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Screening For Lung Cancer Uspstf

Other Approaches To Prevention

Update on ’21 United States Preventive Services Task Force (USPSTF) Lung Cancer Screening Guidelines

Smoking cessation is the most important intervention to prevent NSCLC. Advising smokers to stop smoking and preventing nonsmokers from being exposed to tobacco smoke are the most effective ways to decrease the morbidity and mortality associated with lung cancer. Current smokers should be informed of their continuing risk for lung cancer and offered cessation treatments. Screening with LDCT should be viewed as an adjunct to tobacco cessation interventions.

Modeling Data Identify Optimal Parameters For Screening

The modeling study used four Cancer Intervention and Surveillance Modeling Network simulation models to assess 1092 LDCT screening strategies that estimated the lung cancer risk either based on risk factors or using simplified versions of risk prediction models.

Meza and colleagues report that ompared with no screening, risk factorbased screening strategies were estimated to result in lung cancer deaths averted and life-years gained, with variations according to the level of screening and specific eligibility criteria for each scenario.

They also identified 57 consensus-efficient scenarios, which were estimated to provide the greatest benefit for a given level of screening. Of these, 25 were associated with a 9% or greater reduction in lung cancer mortality, with estimated numbers of deaths averted ranging from 348 to 578 per 100,000 people and lifeyears gained ranging from 4490 to 8186 per 100,000 people. The number of patients needed to screen to avert one lung cancer death ranged from 34 to 63.

The estimates for the six strategies that used 20 packyears as a risk factor and involved annual screening were 469558 per 100,000 people for deaths averted, 60187596 per 100,000 people for lifeyears gained, and 4245 for number needed to screen. By contrast, the 2013 USPSTF criteria were estimated to lead to 381 deaths averted per 100,000 people, 4882 lifeyears gained, and a number needed to screen of 37.

Harms Of Detection And Early Intervention And Treatment

The harms associated with LDCT screening include false-negative and false-positive results, incidental findings, overdiagnosis, and radiation exposure. False-positive LDCT results occur in a substantial proportion of screened persons 95% of all positive results do not lead to a diagnosis of cancer. In a high-quality screening program, further imaging can resolve most false-positive results however, some patients may require invasive procedures.

The USPSTF found insufficient evidence on the harms associated with incidental findings. Overdiagnosis of lung cancer occurs, but its precise magnitude is uncertain. A modeling study performed for the USPSTF estimated that 10% to 12% of screen-detected cancer cases are overdiagnosedthat is, they would not have been detected in the patient’s lifetime without screening. Radiation harms, including cancer resulting from cumulative exposure to radiation, vary depending on the age at the start of screening the number of scans received and the person’s exposure to other sources of radiation, particularly other medical imaging.

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Benefits Of Detection And Early Treatment

Although lung cancer screening is not an alternative to smoking cessation, the USPSTF found adequate evidence that annual screening for lung cancer with LDCT in a defined population of high-risk persons can prevent a substantial number of lung cancerrelated deaths. Direct evidence from a large, well-conducted, randomized, controlled trial provides moderate certainty of the benefit of lung cancer screening with LDCT in this population4. The magnitude of benefit to the person depends on that person’s risk for lung cancer because those who are at highest risk are most likely to benefit. Screening cannot prevent most lung cancerrelated deaths, and smoking cessation remains essential.

New Uspstf Guidelines Increase Lung Cancer Screening Among African Americans

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The US Preventive Services Task Force updated its lung cancer screening guidelines in 2021 to include more members of vulnerable populations, including African Americans, women, and the LGBTQ community.

The US Preventive Services Task Force updated its lung cancer screening guidelines in 2021 to include more members of vulnerable populations, including African Americans, women, and the LGBTQ community. An analysis conducted at Thomas Jefferson University showed that, in the first 9 months since the guidelines were released, the percentage of African Americans undergoing screening through 1 program is up 38.4%.1

USPSTF guidelines issued in 2013 set the minimum age for lung cancer screening at 55 years and smoking intensity at 30 pack-years, defined as smoking 1 pack of cigarettes per day for 30 years or the equivalent. The 2021 guidelines reduced the minimum age to 50 years and smoking intensity to 20 pack-years to increase the number of eligible people.2

Julie Barta, MD, senior study author assistant professor of medicine at Jefferson co-lead for the Lung Cancer, Screening, and Nodules Program at the Jane & Leonard Korman Respiratory Institute and an investigator at the Sidney Kimmel Cancer Center, told OncLive® that investigators wanted to evaluate Jeffersons centralized screening program. They hoped to characterize the demographic and socioeconomic characteristics of participants coming through the screening program.

