Lung Cancer Incidence and Mortality with Extended Follow-up in the National Lung Screening Trial.
Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer
INTRODUCTION:The National Lung Screening Trial (NLST) randomized high-risk current and former smokers to three annual screens with either low-dose computed tomography (LDCT) or chest radiography (CXR) and demonstrated a significant reduction in lung cancer mortality in the LDCT arm after a median of 6.5 years' follow-up. We report on extended follow-up of NLST subjects. METHODS:Subjects were followed by linkage to state cancer registries and the National Death Index. The number needed to screen (NNS) to prevent one lung cancer death was computed as the reciprocal of the difference in the proportion of patients dying of lung cancer across arms. Lung cancer mortality rate ratios (RRs) were computed overall and adjusted for dilution effect, with the latter including only deaths with a corresponding diagnosis close enough to the end of protocol screening. RESULTS:The median follow-up times were 11.3 years for incidence and 12.3 years for mortality. In all, 1701 and 1681 lung cancers were diagnosed in the LDCT and CXR arms, respectively (RR = 1.01, 95% confidence interval [CI]: 0.95-1.09). The observed numbers of lung cancer deaths were 1147 (with LDCT) versus 1236 (with CXR) (RR = 0.92, 95% CI: 0.85-1.00). The difference in the number of patients dying of lung cancer (per 1000) across arms was 3.3, translating into an NNS of 303, which is similar to the original NNS estimate of around 320. The dilution-adjusted lung cancer mortality RR was 0.89 (95% CI: 0.80-0.997). With regard to overall mortality, there were 5253 (with LDCT) and 5366 (with CXR) deaths, for a difference across arms (per 1000) of 4.2 (95% CI: -2.6 to 10.9). CONCLUSION:Extended follow-up of the NLST showed an NNS similar to that of the original analysis. There was no overall increase in lung cancer incidence in the LDCT arm versus in the CXR arm.
Prediction of Lung Cancer Screening Eligibility Using Simplified Criteria.
Triplette Matthew,Donovan Lucas M,Crothers Kristina,Madtes David K,Au David H
Annals of the American Thoracic Society
Lung cancer screening with low-dose chest computed tomography decreases mortality for high-risk current or former smokers. Lifetime smoking intensity (cigarette pack-years), an essential eligibility criterion, is poorly recorded in electronic health records, which may contribute to the overall low appropriate use of screening. We sought to assess whether elements commonly extractable from electronic health records may be useful as prescreening tools to identify individuals for formal assessment of eligibility. This was a cross-sectional cohort study of the National Health and Nutrition Examination Survey (NHANES) continuous survey, years 2011-2016. We included all adult participants with complete smoking interview data, weighted to construct a nationally representative cohort. We determined test characteristics for five criteria, including eligibility age, smoking status (current, former, or never), and current smoking intensity, to predict lung cancer screening eligibility as defined by the U.S. Preventive Services Task Force and Centers for Medicare and Medicaid Services. Almost 9 million individuals (3.8% of the population) may qualify for screening. Simplified criteria, including the appropriate age range (55-77 yr) and smoking status, correctly discriminated individuals who were eligible for screening in most cases (area under the curve = 0.92). When the analysis was restricted to those of eligible age, smoking status retained fair predictive value (area under the curve = 0.85). Incorporating additional information about current smoking behavior would allow for refinement of approaches to identify specific populations for screening. These simplified criteria may be useful for identifying individuals who are eligible for lung cancer screening. Applying these criteria as a prescreening tool may improve appropriate referral and implementation of screening. lung cancer; early detection of lung cancer; cancer prevention; tobacco abuse.
Screening baseline characteristics of early lung cancer on low-dose computed tomography with computer-aided detection in a Chinese population.
Liu Yuanyuan,Luo Hongbin,Qing Haomiao,Wang Xiaodong,Ren Jing,Xu Guohui,Hu Shibei,He Changjiu,Zhou Peng
OBJECTIVES:This study investigated appropriate baseline characteristics for screening a Chinese population at high risk of early lung cancer, assisted by low-dose computed tomography (LDCT) with computer-aided detection (CAD). Included is a discussion of the viability of using LDCT in the screening guideline and optimizing the guideline. METHODS:In 2014, 1016 individuals from Sichuan Province were enrolled who satisfied the criteria for high risk according to the 2013 National Comprehensive Cancer Network (NCCN) Guidelines for Non-Small Cell Lung Cancer. From 2014 to 2018, each subject was followed using LDCT with CAD, and pathologically confirmed lung cancers and baseline nodule characteristics (size and density) were recorded. Positive risk was considered a non-calcified solid or part-solid nodule on LDCT with diameter ≥5 mm and ground-glass nodule ≥8 mm, as newly recommended by the China National Lung Cancer Screening Guideline. RESULTS:From 2014-2018, 13 cases of lung cancer were detected; 5 of these were early stage (38.5%). According to the NCCN criteria, 54 women were included and one of these (1.8%) developed lung cancer. The prevalence of lung cancer was 0.7% at baseline. For the entire population (excluding subjects with a tumor mass at baseline, n = 4), the rate of positivity was 20.4% at baseline; applying the Chinese criteria, the false positive rate was 19.5% (197/1012). CONCLUSIONS:Further studies are warranted to establish appropriate eligible criteria and management strategies for Chinese populations.
Lung Cancer Screening Eligibility, Risk Perceptions, and Clinician Delivery of Tobacco Cessation Among Patients With Schizophrenia.
Irwin Kelly E,Steffens Eleanor B,Yoon YooJin,Flores Efren J,Knight Helen P,Pirl William F,Freudenreich Oliver,Henderson David C,Park Elyse R
Psychiatric services (Washington, D.C.)
OBJECTIVE:Individuals with schizophrenia experience increased lung cancer mortality and decreased access to cancer screening and tobacco cessation treatment. To promote screening among individuals with schizophrenia, it is necessary to investigate the proportion who meet screening criteria and examine smoking behaviors, cancer risk perception, and receipt of tobacco cessation interventions from psychiatry and primary care. METHODS:The authors performed a cross-sectional survey and medical record review with 112 adults with schizophrenia treated with clozapine in a community mental health clinic (CMHC). RESULTS:Among older participants (ages 55-77 years) with schizophrenia, 34% met the criteria for lung screening on the basis of smoking history (heavy current or former smokers), and more than half believed they had a low risk of developing lung cancer. Of all participants, 88% had visited their primary care provider (PCP) in the past year; PCPs represented 35 different practices. Only one in three current smokers reported that their PCP or psychiatrist assisted them in obtaining medications for tobacco cessation. CONCLUSIONS:Given smoking history, many older adults with schizophrenia have potential to benefit from lung screening, yet most older participants underestimated their lung cancer risk. Although participants regularly accessed care, PCP and psychiatric visits may be missed opportunities to engage patients with schizophrenia in tobacco cessation and decrease preventable premature mortality. Embedding interventions in a CMHC, a centralized access point of care delivery for patients with schizophrenia, may have unique potential to increase uptake of cancer screening and tobacco cessation interventions.
Performance of community-based lung cancer screening program in a Histoplasma endemic region.
Bhandari Shruti,Tripathi Prashant,Pham Danh,Pinkston Christina,Kloecker Goetz
Lung cancer (Amsterdam, Netherlands)
OBJECTIVES:Lung cancer screening with low dose computed-tomography (LDCT) is currently recommended for high-risk populations based on mortality benefit shown in the National Lung Screening Trial (NLST). This study evaluated performance of a community-based lung cancer screening program in a Histoplasma endemic region. MATERIALS AND METHODS:Demographic and clinical information was collected through retrospective review of patients in the Lung Cancer Screening program of a Kentucky (Histoplasma endemic region) health system from 2016 and 2017. A positive LDCT screen is defined as Lung-RADS version 1.0 assessment categories 3 or 4. Patients characteristics, initial screening results and follow up were analyzed and compared to NLST results. RESULTS:A total of 4500 LDCT screens were performed in 2016 (39%) and 2017 (61%) with 43% adherence rate to repeat annual screen in 2017. Mean age of patients was 64 years, with majority being females (54%) and current smokers (69%) with average 52-pack year smoking history. The rate of positive LDCT was 13.3% (600) varying based on baseline (14.6%) and annual (9.5%) screen. A total of 70 lung cancers were diagnosed among all positive LDCT screens (11.7%) with a false positive rate of 12%. CONCLUSIONS:Baseline positive screens in our study are similar to NLST data with Lung-RADS criteria implementation (14.6% vs 13.6%, p = 0.15) despite being a Histoplasma endemic region. Our study shows a successful performance of a community-based lung cancer screening program in a Histoplasma endemic region.
Calcium: magnesium intake ratio and colorectal carcinogenesis, results from the prostate, lung, colorectal, and ovarian cancer screening trial.
Zhao Jing,Giri Ayush,Zhu Xiangzhu,Shrubsole Martha J,Jiang Yixing,Guo Xingyi,Ness Reid,Seidner Douglas L,Giovannucci Edward,Edwards Todd L,Dai Qi
British journal of cancer
BACKGROUND:We aimed to evaluate the associations between calcium and various stages of colorectal carcinogenesis and whether these associations are modified by the calcium to magnesium (Ca:Mg) ratio. METHODS:We tested our hypotheses in the prostate lung, colorectal and ovarian cancer screening trial. RESULTS:Calcium intake did not show a dose-response association with incident adenoma of any size/stage (P- = 0.17), but followed an inverse trend when restricted to synchronous/advanced adenoma cases (P- = 0.05). This inverse trend was mainly in participants with Ca:Mg ratios between 1.7 and 2.5 (P- = 0.05). No significant associations were observed for metachronous adenoma. Calcium intake was inversely associated with CRC (P- = 0.03); the association was primarily present for distal CRC (P- = 0.01). The inverse association between calcium and distal CRC was further modified by the Ca:Mg ratio (P- < 0.01); significant dose-response associations were found only in participants with a Ca:Mg ratio between 1.7 and 2.5 (P- = 0.04). No associations for calcium were found in the Ca:Mg ratio above 2.5 or below 1.7. CONCLUSION:Higher calcium intake may be related to reduced risks of incident advanced and/or synchronous adenoma and incident distal CRC among subjects with Ca:Mg intake ratios between 1.7 and 2.5.
Disparities in Follow-Up After Low-Dose Lung Cancer Screening.
Sesti Joanna,Sikora Timothy J,Turner Dusty S,Turner Amber L,Langan Russell C,Nguyen Andrew B,Paul Subroto
Seminars in thoracic and cardiovascular surgery
The National Lung Cancer Screening Trial (NLST) demonstrated an improvement in overall survival with lung cancer screening. Achieving follow-up for a positive screen is essential to impact early intervention for lung cancer. The objective of this study was to determine predictors of follow-up after a positive lung cancer screening test. The NLST database was queried for participants with a positive lung cancer screening exam. This cohort was then subdivided into patients who had follow-up and those who did not. Pairwise comparison was performed within different subgroups. A logistic regression model was then utilized to identify predictive factors associated with follow-up. Of the 53,454 patients who participated in the study, we identified 14,000 patients who had a positive lung cancer screening test. Of those patients, 12,503 followed up appropriately (89.3%). Women had a statistically higher follow-up rate compared to men (90% vs 88.8%, P ≤ 0.05). Patients reported as married or living as married also showed a higher rate of follow-up compared to patients reported as never married, divorced, separated, or widowed (90.2% vs 87.5%, P ≤ 0.05). The rate of follow-up among African-American patients was 82.8%, while those in white patients was 89.6%, this was statistically significant (P ≤ 0.05). Education level was not a significant factor in follow-up rates. Current smokers followed up at lower rates compared to former smokers (87.9 % vs 90.6%, P ≤ 0.05). Logistic regression determined gender, marital status, race, and smoking status to be predictors of follow-up. Follow-up rates after a positive lung cancer screening test were associated with a patient's gender, marital status, race, and smoking status.
Healthcare Access, Utilization, and Preventive Health Behaviors by Eligibility for Lung Cancer Screening.
Miller Eric A,Pinsky Paul F
Journal of cancer education : the official journal of the American Association for Cancer Education
In 2013, the US Preventive Services Task Force recommended low-dose computed tomography screening for smokers at high risk of lung cancer; however, use remains low. Efforts to promote lung cancer screening need to consider how receptive this population is to preventive healthcare and cancer screening. In addition, because of demonstrated heterogeneity in behaviors by smoking status, interventions may need to differ among eligible high-risk subgroups. To assess the engagement of high-risk smokers in other preventive healthcare behaviors, we examined healthcare use, including non-lung cancer screening, and healthcare provider discussions regarding screening by eligibility for lung cancer screening. We used the 2015 National Health Interview Survey to assess smoking history, healthcare use, cancer screening, vaccinations, and healthcare provider discussions regarding non-lung cancer screening. We calculated weighted prevalence estimates and prevalence ratios comparing eligible and ineligible current and former smokers to never smokers. Eligible current and former smokers had significantly different healthcare utilization and screening concordance compared to never smokers and to each other. Compared to never smokers, eligible current smokers were significantly less likely to be concordant with breast, colorectal, and cervical cancer screening while eligible former smokers were only less likely to be concordant with breast cancer screening. Eligible current smokers were less likely to report physician discussions about non-lung screening tests. Provider discussions about screening and engagement in preventive healthcare differed among current and former smokers eligible for lung cancer screening. Intervention efforts to increase lung cancer screening levels will likely need to differ as well.
Effects of Personalized Risk Information on Patients Referred for Lung Cancer Screening with Low-Dose CT.
Han Paul K J,Lary Christine,Black Adam,Gutheil Caitlin,Mandeville Hayley,Yahwak Jason,Fukunaga Mayuko
Medical decision making : an international journal of the Society for Medical Decision Making
Low-dose computed tomography (LDCT) screening for lung cancer is a preference-sensitive intervention that should ideally be individualized according to patients' likelihood of benefit and personal values. Personalized cancer risk information (PCRI) may facilitate this goal, but its effects are unknown. To evaluate the effects of providing PCRI to patients referred for LDCT screening. Mixed-methods, pre-post study using surveys administered to patients before and after provision of PCRI-calculated by the PLCOm2012 risk prediction model-in shared decision-making consultations, and postvisit qualitative interviews. Centralized specialty-based LDCT screening program at a tertiary care hospital. Convenience sample of eligible patients referred for LDCT screening. Pre- and postvisit surveys assessed patients' 1) perceived lung cancer risk, 2) uncertainty about their risk, 3) minimum risk threshold for wanting screening, 4) interest in LDCT screening, and 5) interest in smoking cessation. Qualitative interviews explored patients' perceptions of the value of PCRI. Screening uptake was assessed by chart review. Sixty of 70 (86%) patients received PCRI and completed pre-post surveys, and 17 patients (28%) completed qualitative interviews. Perceived lung cancer risk decreased from 52% previsit to 31% postvisit ( < 0.0001). However, patients' minimum risk thresholds for screening decreased, their screening interest increased, and all patients completed screening. Qualitative interviews corroborated these effects, suggesting that patients discount and interpret PCRI according to preexisting beliefs and attitudes. The study population was a relatively small, single-institution sample of patients referred for screening. Personalized cancer risk information decreases cancer risk perceptions of patients referred for LDCT screening, but has complex effects on screening-related judgments and decisions. The value of PCRI for patients considering LDCT screening requires further investigation.
Cost-Effectiveness Analysis of Lung Cancer Screening in the United States: A Comparative Modeling Study.
Criss Steven D,Cao Pianpian,Bastani Mehrad,Ten Haaf Kevin,Chen Yufan,Sheehan Deirdre F,Blom Erik F,Toumazis Iakovos,Jeon Jihyoun,de Koning Harry J,Plevritis Sylvia K,Meza Rafael,Kong Chung Yin
Annals of internal medicine
Background:Recommendations vary regarding the maximum age at which to stop lung cancer screening: 80 years according to the U.S. Preventive Services Task Force (USPSTF), 77 years according to the Centers for Medicare & Medicaid Services (CMS), and 74 years according to the National Lung Screening Trial (NLST). Objective:To compare the cost-effectiveness of different stopping ages for lung cancer screening. Design:By using shared inputs for smoking behavior, costs, and quality of life, 4 independently developed microsimulation models evaluated the health and cost outcomes of annual lung cancer screening with low-dose computed tomography (LDCT). Data Sources:The NLST; Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial; SEER (Surveillance, Epidemiology, and End Results) program; Nurses' Health Study and Health Professionals Follow-up Study; and U.S. Smoking History Generator. Target Population:Current, former, and never-smokers aged 45 years from the 1960 U.S. birth cohort. Time Horizon:45 years. Perspective:Health care sector. Intervention:Annual LDCT according to NLST, CMS, and USPSTF criteria. Outcome Measures:Incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY). Results of Base-Case Analysis:The 4 models showed that the NLST, CMS, and USPSTF screening strategies were cost-effective, with ICERs averaging $49 200, $68 600, and $96 700 per QALY, respectively. Increasing the age at which to stop screening resulted in a greater reduction in mortality but also led to higher costs and overdiagnosis rates. Results of Sensitivity Analysis:Probabilistic sensitivity analysis showed that the NLST and CMS strategies had higher probabilities of being cost-effective (98% and 77%, respectively) than the USPSTF strategy (52%). Limitation:Scenarios assumed 100% screening adherence, and models extrapolated beyond clinical trial data. Conclusion:All 3 sets of lung cancer screening criteria represent cost-effective programs. Despite underlying uncertainty, the NLST and CMS screening strategies have high probabilities of being cost-effective. Primary Funding Source:CISNET (Cancer Intervention and Surveillance Modeling Network) Lung Group, National Cancer Institute.
Defining the information needs of lung cancer screening participants: a qualitative study.
Ruparel Mamta,Quaife Samantha,Baldwin David,Waller Jo,Janes Samuel
BMJ open respiratory research
Introduction:Lung cancer screening (LCS) by low-dose CT has been shown to improve mortality, but individuals must consider the potential benefits and harms before making an informed decision about taking part. Shared decision-making is required for LCS in USA, though screening-eligible individuals' specific views of these harms, and their preferences for accessing this information, are not well described. Methods:In this qualitative study, we aimed to explore knowledge and perceptions around lung cancer and LCS with a focus on harms. We carried out seven focus groups with screening-eligible individuals, which were divided into current versus former smokers and lower versus higher educational backgrounds; and 16 interviews with health professionals including general practitioners, respiratory physicians, lung cancer nurse specialists and public health consultants. Interviews and focus groups were audio-recorded and transcribed. Data were coded inductively and analysed using the framework method. Results:Fatalistic views about lung cancer as an incurable disease dominated, particularly among current smokers, and participants were often unaware of curative treatment options. Despite this, beliefs that screening is sensible and worthwhile were expressed. Generally participants felt they had the 'right' to an informed decision, though some cautioned against information overload. The potential harms of LCS were poorly understood, particularly overdiagnosis and radiation exposure, but participants were unlikely to be deterred by them. Strong concerns about false-negative results were expressed, while false-positive results and indeterminate nodules were also reported as concerning. Conclusions:These findings demonstrate the need for LCS information materials to highlight information on the benefits of early detection and options for curative treatment, while accurately presenting the possible harms. Information needs are likely to vary between individuals and we recommend simple information materials to be made available to all individuals considering participating in LCS, with signposting to more detailed information for those who require it.
'Reduced' HUNT model outperforms NLST and NELSON study criteria in predicting lung cancer in the Danish screening trial.
