CT Screening For Lung Cancer Research Articles

OA 06.01 Costs and Cost-Effectiveness of Smoking Cessation Within an Organized CT Lung Cancer (LC) Screening Program

OA 06.01 Costs and Cost-Effectiveness of Smoking Cessation Within an Organized CT Lung Cancer (LC) Screening Program

OA 15.06 Management of Nonresolving New Solid Nodules after Initial Detection in Incidence Rounds of CT Lung Cancer Screening

OA 15.06 Management of Nonresolving New Solid Nodules after Initial Detection in Incidence Rounds of CT Lung Cancer Screening

OA 15.02 Benefits, Harms, and Economic Efficiency of Low-Dose CT Lung Cancer Screening Strategies in a Population-Based Setting

OA 15.02 Benefits, Harms, and Economic Efficiency of Low-Dose CT Lung Cancer Screening Strategies in a Population-Based Setting

P2.13-009 Results of Low-Dose CT Lung Cancer Screening at a Non-University Tertiary Hospital System in Oregon, USA

P2.13-009 Results of Low-Dose CT Lung Cancer Screening at a Non-University Tertiary Hospital System in Oregon, USA

OA 06.08 Is Lung Cancer Screening Associated with a Negative Psychological Impact?

Background: Lung cancer screening can reduce lung cancer mortality by 20%. It is currently recommended in the USA, but not in the UK and ensuring any potential psychological harm is minimized is important. Current evidence is limited to the psychological impact of CT lung cancer screening. This study assesses psychological responses in the Early Cancer Detection Test - Lung Cancer Scotland Study (ECLS Study), whose participants have a tumor antibody blood test (Early CDT®-Lung test) and CT scans only for those with positive blood tests. Method: ECLS study participants were randomized to an Early CDT®-Lung test group or a control group. A sample (n=1032) participated in a nested psychological outcomes study. Questionnaires measured psychological responses (positive and negative affect scale (PANAS), lung cancer worry scale (LCWS) and impact of events scale (IES)) at baseline and 1, 3, 6 and 12 months post-trial recruitment. Psychological responses over time were assessed using multilevel modelling and compared between those in the control group, the test-positive group and the test-negative group. Result: In total, 350, 361 and 321 participants were in the control, test-negative and test-positive groups respectively. Follow-up questionnaire completion rates were ≥90% at all time-points. Baseline psychological measures did not differ significantly between groups. Significant differences were found between PANAS scores, but absolute differences between the groups were very small and unlikely to be clinically significant. The IES avoidance and intrusion scores were significantly higher in the positive than the negative group at all time-points and at 1, 3 and 6 months respectively. However, median scores for both subscales at all the time-points were in the subclinical range. Anxiety about future tests and treatment at 1 month was significantly higher in the test-positive group than the control (OR (95%CI) 3.55 (1.70, 7.41)), or the negative group (OR (95%CI) 5.74 (2.69, 12.2)). Worry about getting lung cancer in the future was significantly higher in the test-positive than the test-negative group at 1 month (OR (95%CI) 2.61 (1.35, 5.02)), 3 months (OR (95%CI) 2.52 (1.30, 4.87)) and 6 months ((OR (95%CI) 2.98 (1.53, 5.82)). Conclusion: Lung cancer screening using a blood test followed by CT scanning for test-positive individuals does not appear to impact on affect, intrusive thoughts or avoidant behavior to a clinically important degree. However, anxiety about future tests and treatment and future worry about lung cancer needs to be addressed if lung cancer screening is implemented in the UK.

MA 04.07 Understanding Patient Barriers to Utilization of Low Dose CT Lung Cancer Screening

MA 04.07 Understanding Patient Barriers to Utilization of Low Dose CT Lung Cancer Screening

Quality assurance and quantitative imaging biomarkers in low-dose CT lung cancer screening.

