genetic factors based on age-specific lung cancer incidence and the competing risk. Based on 17 ILCCO studies (24,000 cases and 81,000 controls), we observed a robust association between lung cancer risk and emphysema and pneumonia, even among never smokers, and after long latency period. Based on 24 ILCCO studies, we quantified the association between family history of lung cancer and its risk by their smoking status and affected relative types. Based on 6 studies in UK, Canada, UK and New Zealand, we assessed the association between cannabis smoking and lung cancer risk by intensity, duration and cumulative exposures and by histological subtypes. We have recently completed a largest lung cancer genetic analysis based over 29,000 lung cancer cases and 56,000 controls. We identified 10 novel lung cancer susceptibility loci, in addition to the known regions, such as TERT/CLPTM1L, CHRNA5, MHC region, RAD52, CHEK2 and found specific associations mediated through mRNA expression. We helped to quantify the effect of specific genetic variant in nicotinic receptor gene on smoking cessation and age of onset. Using genetic instruments and Mendelian Randomization approach, we confirmed the association between lung cancer risk and long telomere length. Most recently, we investigated the association between impaired lung function and lung cancer risk based on UK Biobank and ILCCO OncoArray data, and we found that impaired lung function was associated with lung cancer risk in never smokers and particularly for adenocarcinoma, most likely through immune-mediated pathways. When combining all factors into an integrative risk model, we found that individuals with highly polygenic risk scores reached lung cancer screening threshold at younger age than those with average genetic risk background. ILCCO provides a powerful research platform for research on lung cancer. The collaborative projects based on ILCCO have contributed to the understanding of lung cancer etiology beyond tobacco smoking. As future perspectives, ILCCO has obtained clinical prognosis data for over 50,000 lung cancer patients and will also be able to investigate factors associated with lung cancer prognosis in depth. Finally, ILCCO has built close collaborations with several lung cancer low-dose computed tomography screening programs to jointly investigate the optimal strategy for risk stratification and early detection for lung cancer.

IBS30.03 Risk Assessment to Establish Screening Programs: The Canadian Point of View