Røe Oluf Dimitri,Markaki Maria,Tsamardinos Ioannis,Lagani Vincenzo,Nguyen Olav Toai Duc,Pedersen Jesper Holst,Saghir Zaigham,Ashraf Haseem Gary
BMJ open respiratory research
Hypothesis:We hypothesise that the validated HUNT Lung Cancer Risk Model would perform better than the NLST (USA) and the NELSON (Dutch-Belgian) criteria in the Danish Lung Cancer Screening Trial (DLCST). Methods:The DLCST measured only five out of the seven variables included in validated HUNT Lung Cancer Model. Therefore a 'Reduced' model was retrained in the Norwegian HUNT2-cohort using the same statistical methodology as in the original HUNT model but based only on age, pack years, smoking intensity, quit time and body mass index (BMI), adjusted for sex. The model was applied on the DLCST-cohort and contrasted against the NLST and NELSON criteria. Results:Among the 4051 smokers in the DLCST with 10 years follow-up, median age was 57.6, BMI 24.75, pack years 33.8, cigarettes per day 20 and most were current smokers. For the same number of individuals selected for screening, the performance of the 'Reduced' HUNT was increased in all metrics compared with both the NLST and the NELSON criteria. In addition, to achieve the same sensitivity, one would need to screen fewer people by the 'Reduced' HUNT model versus using either the NLST or the NELSON criteria (709 vs 918, p=1.02e-11 and 1317 vs 1668, p=2.2e-16, respectively). Conclusions:The 'Reduced' HUNT model is superior in predicting lung cancer to both the NLST and NELSON criteria in a cost-effective way. This study supports the use of the HUNT Lung Cancer Model for selection based on risk ranking rather than age, pack year and quit time cut-off values. When we know how to rank personal risk, it will be up to the medical community and lawmakers to decide which risk threshold will be set for screening.
[Lung cancer screening with low-dose spiral CT in a unit staff: Results of the baseline screening].
Ouyang Bihan,Guo Jia,Zhou Wei,Tan Ying,Liu Shaohui,Zhang Xuewei
Zhong nan da xue xue bao. Yi xue ban = Journal of Central South University. Medical sciences
OBJECTIVE:To analyze the incidence and imaging characteristics of pulmonary nodules in a unit staff.
Methods: Low-dose spiral CT (LDCT) scan were performed in 1 372 staffs ≥45 years old in a certain unit during the physical examination. The clinical and imaging data were collected to analyze the detection rate, imaging characteristics, and postoperative pathological conditions of pulmonary nodules.
Results: The total detection rate for pulmonary nodules was 30.39% (417/1 372). The detected nodules were mainly single (227 cases), solid (343 cases), <5 mm in diameter (261 cases), and Lung-Reporting and Data System (Lung-RADS) category 2 nodules (340 cases). The single nodules were mostly found in the right upper lung (74 cases, 32.60%). The detection rate of pulmonary nodules tended to decrease but the detection rate of category 4 nodules increased with the increasing age (P<0.05), while the gender had no significant influence on the detection rate (P>0.05). Compared with the Lung-RADS category 3 nodules, the proportions of nodules in subsolid state, with irregular shape, lobulation sign, and vascular penetration in the Lung-RADS category 4 were increased (all P<0.05). Among them, 11 patients received surgical therapy, including 10 women. Postoperative pathology confirmed lung adenocarcinoma in 9 patients (2.16%), including 8 women, all non-smokers.
Conclusion: The nodules in subsolid state with vascular penetration, irregular shape and lobulation sign tend to be malignant. Lung cancer screening with low-dose spiral CT in female non-smokers should be emphasized.
Integration of whole-genome sequencing and functional screening identifies a prognostic signature for lung metastasis in triple-negative breast cancer.
Xie Guangdong,Yang Haiyuan,Ma Ding,Sun Yihua,Chen Haiquan,Hu Xin,Jiang Yi-Zhou,Shao Zhi-Ming
International journal of cancer
Lung metastasis is one of the leading causes of death for triple-negative breast cancer (TNBC). We sought to characterize the genetic alterations underlying TNBC lung metastases by integrating whole-genome sequencing and functional screening. Furthermore, we aimed to develop a metastasis-related gene signature for TNBC patients to improve risk stratification. In this prospective observational study, we first conducted whole-genome sequencing of paired primary tumor and lung metastasis from one TNBC patient to identify potential genetic driver alterations. An in vivo gain-of-function screening using an amplified open reading frame library was then employed to screen candidate genes promoting lung metastasis. Finally, we applied Cox proportional hazard regression modeling to develop a prognostic gene signature from 14 candidate genes in TNBC. Compared to the primary tumor, copy number amplifications of chromosomes 3q and 8q were identified in the lung metastasis. We discovered an enrichment of 14 genes from chromosomes 3q and 8q in mouse lung metastases model. We further developed and validated a four-gene signature (ENY2, KCNK9, TNFRSF11B and KCNMB2) that predicts recurrence-free survival and lung metastasis in TNBC. Our data also demonstrated that upregulated expression of ENY2 could promote invasion and lung metastasis of TNBC cells both in vitro and in vivo. In conclusion, our study reveals functional genes with copy number amplifications among chromosome 3q and 8q in lung metastasis of TNBC. And we develop a functional gene signature that can effectively stratify patients into low- and high-risk subgroups of recurrence, helping frame personalized treatments for TNBC.
Biomarker panel for early detection of endometrial cancer in the Prostate, Lung, Colorectal, and Ovarian cancer screening trial.
Tarney Christopher M,Wang Guisong,Bateman Nicholas W,Conrads Kelly A,Zhou Ming,Hood Brian L,Loffredo Jeremy,Tian Chunqiao,Darcy Kathleen M,Hamilton Chad A,Casablanca Yovanni,Lokshin Anna,Conrads Thomas P,Maxwell G Larry
American journal of obstetrics and gynecology
BACKGROUND:Endometrial cancer is the most common gynecological cancer in the United States. However, no early detection test exists for asymptomatic women at average risk for endometrial cancer. OBJECTIVE:We sought to identify early detection biomarkers for endometrial cancer using prediagnostic serum. STUDY DESIGN:We performed a nested case-control study of postmenopausal women in the Prostate, Lung, Colorectal, and Ovarian cancer screening trial (n = 78,216), including 112 incident endometrial cancer cases and 112 controls. Prediagnostic serum was immunodepleted of high-abundance proteins and digested with sequencing grade porcine trypsin via pressure cycling technology. Quantitative proteomics and phosphoproteomics was performed using high-resolution liquid chromatography-tandem mass spectrometry and highly multiplexed isobaric mass tag combined with basic reversed-phase liquid chromatography. A set of proteins able to predict cancer status was identified with an integrated score assessed by receiver-operator curve analysis. RESULTS:Mean time from blood draw to endometrial cancer diagnosis was 3.5 years (SD, 1.9 years). There were 47 differentially abundant proteins between cases and controls (P < .05). Protein alterations with high predictive potential were selected by regression analysis and compiled into an aggregate score to determine the ability to predict endometrial cancer. An integrated risk score of 6 proteins was directly related to disease incidence in cases with blood draw ≤2 years, >2 years to ≤5 years or >5 years prior to cancer diagnosis. The integrated score distinguished cases from controls with an area under the curve of 0.80 (95% confidence interval, 0.72-0.88). CONCLUSION:An integrated score of 6 proteins using prediagnostic serum from the Prostate, Lung, Colorectal, and Ovarian cancer screening trial distinguishes postmenopausal endometrial cancer cases from controls. Validation is needed to evaluate whether this test can improve prediction or detection of endometrial cancer among postmenopausal women.
Increased Incidence of Lung Cancer Among Patients With Superficial Transitional Cell Carcinoma: A Potential Risk Cohort for Lung Cancer Screening.
Tolwin Yaakov,Gillis Roni,Agmon Inbar Nardi,Shrem Noa Shani,Rosenbaum Eli,Peled Nir
Clinical lung cancer
BACKGROUND:Smoking is a major risk factor for lung cancer (LC) and transitional cell carcinoma of the bladder (TCC). Current recommendations for LC screening do not include TCC as a risk factor for determining screening eligibility. In this study we aimed to evaluate whether TCC patients constitute a population who might benefit from LC screening. PATIENTS AND METHODS:The Surveillance, Epidemiology, and End Results 18 database was used to determine the incidence, standardized incidence ratio (SIR), and the average time to diagnosis of LC in patients with localized TCC of the bladder (American Joint Committee on Cancer, sixth edition, stages 0-1). RESULTS:On the basis of 91,606 patients with localized TCC, The SIR for LC in men was 1.89 (95% confidence interval [CI], 1.8-1.97), significantly different from the risk for all solid tumors. The SIR for LC in women was 2.43 (95% CI, 2.22-2.65), significantly higher than for men. The 5-year incidence of LC was 3.2%, and the 10-year incidence was 5.94%. The average time to diagnosis of LC was 3.4 years, with >80% of LC cases occurring within 5 years of TCC diagnosis. CONCLUSION:Patients with localized TCC have a higher incidence of LC than the general population. The risk is significantly increased among women compared with men. Considering this increased risk, patients with early stage TCC might stand to benefit from LC screening. Additional differences were noted between male and female TCC patients, which bear further study.
Cancer Risk in Subsolid Nodules in the National Lung Screening Trial.
Hammer Mark M,Palazzo Lauren L,Kong Chung Yin,Hunsaker Andetta R
Background Subsolid pulmonary nodules, comprising pure ground-glass nodules (GGNs) and part-solid nodules (PSNs), have a high risk of indolent malignancy. Lung Imaging Reporting and Data System (Lung-RADS) nodule management guidelines are based on expert opinion and lack independent validation. Purpose To evaluate Lung-RADS estimates of the malignancy rates of subsolid nodules, using nodules from the National Lung Screening Trial (NLST), and to compare Lung-RADS to the NELSON trial classification as well as the Brock University calculator. Materials and Methods Subsets of GGNs and PSNs were selected from the NLST for this retrospective study. A thoracic radiologist reviewed the baseline and follow-up CT images, confirmed that they were true subsolid nodules, and measured the nodules. The primary outcome for each nodule was the development of malignancy within the follow-up period (median, 6.5 years). Nodules were stratified according to Lung-RADS, NELSON trial criteria, and the Brock model. For analyses, nodule subsets were weighted on the basis of frequency in the NLST data set. Nodule stratification models were tested by using receiver operating characteristic curves. Results A total of 622 nodules were evaluated, of which 434 nodules were subsolid. At baseline, 304 nodules were classified as Lung-RADS category 2, with a malignancy rate of 3%, which is greater than the 1% in Lung-RADS ( = .004). The malignancy rate for GGNs smaller than 10 mm (two of 129, 1.3%) was smaller than that for GGNs measuring 10-19 mm (11 of 153, 6%) ( = .01). The malignancy rate for Lung-RADS category 3 was 14% (13 of 67), which is greater than the reported 2% in Lung-RADS ( < .001). The Brock model predicted malignancy better than Lung-RADS and the NELSON trial scheme (area under the receiver operating characteristic curve = 0.78, 0.70, and 0.67, respectively; = .02 for Brock model vs NELSON trial scheme). Conclusion Subsolid nodules classified as Lung Imaging Reporting and Data System (Lung-RADS) categories 2 and 3 have a higher risk of malignancy than reported. The Brock risk calculator performed better than measurement-based classification schemes such as Lung-RADS. © RSNA, 2019 See also the editorial by Kauczor and von Stackelberg in this issue.
State-Level Variations in the Utilization of Lung Cancer Screening Among Medicare Fee-for-Service Beneficiaries: An Analysis of the 2015 to 2017 Physician and Other Supplier Data.
Liu Bian,Dharmarajan Kavita,Henschke Claudia I,Taioli Emanuela
BACKGROUND:Lung cancer screening (LCS) is an important secondary prevention measure to reduce lung cancer mortality. The goal of this study was to assess state-level variations in LCS among the US elderly during the first 3 years since Medicare began its LCS reimbursement policy in 2015. METHODS:This ecological study examined the relations between LCS utilization density, defined as the number of low-dose CT (LDCT) or shared decision-making and counseling (SDMC) services per 1,000 Medicare fee-for-service (FFS) beneficiaries derived from the Medicare Provider Utilization and Payment Data: Physician and Other Supplier public use file, and state-level factors from several publicly available data sources. The study included Kruskal-Wallis tests and a cluster analysis. RESULTS:In 2017, the median utilization density per 1,000 Medicare FFS beneficiaries was 3.32 for LDCT and 0.46 for SDMC, which was 24 and 13 times the 2015 level, respectively. From 2015 to 2017, the total number of unique providers billed for LCS increased from 222 to 3,444 for LDCT imaging and from 20 to 523 for SDMC. Higher utilizations for both LDCT and SDMC services tended to concentrate in the northeastern and upper Midwest states than in the southwest states. The cluster of states with high utilization density did not include those states with the most lung cancer mortality and/or smoking prevalence. CONCLUSIONS:A steady increase was noted in LCS utilization since Medicare began its reimbursement policy. The utilization and its growth varied across the United States and differed between LDCT imaging and SDMC, indicating large growth potentials for LCS and for states with high lung cancer mortality and smoking prevalence.
Initial Results from Mobile Low-Dose Computerized Tomographic Lung Cancer Screening Unit: Improved Outcomes for Underserved Populations.
Raghavan Derek,Wheeler Mellisa,Doege Darcy,Doty John D,Levy Henri,Dungan Kia A,Davis Lauren M,Robinson James M,Kim Edward S,Mileham Kathryn F,Oliver James,Carrizosa Daniel
INTRODUCTION:The National Lung Screening Trial (NLST) demonstrated that screening high-risk patients with low-dose computed tomography (CT) of the chest reduces lung cancer mortality compared with screening with chest x-ray. Uninsured and Medicaid patients usually lack access to this hospital-based screening test because of geographic and socioeconomic factors. We hypothesized that a mobile screening unit would improve access and confer the benefits demonstrated by the NLST to this underserved group, which is most at risk of lung cancer deaths. PATIENTS AND METHODS:We created a mobile unit by building a Samsung BodyTom portable 32-slice low-dose CT scanner into a 35-foot coach; it delivers high-quality images for both soft tissue and bone and includes a waiting area and high-speed wireless internet connection for fast image transfer. The unit was extensively tested to show robustness and stability of mobile equipment. This project was designed to screen uninsured and underinsured patients, otherwise with eligibility criteria identical to that of the National Lung Screening Trial, with the only difference being exclusion of patients eligible for Medicare (which provides financial coverage for CT-based lung cancer screening). RESULTS:We screened 550 patients (20% black, 3% Hispanic, 70% rural) with a male-to-female ratio of 1.1:1, median age 61 years (range, 55-64), and found 12 lung cancers at initial screen (2.2%), including 6 at stage I-II (58% of total lung cancers early stage) and 38 Lung-RADS 4 (highly suspicious) lesions that are being followed closely. Incidental findings included nonlung cancers and coronary artery disease. DISCUSSION:In this initial pilot study, using the first mobile low-dose whole body CT screening unit in the U.S., the initial cancer detection rate is comparable to that reported in the NLST, despite excluding patients over the age of 64 years who have Medicare coverage, but with marked improvement of screening rates specifically in underserved sociodemographic, racial, and ethnic groups and with better outcomes than conventionally found in the underserved and at lower cost per case. IMPLICATIONS FOR PRACTICE:This study shows clearly that a mobile low-dose CT scanning unit allows effective lung cancer screening for underserved populations, such as impoverished African Americans, Hispanics, Native Americans, or isolated rural groups, and has a pick-up rate of 1% for early stage disease. If confirmed in a planned randomized trial, this will be policy changing, as these groups usually present with advanced disease; this approach will produce better survival data at lower cost per case.
Common mental disorders in Taiwanese consumers of commercial low-dose computed tomography lung cancer screening: Comparison with a nationally representative sample.
Chen Cheng-Che,Wu Wen-Chi,Chang Shu-Sen,Chang Chirn-Bin,Yang Cheng-Ta Justin,Su Hung-Kuang,Chan Ding-Cheng Derrick
Journal of the Formosan Medical Association = Taiwan yi zhi
BACKGROUND/PURPOSE:We examined the prevalence of probable common mental disorders (CMDs) in commercial low-dose computed tomography (LDCT) lung cancer screening consumers relative to the general population and to determine the correlates of probable CMDs among screening participants. METHODS:Commercial LDCT lung cancer screening consumers (N = 1323) were compared with a nationally representative sample from the Taiwan Social Change Survey (TSCS) (N = 2034). Respondents scoring ≥3 on the Chinese Health Questionnaire were classified as having a probable CMD. Logistic regression was used to investigate differences between the two groups and correlates of probable CMDs among LDCT lung cancer screening participants. RESULTS:The prevalence of probable CMDs was higher among LDCT lung cancer screening participants (25.47%) than among TSCS adults (21.56%). Compared with the TSCS sample, the screening participants had a higher probability of CMDs (OR = 1.40, 95% CI = 1.13-1.73), higher education levels (OR = 7.95, 95% CI = 6.00-10.53), and a history of drinking (OR = 11.85, 95% CI = 9.45-14.85) or betel-quid use (OR = 5.43, 95% CI = 3.98-7.42) but were less likely to smoke (OR = 0.52, 95% CI = 0.40-0.68). Among the screening participants, being female (OR = 1.37, 95% CI = 1.02-1.84) and a current smoker (OR = 1.74, 1.19-2.54) and living near ≥2 smoking family members (OR = 2.30, 95% CI 1.57-3.38) were associated with an increased likelihood of having CMDs. CONCLUSION:Commercial LDCT lung cancer screening users may have a positive association with probable CMDs compared to the general population. Screening programs should consider including criteria and providing psychoeducation to improve the physical and mental outcomes of participants. CLINICAL TRIAL REGISTRATION:Purely observational studies (those in which the assignment of the medical intervention is not at the discretion of the investigator) do not require registration.
Association of invitation to lung cancer screening and tobacco use outcomes in a VA demonstration project.
Fu Steven S,Melzer Anne C,Fabbrini Angela E,Rice Kathryn L,Clothier Barbara,Nelson David B,Doro Elizabeth A,Partin Melissa R
Preventive medicine reports
A potential unintended consequence of lung cancer screening (LCS) is an adverse effect on smoking behaviors. This has been difficult to assess in previous randomized clinical trials. Our goal was to determine whether cessation and relapse behaviors differ between Veterans directly invited (DI) to participate in LCS compared to usual care (UC). We conducted a longitudinal survey of tobacco use outcomes among Veterans (Minneapolis VA) from 2014 to 2015, randomized (2:1) to DI versus UC and stratified by baseline smoking status (current/former). Within the DI group, we explored differences between those who did and did not choose to undergo LCS. A total of 979 patients (n = 660 DI, n = 319 UC) returned the survey at a median of 484 days. Among current smokers (n = 488), smoking abstinence rates and cessation attempts did not differ between DI and UC groups. More baseline smokers in DI were non-daily smokers at follow-up compared to those in UC (25.3% vs 15.6%, OR 1.97 95%CI 1.15-3.36). A significant proportion of former smokers at baseline relapsed, with 17% overall indicating past 30-day smoking. This did not differ between arms. Of those invited to LCS, smoking outcomes did not significantly differ between those who chose to be screened (161/660) versus not. This randomized program evaluation of smoking behaviors in the context of invitation to LCS observed no adverse or beneficial effects on tobacco cessation or relapse among participants invited to LCS, or among those who completed screening. As LCS programs scale and spread nationally, effective cessation programs will be essential.
Do we know enough about the effect of low-dose computed tomography screening for lung cancer on survival to act? A systematic review, meta-analysis and network meta-analysis of randomised controlled trials.
