ABDOMINAL AORTIC ANEURYSM SCREENING

LUNG CANCER

Indications for Screening according to USPSTF

• Adults aged 55 to 80 years

• History of >30 pack-year of smoking and currently smoke or have quit within the past 15 years

• Discontinue low-dose chest CT (LDCT) if patient has not smoked for 15 years or has a health problem that significantly limits life expectancy

• Of note, Medicare covers lung cancer screening for patients aged 55 to 77 years only

What test to perform?

• Yearly low-dose chest CT (LDCT)

• Make sure your patient understands that lung cancer screening is not a single test, but a process that must be done correctly under the direction of a physician.

• Lung cancer screening is NOT an alternative to smoking cessation, which is the most important intervention to decrease the risk of dying from lung cancer.

Follow-up algorithm

• Usually Radiology will make a recommendation on how and when to follow-up a positive test. Most often this involves repeat imaging and, occasionally, invasive tests like a biopsy.

Benefits - Recommend to discuss using a shared-decision making tool (see Resources section)

• Annual screening for lung cancer with LDCT in high-risk persons can prevent a substantial number of lung cancer–related deaths.

• The magnitude of benefit to a particular individual depends on that person's risk for lung cancer — those who are at highest risk are most likely to benefit.

• Screening cannot prevent most lung cancer–related deaths, and smoking cessation remains essential.

Harms - Recommend to discuss using a shared-decision making tool (see Resources section)

• Harms 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.

• A modeling study performed for the USPSTF estimated that 10% to 12% of screen-detected cancer cases are overdiagnosed —that is, they would not have been detected in the patient's lifetime without screening.

Resources

• Shared-decision making tools online:

  • Lung cancer risk calculator. Great guide to use with your patients.

• Shared-decision making tools print:

  • Is Lung Cancer Screening Right for Me? A Decision Aid for People Considering Lung Cancer Screening With Low-Dose Computed Tomography

  • Is Lung Cancer Screening Right for Me? A Decisionmaking Tool for You and Your Health Care Professional

  • Lung Cancer Screening: A Summary Guide for Primary Care Clinicians

  • Lung Cancer Screening: A Clinician’s Checklist

• H. Gilbert Welch has done extensive research on the risk of overdiagnosis and cancer screening. Check his paper Overdiagnosis in cancer or, if interested in a more in-depth review of these topics, his books Overdiagnosed and Less Medicine More Health are great reads.

Bibliography

• Screening for lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.

• Screening for Lung Cancer: Systematic Review to Update the U.S. Preventive Services Task Force Recommendation