The Canadian Task Force on Preventive Health Care (CTFPHC) supports screening with low dose computed tomography (LDCT) of the chest to decrease lung cancer mortality.1 The Task Force recommends annual screening up to three consecutive years in high risk adults aged 55-74 years with at least a 30 pack-year smoking history, who currently smoke or quit less than 15 years ago. Pilot LDCT screening program or studies are being conducted in Canada to help determine how to best implement organized lung cancer screening for people at high risk at the population level. Based on emerging data that suggests both the CTFPHC and the US Preventive Services Task Force (USPSTF) age and pack-years selection criteria2 are suboptimal and that risk prediction tools such as the PLCOm2012 are more sensitive with better positive predictive power to identify ever smokers who will develop lung cancer with a lower number needed to screen to prevent one lung cancer death and are more cost-effective,3-8 pilot studies in Canada adopt the PLCOm2012 risk prediction tool to select high risk ever smokers for LDCT screening. A prospective study is being conducted in newly diagnosed lung cancer patients in the Greater Vancouver area. In 1,076 patients, 37% were never smokers reflecting the foreign-born ethnic distribution. Of the 683 ever smokers, 60% met the PLCOm2012 model 6-year risk ≥1.5% screening criteria while only 39.5% met the USPSTF screening criteria. The International Lung Screen Trial (ILST), a multi-center prospective trial in Canada (British Columbia, Alberta), Australia, Hong Kong, and the United Kingdom, offer screening to ever smokers age 55 to 80 years if they meet the USPSTF criteria or the PLCOm2012 model 6-year risk ≥1.5% criteria. Participants receive two annual screens and are followed for six years for lung cancer outcomes. Interim results in 4,863 participants with 101 lung cancers showed that PLCOm2012 identified 26.6% more lung cancers than USPSTF criteria (99% of all lung cancers versus 78% with USPSTF). However, PLCOm2012 screened 9.9% more people than USPSTF criteria. If 2% six-year lung cancer risk threshold were used for screening selection criteria as is currently used in the Cancer Care Ontario Pilot, PLCOm2012 would be 12.7% more sensitive identifying 88.1% of lung cancers while screening 11% fewer people compared to USPSTF criteria. A 1.7% six-year lung cancer risk threshold would be 24.1% more sensitive identifying 97% of all lung cancers while screening only 1% more people than USPSTF criteria. The 1.7% threshold may be a better screening selection criterion. The worldwide burden of lung cancer is significant and projected to rise during the coming years especially in East Asian countries, namely, China, Japan, South Korea and Taiwan because of the large population size, high stable incidence rates in male and significant upward trends in females many of whom are never smokers.9 With global migration and increasing number of new Canadians who are diagnosed with lung cancer are from Asian countries such as in Vancouver, better lung cancer risk assessment tools need to be developed that take into account ethnicity and other environmental exposures such as outdoor and household air pollution exposures.10 Risk prediction tools may be perceived by some to be more complex to use than age and pack-years. The web based PanCan risk prediction tool, a precursor to the validated PLCOm2012 model, was tested in both English and French in 8 centers across Canada from coast to coast.7 The tool was found to be simple to use and took approximately 5 minutes to administer over the telephone. Similar experience was found with the web based PLCOm2012 risk assessment tool for enrollment into the International Lung Screen Trial and the Cancer Care Ontario pilot screening program. Risk assessment can be readily done by a navigator or a physician for enrollment into lung cancer screening programs as part of the shared decision process. Supported by the Terry Fox Research Institute, BC Cancer Foundation, the VGH-UBC Hospital Foundation, the Alberta Cancer Foundation, and the Australian NHMRC.

Cost-effectiveness of lung cancer screening worldwide: a systematic review

Objective: From the economic point of view, this study was to systematically assess the status quo on lung cancer screening in the world and to provide reference for further research and implementation of the programs, in China. Methods: PubMed, EMbase, The Cochrane Library,CNKI and Wanfang Data were searched to gather papers on studies related to economic evaluation regarding lung cancer screening worldwide, from the inception of studies to June 30(th), 2018. Basic characteristics, methods and main results were extracted. Quality of studies was assessed. Cost were converted to Chinese Yuan under the exchange rates from the World Bank. The ratio of incremental cost-effectiveness ratio (ICER) to local GDP per capita were calculated. Results: A total of 23 studies (only 1 randomized controlled trial) were included and the overall quality was accepted. 22 studies were from the developed countries. Nearly half of the studies (11 studies) took 55 years old as the starting age of the screening program. Smoking history was widely applied for the selection of criteria on target populations (18). Low-dose computed tomography (LDCT) was involved in every study used to evaluate the economic effectiveness. Annual (17) and once-life time (7) screening were more common frequencies. 22 studies reported ICERs for LDCT screening, compared to no screening, of which 17 were less than 3 times local GDP per capita, and were considered as cost-effectiveness, according to the WHO's recommendation. 15 and 7 studies reported ICERs for annual and once-life time screening, of which 12 and 7 studies were in favor the results of their cost-effectiveness, respectively. Additionally, the cost-effectiveness of once-lifetime screening was likely to be superior to the annual screening. Differences of cost-effectiveness among the subgroups, by starting age or by the smoking history, might exist. Conclusions: Based on the studies, evidence from the developed countries demonstrated that LDCT screening programs on lung cancer, implemented among populations selected by age and smoking history, generally appeared more cost-effective. Combined with the local situation of health resource, the findings could provide direction for less developed regions/countries lacking of local evidence. Low frequency of LDCT screening for lung cancer could be adopted when budget was limited. Data on starting ages, smoking history and other important components related to the strategy of screening programs, needs to be precisely evaluated under the situation of local population.