After years of assessment through controlled clinical trials, low-dose CT screening for lung cancer is becoming part of clinical practice. As with any cancer screening test, those undergoing lung cancer screening are not being evaluated for concerning signs or symptoms, but are generally in good health and proactively trying to prevent premature death. Given the resultant obligation to achieve the screening aim of early diagnosis while also minimizing the potential for morbidity from workup of indeterminate but ultimately benign screening abnormalities, careful implementation of screening with conformance to currently recognized best practices and a focus on quality assurance is essential. In this review, we address the importance of each component of the screening process to optimize the effectiveness of CT screening, discussing options for quality assurance at each step. We also discuss the potential added advantages, quality assurance requirements and current status of quantitative imaging biomarkers related to lung cancer screening. Finally, we highlight suggestions for improvements and needs for further evidence in evaluating the performance of CT screening as it transitions from the research trial setting into daily clinical practice.

Participant selection for lung cancer screening by risk modelling (the Pan-Canadian Early Detection of Lung Cancer [PanCan] study): a single-arm, prospective study

Results from retrospective studies indicate that selecting individuals for low-dose CT lung cancer screening on the basis of a highly predictive risk model is superior to using criteria similar to those used in the National Lung Screening Trial (NLST; age, pack-year, and smoking quit-time). We designed the Pan-Canadian Early Detection of Lung Cancer (PanCan) study to assess the efficacy of a risk prediction model to select candidates for lung cancer screening, with the aim of determining whether this approach could better detect patients with early, potentially curable, lung cancer. We did this single-arm, prospective study in eight centres across Canada. We recruited participants aged 50-75 years, who had smoked at some point in their life (ever-smokers), and who did not have a self-reported history of lung cancer. Participants had at least a 2% 6-year risk of lung cancer as estimated by the PanCan model, a precursor to the validated PLCOm2012 model. Risk variables in the model were age, smoking duration, pack-years, family history of lung cancer, education level, body-mass index, chest x-ray in the past 3 years, and history of chronic obstructive pulmonary disease. Individuals were screened with low-dose CT at baseline (T0), and at 1 (T1) and 4 (T4) years post-baseline. The primary outcome of the study was incidence of lung cancer. This study is registered with ClinicalTrials.gov, number NCT00751660. 7059 queries came into the study coordinating centre and were screened for PanCan risk. 15 were duplicates, so 7044 participants were considered for enrolment. Between Sept 24, 2008, and Dec 17, 2010, we recruited and enrolled 2537 eligible ever-smokers. After a median follow-up of 5·5 years (IQR 3·2-6·1), 172 lung cancers were diagnosed in 164 individuals (cumulative incidence 0·065 [95% CI 0·055-0·075], incidence rate 138·1 per 10 000 person-years [117·8-160·9]). There were ten interval lung cancers (6% of lung cancers and 6% of individuals with cancer): one diagnosed between T0 and T1, and nine between T1 and T4. Cumulative incidence was significantly higher than that observed in NLST (4·0%; p<0·0001). Compared with 593 (57%) of 1040 lung cancers observed in NLST, 133 (77%) of 172 lung cancers in the PanCan Study were early stage (I or II; p<0·0001). The PanCan model was effective in identifying individuals who were subsequently diagnosed with early, potentially curable, lung cancer. The incidence of cancers detected and the proportion of early stage cancers in the screened population was higher than observed in previous studies. This approach should be considered for adoption in lung cancer screening programmes. Terry Fox Research Institute and Canadian Partnership Against Cancer.

Lung cancer screening-low dose CT for lung cancer screening: recent trial results and next steps.

Screening for lung cancer using low-dose CT has already been implemented in North America following the results of the National Lung Screening Trial. Outside North America, clinicians and researchers are addressing issues that may have a major impact on the success of screening programmes by reviewing results of existing trials and by designing new research and pilot programmes. This review summarizes the work that has been done to try to answer the remaining questions and highlights potential barriers which may affect screening uptake and cost-effectiveness.