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How Does The Evidence Fit With Biological Understanding

Lung cancer is a proliferation of malignant cells that originate in lung tissue. Smoking is the strongest risk factor for lung cancer. Older age is also associated with increasing incidence of lung cancer. Lung cancer is classified into 2 major categories based on cell type and immunohistochemical and molecular characteristics: NSCLC, which collectively comprises adenocarcinoma, squamous cell carcinoma, and large cell carcinoma, and small cell lung cancer. Screening is aimed at early detection of NSCLC rather than small cell lung cancer because the latter is much less common and typically spreads too quickly to be reliably detected at an early, potentially curable stage by screening.

Currently, 79% of patients present with lung cancer that has spread to regional lymph nodes or metastasized to distant sites. Only 17% of patients present with localized disease. Patients with localized disease have a 59% 5-year survival rate, compared with 32% for those with regional spread and 6% for those with distant metastases.1 By leading to earlier detection and treatment, screening for lung cancer can give patients a greater chance for cure.

The American Academy of Family Physicians has concluded that the evidence is insufficient to recommend for or against screening for lung cancer with LDCT in persons at high risk of lung cancer based on age and smoking history.47

Who Should Be Screened For Lung Cancer

The only recommended screening test for lung cancer is low-dose computed tomography . Screening is recommended only for adults who have no symptoms but are at high risk.

Screeningexternal icon means testing for a disease when there are no symptoms or history of that disease. Doctors recommend a screening test to find a disease early, when treatment may work better.

The only recommended screening test for lung cancer is low-dose computed tomography . During an LDCT scan, you lie on a table and an X-ray machine uses a low dose of radiation to make detailed images of your lungs. The scan only takes a few minutes and is not painful.

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Response To Public Comments

A draft version of this recommendation statement was posted for public comment on the USPSTF Web site from 30 July to 26 August 2013. Most of the comments generally agreed with the recommendation statement, although some suggested restricting screening to a higher-risk group and others suggested expanding eligibility criteria beyond those used in the NLST. Many comments expressed concerns about implementation of a screening program, predicting substantially greater harm in the community setting than was found in the NLST. Some comments expressed concern about the cost of implementing a screening program and the potential paradoxical effect of enabling persons to continue smoking with the perception that medical care can mitigate the risks of smoking.

In response to these comments, the USPSTF further emphasized the importance of tobacco cessation as the primary way to prevent lung cancer and provided links to resources that clinicians can use to help their patients quit smoking. A section on implementation of a screening program was added, emphasizing the need for monitoring this implementation, quality assurance in diagnostic imaging, and appropriate follow-up to replicate the benefits observed in the NLST in the general population. The USPSTF also clarified that, in addition to age and smoking history, such risk factors as occupational exposure, family history, and history of other lung diseases are important when assessing patients’ risks for lung cancer.

Frequently Asked Questions About The New Uspstf Lung Cancer Screening Recommendation

The Facts About Lung Cancer Screening

Overall, more than 14 million people will be eligible for screening under the new guidelines. The expanded criteria will more than double the number of Black and Hispanic people eligible for screening and increase the number of American Indians and Alaskan Natives eligible by 2.7-fold. Close to twice as many women will also be eligible for screening under the revised guidelines.

Most private plans including individual, small group, large group, and self-insured plans and Medicaid expansion plans must update their coverage to comply with the new guidelines for plan years beginning March 31, 2022. However, the Lung Association urges plans to update their coverage policies as soon as possible. Learn more from our screening coverage chart.

On February 10, 2022, the Centers for Medicare and Medicaid Services updated its lung cancer screening eligibility guidelines for people covered by Medicare. Medicare will now cover screening for individuals ages 50 to 77 years who have a 20 pack-year smoking history, currently smoke or have quit within the past 15 years, and are asymptomatic .