Yang Huiqin,Varley-Campbell Jo,Coelho Helen,Long Linda,Robinson Sophie,Snowsill Tristan,Griffin Ed,Peters Jaime,Hyde Chris
Diagnostic and prognostic research
Background:Diagnosis of lung cancer frequently occurs in its later stages. Low-dose computed tomography (LDCT) could detect lung cancer early. Methods:Our objective was to estimate the effect of LDCT lung cancer screening on mortality in high-risk populations. A systematic review of randomised controlled trials (RCTs) comparing LDCT screening programmes with usual care (no screening) or other imaging screening programme (such as chest X-ray (CXR)) was conducted. RCTs of CXR screening were additionally included in the network meta-analysis. Bibliographic sources including MEDLINE, Embase, Web of Science and the Cochrane Library were searched to January 2017. All key review steps were done by two persons. Quality assessment used the Cochrane Risk of Bias tool. Meta-analyses were performed. Results:Four RCTs were included. More will provide data in the future. Meta-analysis demonstrated that LDCT screening with up to 9.80 years of follow-up was associated with a statistically non-significant decrease in lung cancer mortality (pooled relative risk (RR) 0.94, 95% confidence interval (CI) 0.74 to 1.19; = 0.62). There was a statistically non-significant increase in all-cause mortality. Given the considerable heterogeneity for both outcomes, the results should be treated with caution.Network meta-analysis including the four original RCTs plus two further RCTs assessed the relative effectiveness of LDCT, CXR and usual care. The results showed that in terms of lung cancer mortality reduction LDCT was ranked as the best screening strategy, CXR screening as the worst strategy and usual care intermediate. Conclusions:LDCT screening may be effective in reducing lung cancer mortality but there is considerable uncertainty: the largest of the RCTs compared LDCT with CXR screening rather than no screening; there is imprecision of the estimates; and there is important heterogeneity between the included study results. The uncertainty about the effect on all-cause mortality is even greater. Maturing trials may resolve the uncertainty.
Interstitial Lung Abnormalities and Lung Cancer Risk in the National Lung Screening Trial.
Whittaker Brown Stacey-Ann,Padilla Maria,Mhango Grace,Powell Charles,Salvatore Mary,Henschke Claudia,Yankelevitz David,Sigel Keith,de-Torres Juan P,Wisnivesky Juan
BACKGROUND:Some interstitial lung diseases are associated with lung cancer. However, it is unclear whether asymptomatic interstitial lung abnormalities convey an independent risk. OBJECTIVES:The goal of this study was to assess whether interstitial lung abnormalities are associated with an increased risk of lung cancer. METHODS:Data from all participants in the National Lung Cancer Trial were analyzed, except for subjects with preexisting interstitial lung disease or prevalent lung cancers. The primary analysis included those who underwent low-dose CT imaging; those undergoing chest radiography were included in a confirmatory analysis. Participants with evidence of reticular/reticulonodular opacities, honeycombing, fibrosis, or scarring were classified as having interstitial lung abnormalities. Lung cancer incidence and mortality in participants with and without interstitial lung abnormalities were compared by using Poisson and Cox regression, respectively. RESULTS:Of the 25,041 participants undergoing low-dose CT imaging included in the primary analysis, 20.2% had interstitial lung abnormalities. Participants with interstitial lung abnormalities had a higher incidence of lung cancer (incidence rate ratio, 1.61; 95% CI, 1.30-1.99). Interstitial lung abnormalities were associated with higher lung cancer incidence on adjusted analyses (incidence rate ratio, 1.33; 95% CI, 1.07-1.65). Lung cancer-specific mortality was also greater in participants with interstitial lung abnormalities. Similar findings were obtained in the analysis of participants undergoing chest radiography. CONCLUSIONS:Asymptomatic interstitial lung abnormalities are an independent risk factor for lung cancer that can be incorporated into risk score models.
Lung Cancer Screening CT: Sex-Specific Conversion Factors to Estimate Effective Radiation Dose From Dose-Length Product.
Cohen Stuart L,Wang Jason J,Chan Nicholas,O'Connell William,Shah Rakesh,Sanelli Pina,Raoof Suhail
BACKGROUND:Effective dose (ED) is used to understand radiation-related cancer risk of CT scans. Currently, ED for low-dose CT (LDCT) lung cancer screening (LCS) is estimated by multiplying the CT scan-reported dose-length product (DLP) by a DLP-to-ED conversion factor (k-factor) for general chest CT imaging, which does not account for sex. The purpose of this study was to calculate sex-specific k-factors for LDCT LCS. METHODS:This retrospective study evaluated consecutive LCS patients across a large health system from 2016 to 2017. Patient and CT scan-related data were obtained from the radiology information system, the picture archiving and communication system, and a radiation dose index-monitoring system. Each patient's ED was determined by patient-specific Monte-Carlo simulation using Cristy phantoms and divided by study DLP to determine the k-factor. The k-factors were compared vs the standard of 0.014 mSv·mGy⁻·cm⁻ for a chest CT scan by using a one-sample Student t test. Bivariate and multivariable analyses were performed for k-factors based on patient and CT scan factors. RESULTS:A total of 1,890 patients were included in the study. The mean k-factor for all patients was 0.0179 mSv·mGy⁻·cm⁻, which was 22% greater than the standard value of 0.014 mSv·mGy⁻·cm⁻ for a chest CT scan previously applied to LDCT imaging (P < .001). The mean k-factor in women (0.0213 mSv·mGy⁻·cm⁻) was 43% greater than in men (0.0149 mSv·mGy⁻·cm⁻) in the multivariable model (P < .001). CONCLUSIONS:The overall k-factor for LCS is higher than the previously used value for chest CT imaging; when stratified according to sex, it was 43% greater in women than in men. Sex- and LCS-specific k-factors should be used to estimate effective radiation dose in LCS programs.
The importance of CT quantitative evaluation of emphysema in lung cancer screening cohort with negative findings by visual evaluation.
Li Zhaobin,Xia Yi,Fang Yuan,Guan Yu,Wang Yun,Liu Shiyuan,Fan Li
The clinical respiratory journal
INTRODUCTION:One-stop quantitative evaluation of emphysema and lung nodule in lung cancer screening is very important for patient. OBJECTIVE:To evaluate the quantitative emphysema in the large-sample low-dose CT lung cancer screening cohort with negative CT findings by subjective visual assessment. METHODS:One thousand, two hundred and thirty-one participants with negative visual evaluation were included in this retrospective study. The lungs were automatically segmented and the following were calculated: total lung volume (TLV), total emphysema volume (TEV), emphysema index (EI), 15th percentile lung density and mean lung density. EI ≥6% was defined as emphysema. The quantitative parameters were compared between different genders and ages. The quantitative parameters and risk factors were compared between emphysema and non-emphysema groups. RESULTS:The proportion of smokers, TLV, TEV and EI of men were greater than that of women (P < 0.001). No correlation was found between age and volumes; the TEV and EI of people older than 60 years were greater than those younger than 60 years (P < 0.05) by age categorisation. One hundred and two participants showed emphysema, accounting for 8.29%. The incidence of emphysema in men was greater than that in women in total (P < 0.05). All the CT quantitative parameters were significantly different between emphysema and non-emphysema groups. The ratio of male, secondhand smoke exposure and chronic bronchitis history was greater in emphysema than that in the non-emphysema group (P < 0.05). CONCLUSION:CT quantitative emphysema evaluation is recommended in people older than 60 years, especially in males, providing more precise information, aiding the early diagnosis of emphysema and informing early intervention.
Lung cancer screening with submillisievert chest CT: Potential pitfalls of pulmonary findings in different readers with various experience levels.
Martini Katharina,Ottilinger Thorsten,Serrallach Bettina,Markart Stefan,Glaser-Gallion Nicola,Blüthgen Christian,Leschka Sebastian,Bauer Ralf W,Wildermuth Simon,Messerli Michael
European journal of radiology
PURPOSE:To assess the interreader variability of submillisievert CT for lung cancer screening in radiologists with various experience levels. METHOD:Six radiologists with different degrees of clinical experience in radiology (range, 1-15 years), rated 100 submillisievert CT chest studies as either negative screening finding (no nodules, benign nodules, nodules <5 mm), indeterminate finding (nodules 5-10 mm), positive finding (nodules >10 mm). Each radiologist interpreted scans randomly ordered and reading time was recorded. Interobserver agreement was assessed with ak statistic. Reasons for differences in nodule classification were analysed on a case-by-case basis. Reading time was correlated with reader experience using Pearson correlation (r). RESULTS:The overall interobserver agreement between all readers was moderate (k = 0.454; p < 0.001). In 57 patients, all radiologists agreed on the differentiation of negative and indeterminate/positive finding. In 64 cases disagreement between readers led to different nodule classification. In 8 cases some readers rated the nodule as benign, whereas others scored the case as positive. Overall, disagreement in nodule classification was mostly due to failure in identification of target lesion (n = 40), different lesion measurement (n = 44) or different classification (n = 26). Mean overall reading time per scan was of 2 min 2 s (range: 7s-7 min 45 s) and correlated with reader-experience (r = -0.824). CONCLUSIONS:Our study showed substantial interobserver variability for the detection and classification of pulmonary nodules in submillisievert CT. This highlights the importance for careful standardisation of screening programs with the objective of harmonizing efforts of involved radiologists across different institutions by defining and assuring quality standards.
Association of Aspirin Use With Mortality Risk Among Older Adult Participants in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial.
Loomans-Kropp Holli A,Pinsky Paul,Cao Yin,Chan Andrew T,Umar Asad
JAMA network open
Importance:Aspirin use has been associated with reduced risk of cancer mortality, particularly of the colorectum. However, aspirin efficacy may be influenced by biological characteristics, such as obesity and age. With the increasing prevalence of obesity and conflicting data regarding the effect of aspirin in older adults, understanding the potential association of aspirin use with cancer mortality according to body mass index (BMI) and age is imperative. Objectives:To investigate the association of aspirin use with risk of all-cause, any cancer, gastrointestinal (GI) cancer, and colorectal cancer (CRC) mortality among older adults and to perform an exploratory analysis of the association of aspirin use with mortality stratified by BMI. Design, Setting, Participants:This cohort study evaluated aspirin use among participants aged 65 years and older in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial at baseline (November 8, 1993, to July 2, 2001) and follow-up (2006-2008). Analysis began in late 2018 and was completed in September 2019. Main Outcomes and Measures:All-cause, any cancer, GI cancer, or CRC mortality. Multivariable hazard ratios (HRs) and 95% CIs were calculated using time-varying Cox proportional hazards regression modeling, adjusting for additional factors. Results:A total of 146 152 individuals (mean [SD] age at baseline, 66.3 [2.4] years; 74 742 [51.1%] women; 129 446 [88.6%] non-Hispanic white) were included in analysis. The median (interquartile range) follow-up time was 12.5 (8.7-16.4) years, encompassing 1 822 164 person-years. Compared with no use, aspirin use 1 to 3 times per month was associated with reduced risk of all-cause mortality (HR, 0.84; 95% CI, 0.80-0.88; P < .001) and cancer mortality (HR, 0.87; 95% CI, 0.81-0.94; P < .001). Aspirin use 3 or more times per week was associated with decreased risk of mortality of all causes (HR, 0.81; 95% CI, 0.80-0.83; P < .001), any cancer (HR, 0.85; 95% CI, 0.81-0.88; P < .001), GI cancer (HR, 0.75; 95% CI, 0.66-0.84; P < .001), and CRC (HR, 0.71; 95% CI, 0.61-0.84; P < .001). When stratified by BMI (calculated as weight in kilograms divided by height in meters squared), aspirin use 3 or more times per week among individuals with BMI 20 to 24.9 was associated with reduced risk of all-cause mortality (HR, 0.82; 95% CI, 0.78-0.85; P < .001) and any cancer mortality (HR, 0.86; 95% CI, 0.79-0.82; P < .001). Among individuals with BMI 25 to 29.9, aspirin use 3 or more times per week was associated with reduced risk of all-cause mortality (HR, 0.82; 95% CI, 0.79-0.85; P < .001), any cancer mortality (HR, 0.86; 95% CI, 0.81-0.91; P < .001), GI cancer mortality (HR, 0.72; 95% CI, 0.60-0.86; P < .001), and CRC mortality (HR, 0.66; 95% CI, 0.51-0.85; P = .001). Conclusions and Relevance:In this cohort study, aspirin use 3 or more times per week was associated with a reduction in all-cause, cancer, GI cancer and CRC mortality in older adults.
Machine Learning and Feature Selection Methods for Disease Classification With Application to Lung Cancer Screening Image Data.
Delzell Darcie A P,Magnuson Sara,Peter Tabitha,Smith Michelle,Smith Brian J
Frontiers in oncology
As awareness of the habits and risks associated with lung cancer has increased, so has the interest in promoting and improving upon lung cancer screening procedures. Recent research demonstrates the benefits of lung cancer screening; the National Lung Screening Trial (NLST) found as its primary result that preventative screening significantly decreases the death rate for patients battling lung cancer. However, it was also noted that the false positive rate was very high (>94%).In this work, we investigated the ability of various machine learning classifiers to accurately predict lung cancer nodule status while also considering the associated false positive rate. We utilized 416 quantitative imaging biomarkers taken from CT scans of lung nodules from 200 patients, where the nodules had been verified as cancerous or benign. These imaging biomarkers were created from both nodule and parenchymal tissue. A variety of linear, nonlinear, and ensemble predictive classifying models, along with several feature selection methods, were used to classify the binary outcome of malignant or benign status. Elastic net and support vector machine, combined with either a linear combination or correlation feature selection method, were some of the best-performing classifiers (average cross-validation AUC near 0.72 for these models), while random forest and bagged trees were the worst performing classifiers (AUC near 0.60). For the best performing models, the false positive rate was near 30%, notably lower than that reported in the NLST.The use of radiomic biomarkers with machine learning methods are a promising diagnostic tool for tumor classification. The have the potential to provide good classification and simultaneously reduce the false positive rate.
Challenges to Educating Smokers About Lung Cancer Screening: a Qualitative Study of Decision Making Experiences in Primary Care.
Greene Preston A,Sayre George,Heffner Jaimee L,Klein Deborah E,Krebs Paul,Au David H,Zeliadt Steven B
Journal of cancer education : the official journal of the American Association for Cancer Education
We sought to qualitatively explore how those at highest risk for lung cancer, current smokers, experienced, understood, and made decisions about participation in lung cancer screening (LCS) after being offered in the target setting for implementation, routine primary care visits. Thirty-seven current smokers were identified within 4 weeks of being offered LCS at seven sites participating in the Veterans Health Administration Clinical Demonstration Project and interviewed via telephone using semi-structured qualitative interviews. Transcripts were coded by two raters and analyzed thematically using iterative inductive content analysis. Five challenges to smokers' decision-making lead to overestimated benefits and minimized risks of LCS: fear of lung cancer fixated focus on inflated screening benefits; shame, regret, and low self-esteem stemming from continued smoking situated screening as less averse and more beneficial; screening was mistakenly believed to provide general evaluation of lungs and reassurance was sought about potential damage caused by smoking; decision-making was deferred to providers; and indifference about numerical educational information that was poorly understood. Biased understanding of risks and benefits was complicated by emotion-driven, uninformed decision-making. Emotional and cognitive biases may interfere with educating and supporting smokers' decision-making and may require interventions tailored for their unique needs.
Barriers to and Interest in Lung Cancer Screening Among Latino and Non-Latino Current and Former Smokers.
Percac-Lima Sanja,Ashburner Jeffrey M,Atlas Steven J,Rigotti Nancy A,Flores Efren J,Kuchukhidze Salome,Park Elyse R
Journal of immigrant and minority health
Lung cancer is a leading cause of cancer death in Latinos. In a telephone survey, we assessed perceptions about lung cancer and awareness of, interest in, and barriers to lung screening among older current and former smokers. We compared Latino and non-Latino responses adjusting for age, sex, education, and smoking status using logistic regression models. Of the 460 patients who completed the survey (51.5% response rate), 58.0% were women, 49.3% former smokers, 15.7% Latino, with mean age 63.6 years. More Latinos believed that lung cancer could be prevented compared to non-Latinos (74.6% vs. 48.2%, OR 3.07, CI 1.89-5.01), and less worried about developing lung cancer (34.8% vs. 50.3%, OR 0.44, CI 0.27-0.72). Most participants were not aware of lung screening (44.1% Latinos vs. 34.3% Non-Latinos, OR 1.24, CI 0.79-1.94), but when informed, more Latinos wanted to be screened (90.7% vs. 67%, OR 4.58, CI 2.31-9.05). Latinos reported fewer barriers to lung screening.
Lung cancer survival and comorbidities in lung cancer screening participants of the Gdańsk screening cohort.
Ostrowski Marcin,Marczyk Michał,Dziedzic Robert,Jelitto-Górska Małgorzata,Marjański Tomasz,Pisiak Sylwia,Jędrzejczyk Tadeusz,Polańska Joanna,Zdrojewski Tomasz,Wojtyniak Bogdan,Rzyman Witold
European journal of public health
BACKGROUND:In 2010, the World Health Organisation recommended implementation of screening programmes in four groups of diseases-neoplasms, cardiovascular diseases (CVD), diabetes mellitus (DM) and chronic obstructive pulmonary disease (COPD). It is due to the fact that they share the same, modifiable risk factors. METHODS:Between 2009 and 2011, 8637 heavy smokers (aged 50-75, smoking history >20 pack-years) were screened in the Pomeranian Pilot Lung Cancer Screening Programme (PPP) in Gdańsk, Poland. We looked at 5-year follow-up and analysed the medical events and comorbidities of all participants. One health care provider in the Polish health care system provides a unique opportunity to gather most reliable data on all medical events in each person. RESULTS:In 52.0% of lung cancer screening participants CVD (33.5%), DM (26.0%) and COPD (21.0%) were diagnosed. Prevalence of these diseases is higher in lung cancer patients than in the non-cancer screening group (P < 0.0001). One hundred and seven (1.2%) lung cancers were diagnosed during PPP programme performance and another 382 cases (4.4%) in the 5-year follow-up, so the potential mean annual lung cancer detection rate is 0.77%. CONCLUSIONS:Lung cancer screening programme offers a great potential for joint screening of lung cancer, CVD, diabetes and COPD.
A Geospatial Analysis of Factors Affecting Access to CT Facilities: Implications for Lung Cancer Screening.
Tailor Tina D,Tong Betty C,Gao Junheng,Choudhury Kingshuk Roy,Rubin Geoffrey D
Journal of the American College of Radiology : JACR
OBJECTIVE:The association between access to CT facilities for lung cancer screening and population characteristics is understudied. We aimed to determine the relationship between census tract-level socioeconomic characteristics (SEC) and driving distance to an ACR-accredited CT facility. METHODS:Census tract-level SEC were determined from the US Census Bureau. Distance to nearest ACR-accredited CT facility was derived at the census tract level. Census tract-level multivariable regression modeling was used to determine the relationship between driving distance to a CT facility and census tract SEC, including population density (a marker of rural versus urban), gender, race, insurance status or type, and education level. RESULTS:In an adjusted multivariable model, census tract-level population density was the greatest relative determinant of distance to a CT facility. Namely, rural census tracts had relatively longer distances to CT facilities than urban census tracts (P < .001). Census tracts with higher uninsured, Medicaid, undereducated (less <high school degree) populations had relatively greater distances to CT facilities (p<0.001), whereas those with higher non-White, female, and Medicare populations had shorter distances (p<0.001). DISCUSSION:Rural populations have relatively less geographic access to CT facilities. Furthermore, other vulnerable populations, such as the uninsured, those on Medicaid, and the undereducated, may also have relatively less access to CT imaging facilities. These variations in access to CT may affect the uptake and utilization of lung cancer screening.
Attendees of Manchester's Lung Health Check pilot express a preference for community-based lung cancer screening.
