Lung Cancer Screening: The Radiologist's Perspective

 

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Abstract

Lung cancer is the leading cause of cancer death worldwide and accounts for more deaths than breast, prostate, colon, and pancreatic cancers combined. A distinct minority (15%) of lung cancers are diagnosed at an early stage; 5-year survival (all lung cancers) approximates 15%. Randomized, controlled trials in the 1960s and 1970s found that chest radiographic screening did not confer a survival benefit for high-risk patients. Recently, however, the randomized, controlled National Lung Screening Trail (NLST) provided category 1 evidence that low-dose computed tomography (CT) screening conferred a significant survival benefit for screened individuals: lung cancer–specific mortality was reduced by 20% after 6.5 years of follow-up; even all-cause mortality decreased by 6%. The positive outcome triggered many national medical societies in the United States to recommend lung cancer screening in high-risk individuals. However, the favorable results of the NLST trial have not yet been reproduced. Currently, nine randomized, controlled trials are being or have been performed in various European countries. In contrast to the NLST study, three published European studies found no benefit from low-dose CT scanning in at-risk patients. Additional studies are required to establish the benefit and risks associated with repetitive low-dose CT for screening at-risk patients. Many unanswered questions remain. Who should be screened and how often? What is the appropriate workup when lesions are noted in asymptomatic individuals? What is the risk of cumulative radiation exposure from repetitive low-dose CT scans? What is the responsibility of health care personnel to evaluate nonpulmonary issues detected by CT (e.g., coronary calcifications). In this review, we address these and other questions that arise. Further, implementation of screening programs may be logistically difficult, require additional personnel and computer software, and will incur significant health care costs.