Cost-Effectiveness of Smoking Cessation Within a Lung Cancer Screening Program in Canada

Background: Demonstrated lung cancer mortality reductions through low-dose computed tomography (LDCT) has encouraged some jurisdictions to consider implementing organized LDCT screening. A retrospective analysis of former smokers in the National Lung Screening Trial (NLST) suggested that abstention from smoking coupled with low-dose computed tomography (LDCT) screening realized more mortality benefits than abstinence alone or LDCT alone. Aim: We evaluated the potential costs and cost-effectiveness of lung cancer screening with integrated smoking cessation using OncoSim-Lung (version 2.5), a microsimulation model led by the Canadian Partnership Against Cancer, with model development by Statistics Canada. Methods: We compared organized LDCT screening without smoking cessation to various plausible scenarios of screening with cessation. Assumptions included: annual screening of 55-74 year-old individuals with a 30-pack-yr history; a 42% participation rate reached over 10 years; cessation therapy (nicotine replacement therapy + varenicline + 12 weeks' counseling) at a cost of $490; and up to 10 cessation attempts, with a permanent quit rate of 5% per attempt. Cost-effectiveness was estimated with a lifetime horizon, health system perspective and 1.5% discount rate. Costs are in 2016 CAD. Results: OncoSim-Lung projected that LDCT screening integrated with cessation would cost approximately $76 million annually (undiscounted) from 2017 to 2036 in Canada. About 110 fewer lung cancer (LC) cases and 50 fewer LC deaths would occur annually, compared with screening without cessation. Additionally, many other smoking-related deaths would be prevented. Using a lifetime horizon, smoking cessation would cost $14,000/QALYs gained. In one-way sensitivity analysis, with a 72% participation rate there would be 260 fewer deaths, at $24,000/QALY. With a 10% quit rate, cost-effectiveness would improve to $6,000/QALY. A 50% increase in the cost of the cessation intervention would decrease cost-effectiveness to $22,000/QALY. Conclusion: Robust smoking cessation efforts within a LDCT screening program could save lives and be relatively cost-effective. Cancer control planners should consider integrating smoking cessation when implementing a lung cancer screening initiative.

P3.11-26 Results of Initial Low-Dose Computed Tomographic Screening for Lung Cancer from a Single-Institution in China

Lung cancer screening using low-dose computed tomography (LDCT) has been reported to reduce lung cancer-specific mortality for smokers at high risk in patients of the United States. However, there are very few LDCT screening results from Chinese patients. We here report the screening findings at the initial round of LDCT screening program from a single-institution population-based cohort in China. We conducted a retrospective study of a single-institution population-based LDCT screening program for lung cancer. Patients participated LDCT in Taizhou Hospital of Enze Medical Center were eligible. All noncalcified nodules with long-axis diameters of 4mm or greater in the axial plane were considered to be positive for potential lung cancer according to NLST definition. If more than three nodules were found, one dominant nodules were selected for this analysis. From July 2017 through December 2017, a total of 8611 participants with LDCT screening were included in this report. A total of 78 participants with history of cancer and 437 participants were follow-up procedures were excluded in this analysis. Of the remaining 8096 participants, the median age was 51 years (range, 16-97 years). A total of 1516 (18.8%) participants were younger than 40 years, 5264 (65.2%) were 40-64 years and 1316 (16.3%) were greater than 64 years. The total proportion of positive nodules was 21.8%, slightly higher in females (535/2258, 23.7%) than males (1233/5838, 21.1%). Lung cancer was diagnosed in 26 participants (0.32%) (11 males and 14 females) of the 1768 positive nodules. The comprehensive demographics of 26 lung cancer patients (included one patients with multiple metastases tumor from pancreas) is shown table 1. The overall rate of positive nodules is similar to previous reports, and the overall cancer detection rate by LDCT in our cohort was lower than previous reports from others (0.36-3.3%).