Balata Haval,Tonge Janet,Barber Phil V,Colligan Denis,Elton Peter,Evison Matthew,Kirwan Marie,Novasio Juliette,Sharman Anna,Slevin Kathryn,Taylor Sarah,Waplington Sara,Booton Richard,Crosbie Phil A
Manchester's 'Lung Health Check' pilot utilised mobile CT scanners in convenient retail locations to deliver lung cancer screening to socioeconomically disadvantaged communities. We assessed whether screening location was an important factor for those attending the service. Location was important for 74.7% (n=701/938) and 23% (n=216/938) reported being less likely to attend an equivalent hospital-based programme. This preference was most common in current smokers (27% current smokers vs 19% former smokers; OR 1.46, 95% CI 1.03 to 2.08, p=0.036) and those in the lowest deprivation quartile (25% lowest quartile vs 17.6% highest quartile; OR 2.0, 95% CI 1.24 to 3.24, p=0.005). Practical issues related to travel were most important in those less willing to attend a hospital-based service, with 83.3% citing at least one travel related barrier to non-attendance. A convenient community-based screening programme may reduce inequalities in screening adherence especially in those at high risk of lung cancer in deprived areas.
Evaluation of cardiovascular risk in a lung cancer screening cohort.
Ruparel Mamta,Quaife Samantha L,Dickson Jennifer L,Horst Carolyn,Burke Stephen,Taylor Magali,Ahmed Asia,Shaw Penny,Soo May-Jan,Nair Arjun,Devaraj Anand,O'Dowd Emma Louise,Bhowmik Angshu,Navani Neal,Sennett Karen,Duffy Stephen W,Baldwin David R,Sofat Reecha,Patel Riyaz S,Hingorani Aroon,Janes Sam M
INTRODUCTION:Lung cancer screening (LCS) by low-dose computed tomography (LDCT) offers an opportunity to impact both lung cancer and coronary heart disease mortality through detection of coronary artery calcification (CAC). Here, we explore the value of CAC and cardiovascular disease (CVD) risk assessment in LCS participants in the Lung Screen Uptake Trial (LSUT). METHODS:In this cross-sectional study, current and ex-smokers aged 60-75 were invited to a 'lung health check'. Data collection included a CVD risk assessment enabling estimation of 10 year CVD risk using the QRISK2 score. Participants meeting the required lung cancer risk underwent an ungated, non-contrast LDCT. Descriptive data, bivariate associations and a multivariate analysis of predictors of statin use are presented. RESULTS:Of 1005 individuals enrolled, 680 were included in the final analysis. 421 (61.9%) had CAC present and in 49 (7.2%), this was heavy. 668 (98%) of participants had a QRISK2≥10% and QRISK2 was positively associated with increasing CAC grade (OR 4.29 (CI 0.93 to 19.88) for QRISK2=10%-20% and 12.29 (CI 2.68 to 56.1) for QRISK2≥20% respectively). Of those who qualified for statin primary prevention (QRISK2≥10%), 56.8% did not report a history of statin use. In the multivariate analysis statin use was associated with age, body mass index and history of hypertension and diabetes. CONCLUSIONS:LCS offers an important opportunity for instituting CVD risk assessment in all LCS participants irrespective of the presence of LDCT-detected CAC. Further studies are needed to determine whether CAC could enhance uptake and adherence to primary preventative strategies.
Decreased cardiovascular mortality in the ITALUNG lung cancer screening trial: Analysis of underlying factors.
Puliti Donella,Mascalchi Mario,Carozzi Francesca Maria,Carrozzi Laura,Falaschi Fabio,Paci Eugenio,Lopes Pegna Andrea,Aquilini Ferruccio,Barchielli Alessandro,Bartolucci Maurizio,Grazzini Michela,Picozzi Giulia,Pistelli Francesco,Rosselli Alessandro,Zappa Marco,
Lung cancer (Amsterdam, Netherlands)
OBJECTIVES:In the ITALUNG lung cancer screening trial after 9.3 years of follow-up we observed an unexpected significant decrease of cardiovascular (CV) mortality in subjects invited for low-dose CT (LDCT) screening as compared to controls undergoing usual care. Herein we extended the mortality follow-up and analyzed the potential factors underlying such a decrease. MATERIALS AND METHODS:The following factors were assessed in screenes and controls: burden of CV disease at baseline, changes in smoking habits, use of CV drugs and frequency of planned vascular procedures after randomisation. Moreover, in the screenes we evaluated inclusion of presence of coronary artery calcification (CAC) in the LDCT report form that was transmitted to the participant and his/her General Practitioner. RESULTS:The 2-years extension of follow-up confirmed a significant decrease of CV mortality in the subjects of the active group compared to control subjects (15.6 vs 34.0 per 10,000; p = 0.001) that was not observed in the drops-out of the active group. None of the explaining factors we considered significantly differed between active and control group. However, the subjects of the active group with reported CAC experienced a not significantly lower CV mortality and showed a significantly higher use of CV drugs and frequency of planned vascular procedures than the control group. CONCLUSIONS:LDCT screening for lung cancer offers the opportunity for detection of CAC that is an important CV risk factor. Although the underlying mechanisms are not clear, our results suggest that the inclusion of information about CAC presence in the LDCT report may represent a candidate factor to explain the decreased CV mortality observed in screened subjects of the ITALUNG trial, possibly resulting in intervention for patient care to prevent CV deaths. Further studies investigating whether prospective reporting and rating of CAC have independent impact on such interventions and CV mortality are worthy.
The Effects of Health Disparities on Perceptions About Lung Cancer Screening (LCS): Survey Results of a Patient Sample.
Stephens Sarah Ellen,Foley Kristie Long,Miller David,Bellinger Christina R
Lung cancer screening (LCS) is currently advocated in a subset of current or former smokers with a thirty pack-year smoking history or higher. Studies report that few patients meeting the criteria for screening are undergoing LCS. We conducted a survey to assess if barriers to LCS (race, ethnicity, and socioeconomic status) affect the perceptions about LCS that could influence screening uptake. We did not detect different perceptions based on race, ethnicity, or socioeconomic status; however, our survey found that fewer barriers and more benefits to LCS may be perceived in patients who undergo other types of health screening and more benefits for those with internet capable devices.
Screening of potential biomarkers and their predictive value in early stage non-small cell lung cancer: a bioinformatics analysis.
Tu Hongbin,Wu Meihong,Huang Weiling,Wang Lixin
Translational lung cancer research
Background:Non-small cell lung cancer (NSCLC) remains the first leading cause of death in malignancies worldwide. Despite the early screening of NSCLC by low-dose spiral computed tomography (CT) in high-risk individuals caused a 20% reduction in the mortality, there still exists imperative needs for the identification of novel biomarkers for the diagnosis and treatment of lung cancer. Methods:mRNA microarray datasets GSE19188, GSE33532, and GSE44077 were searched, and the differentially expressed genes (DEGs) were obtained using GEO2R. Functional and pathway enrichment analyses were performed for the DEGs using DAVID database. Protein-protein interaction (PPI) network was plotted with STRING and visualized by Cytoscape. Module analysis of the PPI network was done through MCODE. The overall survival (OS) analysis of genes from MCODE was performed with the Kaplan Meier-plotter. Results:A total of 221 DEGs were obtained, which were mainly enriched in the terms related to cell division, cell proliferation, and signal transduction. A PPI network was constructed, consisting of 221 nodes and 739 edges. A significant module including 27 genes was identified in the PPI network. Elevated expression of these genes was associated with poor OS of NSCLC patients, including UBE2T, UNF2, CDKN3, ANLN, CCNB2, and CKAP2L. The enriched functions and pathways included protein binding, ATP binding, cell cycle, and p53 signaling pathway. Conclusions:The DEGs in NSCLC have the potential to become useful targets for the diagnosis and treatment of NSCLC.
Attitudes of Clinicians about Screening Head and Neck Cancer Survivors for Lung Cancer Using Low-Dose Computed Tomography.
Dukes Kimberly,Seaman Aaron T,Hoffman Richard M,Christensen Alan J,Kendell Nicholas,Sussman Andrew L,Vélez-Bermúdez Miriam,Volk Robert J,Pagedar Nitin A
The Annals of otology, rhinology, and laryngology
OBJECTIVE:National guidelines recommend lung cancer screening (LCS) using low-dose computed tomography (LDCT) for high-risk patients, including survivors of other tobacco-related cancers like head and neck cancer (HNC). This qualitative study investigated clinicians' practices and attitudes toward LCS with LDCT with patients who have survived HNC, in the context of mandated requirements for shared decision making (SDM) using decision aids. METHODS:Thematic analysis of transcribed semi-structured clinician interviews and focus group. RESULTS:Clinicians recognized LCS' utility for some HNC survivors with smoking histories. However, they identified many challenges to SDM in diverse clinic settings, including time, workflow, uncertainty about guidelines and reimbursement, decision aids, competing patient priorities, unclear evidence, potentially heightened patient receptivity and stress, and the complexity of discussions. They also identified challenges to LCS implementation. CONCLUSIONS:While clinicians feel that LDCT LCS may benefit some HNC survivors, there are barriers both to implementing LCS SDM for these patients in primary care as currently recommended and to integrating it into cancer clinics. Challenges for SDM across settings include a lack of decision aids tailored to patients with cancer histories. Given recommendations to broaden LCS eligibility criteria, more research may be required before refinement of current guidelines.
Epidemiology of lung cancer and lung cancer screening programs in China and the United States.
Yang Dawei,Liu Yang,Bai Chunxue,Wang Xiandong,Powell Charles A
Lung cancer is a heterogeneous disease that is impacted by environmental exposures and by constitutional genetic or epigenetic susceptibilities to disease development and progression. The United States and China have distinct and diverse populations and geographic environmental exposures that contribute to unique patterns of lung cancer incidence and mortality. In this paper, the authors compare trends of incidence and mortality of lung cancer in the US and China, and the impact on lung cancer screening programs in the two countries. It is worth noting that the mortality of lung cancer in the US has decreased gradually while in China it is still increasing over recent years. While decreasing smoking prevalence and the impact of clean air legislation have helped to mitigate the trend in the US relative to China, the increasingly widespread implementation of lung cancer chest CT screening is expected to impact lung cancer incidence and mortality in both countries. Currently there are few studies to compare the environmental and genetic risk factors for US and Chinese populations with regards to lung cancer incidence and mortality. The authors discuss the impact of gender and exposure risks, mainly smoking and environmental pollutants. Of high importance is the incidence of lung cancer in never smokers that is significantly higher in China than in the United States; this is particularly notable in women. These data suggest inclusion of ambient air pollution exposure and gender into lung cancer risk prognostic models to better capture high-risk individuals, especially for non-smoking women.
Attending community-based lung cancer screening influences smoking behaviour in deprived populations.
Balata Haval,Traverse-Healy Liam,Blandin-Knight Sean,Armitage Christopher,Barber Philip,Colligan Denis,Elton Peter,Kirwan Marie,Lyons Judith,McWilliams Lorna,Novasio Juliette,Sharman Anna,Slevin Kathryn,Taylor Sarah,Tonge Janet,Waplington Sara,Yorke Janelle,Evison Matthew,Booton Richard,Crosbie Philip A J
Lung cancer (Amsterdam, Netherlands)
OBJECTIVES:The impact of lung cancer screening on smoking is unclear, especially in deprived populations who are underrepresented in screening trials. The aim of this observational cohort study was to investigate whether a community-based lung cancer screening programme influenced smoking behaviour and smoking attitude in socio-economically deprived populations. MATERIAL AND METHODS:Ever-smokers, age 55-74, registered at participating General Practices were invited to a community-based Lung Health Check (LHC). This included an assessment of respiratory symptoms, lung cancer risk (PLCO), spirometry and signposting to stop smoking services. Those at high risk (PLCO≥1.51%) were offered annual low-dose CT screening over two rounds. Self-reported smoking status and behaviour were recorded at the LHC and again 12 months later, when attitudes to smoking were also assessed. RESULTS:919 participants (51% women) were included in the analysis (77% of attendees); median deprivation rank in the lowest decile for England. At baseline 50.3% were current smokers. One-year quit rate was 10.2%, quitting was associated with increased baseline symptoms (OR 2.62, 95% CI 1.07-6.41; p = 0.035) but not demographics or screening results. 55% attributed quitting to the LHC. In current smokers, 44% reported the LHC had made them consider stopping, 29% it made them try to stop and 25% made them smoke less whilst only 1.7% and 0.7% said it made them worry less about smoking or think it acceptable to smoke. CONCLUSIONS:Our data suggest a community-based lung cancer screening programme in deprived areas positively impacts smoking behaviour, with no evidence of a 'licence to smoke' in those screened.
Lung Cancer Screening at a Military Treatment Facility: A Retrospective Review.
White Lindsey J,Kaur Antarpreet,Lapel Raechel T,E Boswell Gilbert,Luceri Robert E,Parrish John Scott,Seda Gilbert
INTRODUCTION:Lung cancer is the leading cause of cancer death among men and women, accounting for more fatalities than colon, breast, and prostate cancers combined. Smoking causes about 85% of all lung cancers in the United States and is the single greatest risk factor. In 2013, the US Preventive Services Task Force (USPSTF) published initial guidelines for low-dose computed tomography lung cancer screening (LCS) among patients 55-80 years old, with a 30-pack-year history, who are current smokers or who quit within the previous 15 years. Smoking prevalence is higher among military personnel compared to the civilian population, demonstrating a need for vigilant screening. MATERIALS AND METHODS:A retrospective review of Naval Medical Center San Diego's (NMCSD) LCS data was conducted to examine screening numbers, lung cancer rates, and initial analysis of screening results. Patients were referred for screening if they met the USPSTF criteria. Between September 2013 and September 2018, 962 patients underwent LCS. A total of 1758 examinations were performed, including follow-up and annual surveillance examinations. The American College of Radiology's Lung CT Screening Reporting and Data System (Lung-RADS) was used to classify lung nodules' risk for malignancy. RESULTS:On this initial analysis, 42 enrolled patients received the diagnosis of lung cancer detected by screening. The initial calculated lung cancer rate is 4.4% (42/962) over the 5-year reporting period. The lung cancer rate among those patients with a Lung-RADS score of 3 or 4 was 31% (42/135). Thirty-seven patients were classified as having non-small cell lung cancer (NSCLC), while five were classified as having small cell lung cancer. Of the 37 NSCLC patients, 76% (28/37) were diagnosed at stage I and II, 11% (4/37) were diagnosed at stage III, and 13% (5/37) were diagnosed at stage IV. The total number of years a person smoked was a significant risk factor (P = 0.004), but not pack-years a person smoked (P = 0.052). CONCLUSIONS:These preliminary results demonstrate the success of a Military Treatment Facility (MTF)-based LCS Program in the detection of early stage lung cancer. Earlier stage detection may result in better health outcomes for affected patients. In the population studied, duration of smoking proved to be more significant than pack-years in predicting lung cancer risk. These results validate the newly dedicated resources and continued efforts to strengthen the LCS program at NMCSD and across MTFs.
Real-world Clinical Implementation of Lung Cancer Screening-Evaluating Processes to Improve Screening Guidelines-Concordance.
Carroll Nikki M,Burnett-Hartman Andrea N,Joyce Caroline A,Kinnard William,Harker Eric J,Hall Virginia,Steiner Julie S,Blum-Barnett Erica,Ritzwoller Debra P
Journal of general internal medicine
BACKGROUND:Lung cancer screening (LCS) requires complex processes to identify eligible patients, provide appropriate follow-up, and manage findings. It is unclear whether LCS in real-world clinical settings will realize the same benefits as the National Lung Screening Trial (NLST). OBJECTIVE:To evaluate the impact of process modifications on compliance with LCS guidelines during LCS program implementation, and to compare patient characteristics and outcomes with those in NLST. DESIGN:Retrospective cohort study. SETTING:Kaiser Permanente Colorado (KPCO), a non-profit integrated healthcare system. PATIENTS:A total of 3375 patients who underwent a baseline lung cancer screening low-dose computed tomography (S-LDCT) scan between May 2014 and June 2017. MEASUREMENTS:Among those receiving an S-LDCT, proportion who met guidelines-based LCS eligibility criteria before and after LCS process modifications, differences in patient characteristics and outcomes between KPCO LCS patients and the NLST cohort, and factors associated with a positive screen. RESULTS:After modifying LCS eligibility confirmation processes, patients receiving S-LDCT who met guidelines-based LCS eligibility criteria increased from 45.6 to 92.7% (P < 0.001). Prior to changes, patients were older (68 vs. 67 years; P = 0.001), less likely to be current smokers (51.3% vs. 52.5%; P < 0.001), and less likely to have a ≥ 30-pack-year smoking history (50.0% vs. 95.3%; P < 0.001). Compared with NLST participants, KPCO LCS patients were older (67 vs. 60 years; P < 0.001), more likely to currently smoke (52.3% vs. 48.1%; P < 0.001), and more likely to have pulmonary disease. Among those with a positive baseline S-LDCT, the lung cancer detection rate was higher at KPCO (9.4% vs. 3.8%; P < 0.001) and was positively associated with prior pulmonary disease. CONCLUSION:Adherence to LCS guidelines requires eligibility confirmation procedures. Among those with a positive baseline S-LDCT, comorbidity burden and lung cancer detection rates were notably higher than in NLST, suggesting that the study of long-term outcomes in patients undergoing LCS in real-world clinical settings is warranted.
Effect of a Patient Decision Aid on Lung Cancer Screening Decision-Making by Persons Who Smoke: A Randomized Clinical Trial.
Volk Robert J,Lowenstein Lisa M,Leal Viola B,Escoto Kamisha H,Cantor Scott B,Munden Reginald F,Rabius Vance A,Bailey Linda,Cinciripini Paul M,Lin Heather,Housten Ashley J,Luckett Pamela Graef,Esparza Angelina,Godoy Myrna C,Bevers Therese B
JAMA network open
Importance:Lung cancer screening with low-dose computed tomography lowers lung cancer mortality but has potential harms. Current guidelines support patients receiving information about the benefits and harms of lung cancer screening during decision-making. Objective:To examine the effect of a patient decision aid (PDA) about lung cancer screening compared with a standard educational material (EDU) on decision-making outcomes among smokers. Design, Setting, and Participants:This randomized clinical trial was conducted using 13 state tobacco quitlines. Current and recent tobacco quitline clients who met age and smoking history eligibility for lung cancer screening were enrolled from March 30, 2015, to September 12, 2016, and followed up for 6 months until May 5, 2017. Data analysis was conducted between May 5, 2017, and September 30, 2018. Interventions:Participants were randomized to the PDA video Lung Cancer Screening: Is It Right for Me? (n = 259) or to EDU (n = 257). Main Outcomes and Measures:The primary outcomes were preparation for decision-making and decisional conflict measured at 1 week. Secondary outcomes included knowledge, intentions, and completion of screening within 6 months of receiving the intervention measured by patient report. Results:Of 516 quit line clients enrolled, 370 (71.7%) were younger than 65 years, 320 (62.0%) were female, 138 (26.7%) identified as black, 47 (9.1%) did not have health insurance, and 226 (43.8%) had a high school or lower educational level. Of participants using the PDA, 153 of 227 (67.4%) were well prepared to make a screening decision compared with 108 of 224 participants (48.2%) using EDU (odds ratio [OR], 2.31; 95% CI, 1.56-3.44; P < .001). Feeling informed about their screening choice was reported by 117 of 234 participants (50.0%) using a PDA compared with 66 of 233 participants (28.3%) using EDU (OR, 2.56; 95% CI, 1.72-3.79; P < .001); 159 of 234 participants (68.0%) using a PDA compared with 110 of 232 (47.4%) participants using EDU reported being clear about their values related to the harms and benefits of screening (OR, 2.37; 95% CI, 1.60-3.51; P < .001). Participants using a PDA were more knowledgeable about lung cancer screening than participants using EDU at each follow-up assessment. Intentions to be screened and screening behaviors did not differ between groups. Conclusions and Relevance:In this study, a PDA delivered to clients of tobacco quit lines improved informed decision-making about lung cancer screening. Many smokers eligible for lung cancer screening can be reached through tobacco quit lines. Trial Registration:ClinicalTrials.gov identifier: NCT02286713.
