Clinicians should ascertain the smoking status and smoking history of their patients aged 55 years to 74 years (Table 1). Clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening with patients aged 55 years to 74 years who have at least a 30–pack-year smoking history, currently smoke, or have quit within the past 15 years, and who are in relatively good health. Core elements of this discussion should include the following benefits, uncertainties, and harms of screening:
Table 1. Eligibility Criteria for the National Lung Screening Trial
|Ages 55-74 y, with no signs or symptoms of lung cancer.
|Active or former smoker with a 30–pack-y history (a pack-y is the equivalent of 1 pack of cigarettes per d per y. One pack per d for 30 y or 2 packs per d for 15 y would both be 30 pack-y).
|If active smoker, should also be vigorously urged to enter a smoking cessation program.
|If former smoker, must have quit within the past 15 y.
|General health exclusions
|Life-limiting comorbid conditions. Metallic implants or devices in the chest or back. Requirement for home oxygen supplementation.
Benefit: Screening with LDCT has been shown to substantially reduce the risk of dying from lung cancer.
Limitations: LDCT will not detect all lung cancers or all lung cancers early, and not all patients who have a lung cancer detected by LDCT will avoid death from lung cancer.
Harms: There is a significant chance of a false-positive result, which will require additional periodic testing and, in some instances, an invasive procedure to determine whether or not an abnormality is lung cancer or some nonlung cancer-related incidental finding. Fewer than 1 in 1000 patients with a false-positive result experience a major complication resulting from a diagnostic workup. Death within 60 days of a diagnostic evaluation has been documented, but is rare and most often occurs in patients with lung cancer.
Smoking cessation counseling constitutes a high priority for clinical attention for patients who are currently smoking. Current smokers should be informed of their continuing risk of lung cancer, and referred to smoking cessation programs. Screening should not be viewed as an alternative to smoking cessation.
Eligible patients should make the screening decision together with their health care provider. Helping individuals to clarify their personal values can facilitate effective decision-making:
○ Individuals who value the opportunity to reduce their risk of dying from lung cancer and who are willing to accept the risks and costs associated with having a LDCT and the relatively high likelihood of the need for further tests, even tests that have the rare but real risk of complications and death, may opt to be screened with LDCT every year.
○ Individuals who place greater value on avoiding testing that carries a high risk of false-positive results and a small risk of complications, and who understand and accept that they are at a much higher risk of death from lung cancer than from screening complications, may opt not to be screened with LDCT.
Clinicians should not discuss lung cancer screening with LDCT with patients who do not meet the above criteria. If lung cancer screening is requested, these patients should be informed that at this time, there is too much uncertainty regarding the balance of benefits and harms for individuals at younger or older ages and/or with less lifetime exposure to tobacco smoke and/or with sufficiently severe lung damage to require oxygen (or other health-related NLST exclusion criteria), and therefore screening is not recommended.
Adults who choose to be screened should follow the NLST protocol of annual LDCT screening until they reach age 74 years.
CXR should not be used for cancer screening.
Wherever possible, adults who choose to undergo lung screening preferably should enter an organized screening program at an institution with expertise in LDCT screening, with access to a multidisciplinary team skilled in the evaluation, diagnosis, and treatment of abnormal lung lesions. If an organized, experienced screening program is not accessible, but the patient strongly wishes to be screened, they should be referred to a center that performs a reasonably high volume of lung CT scans, diagnostic tests, and lung cancer surgeries. If such a setting is not available and the patient is not willing or able to travel to such a setting, the risks of cancer screening may be substantially higher than the observed risks associated with screening in the NLST, and screening is not recommended. Referring physicians should help their patients identify appropriate settings with this expertise.
At this time, very few government or private insurance programs provide coverage for the initial LDCT preformed for the indication of lung cancer screening. Clinicians who decide to offer screening bear the responsibility of helping patients determine if they will have to pay for the initial test themselves and to help the patient know how much they will have to pay. In light of the firm evidence that screening high-risk individuals can substantially reduce death rates from lung cancer, both private and public health care insurers should expand coverage to include the cost of annual LDCT screening for lung cancer in appropriate high-risk individuals.
Ron Korb: The Day I Lost My Love