Characteristic of Lung Cancer From Secondary Lung Nodule in Patient With Preexisting Indeterminate Solitary Pulmonary Nodule

SESSION TITLE: Lung Cancer SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: New lung nodules detected during CT screening for lung cancer have shown to be at higher risk of lung cancer than incidentally detected at baseline screening. As these nodule develop within short time from the previous CT scans one year back, they are also considered to be more aggressive growth behavior. However, as of now, there is no information of the characteristics of lung cancer from secondary nodules detected in patient with preexisting indeterminate solitary pulmonary nodules. We describe our experience with these similar patients enrolled in lung nodule surveillance program METHODS: Patients with incidentally detected lung nodule ( Primary nodule) without any major medical problem requiring pulmonary specialist follow up were enrolled in lung nodule surveillance program and followed with repeat CT scan as per American college of chest physicians guidelines. Retrospective analysis of all patients enrolled in lung nodule surveillance program was done and patient with secondary nodule were analyzed. Also, all lung cancer from both primary and secondary nodules were compared. From January 2009 to June 2016, 866 patients with primary nodule enrolled were enrolled in the program. 108 (12%) developed secondary nodule during the surveillance period, Out of which, eight patients (7% of secondary nodule) were ultimately diagnosed with lung cancer(Table1). Four patients had Nonsmall lung cancer, two had poorly differentiated cancer and one patient had limited small cell cancer. Out of the 7 primary lung cancer, Five (71%) were diagnosed as early stage lung cancer and underwent curative treatment with either resection or radiation. RESULTS: The risk of lung cancer from the primary nodule was 1.06%( 8 patients) and 71% of these cases were diagnosed in early stage, and 57% were adenocarcinoma. No small cell or poorly differentiated caner was noted. There was significant difference between the probability of lung cancer predicted by from Mayo clinic , Veteran affairs and Brockufull model formula. In general, Mayo clinic model had the highest probability of lung cancer and Brocku model has the least probability of risk of lung cancer. Nine (56%) patients with lung cancer had probability of lung cancer more than 65% based on Mayo clinic model, compared to only one patients ( 6%) based on VA and Brocku model. There was no difference in the predictive probability of lung cancer from primary and secondary nodule( graph1). CONCLUSIONS: The incidence of secondary nodule detected during lung nodule surveillance program is 12% , and is higher than reported in lung cancer screening trials rate of 3 to 7%. Also, incidence of cancer in these secondary nodule is 8%, higher than risk of cancer from primary nodule( <5%) and higher than reported in lung cancer screening trials( 4%). Even though the lung cancer from secondary nodules were rapidly growing and more aggressive, most cases (70%) were detected in early stage. CLINICAL IMPLICATIONS: Newly detected secondary solitary pulmonary nodule in patient with existing nodule are at higher risk of lung cancer than incidental nodule. All the available predictive model underestimate the probability of lung cancer in these nodules. Patients with secondary nodules should be followed more carefully. DISCLOSURE: The following authors have nothing to disclose: Mohan Rudrappa, Laxmi Kokatnur No Product/Research Disclosure Information

The Effect of Positive Lung-RADS Results in a Lung Cancer Screening Program: The Beaumont Health Experience

To evaluate the initial outcomes and cost effectiveness of who received a positive screening result and were diagnosed with lung cancer. Three thousand four hundred sixty-eight patients were screened from January 2014 to December 2016. These patients were screened on a low-dose CT screening protocol at Beaumont Health System. The ACR Lung Imaging Reporting and Data System (Lung-RADS™) were used to assign the score for each patient. Screening eligibility criteria were based on the CMS guidelines and follow up was based on Lung-RADS guidelines. Costs were calculated using patient data from internal financial systems. The expected costs quality adjusted life years (QALY) were calculated with a cost-effectiveness between $100,000 to $150,000 QALY. Six hundred twenty-four patients were categorized with a positive Lung-RADS score (3 or 4). The median age, packs per day and pack years smoked for all patients was 65, 1.0 and 40.0 years respectively. The Lung-RADS score for these patients was 55.6% (3), 22.2% (4A), and 17.1% (4BX). Lung cancer diagnosis rates for each score was 0.9% (3), 8.6% (4A) and 30.8% (4BX) with 49 lung cancers diagnosed. Median follow up was 1.2 years with 5 deaths in cohort. We found that screening for this high risk population would cost $92,132 per QALY, therefore making it cost effective. The establishment of a low-dose CT lung cancer screening program improved the ability to screen patients as demonstrated by the number of patients screened and those diagnosed with a malignancy. These findings were also consistent with the findings from the National Lung Screening Trial study and reiterates the need for a coordinated screening program.

Lung Cancer Risk Associated With New Solid Nodules in the National Lung Screening Trial.