Provider-Patient Discussions About Smoking and the Impact of Lung Cancer Screening Guidelines: NHIS 2011-2015.
Huo Jinhai,Chung Tong Han,Kim Bumyang,Deshmukh Ashish A,Salloum Ramzi G,Bian Jiang
Journal of general internal medicine
BACKGROUND:Clinical practice guidelines for treating tobacco use and lung cancer screening guidelines recommend smoking cessation counseling to current smokers by health care professionals. OBJECTIVE:Our objective was to determine the contemporary patterns of current smokers' discussions about smoking with their health care professionals in the USA. DESIGN, SETTING, AND PARTICIPANTS:We conducted an observational study of 30,132 current smokers (weighted sample 40,126,006) for the years 2011 to 2015 using data from the National Health Interview Survey. MAIN MEASURES:Our main outcome was the proportion of current smokers who had discussions about smoking with their health care professionals. We used the Cochran-Armitage trend test to evaluate the temporal trends in current smokers' discussions about smoking, and used a multivariable logistic model to determine the predictors of discussions about smoking, controlling for smokers' demographics, health status, and receipts of lung cancer screening. KEY RESULTS:Our study found the proportion of current smokers who had discussions about smoking with their health care professionals increased from 51.3% in 2011 to 55.4% in 2015 (P-trend < 0.0001). However, about 15% of current smokers who underwent lung cancer screening did not have or could not recall discussions about smoking with their health care professionals. In multivariable analyses and sensitivity analysis, the predictors of discussions about smoking were being a heavy smoker, receipt of lung cancer screening, being non-Hispanic white, having a physician office visit in the past year, being diagnosed with respiratory conditions, having fair or poor health, and having insurance coverage. CONCLUSIONS:The results demonstrated a steady but slow increase in current smokers' discussions about smoking with their health care professionals in recent years, especially among heavy smokers. More than 40% of current smokers did not have or could not recall any discussions about smoking with their health care professionals.
Growth of the thoracic aorta in the smoking population: The Danish Lung Cancer Screening Trial.
Bons Lidia R,Sedghi Gamechi Zahra,Thijssen Carlijn G E,Kofoed Klaus F,Pedersen Jesper H,Saghir Zaigham,Takkenberg Johanna J M,Kardys Isabella,Budde Ricardo P J,de Bruijne Marleen,Roos-Hesselink Jolien W
International journal of cardiology
BACKGROUND:Although the descending aortic diameter is larger in smokers, data about thoracic aortic growth is missing. Our aim is to present the distribution of thoracic aortic growth in smokers and to compare it with literature of the general population. METHODS:Current and ex-smokers aged 50-70 years from the longitudinal Danish Lung Cancer Screening Trial, were included. Mean and 95th percentile of annual aortic growth of the ascending aortic (AA) and descending aortic (DA) diameters were calculated with the first and last non-contrast computed tomography scans during follow-up. Determinants of change in aortic diameter over time were investigated with linear mixed models. RESULTS:A total of 1987 participants (56% male, mean age 57.4 ± 4.8 years) were included. During a median follow-up of 48 months, mean AA and DA growth rates were comparable between males (AA 0.12 ± 0.31 mm/year and DA 0.10 ± 0.30 mm/year) and females (AA 0.11 ± 0.29 mm/year and DA 0.13 ± 0.27 mm/year). The 95th percentile ranged from 0.42 to 0.47 mm/year, depending on sex and location. Aortic growth was comparable between current and ex-smokers and aortic growth was not associated with pack-years. Our findings are consistent with aortic growth rates of 0.08 to 0.17 mm/years in the general population. Larger aortic growth was associated with lower age, increased height, absence of medication for hypertension or hypercholesterolemia and lower Agatston scores. CONCLUSIONS:This longitudinal study of smokers in the age range of 50-70 years shows that ascending and descending aortic growth is approximately 0.1 mm/year and is consistent with growth in the general population.
New Fissure-Attached Nodules in Lung Cancer Screening: A Brief Report From The NELSON Study.
Han Daiwei,Heuvelmans Marjolein A,van der Aalst Carlijn M,van Smoorenburg Lisa H,Dorrius Monique D,Rook Mieneke,Nackaerts Kristiaan,Walter Joan E,Groen Harry J M,Vliegenthart Rozemarijn,de Koning Harry J,Oudkerk Matthijs
Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer
INTRODUCTION:In incidence lung cancer screening rounds, new pulmonary nodules are regular findings. They have a higher lung cancer probability than baseline nodules. Previous studies have shown that baseline perifissural nodules (PFNs) represent benign lesions. Whether this is also the case for incident PFNs is unknown. This study evaluated newly detected nodules in the Dutch-Belgian randomized-controlled NELSON study with respect to incidence of fissure-attached nodules, their classification, and lung cancer probability. METHODS:Within the NELSON trial, 7557 participants underwent baseline screening between April 2004 and December 2006. Participants with new nodules detected after baseline were included. Nodules were classified based on location and attachment. Fissure-attached nodules were re-evaluated to be classified as typical, atypical, or non-PFN by two radiologists without knowledge of participant lung cancer status. RESULTS:One thousand four hundred eighty-four new nodules were detected in 949 participants (77.4% male, median age 59 years [interquartile range: 55-63 years]) in the second, third, and final NELSON screening round. Based on 2-year follow-up or pathology, 1393 nodules (93.8%) were benign. In total, 97 (6.5%) were fissure-attached, including 10 malignant nodules. None of the new fissure-attached malignant nodules was classified as typical or atypical PFN. CONCLUSIONS:In the NELSON study, 6.5% of incident lung nodules were fissure-attached. None of the lung cancers that originated from a new fissure-attached nodule in the incidence lung cancer screening rounds was classified as a typical or atypical PFN. Our results suggest that also in the case of a new PFN, it is highly unlikely that these PFNs will be diagnosed as lung cancer.
Screening of tumor-associated antigens based on Oncomine database and evaluation of diagnostic value of autoantibodies in lung cancer.
Wang Tingting,Liu Hongchun,Pei Lu,Wang Kaijuan,Song Chunhua,Wang Peng,Ye Hua,Zhang Jianying,Ji Zhenyu,Ouyang Songyun,Dai Liping
Clinical immunology (Orlando, Fla.)
OBJECTIVES:The purpose of this study is to discover novel tumor-associated antigens (TAAs) to improve the diagnosis of lung cancer (LC). MATERIALS AND METHODS:Oncomine database was used to discover potential TAAs from LC tissues, enzyme-linked immunosorbent assay (ELISA) was used to detect the levels of autoantibodies against TAAs in two independent sets (identification set, n = 368; validation set, n = 1011). RESULTS:Analyses of sera from identification set showed that the sensitivity of autoantibodies against five TAAs (HMGB3, ZWINT, GREM1, NUSAP1 and MMP12) reached 57.1%, 42.4%, 38.0%, 36.4% and 20.7%, with area under ROC curve (AUC) of 0.85, 0.75, 0.71, 0.73 and 0.70, respectively. It also validated the diagnostic performances of these autoantibodies with AUC of 0.72, 0.65, 0.61, 0.64 and 0.64, respectively. Autoantibody against HMGB3 exhibited significantly increased frequency in early LC (53.3%) compared to advanced LC (29.3%) (P < .05). The positive rates of autoantibody against HMGB3 and NUSAP1 in serum of LC patients without distant metastasis were significantly higher than that of distant metastatic LC (P < .05). When each of the three protein biomarkers (CEA, CA125 and CYFRA21-1) was combined with anti-HMGB3 autoantibody, the sensitivity of early LC increased to 72.7%, 63.3% and 75.9% from 36.4%, 13.3% and 27.6%, respectively. CONCLUSION:Autoantibodies against 5 TAAs (HMGB3, ZWINT, GREM1, NUSAP1 and MMP12) might have favorable diagnostic values in LC detection, and autoantibody against HMGB3 has the potential to serve as a serological biomarker in early-stage LC. The combination of protein biomarkers and anti-HMGB3 might contribute to detection of early-stage LC.
Long-term cancer risk associated with lung nodules observed on low-dose screening CT scans.
Pinsky Paul,Gierada David S
Lung cancer (Amsterdam, Netherlands)
OBJECTIVE:Non-calcified nodules (NCNs) associated with false positive low-dose CT (LDCT) lung cancer screens have been attributed to various causes. Some, however, may represent lung cancer precursors. An association of NCNs with long-term lung cancer risk would provide indirect evidence of some NCNs being cancer precursors. METHODS:LDCT arm participants in the National Lung Screening Trial (NLST) received LDCT screens at baseline and years 1-2. The relationship between NCNs found on LDCT screens and subsequent lung cancer diagnosis over different time periods was examined at the person and lobe level. For the latter, a lobe had a cancer outcome only if the cancer was located in the lobe. Separate analyses were performed on baseline and post-baseline LDCT findings; for the latter, those with baseline NCNs were excluded and only new (non-pre-existing) NCNs examined. Raw and adjusted rate-ratios (RRs) were computed for presence of NCNs and subsequent lung cancer risk; adjusted RRs controlled for demographic and smoking factors. RESULTS:26,309 participants received the baseline LDCT screen. Over median 11.3 years follow-up, 1675 lung cancers were diagnosed. Adjusted RRs for time periods 0-4, 4-8 and 8-12 years following the baseline screen were 5.1 (95 % CI:4.4-5.9), 1.5 (95 % CI:1.3-1.9) and 1.5 (95 % CI:1.2-1.8) at the person-level and 14.7 (95 % CI:12.6-17.2), 2.6 (95 % CI: 2.0-3.4) and 2.2 (95 % CI:1.6-2.9) at the lobe-level. 18,585 participants were included in the post-baseline analysis. Adjusted RRs for periods 0-4, 4-8 and 8-11 years were 5.6 (95 % CI: 4.5-7.0), 1.9 (95 % CI: 1.3-2.7) and 1.6 (95 % CI: 0.9-2.9) at the person-level and 19.6 (95 % CI:14.9-25.3), 2.5 (95 % CI:1.3-4.7) and 3.3 (95 % CI:1.4-7.6) at the lobe-level. Raw RRs were similar. CONCLUSION:NCNs are associated with excess long-term lung cancer risk, suggesting that some may be lung cancer precursors.
Trends in lung cancer risk and screening eligibility affect overdiagnosis estimates.
Blom Erik F,Ten Haaf Kevin,de Koning Harry J
Lung cancer (Amsterdam, Netherlands)
OBJECTIVES:The degree of overdiagnosis due to lung cancer screening in the general US population remains unknown. Estimates may be influenced by the method used and by decreasing smoking trends, which reduce lung cancer risk and screening eligibility over time. Therefore, we aimed to estimate the degree of overdiagnosis due to lung cancer screening in the general US population, using three distinct methods. MATERIAL AND METHODS:The MISCAN-Lung model was used to project lung cancer incidence and overdiagnosis in the general US population between 2018-2040, assuming perfect adherence to the United States Preventive Task Force recommendations. MISCAN-Lung was calibrated to the NLST and PLCO trials and incorporates birth-cohort-specific smoking trends and life expectancies. We estimated overdiagnosis using the cumulative excess-incidence approach, the annual excess-incidence approach, and the microsimulation approach. RESULTS:Using the cumulative excess-incidence approach, 10.5 % of screen-detected cases were overdiagnosed in the 1950 birth-cohort compared to 5.9 % in the 1990 birth-cohort. Incidence peaks and drops due to screening were larger for older birth-cohorts than younger birth-cohorts. In the general US population, these differing incidence peaks and drops across birth-cohorts overlap. Therefore, annual excess-incidence would be absent between 2029-2040, suggesting no overdiagnosis occurs. Using the microsimulation approach, overdiagnosis among screen-detected cases increased from 7.1 % to 9.5 % between 2018-2040, while overdiagnosis among all lung cancer cases decreased from 3.7 % to 1.4 %. CONCLUSION:Overdiagnosis studies should use appropriate methods to account for trends in background risk and screening eligibility in the general population. Estimates from randomized trials, based on the cumulative excess-incidence approach, are not generalizable to the general population. The annual excess-incidence approach does not account for trends in background risk and screening eligibility, and falsely suggests no overdiagnosis occurs in the general population. Using the microsimulation approach, overdiagnosis was limited but not nil. Overdiagnosis increased among screen-detected cases, while overdiagnosis among all cases decreased.
Screening Mammography Visits as Opportunities to Engage Smokers With Tobacco Cessation Services and Lung Cancer Screening.
Wang Gary X,Narayan Anand K,Park Elyse R,Lehman Constance D,Gorenstein Jonina T,Flores Efren J
Journal of the American College of Radiology : JACR
OBJECTIVE:Tobacco use is the leading cause of preventable mortality in the United States. Screening mammography (SM) visits present opportunities for radiology practices to reduce tobacco-related morbidity and mortality. Our study evaluates implementation of a program that provides tobacco cessation service referrals and screens for lung cancer screening (LCS) eligibility among smokers presenting for SM at a community health center. METHODS:In 2018, two sets of questions were added to our SM patient intake questionnaire to assess (1) smoking history and (2) interest in referral to the health center-based tobacco cessation program for mailed information, telephone-based consultation, and in-person counseling. Primary outcomes were proportion of current smokers who requested a referral and of all smokers who were LCS-eligible. Bivariate logistic regression analyses compared sociodemographic characteristics of smokers who requested versus declined a referral. RESULTS:Of the 89.3% (1,907 of 2,136) who responded, 10.5% (201 of 1,907) were current and 29.1% (555 of 1,907) were former smokers. Of current smokers, 26.4% (53 of 201) requested referrals: mailed information by 23.9% (48 of 201), in-person counseling by 9% (18 of 201), and telephone-based consultation by 7.5% (15 of 201). No sociodemographic predictors for referral requests were identified. Of all smokers, 9.3% (70 of 756) were eligible for LCS, of which 31.4% (22 of 70) were up to date. CONCLUSION:One in ten women who underwent SM at our community health center were current smokers, of which one-quarter requested tobacco cessation referrals. Among LCS-eligible smokers, one-third were up to date. SM presents opportunities for radiology practices to advance population health goals such as tobacco cessation and LCS.
Education Level Predicts Appropriate Follow-Up of Incidental Findings From Lung Cancer Screening.
Kapoor Suraj,Deppen Stephen A,Paulson Alexis B,Haddad Diane,Cook James P,Sandler Kim L
Journal of the American College of Radiology : JACR
PURPOSE:The aim of this study was to identify predictors of appropriate follow-up for clinically significant incidental findings (IFs) detected with low-dose CT during lung cancer screening. METHODS:Charts of 1,458 prospectively enrolled lung screening patients from January 1, 2015, to October 31, 2018, were reviewed. IFs, other than coronary artery calcification and emphysema, were identified. ACR practice guidelines defined appropriate patient follow-up. Patient demographic and social characteristics were obtained from the initial shared decision-making visit and the electronic medical record. Factors of interest included age, gender, race, education level, and insurance status. Education level was reported as high school graduate or less or education past high school. A multivariate logistic regression was estimated to assess patient factors associated with appropriate follow-up. RESULTS:One hundred thirty-eight participants (9%) with 141 actionable IFs were identified. The overall appropriate follow-up rate was 82%. The most common IFs were renal lesions (16%), dilated thoracic aorta (10%), and pulmonary fibrosis (10%). Univariate analysis of appropriate patient follow-up revealed a significant difference for education level (P = .02). A greater than high school education remained strongly associated with appropriate follow-up after controlling for other demographic factors. CONCLUSIONS:Appropriate patient follow-up of clinically significant IFs from lung cancer screening is a well-recognized avenue to improve population health. Education level is a significant independent predictor of appropriate follow-up of IFs, whether as a surrogate for low socioeconomic status or as an indication of health literacy. To address these realities, lung screening shared decision making should adapt to consider health care access and health literacy.
Reliability of self-reported smoking history and its implications for lung cancer screening.
Volk Robert J,Mendoza Tito R,Hoover Diana S,Nishi Shawn P E,Choi Noah J,Bevers Therese B
Preventive medicine reports
Clinical guidelines endorse either a 30 or 20 pack-year smoking history threshold when determining eligibility for lung cancer screening (LCS). However, self-reported smoking history is subject to recall bias that can affect patient eligibility. We examined the reliability of smokers' self-reported tobacco use and its impact on eligibility for LCS. Current or former smokers aged 55-77 years completed questionnaires requesting demographic information and smoking history. Data were collected between December 2014 and September 2015. Total pack-year smoking history was calculated for each participant based on their responses at baseline and one month later. One hundred and two participants completed the study (mean age = 63.6 years). The intraclass correlation coefficient for the pack-year estimate was 0.93. For the 30 pack-year threshold, eight (7.8%) participants were eligible at one but not both assessment periods. For the 20 pack-year threshold, twelve participants (11.8%) were eligible at one but not both assessment periods. Inconsistent reporting was higher among current compared to former smokers. Smokers' self-reported tobacco use appears highly reliable over short time periods. Nevertheless, there is some inconsistent reporting. We recommend that clinicians carefully assess smoking history, probe patients' recall of duration and quantity of smoking, and collect tobacco use information at every encounter.
Association of Baseline Prostate-Specific Antigen Level With Long-term Diagnosis of Clinically Significant Prostate Cancer Among Patients Aged 55 to 60 Years: A Secondary Analysis of a Cohort in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial.
Kovac Evan,Carlsson Sigrid V,Lilja Hans,Hugosson Jonas,Kattan Michael W,Holmberg Erik,Stephenson Andrew J
JAMA network open
Importance:The use of prostate-specific antigen (PSA) screening for prostate cancer is controversial because of the risk of overdiagnosis and overtreatment of indolent cancers. Optimal screening strategies are highly sought. Objective:To estimate the long-term risk of any prostate cancer and clinically significant prostate cancer based on baseline PSA levels among men aged 55 to 60 years. Design, Setting, and Participants:This secondary analysis of a cohort in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial uses actuarial analysis to analyze the association of baseline PSA levels with long-term risk of any prostate cancer and of clinically significant prostate cancer among men aged 55 to 60 years enrolled in the screening group of the trial between 1993 and 2001. Exposure:Single PSA measurement at study entry. Main Outcomes and Measures:Long-term risk of any prostate cancer and clinically significant prostate cancer diagnoses. Results:There were 10 968 men aged 55 to 60 years (median [interquartile range] age, 57 [55-58] years) at study enrollment in the screening group of the PLCO Cancer Screening Trial who had long-term follow-up. Actuarial 13-year incidences of clinically significant prostate cancer diagnosis among participants with a baseline PSA of 0.49 ng/mL or less was 0.4% (95% CI, 0%-0.8%); 0.50-0.99 ng/mL, 1.5% (95% CI, 1.1%-1.9%); 1.00-1.99 ng/mL, 5.4% (95% CI, 4.4%-6.4%); 2.00-2.99 ng/mL, 10.6% (95% CI, 8.3%-12.9%); 3.00-3.99 ng/mL, 15.3% (95% CI, 11.4%-19.2%); and 4.00 ng/mL and greater, 29.5% (95% CI, 24.2%-34.8%) (all pairwise log-rank P ≤ .004). Only 15 prostate cancer-specific deaths occurred during 13 years of follow-up, and 9 (60.0%) were among men with a baseline PSA level of 2.00 ng/mL or higher. Conclusions and Relevance:In this secondary analysis of a cohort from the PLCO Cancer Screening Trial, baseline PSA levels among men aged 55 to 60 years were associated with long-term risk of clinically significant prostate cancer. These findings suggest that repeated screening can be less frequent among men aged 55 to 60 years with a low baseline PSA level (ie, <2.00 ng/mL) and possibly discontinued among those with baseline PSA levels of less than 1.00 ng/mL.