ADHERENCE TO ANNUAL LUNG CANCER SCREENING WITHIN THE VETERANS HEALTH ADMINISTRATION LUNG CANCER SCREENING DEMONSTRATION PROJECT

SESSION TITLE: Lung Cancer Screening: New Questions and New Answers SESSION TYPE: Original Investigations PRESENTED ON: 10/09/2018 08:45 AM - 09:45 AM PURPOSE: The National Lung Screening Trial (NLST) demonstrated a lung cancer mortality reduction from screening high risk individuals with low-dose computed tomography (LDCT) annually for three years. Mortality benefit and cost-efficacy of LDCT screening is dependent on adherence with screening and in the NLST the adherence rate was 95%. This is high compared to adherence rates from colon cancer, breast cancer, and cervical cancer in the community which have reportedly averaged 40-65%. We aimed to examine the adherence to annual LDCT screening after baseline LDCT within the Veterans Health Administration (VHA) Lung Cancer Screening Demonstration Project (LCSDP). METHODS: This is a retrospective observational cohort study of Veterans screened for lung cancer within the VHA LCSDP. The original project was conducted from July 1, 2013, and June 30, 2015 at eight geographically diverse Veterans Affairs hospitals. Screening was performed in current or former smokers (quit within the past 15 years) ages 55-80 with at least a 30-pack year smoking history. We utilized data generated from the LCSDP and 18 months following its completion stored in the VHA Corporate Data Warehouse. Adherence to screening was defined as it was in the NLST as having undergone a follow-up LDCT within 15 months from baseline scan. RESULTS: A total 2,106 Veterans underwent a baseline LDCT across all sites. Sixty percent (n=1269) had scans negative for nodules ≥ 4mm in size and repeat annual LDCT was recommended. In this group with a negative baseline scan, 149 were considered no longer eligible for screening because they had been diagnosed with lung cancer, were undergoing evaluation for cancer, no longer met the target age or years of cessation, were considered to have other life-limiting disease or were no longer interested in participating. Of the 1120 remaining eligible for repeat annual LDCT, 870 went on to undergo the follow-up scan yielding a 77.6% adherence rate for annual screening in those with a normal baseline scan. CONCLUSIONS: The American College of Chest Physicians (ACCP) and the American Thoracic Society (ATS) have outlined the components necessary for high-quality screening programs. One highlighted component is adherence with annual repeat LDCT. This study demonstrates that even within the context of a well-designed, implemented and guideline adherent LDCT screening program, adherence is not optimal and does not reach the reported 95% of the NLST when the baseline scan is negative. Both mortality benefit and cost-efficacy are likely to suffer without better adherence. Future research is needed to identify mechanisms and interventions to improve adherence. CLINICAL IMPLICATIONS: This study demonstrates that adherence with annual LDCT following a negative baseline scan is not optimal and highlights the need for measures to improve adherence to ensure that lung cancer screening achieves the most benefit possible. DISCLOSURES: No relevant relationships by Paul Brasher, source=Web Response research grant relationship with auris Please note: $5001 - $20000 Added 05/24/2018 by Gerard Silvestri, source=Web Response, value=Grant/Research Support Research grant relationship with Exact Sciences Please note: $20001 - $100000 Added 11/21/2017 by Nichole Tanner, source=Web Response, value=Grant/Research Consultant relationship with Exact Sciences Please note: $1001 - $5000 Added 11/21/2017 by Nichole Tanner, source=Web Response, value=Honoraria Grant/Research relationship with Oncimmune Please note: $5001 - $20000 Added 11/21/2017 by Nichole Tanner, source=Web Response, value=Grant/Research Support Speaker/Speaker's Bureau relationship with Oncocyte Please note: $1-$1000 Added 11/21/2017 by Nichole Tanner, source=Web Response, value=Honoraria Consultant relationship with Cook Medical Please note: $1001 - $5000 Added 11/21/2017 by Nichole Tanner, source=Web Response, value=Consulting fee Consultant relationship with Olympus America Please note: $1-$1000 Added 11/21/2017 by Nichole Tanner, source=Web Response, value=Consulting fee Grant relationship with Cook Medical Please note: >$100000 Added 11/21/2017 by Nichole Tanner, source=Web Response, value=Grant/Research Support Research relationship with Olympus Medical Please note: >$100000 Added 11/21/2017 by Nichole Tanner, source=Web Response, value=Grant/Research Support No relevant relationships by Derik Yeager, source=Web Response