As low-dose CT (LDCT) lung cancer screening moves into routine clinical practice, evaluation of nodules identified as new becomes critical. We examine the frequency and clinical outcomes of new lung nodules reported at the two postbaseline annual screening examinations (hereafter referred to as postbaseline time 1 [T1] and time 2 [T2]), compared with those detected at baseline in the National Lung Screening Trial. Radiologists classified nodules detected at T1 and T2 as new or preexisting on the basis of comparison with findings from prior LDCT screening examinations. Subjects were tracked for lung cancer incidence and mortality. We examined the incidence of new nodules and their associated lung cancer risk by nodule size (i.e., mean diameter). A total of 25,002 subjects underwent the baseline LDCT screening examination and either a T1 or T2 LDCT screen. At both T1 and T2, 2.6% of subjects had new solid nodules. Of the new solid nodules, 53.0% were < 6 mm, 29.5% were 6 to < 10 mm, and 17.1% were ≥ 10 mm. Lung cancer risk (defined as diagnosis within 2 years of baseline) increased from 1.1% for nodules < 4 mm to 24.0% for those ≥ 20 mm. Compared with solid nodules detected at baseline, the cancer risk was higher for new solid nodules that were 4 to < 6 mm (p < 0.001) and 6 to < 8 mm (p < 0.001) but lower for new nodules ≥ 20 mm (p = 0.03). Cancers associated with new nodules had significantly poorer survival than did those associated with baseline nodules and were significantly less likely to be adenocarcinoma. The incidence of new nodules was 2-3% annually, with the cancer risk increasing by nodule size. New nodules may convey differential lung cancer risks by size, compared with baseline nodules.

Screening for Lung Cancer: Current Status

The evidence for the benefit and risks of lung cancer screening is based on a single large randomised controlled trial that showed a significant reduction in lung cancer mortality among lung cancer patients in the CT screening group compared to the control group. However, there are significant risks to the proven benefit. The large and unresolved problem in CT screening for lung cancer is the high rate of false positive findings. Further diagnostic work-up of these findings often requires invasive procedures. The complications that may occur are the main risk associated with CT screening for lung cancer. The German and European specialist associations are currently still holding back a recommendation for comprehensive CT screening for lung cancer. The risk benefit ratio is assessed as unfavourable. The results are awaited of the ongoing European studies ("NELSON" in the Netherlands and "LUSI" in Germany), which probably will be available by the end of 2018. Data are expected on more effective work-up algorithms with lower rates of false positive findings and thus lower complication rates. With these data, there will be a new risk benefit assessment.

Relationship between nodule count and lung cancer probability in baseline CT lung cancer screening: The NELSON study

ObjectivesTo explore the relationship between nodule count and lung cancer probability in baseline low-dose CT lung cancer screening. Materials and MethodsIncluded were participants from the NELSON trial with at least one baseline nodule (3392 participants [45% of screen-group], 7258 nodules). We determined nodule count per participant. Malignancy was confirmed by histology. Nodules not diagnosed as screen-detected or interval cancer until the end of the fourth screening round were regarded as benign. We compared lung cancer probability per nodule count category. Results1746 (51.5%) participants had one nodule, 800 (23.6%) had two nodules, 354 (10.4%) had three nodules, 191 (5.6%) had four nodules, and 301 (8.9%) had>4 nodules. Lung cancer in a baseline nodule was diagnosed in 134 participants (139 cancers; 4.0%). Median nodule count in participants with only benign nodules was 1 (Inter-quartile range [IQR]: 1–2), and 2 (IQR 1–3) in participants with lung cancer (p=NS). At baseline, malignancy was detected mostly in the largest nodule (64/66 cancers). Lung cancer probability was 62/1746 (3.6%) in case a participant had one nodule, 33/800 (4.1%) for two nodules, 17/354 (4.8%) for three nodules, 12/191 (6.3%) for four nodules and 10/301 (3.3%) for>4 nodules (p=NS). ConclusionIn baseline lung cancer CT screening, half of participants with lung nodules have more than one nodule. Lung cancer probability does not significantly change with the number of nodules. Baseline nodule count will not help to differentiate between benign and malignant nodules. Each nodule found in lung cancer screening should be assessed separately independent of the presence of other nodules.