Direct and indirect healthcare costs of lung cancer CT screening in Denmark: a registry study.
Jensen Manja Dahl,Siersma Volkert,Rasmussen Jakob Fraes,Brodersen John
INTRODUCTION:A study based on the Danish Randomised Controlled Lung Cancer Screening Trial (DLCST) calculated the healthcare costs of lung cancer screening by comparing costs in an intervention group with a control group. Participants in both groups, however, experienced significantly increased negative psychosocial consequences after randomisation. Substantial participation bias has also been documented: The DLCST participants reported fewer negative psychosocial aspects and experienced better living conditions compared with the random sample. OBJECTIVE:To comprehensively analyse the costs of lung cancer CT screening and to determine whether invitations to mass screening alter the utilisation of the healthcare system resulting in indirect costs. Healthcare utilisation and costs are analysed in the primary care sector (general practitioner psychologists, physiotherapists, other specialists, drugs) and the secondary care sector (emergency room contacts, outpatient visits, hospitalisation days, surgical procedures and non-surgical procedures). DESIGN:To account for bias in the original trial, the costs and utilisation of healthcare by participants in DLCST were compared with a new reference group, selected in the period from randomisation (2004-2006) until 2014. SETTING:Four Danish national registers. PARTICIPANTS:DLCST included 4104 current or former heavy smokers, randomly assigned to the CT group or the control group. The new reference group comprised a random sample of 535 current or former heavy smokers in the general Danish population who were never invited to participate in a cancer screening test. MAIN OUTCOME MEASURES:Total healthcare costs including costs and utilisation of healthcare in both the primary and the secondary care sector. RESULTS:Compared with the reference group, the participants in both the CT group (offered annual CT screening, lung function test and smoking counselling) and the control group (offered annual lung function test and smoking counselling) had significantly increased total healthcare costs, calculated at 60% and 48% respectively. The increase in costs was caused by increased use of healthcare in both the primary and the secondary sectors. CONCLUSION:CT screening leads to 60% increased total healthcare costs. Such increase would raise the expected annual healthcare cost per participant from EUR 2348 to EUR 3756. Cost analysis that only includes costs directly related to the CT scan and follow-up procedures most likely underestimates total costs. Our data show that the increased costs are not limited to the secondary sector. TRIAL REGISTRATION NUMBER:NCT00496977.
Patient-derived organoids of non-small cells lung cancer and their application for drug screening.
Li Y F,Gao Y,Liang B W,Cao X Q,Sun Z J,Yu J H,Liu Z D,Han Y
Patient-derived organoids (PDOs) are emerging as preclinical models with promising values in personalized cancer therapy. The purpose of this study was to establish a living biobank of PDOs from patients with non-small cell lung cancer (NSCLC) and to study the responses of PDOs to drugs. PDOs derived from NSCLC were cultured in vitro, and then treated with natural compounds including chelerythrine chloride, cantharidin, harmine, berberine and betaine with series of concentrations (0.5-30 μM) for drug screening. Phenotypic features and treatment responses of established PDOs were reported. Cell lines (H1299, H460 and H1650) were used for drug screening. We successfully established a living NSCLC organoids biobank of 10 patients, which showed similar pathological features with primary tumors. Nine of the 10 patients showed mutations in EGFR. Natural compounds chelerythrine chloride, cantharidin and harmine showed anticancer activity on PDOs and cell lines. There was no significant difference in the 95% confidence interval (CI) for the IC50 value of chelerythrine chloride between PDOs (1.56-2.88 μM) and cell lines (1.45-3.73 μM, p>0.05). PDOs were sensitive to berberine (95% CI, 0.092-1.55 μM), whereas cell lines showed a resistance (95% CI, 46.57-2275 μM, p<0.0001). PDOs had a higher IC50 value of cantharidin, and a lower IC50 value of harmine than cell lines (p<0.05, 7.50-10.45 μM and 4.27-6.50 μM in PDOs, 3.07-4.44 μM and 4.69-544.99 μM in cell lines, respectively). Both PDOs and cell lines were resistant to betaine. Chelerythrine chloride showed the highest inhibitory effect in both models. Our study established a living biobank of PDOs from NSCLC patients, which might be used for high-throughput drug screening and for promising personalized therapy design.
Brief Education and a Conjoint Valuation Survey May Reduce Decisional Conflict Regarding Lung Cancer Screening.
Studts Jamie L,Thurer Richard J,Brinker Kory,Lillie Sarah E,Byrne Margaret M
MDM policy & practice
Recent data and policy decisions have led to the availability of lung cancer screening (LCS) for individuals who are at increased risk of developing lung cancer. In establishing implementation policies, the US Preventive Services Task Force recommended and the Centers for Medicare and Medicaid Services required that individuals who meet eligibility criteria for LCS receive a patient counseling and shared decision-making consultation prior to LCS. This study evaluated the potential of a values clarification/preference elicitation exercise and brief educational intervention to reduce decisional conflict regarding LCS. Participants ( = 210) completing a larger online survey responded to a measure of decisional conflict prior to and following administration of a conjoint survey and brief educational narrative about LCS. The conjoint survey included 22 choice sets (two of which were holdout cards), incorporating 5 attributes with 17 levels. Results pertaining to changes in decisional conflict showed that participants reported statistically significantly and clinically meaningful reductions in decisional conflict following administration of the brief educational narrative and conjoint survey across the total score (Δ = 29.30; = 1.09) and all four decisional conflict subscales: Uncertainty (Δ = 27.75; = 0.73), Informed (Δ = 35.32; = 1.11), Values Clarity (Δ = 31.82; = 0.85), and Support (Δ = 18.78; = 0.66). While the study design precludes differentiating the effects of the brief educational narrative and the conjoint survey, data suggest that these tools offer a reasonable approach to clarifying personal beliefs and perspectives regarding LCS participation. Given the complicated nature of LCS decisions and recent policies advocating informed and shared decision-making approaches, conjoint surveys should be evaluated as one of the tools that could help individuals make choices about LCS participation.
Evaluation of the Informational Content and Readability of US Lung Cancer Screening Program Websites.
Gagne Staci M,Fintelmann Florian J,Flores Efren J,McDermott Shaunagh,Mendoza Dexter P,Petranovic Milena,Price Melissa C,Stowell Justin T,Little Brent P
JAMA network open
Importance:The internet is an important source of medical information for many patients and may have a key role in the education of patients about lung cancer screening (LCS). Although most LCS programs in the United States have informational websites, the accuracy, completeness, and readability of these websites have not previously been studied. Objective:To evaluate the informational content and readability of US LCS program websites. Design, Setting, and Participants:This cross-sectional study assessed US LCS program websites identified on September 15, 2018. A standardized checklist was used to assess key informational content of each website, and text was analyzed for reading level, word count, and reading time. Links to US websites of national advocacy organizations with LCS program content were tabulated. All functional LCS program websites in Google internet search engine results using the search terms lung cancer screening, low-dose CT screening, and lung screening were included in the analysis. Main Outcomes and Measures:Radiologists used a standardized checklist to evaluate content, and readability was assessed with validated scales. Website word count, reading time, and number of links to outside LCS informational websites were assessed. Results:A total of 257 LCS websites were included in the analysis. The word count ranged from 73 to 4410 (median, 571; interquartile range, 328-909). The reading time ranged from 0.3 to 19.6 minutes (median, 2.5; interquartile range, 1.5-4.0). The median reading level of all websites was grade 10 (interquartile range, 9-11). Only 26% (n = 66) of websites had at least 1 web link to a national website with additional information on LCS. There was wide variability regarding reported eligibility age criteria, with ages 55 to 77 years most frequently cited (42% [n = 108]). Only 56% (n = 143) of websites mentioned smoking cessation. The subject of patient cost was mentioned on 75% (n = 192) of websites. Although major LCS benefits, such as detection of lung cancer, were discussed by most (93% [n = 239]) websites, less than half of the websites (45% [n = 115]) made any mention of possible risks associated with screening. Conclusions and Relevance:There appears to be marked variability in the informational content of US LCS program websites, and the reading level of most websites is above that recommended by the American Medical Association and the National Institutes of Health. Efforts to improve website content and readability may be warranted.
Burden of male hardcore smokers and its characteristics among those eligible for lung cancer screening.
Park Dong Won,Jang Ji-Yun,Park Tai Sun,Lee Hyun,Moon Ji-Yong,Kim Sang-Heon,Kim Tae-Hyung,Yoon Ho Joo,Kang Dae Ryong,Sohn Jang Won
BMC public health
BACKGROUND:There are few data available about hardcore smokers and their behavioral characteristics among the lung cancer screening (LCS) population. The study investigated the burden of hardcore smokers within the LCS population, and determine the characteristics of hardcore smokers using nationally representative data in South Korea. METHODS:We used data from 2007 to 2012 from the Korean National Health and Nutrition Examination Survey. This study enrolled current male smokers aged 55-74 years. Among them, subjects eligible for LCS were defined as these populations with smoking histories of at least 30 PY. Hardcore smoking was defined as smoking >15 cigarettes per day, with no plan to quit, and having made no attempt to quit. Multivariate logistic regression analyses were used to estimate associations between hardcore smokers and various sociodemographic and other variables. RESULTS:The proportion of hardcore smokers among those who met LCS eligibility criteria decreased from 2007 to 2012 (from 39.07 to 29.47% of the population) but did not change significantly thereafter (P = 0.2770), and that proportion was consistently 10-15% higher than that of hardcore smokers among all male current smokers. The proportion without any plan to quit smoking decreased significantly from 54.35% in 2007 to 38.31% in 2012. However, the smokers who had made no intentional quit attempt in the prior year accounted for more than half of those eligible for LCS, and the proportion of such smokers did not change significantly during the study period (50.83% in 2007 and 51.03% in 2012). Multivariate logistic regression analyses showed that hardcore smokers were older (OR = 1.05, 95% confidence interval [CI] 1.01-1.09) than non-hardcore smokers. Hardcore smokers exhibited higher proportion of depression (OR = 6.55, 95% CI 1.75-24.61) and experienced extreme stress more frequently (OR = 1.93, 95% CI 1.13-3.29). Smokers who did not receive smoking cessation education within the past year were significantly more likely to be hardcore smokers (OR = 4.15, 95% CI 1.30-13.22). CONCLUSIONS:It is important to identify a subset of smokers unwilling or minimally motivated to quit within the context of lung cancer screening. Anti-smoking education should be enhanced to influence hardcore smokers' behavior.
Effectiveness and Feasibility of Complementary Lung-RADS Version 1.1 in Risk Stratification for pGGN in LDCT Lung Cancer Screening in a Chinese Population.
Meng Qingcheng,Ren Pengfei,Gao Pengrui,Dou Xinmin,Chen Xuejun,Guo Lanwei,Song Yongping
Cancer management and research
Purpose:To evaluate the effectiveness of using a modified lung imaging reporting and data system (Lung-RADS) for risk stratification of pure ground-glass nodules (pGGNs) in low-dose computed tomography (LDCT) for lung cancer (LC) screenings in China. Patients and Methods:Eight subjects with nine pGGNs originating from a Cancer Screening Program were enrolled as training set and 32 asymptomatic subjects with 35 pGGNs were selected as validation set from November 2013 to October 2018. The complementary Lung-RADS categories were set based on the GGN-vessel relationship (GVR). The correlations between GGN-vessel relationships and pathology were evaluated, and the diagnostic value of complementary Lung-RADS version 1.1 in discriminating malignant pGGNs were analyzed. Results:The inter-reader agreements for Lung-RADS 1.1 (intraclass correlation coefficient (ICC= 0.999) and complementary Lung-RADS 1.1 (ICC= 0.971) displayed good reliability. The combined incidence of invasive adenocarcinoma in type III and IV was more than that of benign and preinvasive diseases (30% vs 75%, =0.013). Type II GVR between two benign (66.7%), seven preinvasive (53.8%), and six invasive (21.4%) GGN cases was statistically significant ( =0.019). GGN pathological groups and GVR had a significant correlation (r=0.584, =0.00). Compared to Lung-RADS 1.1, complementary Lung-RADS 1.1 had better performance in the training set, with its sensitivity increased from 33.3% to 88.9%, accuracy increased from 44.4% to 88.9%, false-negative proportion (FNP) decreased from 66.7% to 11.1%, and the sensitivity to predict malignant nodules increased from 13.8% to 93.1%, accuracy increased from 28.6% to 80.0%, and FNP decreased from 86.2% to 6.9% in validation set. The detection rate of preinvasive disease and adenocarcinoma was increased from 12.5% to 90.6% and that of missed diagnosis decreased from 87.5% to 9.4% in the validation set, 0.004. Conclusion:Complementary Lung-RADS 1.1 is superior to Lung-RADS 1.1 and would be beneficial for LC screening of LDCT in China.
Preoperative diagnosis of malignant pulmonary nodules in lung cancer screening with a radiomics nomogram.
Liu Ailing,Wang Zhiheng,Yang Yachao,Wang Jingtao,Dai Xiaoyu,Wang Lijie,Lu Yuan,Xue Fuzhong
Cancer communications (London, England)
BACKGROUND:Lung cancer is the most commonly diagnosed cancer worldwide. Its survival rate can be significantly improved by early screening. Biomarkers based on radiomics features have been found to provide important physiological information on tumors and considered as having the potential to be used in the early screening of lung cancer. In this study, we aim to establish a radiomics model and develop a tool to improve the discrimination between benign and malignant pulmonary nodules. METHODS:A retrospective study was conducted on 875 patients with benign or malignant pulmonary nodules who underwent computed tomography (CT) examinations between June 2013 and June 2018. We assigned 612 patients to a training cohort and 263 patients to a validation cohort. Radiomics features were extracted from the CT images of each patient. Least absolute shrinkage and selection operator (LASSO) was used for radiomics feature selection and radiomics score calculation. Multivariate logistic regression analysis was used to develop a classification model and radiomics nomogram. Radiomics score and clinical variables were used to distinguish benign and malignant pulmonary nodules in logistic model. The performance of the radiomics nomogram was evaluated by the area under the curve (AUC), calibration curve and Hosmer-Lemeshow test in both the training and validation cohorts. RESULTS:A radiomics score was built and consisted of 20 features selected by LASSO from 1288 radiomics features in the training cohort. The multivariate logistic model and radiomics nomogram were constructed using the radiomics score and patients' age. Good discrimination of benign and malignant pulmonary nodules was obtained from the training cohort (AUC, 0.836; 95% confidence interval [CI]: 0.793-0.879) and validation cohort (AUC, 0.809; 95% CI: 0.745-0.872). The Hosmer-Lemeshow test also showed good performance for the logistic regression model in the training cohort (P = 0.765) and validation cohort (P = 0.064). Good alignment with the calibration curve indicated the good performance of the nomogram. CONCLUSIONS:The established radiomics nomogram is a noninvasive preoperative prediction tool for malignant pulmonary nodule diagnosis. Validation revealed that this nomogram exhibited excellent discrimination and calibration capacities, suggesting its clinical utility in the early screening of lung cancer.
Reduced Lung-Cancer Mortality with Volume CT Screening in a Randomized Trial.
de Koning Harry J,van der Aalst Carlijn M,de Jong Pim A,Scholten Ernst T,Nackaerts Kristiaan,Heuvelmans Marjolein A,Lammers Jan-Willem J,Weenink Carla,Yousaf-Khan Uraujh,Horeweg Nanda,van 't Westeinde Susan,Prokop Mathias,Mali Willem P,Mohamed Hoesein Firdaus A A,van Ooijen Peter M A,Aerts Joachim G J V,den Bakker Michael A,Thunnissen Erik,Verschakelen Johny,Vliegenthart Rozemarijn,Walter Joan E,Ten Haaf Kevin,Groen Harry J M,Oudkerk Matthijs
The New England journal of medicine
BACKGROUND:There are limited data from randomized trials regarding whether volume-based, low-dose computed tomographic (CT) screening can reduce lung-cancer mortality among male former and current smokers. METHODS:A total of 13,195 men (primary analysis) and 2594 women (subgroup analyses) between the ages of 50 and 74 were randomly assigned to undergo CT screening at T0 (baseline), year 1, year 3, and year 5.5 or no screening. We obtained data on cancer diagnosis and the date and cause of death through linkages with national registries in the Netherlands and Belgium, and a review committee confirmed lung cancer as the cause of death when possible. A minimum follow-up of 10 years until December 31, 2015, was completed for all participants. RESULTS:Among men, the average adherence to CT screening was 90.0%. On average, 9.2% of the screened participants underwent at least one additional CT scan (initially indeterminate). The overall referral rate for suspicious nodules was 2.1%. At 10 years of follow-up, the incidence of lung cancer was 5.58 cases per 1000 person-years in the screening group and 4.91 cases per 1000 person-years in the control group; lung-cancer mortality was 2.50 deaths per 1000 person-years and 3.30 deaths per 1000 person-years, respectively. The cumulative rate ratio for death from lung cancer at 10 years was 0.76 (95% confidence interval [CI], 0.61 to 0.94; P = 0.01) in the screening group as compared with the control group, similar to the values at years 8 and 9. Among women, the rate ratio was 0.67 (95% CI, 0.38 to 1.14) at 10 years of follow-up, with values of 0.41 to 0.52 in years 7 through 9. CONCLUSIONS:In this trial involving high-risk persons, lung-cancer mortality was significantly lower among those who underwent volume CT screening than among those who underwent no screening. There were low rates of follow-up procedures for results suggestive of lung cancer. (Funded by the Netherlands Organization of Health Research and Development and others; NELSON Netherlands Trial Register number, NL580.).
Plasma screening for the T790M mutation of EGFR and phase 2 study of osimertinib efficacy in plasma T790M-positive non-small cell lung cancer: West Japan Oncology Group 8815L/LPS study.
Takahama Takayuki,Azuma Koichi,Shimokawa Mototsugu,Takeda Masayuki,Ishii Hidenobu,Kato Terufumi,Saito Haruhiro,Daga Haruko,Tsuboguchi Yuko,Okamoto Isamu,Otsubo Kohei,Akamatsu Hiroaki,Teraoka Shunsuke,Takahashi Toshiaki,Ono Akira,Ohira Tatsuo,Yokoyama Toshihide,Sakai Kazuko,Yamamoto Nobuyuki,Nishio Kazuto,Nakagawa Kazuhiko
BACKGROUND:Liquid biopsy allows the identification of patients whose tumors harbor specific mutations in a minimally invasive manner. No prospective data have been available for the efficacy of osimertinib in patients with non-small cell lung cancer (NSCLC) who develop resistance to first- or second-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) and who test positive for the TKI resistance-conferring T790M mutation of EGFR by liquid biopsy. Therefore, a phase 2 study was conducted to assess the efficacy and safety of osimertinib in such patients. METHODS:Eligible patients had advanced or recurrent NSCLC with known TKI-sensitizing mutations of EGFR, had documented disease progression after treatment with at least 1 first- or second-generation EGFR TKI, and were positive for the T790M mutation in plasma according to the Cobas EGFR Mutation Test v2 (Roche Diagnostics) or droplet digital polymerase chain reaction analysis. Patients were treated with osimertinib (80 mg/d) until disease progression. The primary endpoint was the overall response rate (ORR) in patients positive for T790M in plasma by the Cobas assay. RESULTS:Between June 2016 and November 2017, 276 patients were screened for their T790M status with a liquid biopsy. Seventy-four patients were positive for T790M in plasma, and 53 of these individuals were enrolled in the study. The ORR for evaluable patients positive for T790M in plasma by the Cobas assay (n = 49) was 55.1% (95% confidence interval [CI], 40.2%-69.3%). The median progression-free survival for all evaluable patients (n = 52) was 8.3 months (95% CI, 6.9-12.6 months). CONCLUSIONS:The results demonstrate the utility of liquid biopsy for the detection of T790M with the Cobas EGFR Mutation Test v2. Plasma genotyping with this assay is informative for treatment selection in clinical practice when tumor sampling is not feasible.