• References

• 1 Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin 2013; 63 (1) 11-30
  CrossrefPubMedGoogle Scholar
• 2 Lung Cancer Mortality Reduction Act. Available at: http://www.gpo.gov/fdsys/pkg/BILLS-112hr1394ih/pdf/BILLS-112hr1394ih.pdf
  PubMedGoogle Scholar
• 3 Vazquez M, Carter D, Brambilla E , et al; International Early Lung Cancer Action Program Investigators. Solitary and multiple resected adenocarcinomas after CT screening for lung cancer: histopathologic features and their prognostic implications. Lung Cancer 2009; 64 (2) 148-154
  CrossrefPubMedGoogle Scholar
• 4 Frost JK, Ball Jr WC, Levin ML , et al. Early lung cancer detection: results of the initial (prevalence) radiologic and cytologic screening in the Johns Hopkins study. Am Rev Respir Dis 1984; 130 (4) 549-554
  PubMedGoogle Scholar
• 5 Oken MM, Hocking WG, Kvale PA , et al; PLCO Project Team. Screening by chest radiograph and lung cancer mortality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized trial. JAMA 2011; 306 (17) 1865-1873
  CrossrefPubMedGoogle Scholar
• 6 Field JK, Oudkerk M, Pedersen JH, Duffy SW. Prospects for population screening and diagnosis of lung cancer. Lancet 2013; 382 (9893) 732-741
  CrossrefPubMedGoogle Scholar
• 7 Aberle DR, Adams AM, Berg CD , et al; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011; 365 (5) 395-409
  CrossrefPubMedGoogle Scholar
• 8 Bach PB, Mirkin JN, Oliver TK , et al. Benefits and harms of CT screening for lung cancer: a systematic review. JAMA 2012; 307 (22) 2418-2429
  CrossrefPubMedGoogle Scholar
• 9 Saghir Z, Dirksen A, Ashraf H , et al. CT screening for lung cancer brings forward early disease. The randomised Danish Lung Cancer Screening Trial: status after five annual screening rounds with low-dose CT. Thorax 2012; 67 (4) 296-301
  CrossrefPubMedGoogle Scholar
• 10 Infante M, Cavuto S, Lutman FR , et al; DANTE Study Group. A randomized study of lung cancer screening with spiral computed tomography: three-year results from the DANTE trial. Am J Respir Crit Care Med 2009; 180 (5) 445-453
  CrossrefPubMedGoogle Scholar
• 11 Pastorino U, Rossi M, Rosato V , et al. Annual or biennial CT screening versus observation in heavy smokers: 5-year results of the MILD trial. Eur J Cancer Prev 2012; 21 (3) 308-315
  CrossrefPubMedGoogle Scholar
• 12 Hassanein M, Callison JC, Callaway-Lane C, Aldrich MC, Grogan EL, Massion PP. The state of molecular biomarkers for the early detection of lung cancer. Cancer Prev Res (Phila) 2012; 5 (8) 992-1006
  CrossrefPubMedGoogle Scholar
• 13 Jaklitsch MT, Jacobson FL, Austin JH , et al. The American Association for Thoracic Surgery guidelines for lung cancer screening using low-dose computed tomography scans for lung cancer survivors and other high-risk groups. J Thorac Cardiovasc Surg 2012; 144 (1) 33-38
  CrossrefPubMedGoogle Scholar
• 14 Henschke CI, McCauley DI, Yankelevitz DF , et al. Early Lung Cancer Action Project: overall design and findings from baseline screening. Lancet 1999; 354 (9173) 99-105
  CrossrefPubMedGoogle Scholar
• 15 de Hoop B, Gietema H, van Ginneken B, Zanen P, Groenewegen G, Prokop M. A comparison of six software packages for evaluation of solid lung nodules using semi-automated volumetry: what is the minimum increase in size to detect growth in repeated CT examinations. Eur Radiol 2009; 19 (4) 800-808
  CrossrefPubMedGoogle Scholar
• 16 Xu DM, Gietema H, de Koning H , et al. Nodule management protocol of the NELSON randomised lung cancer screening trial. Lung Cancer 2006; 54 (2) 177-184
  CrossrefPubMedGoogle Scholar
• 17 van Klaveren RJ, Oudkerk M, Prokop M , et al. Management of lung nodules detected by volume CT scanning. N Engl J Med 2009; 361 (23) 2221-2229
  CrossrefPubMedGoogle Scholar
• 18 Xu DM, van der Zaag-Loonen HJ, Oudkerk M , et al. Smooth or attached solid indeterminate nodules detected at baseline CT screening in the NELSON study: cancer risk during 1.  year of follow-up. Radiology 2009; 250 (1) 264-272
  CrossrefPubMedGoogle Scholar
• 19 Heuvelmans MA, Oudkerk M, de Bock GH , et al. Optimisation of volume-doubling time cutoff for fast-growing lung nodules in CT lung cancer screening reduces false-positive referrals. Eur Radiol 2013; 23 (7) 1836-1845
  CrossrefPubMedGoogle Scholar
• 20 de Hoop B, van Ginneken B, Gietema H, Prokop M. Pulmonary perifissural nodules on CT scans: rapid growth is not a predictor of malignancy. Radiology 2012; 265 (2) 611-616
  CrossrefPubMedGoogle Scholar
• 21 McWilliams A, Tammemagi MC, Mayo JR , et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med 2013; 369 (10) 910-919
  CrossrefPubMedGoogle Scholar
• 22 Naidich DP, Bankier AA, MacMahon H , et al. Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. Radiology 2013; 266 (1) 304-317
  CrossrefPubMedGoogle Scholar
• 23 Henschke CI, Yankelevitz DF, Mirtcheva R, McGuinness G, McCauley D, Miettinen OS ; ELCAP Group. CT screening for lung cancer: frequency and significance of part-solid and nonsolid nodules. AJR Am J Roentgenol 2002; 178 (5) 1053-1057
  CrossrefPubMedGoogle Scholar
• 24 Hall EJ, Brenner DJ. Cancer risks from diagnostic radiology. Br J Radiol 2008; 81 (965) 362-378
  CrossrefPubMedGoogle Scholar
• 25 Peloschek P, Sailer J, Weber M, Herold CJ, Prokop M, Schaefer-Prokop C. Pulmonary nodules: sensitivity of maximum intensity projection versus that of volume rendering of 3D multidetector CT data. Radiology 2007; 243 (2) 561-569
  CrossrefPubMedGoogle Scholar
• 26 van Ginneken B, Schaefer-Prokop CM, Prokop M. Computer-aided diagnosis: how to move from the laboratory to the clinic. Radiology 2011; 261 (3) 719-732
  CrossrefPubMedGoogle Scholar
• 27 National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Lung Cancer Screening. Available at: http://www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf
  PubMedGoogle Scholar
• 28 Sinicrope PS, Rabe KG, Brockman TA , et al. Perceptions of lung cancer risk and beliefs in screening accuracy of spiral computed tomography among high-risk lung cancer family members. Acad Radiol 2010; 17 (8) 1012-1025
  CrossrefPubMedGoogle Scholar
• 29 Mets OM, de Jong PA, Prokop M. Computed tomographic screening for lung cancer: an opportunity to evaluate other diseases. JAMA 2012; 308 (14) 1433-1434
  CrossrefPubMedGoogle Scholar
• 30 Jacobs PC, Prokop M, van der Graaf Y , et al. Comparing coronary artery calcium and thoracic aorta calcium for prediction of all-cause mortality and cardiovascular events on low-dose non-gated computed tomography in a high-risk population of heavy smokers. Atherosclerosis 2010; 209 (2) 455-462
  CrossrefPubMedGoogle Scholar
• 31 Mets OM, Buckens CF, Zanen P , et al. Identification of chronic obstructive pulmonary disease in lung cancer screening computed tomographic scans. JAMA 2011; 306 (16) 1775-1781
  PubMedGoogle Scholar
• 32 Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst 2010; 102 (9) 605-613
  CrossrefPubMedGoogle Scholar
• 33 Yankelevitz DF, Kostis WJ, Henschke CI , et al. Overdiagnosis in chest radiographic screening for lung carcinoma: frequency. Cancer 2003; 97 (5) 1271-1275
  CrossrefPubMedGoogle Scholar
• 34 Lindell RM, Hartman TE, Swensen SJ, Jett JR, Midthun DE, Mandrekar JN. 5-year lung cancer screening experience: growth curves of 18 lung cancers compared to histologic type, CT attenuation, stage, survival, and size. Chest 2009; 136 (6) 1586-1595
  CrossrefPubMedGoogle Scholar
• 35 Esserman LJ, Thompson Jr IM, Reid B. Overdiagnosis and overtreatment in cancer: an opportunity for improvement. JAMA 2013; 310 (8) 797-798
  CrossrefPubMedGoogle Scholar