International Early Lung Cancer Action Program: update on lung cancer screening and the management of CT screen-detected findings

CT screening for lung cancer is a complex undertaking requiring specifications of all of its components. This includes questions as to who should be screened, how frequently screening should be performed, and an optimal regimen of screening. The regimen of screened defines who requires further workup during the year the screening is performed in addition to the specification of the CT acquisition parameters, how the readings are performed, and the results communicated to the participants being screened. In addition to looking for suspicious pulmonary nodules, the CT scan also shows the heart, mediastinum thyroid, and the organs in the upper abdomen. The recommendations for abnormal findings in all these organs and the workup also need to be interpreted in light of the fact that they are found in asymptomatic people at risk of lung cancer and not that they presented for clinical care because of symptoms. This report provides the International Early Lung Cancer Action Program (I-ELCAP) protocol for screening and also provides the references that provide the basis for the protocol. This protocol has been continually updated in light of advancing CT and diagnostic technology and knowledge that has emerged as a result of screening, particularly large databases that have been developed.

Trade-off between benefits, harms and economic efficiency of low-dose CT lung cancer screening: a microsimulation analysis of nodule management strategies in a population-based setting

BackgroundIn lung cancer screening, a nodule management protocol describes nodule assessment and thresholds for nodule size and growth rate to identify patients who require immediate diagnostic evaluation or additional imaging exams. The Netherlands-Leuvens Screening Trial and the National Lung Screening Trial used different selection criteria and nodule management protocols. Several modelling studies have reported variations in screening outcomes and cost-effectiveness across selection criteria and screening intervals; however, the effect of variations in the nodule management protocol remains uncertain. This study evaluated the effects of the eligibility criteria and nodule management protocols on the benefits, harms and cost-effectiveness of lung screening scenarios in a population-based setting in Germany.MethodsWe developed a modular microsimulation model: a biological module simulated individual histories of lung cancer development from carcinogenesis onset to death; a screening module simulated patient selection, screening-detection, nodule management protocols, diagnostic evaluation and screening outcomes. Benefits included mortality reduction, life years gained and averted lung cancer deaths. Harms were costs, false positives and overdiagnosis. The comparator was no screening. The evaluated 76 screening scenarios included variations in selection criteria and thresholds for nodule size and growth rate.ResultsFive years of annual screening resulted in a 9.7–12.8% lung cancer mortality reduction in the screened population. The efficient scenarios included volumetric assessment of nodule size, a threshold for a volume of 300 mm3 and a threshold for a volume doubling time of 400 days. Assessment of volume doubling time is essential for reducing overdiagnosis and false positives. Incremental cost-effectiveness ratios of the efficient scenarios were 16,754–23,847 euro per life year gained and 155,287–285,630 euro per averted lung cancer death.ConclusionsLung cancer screening can be cost-effective in Germany. Along with the eligibility criteria, the nodule management protocol influences screening performance and cost-effectiveness. Definition of the thresholds for nodule size and nodule growth in the nodule management protocol should be considered in detail when defining optimal screening strategies.

Hepatic steatosis in participants in a program of low-dose CT screening for lung cancer

ObjectiveDetermine the frequency of moderate-to-severe hepatic steatosis (HS) in asymptomatic participants in a low-dose CT (LDCT) screening program for lung cancer, to identify risk factors, and develop recommendations. MethodsBaseline LDCT scans of the chest of 170 participants in an IRB-approved study between August 2011 and April 2016 were reviewed. Demographic variables, comorbidities, and liver function tests were documented. Hepatic and splenic attenuation values hounsfield unit (HU) were measured. Regression analyses were performed. ResultsAverage liver attenuation was 57.6HU (standard deviation (SD) 9.3) and average liver/spleen (L/S) ratio was 1.3 (SD 0.3). Liver attenuation was <40HU for 9 (5.3%), liver/spleen (L/S) ratio <0.8 for 6 (3.5%), and either <40HU or L/S ratio <0.8 for 9 (5.3%). Male sex (p=0.004), diabetes (p=0.0005), emphysema (p=0.03), and high BMI (p=0.0006) were significant predictors of HS. Aspartate aminotransferase (p=0.0018) and alanine aminotransferase (p=0.012) were negatively correlated with liver attenuation. Reduced serum levels of alpha-1-antitrypsin may be a common factor of emphysema and HS. ConclusionLDCT can detect HS in asymptomatic participants with frequencies similar to previous reports. If liver attenuation is below 40HU and/or L/S ratio below 0.8, further evaluation of HS to the primary care physician or liver specialist is recommended.