Evaluating Knowledge, Attitudes, and Beliefs About Lung Cancer Screening Using Crowdsourcing.
Monu John,Triplette Matthew,Wood Douglas E,Wolff Erika M,Lavallee Danielle C,Flum David R,Farjah Farhood
BACKGROUND:Lung cancer screening, despite its proven mortality benefit, remains vastly underutilized. Previous studies examined knowledge, attitudes, and beliefs to better understand the reasons underlying the low screening rates. These investigations may have limited generalizability because of traditional participant recruitment strategies and examining only subpopulations eligible for screening. The current study used crowdsourcing to recruit a broader population to assess these factors in a potentially more general population. METHODS:A 31-item survey was developed to assess knowledge, attitudes, and beliefs regarding screening among individuals considered high risk for lung cancer by the United States Preventive Services Task Force. Amazon's crowdsourcing platform (Mechanical Turk) was used to recruit subjects. RESULTS:Among the 240 respondents who qualified for the study, 106 (44%) reported knowledge of a screening test for lung cancer. However, only 36 (35%) correctly identified low-dose CT scanning as the appropriate test. A total of 222 respondents (93%) reported believing that early detection of lung cancer has the potential to save lives, and 165 (69%) were willing to undergo lung cancer screening if it was recommended by their physician. Multivariable regression analysis found that knowledge of lung cancer screening, smoking status, chronic pulmonary disease, and belief in the efficacy of early detection of lung cancer were associated with willingness to screen. CONCLUSIONS:Although a minority of individuals at high risk for lung cancer are aware of screening, the majority believe that early detection saves lives and would pursue screening if recommended by their primary care physician. Health systems may increase screening rates by improving patient and physician awareness of lung cancer screening.
Outcomes and cost of lung cancer patients treated surgically or medically in Catalunya: cost-benefit implications for lung cancer screening programs.
Guzman Rudith,Guirao Àngela,Vela Emili,Clèries Montserrat,García-Altés Anna,Sagarra Joan,Magem David,Espinas Josep A,Grau Jaume,Nadal Cristina,Agusti Àlvar,Molins Laureano
European journal of cancer prevention : the official journal of the European Cancer Prevention Organisation (ECP)
Lung cancer screening programs with computed tomography of the chest reduce mortality by more than 20%. Yet, they have not been implemented widely because of logistic and cost implications. Here, we sought to: (1) use real-life data to compare the outcomes and cost of lung cancer patients with treated medically or surgically in our region and (2) from this data, estimate the cost-benefit ratio of a lung cancer screening program (CRIBAR) soon to be deployed in our region (Catalunya, Spain). We accessed the Catalan Health Surveillance System (CHSS) and analysed data of all patients with a first diagnosis of lung cancer between 1 January 2014 and 31 December 2016. Analysis was carried forward until 30 months (t = 30) after lung cancer diagnosis. Main results showed that: (1) surgically treated lung cancer patients have better survival and return earlier to regular home activities, use less healthcare related resources and cost less tax-payer money and (2) depending on incidence of lung cancer identified and treated in the program (1-2%), the return on investment for CRIBAR is expected to break even at 3-6 years, respectively, after its launch. Surgical treatment of lung cancer is cheaper and offers better outcomes. CRIBAR is estimated to be cost-effective soon after launch.
Visual scoring of aortic valve calcifications on low-dose CT in lung cancer screening.
Zhu Yeqing,Wang Yong,Gioia William E,Yip Rowena,Jirapatnakul Artit C,Chung Michael S,Yankelevitz David F,Henschke Claudia I
OBJECTIVES:To evaluate risk factors for prevalence and progression of aortic valve calcification (AVC) in lung cancer screening participants and also to assess the sensitivity and reliability of visual AVCs on low-dose CT (LDCT) for predicting aortic stenosis (AS) in high-risk smokers. METHODS:We reviewed 1225 consecutive participants in annual LDCT screening for lung cancer at the Mount Sinai Hospital between 2010 and 2017. Sensitivity and specificity of moderate/severe AVC score on LDCT to identify AS on echocardiogram were calculated for 126 participants who had both within 12 months. Using regression analyses, risk factors for AVC at baseline, for progression, and for new AVC on annual rounds of screening were identified. Reliability of AVC assessment on LDCT was assessed by comparing visual AVC scores (1) with standard-dose, electrocardiography (ECG)-gated CT for 31 participants who had both within 12 months and (2) with Agatston scores of 1225 participants and by determining (3) the intra-reader agreement of 1225 participants. RESULTS:Visual AVC scores on LDCT had substantial agreement with the severity of AS on echocardiography and substantial inter-observer and excellent intra-observer agreement. Sensitivity and specificity of moderate/severe visual AVC scores for moderate/severe AS on echocardiogram were 100% and 94%, respectively. Significant predictors for baseline AVC were male sex (OR = 2.52), age (OR = 2.87), and coronary artery calcification score (OR = 1.18), the significant predictor for AVC progression after baseline was pack-years of smoking (HR = 1.14), and significant predictors for new AVC on annual LDCT were male sex (HR = 1.51), age (HR = 2.17), CAC (HR = 1.09) and BMI (HR = 1.06). CONCLUSIONS:AVC scores on LDCT should be documented, especially in lung cancer screening program. KEY POINTS:• LDCT screening for lung cancer provides an opportunity to identify lung cancer and cardiovascular disease in asymptomatic smokers. • Visual aortic valve calcification scores could be reliably evaluated on LDCT and had substantial agreement with the severity of aortic valve stenosis on echocardiography. • Sensitivity and specificity of moderate/severe visual AVC scores on LDCT for moderate/severe AS on echocardiogram were 100% and 94%, respectively.
Evaluating Potential Racial Inequities in Low-dose Computed Tomography Screening for Lung Cancer.
Richmond Jennifer,Mbah Olive M,Dard Sofia Z,Jordan Lauren C,Cools Katherine S,Samuel Cleo A,Khan Jalaal M,Manning Matthew A
Journal of the National Medical Association
BACKGROUND:Lung cancer is the leading cause of cancer death in the US, and significant racial disparities exist in lung cancer outcomes. For example, Black men experience higher lung cancer incidence and mortality rates than their White counterparts. New screening recommendations for low-dose computed tomography (LDCT) promote earlier detection of lung cancer in at-risk populations and can potentially help mitigate racial disparities in lung cancer mortality if administered equitably. Yet, little is known about the extent of racial differences in uptake of LDCT. OBJECTIVE:To evaluate potential racial disparities in LDCT screening in a large community-based cancer center in central North Carolina. METHODS:We conducted a retrospective study of the initial patients undergoing LDCT in a community-based cancer center (n = 262). We used the Pearson chi-squared test to assess potential racial disparities in LDCT screening. RESULTS:Study results suggest that Black patients may be less likely than White patients to receive LDCT screening when eligible (χ2 = 51.41, p < 0.0001). CONCLUSION:Collaboration among healthcare providers, researchers, and decision makers is needed to promote LDCT equity.
Magnesium intake and primary liver cancer incidence and mortality in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial.
Zhong Guo-Chao,Peng Yang,Wang Kang,Wan Lun,Wu You-Qi-Le,Hao Fa-Bao,Hu Jie-Jun,Gu Hai-Tao
International journal of cancer
Epidemiological studies on magnesium intake and primary liver cancer (PLC) are scarce, and no prospective studies have examined the associations of magnesium intake with PLC incidence and mortality. We sought to clarify whether higher magnesium intake from diet and supplements was associated with lower risks of PLC incidence and mortality in the US population. Magnesium intake from diet and supplements was evaluated through a food frequency questionnaire in a cohort of 104,025 participants. Cox regression was employed to calculate hazard ratios for PLC incidence and competing risk regression was employed to calculate subdistribution hazard ratios for PLC mortality. Restricted cubic spline regression was employed to test nonlinearity. We documented 116 PLC cases during 1,193,513.5 person-years of follow-up and 100 PLC deaths during 1,198,021.3 person-years of follow-up. Total (diet + supplements) magnesium intake was found to be inversely associated with risks of PLC incidence (hazard ratio : 0.44; 95% confidence interval: 0.24, 0.80; p = 0.0065) and mortality (subdistribution hazard ratio : 0.37; 95% confidence interval: 0.19, 0.71; p = 0.0008). Similar results were obtained for dietary magnesium intake. Nonlinear inverse dose-response associations with PLC incidence and mortality were observed for both total and dietary magnesium intakes (all p < 0.05). In summary, in the US population, a high magnesium intake is associated with decreased risks of PLC incidence and mortality in a nonlinear dose-response manner. These findings support that increasing the consumption of foods rich in magnesium may be beneficial in reducing PLC incidence and mortality.
Leveraging the Mammography Setting to Raise Awareness and Facilitate Referral to Lung Cancer Screening: A Qualitative Analysis.
Eberth Jan M,Ersek Jennifer L,Terry Leah M,Bills Sarah E,Chintanippu Nirupama,Carlos Ruth,Hughes Danny R,Studts Jamie L
Journal of the American College of Radiology : JACR
PURPOSE:Despite compelling support for the benefits of low-dose CT (LDCT) screening for lung cancer among high-risk individuals, awareness of LDCT screening and uptake remain low. The aim of this project was to explore the perspectives of ACR mammography screening program directors (MPDs) regarding efforts to raise LDCT screening awareness and appropriate referrals by identifying high-risk individuals participating in routine mammography. METHODS:MPDs were recruited from ACR-accredited mammography facilities to participate in semistructured interviews after the completion of an online survey. Interviews were conducted over the telephone, recorded, transcribed, and subsequently reviewed for accuracy. Twenty MPDs were interviewed, and 18 interviews were transcribed and included in the thematic analysis. A theme codebook was developed, and all interviews were coded using NVivo by two trained reviewers. RESULTS:Key themes were organized into four broad domains: (1) general attitudes toward the integration of LDCT screening, (2) identifying mammography patients at high risk for lung cancer, (3) counseling about LDCT screening, and (4) strategies to identify high-risk women and increase awareness and knowledge of LDCT screening. Overall, MPDs recognized the benefits of integrating mammography and LDCT screening and were receptive to educating and referring women for LDCT screening. However, training and workflow changes are needed to ensure successful implementation. CONCLUSIONS:Qualitative data suggest that MPDs are amenable to leveraging the mammography setting to engage women about LDCT screening; however, additional tools, training, and/or staffing may be necessary to leverage the full potential of reaching women at high risk for lung cancer within the context of mammographic screening.
Tracking the Nonenrolled: Lung Cancer Screening Patterns Among Individuals not Accrued to a Clinical Trial.
Gerber David E,Hamann Heidi A,Chavez Claudia,Dorsey Olivia,Santini Noel O,Browning Travis,Ochoa Cristhiaan D,Adesina Joyce,Natchimuthu Vijaya Subbu,Steen Eric,Zhu Hong,Lee Simon J Craddock
Clinical lung cancer
INTRODUCTION:For lung cancer screening, the available data are often derived from patients enrolled prospectively in clinical trials. We, therefore, investigated lung cancer screening patterns among individuals eligible for, but not enrolled in, a screening trial. PATIENTS AND METHODS:From February 2017 through February 2019, we enrolled subjects in a trial examining telephone-based navigation during low-dose computed tomography (LDCT) for lung cancer screening. We identified patients for whom LDCT was ordered and who were approached, but not enrolled, in the trial. We categorized nonenrollment as the patient had declined or could not be reached. We compared the characteristics and LDCT completion rates among these groups and the enrolled population using the 2-sample t test and χ test. RESULTS:Of 900 individuals approached for participation (mean age, 62 years; 45% women, 53% black), 447 were enrolled in the screening clinical trial. No significant demographic differences were found between the enrolled and nonenrolled cohorts. Of the 453 individuals not enrolled, 251 (55%) had declined participation and 202 (45%) could not be reached, despite up to 6 attempts. LDCT completion was significantly associated with enrollment status: 81% of enrolled individuals, 73% of individuals who declined participation, and 49% of those who could not be reached (P < .001). CONCLUSIONS:In the present single-center study, demographic factors did not predict for participation in a lung cancer screening trial. Lung cancer screening adherence rates were substantially lower for those not enrolled in a screening trial, especially for those who could not be contacted. These findings may inform the broader implementation of screening programs.
Racial disparities in bone metastasis patterns and targeted screening and treatment strategies in newly diagnosed lung cancer patients.
Xu Guijun,Cui Ping,Zhang Chao,Lin Feng,Xu Yao,Guo Xu,Cai Jun,Baklaushev Vladimir P,Peltzer Karl,Chekhonin Vladimir P,Wang Xin,Wang Guowen
Ethnicity & health
Race disparities exist in bone metastasis (BM) development and survival in lung cancer (LC) patients. The Surveillance, Epidemiology, and End Results (SEER) database was used to investigate different patterns of BM development and survival in different races. LC patients with BM were identified from the database from 2010 to 2014. Risk factors were investigated by univariable and multivariable logistic regression. Potential factors for prognosis were evaluated by univariable and multivariable Cox regression. Asian and Pacific Islander (API) patients presented the highest prevalence of BM (24.6%), followed by white (20.7%) and black patients (19.9%) (2 = 78.74; < .001). After adjusting for the demographic and clinical factors, API race was independently associated with a high risk of BM development. The median survival times for the API, white and black LC patients with BM were 16 months (95% CI: 15.2-16.8), 11 months (95% CI: 10.9-11.1) and 10 months (95% CI: 9.7-10.3), respectively, with significant differences ( < .001). Multivariable Cox regression showed that API race was positively associated with greater overall survival compared with white and black patients. Male gender, larger tumor size, lymph node involvement, lower tumor differentiated grade, and the presence of lung, liver and brain metastases were independently associated with a high risk of developing BM and worse survival with LC across all races. Age, income, insurance and histological types had different impacts on BM among different races. Homogeneous and heterogeneous associated factors for BM were revealed among different races. Individualized screening and treatment should be performed race-specifically.
Smoking pattern and risk of lung cancer among women participating in cancer screening programmes.
Martín-Sánchez Juan C,González-Marrón Adrián,Lidón-Moyano Cristina,Matilla-Santander Nuria,Fu Marcela,Vidal Carmen,Garcia Montse,Martinez-Sanchez Jose M
Journal of public health (Oxford, England)
OBJECTIVES:The aim of this study was to describe the smoking prevalence, the smoking pattern, and the risk of lung cancer among women who participated in a cancer screening (breast, cervical and colorectal) in Spain. METHODS:We used data from the Spanish National Health Survey of 2011-12, a cross-sectional study of the adult Spanish population from women in the age of participation in the population cancer screening. We used two definitions of the high risk of lung cancer according to the National Lung Screening Trial (NLST) criteria and the NELSON criteria. RESULTS:Participation in screening was 76.6% in breast cancer, 6.6% in colorectal cancer, and 70.3% in cervical cancer. The percentage of current smokers was 17.1 of women who participated breast cancer, 15.4 of women who participated colorectal cancer, and 26.1 of women who participated cervical cancer. According to NLST criteria, the percentage of current smokers women who had a high risk of lung cancer was 23.1 for breast cancer, 23.5 for colorectal cancer and 4.5 for cervical cancer. These figures were higher with the NELSON criteria. CONCLUSION:At least 250 000 women in Spain have a high risk of lung cancer and are participating in a cancer screening programme. These programmes might be an opportunity for implementing specific interventions aiming to reduce this risk.
Multidisciplinary approach to low-dose CT screening for lung cancer in a metropolitan community.
Shields Lisa B E,Wilkett Barnes Jessica G,Buckley Connie,Mikos George J,Rogers Katie N,Hamm John T,Flynn Joseph M,Hester Steven T,Honaker Joshua T
BACKGROUND:Lung cancer is the primary cause of cancer death in men and women in the USA, led by Kentucky. In 2015, the Centers for Medicare and Medicaid Services initiated annual lung cancer screening with a low-dose computed tomography (LDCT) scan. This observational cohort study evaluated the multidisciplinary approach to this screening in our metropolitan community. METHODS:We present the prospective findings of patients who underwent a screening lung LDCT scan over a 2-year period at our institution in Kentucky. Patients who fulfilled the screening criteria were identified during an office visit with their primary care provider. RESULTS:Of the 4170 patients who underwent a screening lung LDCT scan, a total of 838 (20.9%) patients had nodules >4 mm. Of the 70 patients diagnosed with lung cancer, Stage 1 non-small cell lung cancer was most commonly detected [38 cases (54.3%)]. A follow-up lung LDCT scan (n = 897), pulmonary function test (n = 157), positron emission tomography scan (n = 12) and a lung biopsy (n = 53) were performed for certain individuals who had anomalies observed on the screening lung LDCT scan. A total of 42% of patients enrolled in group tobacco cessation classes quit smoking. CONCLUSIONS:This study provides a unique perspective of a lung LDCT scan screening program driven by primary care providers in a state plagued by cigarette smoking and lung cancer deaths and offers a valuable message into the prevention, high-risk screening and diagnosis of lung cancer.
Use of Imaging and Diagnostic Procedures After Low-Dose CT Screening for Lung Cancer.
Nishi Shawn P E,Zhou Jie,Okereke Ikenna,Kuo Yong-Fang,Goodwin James
BACKGROUND:Clinical trials have demonstrated a mortality benefit from lung cancer screening by low-dose CT (LDCT) in current or past tobacco smokers who meet criteria. Potential harms of screening mostly relate to downstream evaluation of abnormal screens. Few data exist on the rates outside of clinical trials of imaging and diagnostic procedures following screening LDCT. We describe rates in the community setting of follow-up imaging and diagnostic procedures after screening LDCT. METHODS:We used Clinformatics Data Mart national database to identify enrollees age 55 to 80 year who underwent screening LDCT from January 1, 2016, to December 31, 2016. We assessed rates of follow-up imaging (diagnostic chest CT scan, MRI, and PET) and follow-up procedures (bronchoscopy, percutaneous biopsy, thoracotomy, mediastinoscopy, and thoracoscopy) in the 12 months following LDCT for lung cancer screening. We also assessed these rates in an age-, sex-, and number of comorbidities-matched population that did not undergo LDCT to estimate rates unrelated to the screening LDCT. We then reported the adjusted rate of follow-up testing as the observed rate in the screening LDCT population minus the rate in the non-LDCT population. RESULTS:Among 11,520 enrollees aged 55 to 80 years who underwent LDCT in 2016, the adjusted rates of follow up 12 months after LDCT examinations were low (17.7% for imaging and 3.1% for procedures). Among procedures, the adjusted rates were 2.0% for bronchoscopy, 1.3% for percutaneous biopsy, 0.9% for thoracoscopy, 0.2% for mediastinoscopy, and 0.4% for thoracotomy. Adjusted rates of follow-up procedures were higher in enrollees undergoing an initial screening LDCT (3.3%) than in those after a second screening examination (2.2%). CONCLUSIONS:In general, imaging and rates of procedures after screening LDCT was low in this commercially insured population.
What Exactly Is Shared Decision-Making? A Qualitative Study of Shared Decision-Making in Lung Cancer Screening.