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Implementation Of Lung Cancer Screening

Available data indicate that uptake of lung cancer screening is low. One recent study using data for 10 states found that 14.4% of persons eligible for lung cancer screening had been screened in the prior 12 months.18 Increasing lung cancer screening discussions and offering screening to eligible persons who express a preference for it is a key step to realizing the potential benefit of lung cancer screening.

Screening Eligibility, Screening Intervals, and Starting and Stopping Ages

As noted above, the USPSTF recommends annual screening for lung cancer with LDCT in adults aged 50 to 80 years who have at least a 20 pack-year smoking history. Screening should be discontinued once a person has not smoked for 15 years.

The NLST9 and the NELSON trial11 enrolled generally healthy persons, so those study findings may not accurately reflect the balance of benefits and harms in persons with comorbid conditions. The USPSTF recommends discontinuing screening if a person develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

Smoking Cessation Counseling

Standardization of LDCT Screening and Follow-up of Abnormal Findings

Potential Harms Of Screening And Treatment

Harms associated with LDCT screening include false-negative and false-positive results, incidental findings, overdiagnosis, radiation exposure, and psychological distress. The sensitivity of LDCT ranged from 80% to 100%, suggesting a false-negative rate of 0% to 20%. The specificity of LDCT ranged from 28% to 100%.

The positive predictive value for lung cancer of an abnormal test result ranged from 2% to 42% . As mentioned previously, the NLST is the largest trial of lung cancer screening to date, and recent results showed a sensitivity of 93.8% and specificity of 73.4% for LDCT. In the NLST, the positive predictive value for a positive finding of a pulmonary nodule measuring 4 mm or larger was 3.8%11.

Over the 3 rounds of screening in the NLST, 24.2% of screening test results were positive 96.4% of these were false-positives. Most positive test results were followed by additional imaging. Approximately 2.5% of positive test results required additional invasive diagnostic procedures, such as bronchoscopy, needle biopsy, or thoracoscopy. Of the 17,053 positive test results evaluated, there were approximately 61 complications and 6 deaths after a diagnostic procedure. Recently published data from the first round of screening in the NLST showed an average of 1 follow-up scan per positive screening test result. Approximately 1.9% of NLST participants had a biopsy 11.

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Harms Of Screening And Treatment

Harms of screening can include false-positive results leading to unnecessary tests and invasive procedures, overdiagnosis, radiation-induced cancer, incidental findings, and increases in distress or anxiety.

The NLST reported false-positive rates of 26.3% for baseline, 27.2% for year 1, and 15.9% for year 2.9 The NELSON trial reported false-positive rates of 19.8% at baseline, 7.1% at year 1, 9.0% for males at year 3, and 3.9% for males at year 5.5 of screening.11,37 An implementation study through the Veterans Health Administration revealed a false-positive rate of 28.9% of veterans eligible for screening at baseline.38 Both of these studies were conducted prior to the use of the Lung-RADS protocol for nodule classification, the use of which may reduce false-positives, albeit at the cost of some false-negatives. One retrospective study assessed how use of Lung-RADS would have changed the false-positive result rate in the NLST and found a false-positive rate among baseline results for Lung-RADS of 12.8% vs 26.6% for the NLST approach.21

In the NLST, false-positive results led to invasive procedures in 1.7% of patients screened. Complications occurred in 0.1% of patients screened, and death in the 60 days following the most invasive procedure performed to evaluate a false-positive result occurred in 0.007% of those screened.9 One study estimated that the use of Lung-RADS criteria would have prevented 23.4% of invasive procedures due to false-positive results.21

Uspstf Expands Lung Cancer Screening Recommendations

Lung Screening

The US Preventive Services Task Force has updated its recommendations for lung cancer screening in adults aged 50 to 80 years with a history of smoking.

This update to the groups 2013 recommendation is intended for older adults who have a history of smoking at least 20 packs per year, and who currently smoke or have quit within the last 15 years.