Multiregion whole exome seuquencing of pre- and early neoplastic lung lesions.

e20042 Background: The widespread use of CT for lung cancer screening and other reasons has resulted in a dramatic increase in the number of indeterminate ground glass opacities (GGOs). While many of GGOs can be resected with minimal morbidity, the cost has been called into question. Furthermore, multifocality is a relatively common, which makes decisions on extent of surgical resection and potential benefit less clear. Chemoprevention is a theoretically appealing approach to reduce lung cancer incidence and mortality. However, randomized trials have been disappointing to date. This may be due to the constellation of many factors including lack of reliable biomarkers to identify high-risk patients, lack of appropriate molecular targets and appropriate drugs because of our rudimentary knowledge on early carcinogenesis of lung cancers. It has been postulated that atypical adenomatous hyperplasia (AAH) represents preneoplastic lesion that can progress to adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA) and further to frankly invasive adenocarcinoma (ADC). However, the biology of these lesions is poorly understood and the definition and management of these lesions remain controversial. Methods: Study on early carcinogenesis is hampered by the small size of lesions and challenge of obtaining longitudinal samples at different stages of disease progression. Multiregion sequencing can depict genomic events relative to molecular time with early events ubiquitously present in all regions and late mutations confined to spatially separated regions of lesions. Using this approach, our recent work has reported that 20/21 canonical cancer gene mutations were early genetic events. Results: With intent to delineate the pivotal molecular events driving early carcinogenesis of lung cancer, we have collected 154 resected GGOs with including AAH (N = 40), AIS (N = 39), MIA (N = 55) and ADC (N = 20) based on the IASLC/ATS/ERS classification from 89 patients including 38 patients presenting with multifocal GGOs and 18 patients carry more than one type of pathology. Two to five spatially separated regions from each of the 154 lesions are subjected to whole exome sequencing. Conclusions: The data will be ready to present at the meeting.

Socio-demographic variations in lung cancer screening before and after USPSTF recommendation: Results from national health interview surveys (NHIS).

1563 Background: In 2013, USPSTF recommended low-dose CT screening (LCS) for lung cancer in high-risk adults. The change in real-world practice is largely unknown, as well as the association with socio-demographic factors. Methods: Data were extracted from the population-based 2010 and 2015 NHIS. LCS was defined as a chest CT to check for lung cancer within the past year. We included adults aged 55 to 80 years who 1) have 30+ pack-year smoking history; 2) are currently smokers or have quitted within the past 15 years. We excluded adults who 1) have lung cancer; 2) had not seen a physician in the past year. We used weighted analyses to estimate national lung cancer screening rates. Results: A total of 874 and 1041 high-risk smokers responded to the LCS questions for lung cancer in 2010 and 2015, respectively. The screening rate more than doubled from 4.1% to 9.1% (P &lt; 0.01) in all respondents. The increase was greater in women (2.9% to 9.5%, p &lt; 0.01) than men (5.2% to 8.8%, p = 0.03) and in age 65-80 (4.7% to 12.3%, p &lt; 0.01) than age 55-64 (3.8% to 6.3%, p = 0.16). White saw the largest increase and highest rate in 2015 (4.0% to 9.3%, p = &lt; 0.01). Those with some college or above education had the highest rate in 2010, but the lowest in 2015. Household income above 75,000 dollars was associated with the lowest rate in both 2010 and 2015. Conclusions: Since the recommendation of USPSTF, LCS rate for lung cancer has doubled but remains less than 10%. Higher education and household income are associated with lower screening rate, in contrast to studies of other cancers. [Table: see text]

Low-Dose CT for Lung Cancer Screening

Low-Dose CT for Lung Cancer Screening