MTE22.01 Integration of Cessation and Lung Cancer Screening

Lung cancer screening with low dose computed tomography (LDCT) has been studied extensively and is recommended for individuals who are deemed to be at increased risk, typically with a smoking history of 30 pack-years or more. The National Lung Screening Trial (NLST) demonstrated that with a screening program, there was a 20% reduction in lung cancer mortality. The overall incidence of lung cancer in the NLST was around 2%. Unfortunately, an often overlooked, yet treatable condition in any lung cancer screening program is continued tobacco use. In the NLST, 48% of participants were actively smoking at the time of the screening, and in our institutional program 71% are actively smoking. Cessation in this group may be seen as a challenge, as many of these patients have a much greater than 30 pack-year history and have not quit despite being advised by their primary physician. However, the lung cancer screening program may interact with the patient in a 'teachable moment' and these patients receiving screening may have increased motivation and willingness to quit if given the right resources. External resources such as quitlines or referrals to external tobacco cessation programs require action and increased motivation on the aprt of the patient, while integrating resources in the workflow of the screening program deliver the resources to the patient as a standard part of practice. Furthermore, the lung cancer screening program may be able to interact with the patient over time (through annual follow up at least) and may be an optimal way to deliver cessation resources to these patients. This session will explore different programmatic strategies to deliver cessation resources to patients in the construct of a LDCT Lung Cancer screening program. The coordinator of our screening program is a Advance Practice Registered Nurse (APRN) who sought out training and certification as a certified Tobacco Treatment Specialist (TTS). Referrals to the LDCT screening program are initially contacted by phone for a scheduling phone call, which also includes the initial elements of counseling these patients regarding tobacco cessation. An initial intake phone call determines appropriateness for screening and also can include elements of the 5A framework: ASK, ADVISE, ASSESS, ASSIST, ARRANGE. Then on the day of the scan, the APRN coordinator meets with the patient face-to-face at the point of the scan, and has already established rapport by telephone prior to the visit. The day of the scan, the patient receives in person counseling as part of their visit, and a cessation strategy or "Quit Plan” is made which may include medications such as nicotine patches and/or gum. After the scan, telephone follow up is conducted to both discuss cessation and discuss scan results with a plan for follow up. Additionally, patients can be enrolled in a state Quitline program as a standard part of the workflow which provides them with ongoing support. Another option for patients is for the screening program to refer them to group counseling sessions. The American Lung Association's Freedom From Smoking is one such structured program. Patients may not independently seek these programs out, but as a lung screening program, developing ties to programs in the community with integrated referrals to group counseling programs can be another way to further the delivery of resources to these patients. As patients return for repeat scans to follow up indeterminate nodules, or return the following year for routine scans, further cessation support is delivered, and if they have quit, abstinence support is provided. Quitlines, group counseling, and nicotine replacement therapy have been shown to be cost effective strategies to help people who smoke to increase chances of quitting. A lung screening program may identify 2% of its participants with lung cancer, but if half (or in our case 71%) are smoking, and integrated cessation resources help those patients to reduce or quit smoking, the benefit of the lung screening program is greatly amplified, and patients can reduce risk for future cancers as well as cardiovascular and non-oncologic respiratory diseases. Smoking Cessation, Screening, tobacco