After a systematic review of the accuracy, benefits, and harms of screening, it is recommended that this patient population be screened annually for lung cancer with low-dose computed tomography . Screening should continue until the patient has not smoked for 15 years or is unable to have curative lung surgery in the event of lung cancer.

The USPSTF concluded with moderate certainty that annual screening for lung cancer with LDCT has a moderate net benefit in persons at high risk of lung cancer based on age, total cumulative exposure to tobacco smoke, and years since quitting smoking, the group concluded.

Reference:

US Preventive Task Force. Screening for lung cancer: US preventive services task force recommendation statement. JAMA. 2021 325:962-970. doi: 10.1001/jama.2021.1117

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Eligibility For Screening Increased

Based on the findings in the evidence review, the task force made two notable changes regarding screening eligibility. First, the new recommendation lowers the age at which the task force recommends that annual screening for lung cancer begin from 55 to 50. Second, the new recommendation lowers the number of pack years of smoking history that makes an individual eligible for screening from 30 to 20.

Based on the expanded screening criteria, the task force stated in its press release that these changes will nearly double the number of people eligible for lung cancer screening. The new screening criteria could also prove beneficial to Black patients, as recent research has indicated that collectively, Black individuals have the highest death rates and shortest survival times of any racial or ethnic group in the United States for most cancers.

The changes to this recommendation mean more Black people and women are now eligible for lung cancer screening, which is a step in the right direction, said John Wong, M.D., a task force member. However, to save more lives and ensure that everyone who would benefit is screened, it is critical that screening is implemented broadly and equitably.

Is Lung Cancer Treatable If Doctors Find It Early

The LDCT screening test can help detect lung cancer before an individual experiences symptoms. Finding lung cancer in the early stages increases the likelihood of recovering from this disease.

Research indicates that people who receive an early diagnosis have around a 56% likelihood of survival 5 years following their diagnosis. However, the overall 5-year survival rate for lung cancer is 18.6%.

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Draft Recommendation Expands Eligibility Criteria

On July 7, the U.S. Preventive Services Task Force issued a draft recommendation statement, draft evidence review and draft decision analysis on screening for lung cancer.

Based on its review of the evidence, the task force expanded screening eligibility to recommend annual screening with low-dose CT in adults ages 50-80 who have a 20 pack-year smoking history and who currently smoke or have quit smoking within the past 15 years. This is a “B” recommendation.

The task force also recommended that screening be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

The draft recommendation updates and expands on the task force’s December 2013 recommendation statement that recommended annual screening with low-dose CT in adults 55-80 who had a 30 pack-year smoking history and who currently smoked or had quit within the past 15 years.

“New evidence provides proof that there are real benefits to starting to screen at a younger age and among people with a lighter smoking history,” said task force member Michael Barry, M.D., in a news release. “We can not only save more lives, we can also help people stay healthy longer.”

STORY HIGHLIGHTS

The Uspstf Has Made Two Changes That Will Nearly Double The Number Of People Eligible For Lung Cancer Screening: First Start Screening At Age 50 Rather Than 55 Second Reduce The Pack

Changes in recommendations for lung cancer screening

Today, the U.S. Preventive Services Task Force published a final recommendation statement on screening for lung cancer in people who do not have signs or symptoms. Based on the evidence, the USPSTF recommends yearly screening using a low-dose computed tomography scan for people aged 50 to 80 who are at high risk for lung cancer because of their smoking history. This is a B recommendation, meaning that the USPSTF recommends the service and that there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

The Task Forces final recommendation statement and corresponding evidence summary and modeling studies have been published by Jonas et al in JAMA, as well as on the Task Force website. A draft version of the recommendation statement, evidence review, and modeling studies were available for public comment from July 7 to August 3, 2020.

Michael J. Barry, MD

The Task Force reviewed new evidence that shows screening can help many more people who are at high risk for lung cancer, said USPSTF member Michael J. Barry, MD, Director of the Informed Medical Decisions Program in the Health Decision Sciences Center at Massachusetts General Hospital, Professor of Medicine at Harvard Medical School, and a clinician at Massachusetts General Hospital. By screening people who are younger and who have smoked fewer cigarettes, we can save more lives and help people remain healthy longer.

John B. Wong, MD

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