Melzer Anne C,Golden Sara E,Ono Sarah S,Datta Santanu,Crothers Kristina,Slatore Christopher G
Journal of general internal medicine
BACKGROUND:Shared decision-making (SDM) is widely recommended and required by the Centers for Medicare and Medicaid for patients considering lung cancer screening (LCS). OBJECTIVE:We examined clinicians' communication practices and perceived barriers of SDM for LCS at three medical centers with established screening programs. DESIGN:Multicenter qualitative study of clinicians participating in LCS. APPROACH:We performed semi-structured interviews, which were transcribed and analyzed using directed content analysis, guided by a theoretical model of patient-clinician communication. PARTICIPANTS:We interviewed 24 clinicians including LCS coordinators (2), pulmonologists (3), and primary care providers (17), 4 of whom worked for the LCS program, a thoracic surgeon, and a radiologist. RESULTS:All clinicians agreed with the goal of SDM, to ensure the screening decision was congruent with the patient's values. The depth and type of information presented by each clinician role varied considerably. LCS coordinators presented detailed information including numeric estimates of benefit and harm. Most PCPs explained the process more generally, focusing on logistics and the high rate of nodule detection. No clinician explicitly elicited values or communication preferences. Many PCPs tailored the conversation based on their implicit understanding of patients' values and preferences, gained from past experiences. PCPs reported that time, lack of detailed personal knowledge of LCS, and patient preferences were barriers to SDM. Many clinicians perceived that a significant proportion of patients were not interested in specific percentages and preferred to receive a clinician recommendation. CONCLUSIONS:Our results suggest that clinicians support the goal of SDM for LCS decisions but PCPs may not perform some of its elements. The lack of completion of some elements, such as PCPs' lack of in-depth information exchange, may reflect perceived patient preferences for communication. As LCS is implemented, further research is needed to support a personalized, patient-centered approach to produce better outcomes.
Evaluating Lung Cancer Screening Across Diverse Healthcare Systems: A Process Model from the Lung PROSPR Consortium.
Rendle Katharine A,Burnett-Hartman Andrea N,Neslund-Dudas Christine,Greenlee Robert T,Honda Stacey,Elston Lafata Jennifer,Marcus Pamela M,Cooley Mary E,Vachani Anil,Meza Rafael,Oshiro Caryn,Simoff Michael J,Schnall Mitchell D,Beaber Elisabeth F,Doria-Rose V Paul,Doubeni Chyke A,Ritzwoller Debra P
Cancer prevention research (Philadelphia, Pa.)
Numerous organizations, including the United States Preventive Services Task Force, recommend annual lung cancer screening (LCS) with low-dose CT for high risk adults who meet specific criteria. Despite recommendations and national coverage for screening eligible adults through the Centers for Medicare and Medicaid Services, LCS uptake in the United States remains low (<4%). In recognition of the need to improve and understand LCS across the population, as part of the larger Population-based Research to Optimize the Screening PRocess (PROSPR) consortium, the NCI (Bethesda, MD) funded the Lung PROSPR Research Consortium consisting of five diverse healthcare systems in Colorado, Hawaii, Michigan, Pennsylvania, and Wisconsin. Using various methods and data sources, the center aims to examine utilization and outcomes of LCS across diverse populations, and assess how variations in the implementation of LCS programs shape outcomes across the screening process. This commentary presents the PROSPR LCS process model, which outlines the interrelated steps needed to complete the screening process from risk assessment to treatment. In addition to guiding planned projects within the Lung PROSPR Research Consortium, this model provides insights on the complex steps needed to implement, evaluate, and improve LCS outcomes in community practice.
The preventive role of cardiorespiratory fitness in current male smokers who meet the American Cancer Society criteria for lung cancer screening: a prospective pilot study.
Vainshelboim Baruch,Myers Jonathan
Cancer causes & control : CCC
PURPOSE:Survival benefits could be potentially improved by adding cardiorespiratory fitness (CRF) to lung cancer screening. The current pilot study aimed to assess the association between CRF and adverse outcomes in current male smokers who are meeting the American Cancer Society (ACS) criteria for lung cancer screening. METHODS:A total of 260 men with a baseline CRF assessment (treadmill exercise test) who are met the ACS lung cancer screening criteria ("current smokers aged 55-74 years with ≥ 30 pack/years smoking history") were prospectively studied. Cox proportional hazard models were analyzed for all-cause and cancer mortality, total and lung cancer incidence. RESULTS:Mean age was 63.3 ± 5.4 years, smoking history 50.4 ± 26.7 pack/years, and CRF was 7.8 ± 3.2 metabolic equivalents (METs). During a mean of 10.2 ± 6.1 years follow-up, 80 participants developed any type of cancer, 19 were diagnosed with lung cancer and 66 died (cancer, n = 39, other causes, n = 27). In multivariable models, only CRF was associated with all-cause and cancer mortality. Each 1-MET higher CRF was associated with a 10% reduced risk for all-cause mortality [0.9, 95% CI (0.83 to 0.98), p = 0.017] and cancer mortality [0.9, 95% CI (0.8 to 0.99), p = 0.048]. CRF was not associated with total cancer incidence (p = 0.59) or lung cancer incidence (p = 0.96). CONCLUSION:Higher CRF is independently associated with lower risk of all-cause and cancer mortality in current male smokers who meet the ACS criteria for lung cancer screening. Screening for CRF and achieving higher CRF levels could potentially reduce mortality and serve as complementary preventive strategy in heavy smokers.
Prognostic effect of implementation of the mass low-dose computed tomography lung cancer screening program: a hospital-based cohort study.
Wu Fu-Zong,Huang Yi-Luan,Wu Yun-Ju,Tang En-Kuei,Wu Ming-Ting,Chen Chi-Shen,Lin Yun-Pei
European journal of cancer prevention : the official journal of the European Cancer Prevention Organisation (ECP)
Low-dose computed tomography lung cancer screening aims to detect early-stage lung cancers in order to decrease the incidence of advanced-stage lung cancers and to reduce lung cancer mortality. We analyzed the time trends of lung cancer stage distribution and mortality rates after the gradual implementation of the low-dose computed tomography lung cancer screening in a hospital-based cohort. Using the hospital-based cancer registry data on lung cancer number and death from 2007 to 2014, we aim to evaluate the trends in stage distribution and mortality rate after the gradual implementation of low-dose computed tomography lung cancer screening program over recent years. From 2007 to 2014, overall 2542 cases of lung cancers were diagnosed according to hospital-based cancer registry. For the 1-year mortality rate, the mortality rate decreased gradually from 48.16 to 37.04% between 2007 and 2014. For the 5-year mortality rate, the mortality rate decreased gradually from 88.49 to 69.44% between 2007 and 2014. There was a gradual decrease in stage IV lung cancer with the corresponding sharp increase in stage I early lung cancer after following the implementation of the large volume of the low-dose computed tomography examination between the years 2011 and 2014. In conclusion, these results suggest that the gradual implementation of low-dose computed tomography lung screening program could lead to a remarkable decrease in lung cancer mortality and a remarkable stage shift in the trend over time in this hospital-based cohort.
Disparities of National Lung Cancer Screening Guidelines in the US Population.
Han Summer S,Chow Eric,Ten Haaf Kevin,Toumazis Iakovos,Cao Pianpian,Bastani Mehrad,Tammemagi Martin,Jeon Jihyoun,Feuer Eric J,Meza Rafael,Plevritis Sylvia K
Journal of the National Cancer Institute
BACKGROUND:Current US Preventive Services Task Force (USPSTF) lung cancer screening guidelines are based on smoking history and age (55-80 years). These guidelines may miss those at higher risk, even at lower exposures of smoking or younger ages, because of other risk factors such as race, family history, or comorbidity. In this study, we characterized the demographic and clinical profiles of those selected by risk-based screening criteria but were missed by USPSTF guidelines in younger (50-54 years) and older (71-80 years) age groups. METHODS:We used data from the National Health Interview Survey, the CISNET Smoking History Generator, and results of logistic prediction models to simulate lifetime lung cancer risk-factor data for 100 000 individuals in the 1950-1960 birth cohorts. We calculated age-specific 6-year lung cancer risk for each individual from ages 50 to 90 years using the PLCOm2012 model and evaluated age-specific screening eligibility by USPSTF guidelines and by risk-based criteria (varying thresholds between 1.3% and 2.5%). RESULTS:In the 1950 birth cohort, 5.4% would have been ineligible for screening by USPSTF criteria in their younger ages but eligible based on risk-based criteria. Similarly, 10.4% of the cohort would be ineligible for screening by USPSTF in older ages. Notably, high proportions of blacks were ineligible for screening by USPSTF criteria at younger (15.6%) and older (14.2%) ages, which were statistically significantly greater than those of whites (4.8% and 10.8%, respectively; P < .001). Similar results were observed with other risk thresholds and for the 1960 cohort. CONCLUSIONS:Further consideration is needed to incorporate comprehensive risk factors, including race and ethnicity, into lung cancer screening to reduce potential racial disparities.
ESR/ERS statement paper on lung cancer screening.
Kauczor Hans-Ulrich,Baird Anne-Marie,Blum Torsten Gerriet,Bonomo Lorenzo,Bostantzoglou Clementine,Burghuber Otto,Čepická Blanka,Comanescu Alina,Couraud Sébastien,Devaraj Anand,Jespersen Vagn,Morozov Sergey,Nardi Agmon Inbar,Peled Nir,Powell Pippa,Prosch Helmut,Ravara Sofia,Rawlinson Janette,Revel Marie-Pierre,Silva Mario,Snoeckx Annemiek,van Ginneken Bram,van Meerbeeck Jan P,Vardavas Constantine,von Stackelberg Oyunbileg,Gaga Mina,
The European respiratory journal
In Europe, lung cancer ranks third among the most common cancers, remaining the biggest killer. Since the publication of the first European Society of Radiology and European Respiratory Society joint white paper on lung cancer screening (LCS) in 2015, many new findings have been published and discussions have increased considerably. Thus, this updated expert opinion represents a narrative, non-systematic review of the evidence from LCS trials and description of the current practice of LCS as well as aspects that have not received adequate attention until now. Reaching out to the potential participants (persons at high risk), optimal communication and shared decision-making will be key starting points. Furthermore, standards for infrastructure, pathways and quality assurance are pivotal, including promoting tobacco cessation, benefits and harms, overdiagnosis, quality, minimum radiation exposure, definition of management of positive screen results and incidental findings linked to respective actions as well as cost-effectiveness. This requires a multidisciplinary team with experts from pulmonology and radiology as well as thoracic oncologists, thoracic surgeons, pathologists, family doctors, patient representatives and others. The ESR and ERS agree that Europe's health systems need to adapt to allow citizens to benefit from organised pathways, rather than unsupervised initiatives, to allow early diagnosis of lung cancer and reduce the mortality rate. Now is the time to set up and conduct demonstration programmes focusing, among other points, on methodology, standardisation, tobacco cessation, education on healthy lifestyle, cost-effectiveness and a central registry.
Total Antioxidant Capacity and Pancreatic Cancer Incidence and Mortality in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial.
Zhong Guo-Chao,Pu Jian-Yuan,Wu Yi-Lin,Yi Zhu-Jun,Wan Lun,Wang Kang,Hao Fa-Bao,Zhao Yong,Gong Jian-Ping
Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology
BACKGROUND:Total antioxidant capacity (TAC) reflects an individual's overall antioxidant intake. We sought to clarify whether higher TAC is associated with lower risks of pancreatic cancer incidence and mortality in the U.S. general population. METHODS:A total of 96,018 American adults were identified from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. A ferric-reducing ability of plasma score was used to reflect an individual's TAC intake from diet and/or supplements. Cox regression was used to calculate hazard ratios (HR) for pancreatic cancer incidence, and competing risk regression was used to calculate subdistribution HRs for pancreatic cancer mortality. Restricted cubic spline regression was used to test nonlinearity. RESULTS:A total of 393 pancreatic cancer cases and 353 pancreatic cancer-related deaths were documented. Total (diet + supplements) TAC was found to be inversely associated with pancreatic cancer incidence (HR = 0.53; 95% confidence interval, 0.39-0.72; = 0.0002) and mortality (subdistribution HR = 0.52; 95% confidence interval 0.38-0.72; = 0.0003) in a nonlinear dose-response manner (all < 0.01). Similar results were observed for dietary TAC. No association of supplemental TAC with pancreatic cancer incidence and mortality was found. CONCLUSIONS:In the U.S. general population, dietary but not supplemental TAC level is inversely associated with risks of pancreatic cancer incidence and mortality in a nonlinear dose-response pattern. IMPACT:This is the first prospective study indicating that a diet rich in antioxidants may be beneficial in decreasing pancreatic cancer incidence and mortality.
Automatic opportunistic osteoporosis screening using low-dose chest computed tomography scans obtained for lung cancer screening.
Pan Yaling,Shi Dejun,Wang Hanqi,Chen Tongtong,Cui Deqi,Cheng Xiaoguang,Lu Yong
OBJECTIVE:Osteoporosis is a prevalent and treatable condition, but it remains underdiagnosed. In this study, a deep learning-based system was developed to automatically measure bone mineral density (BMD) for opportunistic osteoporosis screening using low-dose chest computed tomography (LDCT) scans obtained for lung cancer screening. METHODS:First, a deep learning model was trained and tested with 200 annotated LDCT scans to segment and label all vertebral bodies (VBs). Then, the mean CT numbers of the trabecular area of target VBs were obtained based on the segmentation mask through geometric operations. Finally, a linear function was built to map the trabecular CT numbers of target VBs to their BMDs collected from approved software used for osteoporosis diagnosis. The diagnostic performance of the developed system was evaluated using an independent dataset of 374 LDCT scans with standard BMDs and osteoporosis diagnosis. RESULTS:Our deep learning model achieved a mean Dice coefficient of 86.6% for VB segmentation and 97.5% accuracy for VB labeling. Line regression and Bland-Altman analyses showed good agreement between the predicted BMD and the ground truth, with correlation coefficients of 0.964-0.968 and mean errors of 2.2-4.0 mg/cm. The area under the curve (AUC) was 0.927 for detecting osteoporosis and 0.942 for distinguishing low BMD. CONCLUSION:The proposed deep learning-based system demonstrated the potential to automatically perform opportunistic osteoporosis screening using LDCT scans obtained for lung cancer screening. KEY POINTS:• Osteoporosis is a prevalent but underdiagnosed condition that can increase the risk of fracture. • A deep learning-based system was developed to fully automate bone mineral density measurement in low-dose chest computed tomography scans. • The developed system achieved high accuracy for automatic opportunistic osteoporosis screening using low-dose chest computed tomography scans obtained for lung cancer screening.
Did psychosocial status, sociodemographics and smoking status affect non-attendance in control participants in the Danish Lung Cancer Screening Trial? A nested observational study.
Malmqvist Jessica,Siersma Volkert,Thorsen Hanne,Heleno Bruno,Rasmussen Jakob Fraes,Brodersen John
OBJECTIVES:We investigated if psychosocial status, sociodemographics and smoking status affected non-attendance in the control group in the randomised Danish Lung Cancer Screening Trial (DLCST). DESIGN AND SETTING:This study was an observational study nested in the DLCST. Due to large non-attendance in the control group in the second screening round we made an additional effort to collect questionnaire data from non-attenders in this group in the third screening round. We used a condition-specific questionnaire to assess psychosocial status. We analysed the differences in psychosocial status in the third and preceding rounds between non-attenders and attenders in the control group in multivariable linear regression models adjusted for sociodemographics and smoking status reported at baseline. Differences in sociodemographics and smoking status were analysed with χ tests (categorical variables) and t-tests (continuous variables). PRIMARY OUTCOME MEASURE:Primary outcome was psychosocial status. PARTICIPANTS:All control persons participating in the third screening round in the DLCST were included. RESULTS:Non-attenders in the third round had significantly worse psychosocial status than attenders in the scales: 'behaviour' 0.77 (99% CI 0.18 to 1.36), 'self-blame' 0.59 (99% CI 0.14 to 1.04), 'focus on airway symptoms' 0.22 (99% CI 0.08 to 0.36), 'stigmatisation' 0.51 (99% CI 0.16 to 0.86), 'introvert' 0.56 (99% CI 0.23 to 0.89) and 'harms of smoking' 0.35 (99% CI 0.11 to 0.59). Moreover, non-attenders had worse scores than attendees in the preceding screening rounds. Non-attenders also reported worse sociodemographics at baseline. CONCLUSIONS:Non-attenders had a significantly worse psychosocial status and worse sociodemographics compared with attenders. The results of our study contribute with evidence of non-response and attrition driven by psychosocial status, which in turn may be influenced by the screening intervention itself. This can be used to adjust cancer screening trial results for bias due to differential non-attendance. TRIAL REGISTRATION NUMBER:Clinicaltrials.gov Protocol Registration System (NCT00496977).
The OaSiS trial: A hybrid type II, national cluster randomized trial to implement smoking cessation during CT screening for lung cancer.
Foley Kristie Long,Miller David P,Weaver Kathryn,Sutfin Erin L,Petty W Jeffrey,Bellinger Christina,Spangler John,Stone Rebecca J,Lawler Donna,Davis Whitney,Dressler Emily,Lesser Glenn,Chiles Caroline
Contemporary clinical trials
INTRODUCTION:When the Centers for Medicare and Medicaid Services announced coverage for low dose CT lung cancer screening, they also mandated that imaging centers offer smoking cessation services. We designed the Optimizing Lung Screening (OaSiS) trial to evaluate strategies to implement the Public Health Service Guidelines for Treating Tobacco Use and Dependence during CT screening for lung cancer. METHODS AND DESIGN:OaSiS was implemented using a pragmatic effectiveness-implementation hybrid design in 26 imaging clinics across the United States affiliated with the National Cancer Institute's National Community Oncology Research Program (NCORP). The 26 sites selected for participation in the OaSiS trial were randomized to receive either a compendium of implementation strategies to add or enhance smoking cessation services during lung screening or to usual care. Usual care sites were given the option to receive the full compendium of implementation strategies at the conclusion of data collection. We have evaluated both the effectiveness of the implementation strategies to improve smoking cessation at six months among patients undergoing LDCT screening as well as the adoption and sustainability of evidence-based tobacco cessation strategies in imaging clinics. DISCUSSION:The OaSiS trial was designed to identify opportunities for implementing evidence-based smoking cessation into LDCT lung cancer screening imaging facilities and to establish the effectiveness of these services. We report our study design and evaluation, including strengths of the pragmatic design and the inclusion of a diverse range of screening programs. Establishing these tobacco cessation services will be critical to reducing smoking related morbidity and mortality.
Screening for Lung Cancer - 10 States, 2017.
Richards Thomas B,Soman Ashwini,Thomas Cheryll C,VanFrank Brenna,Henley S Jane,Gallaway M Shayne,Richardson Lisa C
MMWR. Morbidity and mortality weekly report
Lung cancer is the leading cause of cancer death in the United States; 148,869 lung cancer-associated deaths occurred in 2016 (1). Mortality might be reduced by identifying lung cancer at an early stage when treatment can be more effective (2). In 2013, the U.S. Preventive Services Task Force (USPSTF) recommended annual screening for lung cancer with low-dose computed tomography (CT) for adults aged 55-80 years who have a 30 pack-year* smoking history and currently smoke or have quit within the past 15 years (2). This was a Grade B recommendation, which required health insurance plans to cover lung cancer screening as a preventive service. To assess the prevalence of lung cancer screening by state, CDC used Behavioral Risk Factor Surveillance System (BRFSS) data collected in 2017 by 10 states.** Overall, 12.7% adults aged 55-80 years met the USPSTF criteria for lung cancer screening. Among those meeting USPSTF criteria, 12.5% reported they had received a CT scan to check for lung cancer in the last 12 months. Efforts to educate health care providers and provide decision support tools might increase recommended lung cancer screening.
New evidence supporting lung cancer screening with low dose CT & surgical implications.
Dezube Aaron R,Jaklitsch Michael T
European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology
INTRODUCTION:Lung cancer is the leading cause of cancer-death worldwide. The U.S. Preventative Services Task Force (USPTSF) approved screening for current or former smokers aged 55-80 based on the results of the National Lung Screening trial (NLST). Following the NLST, new evidence has emerged from clinical trials and updates to previous trials prior to the anticipated update to the USPSTF guideline. We review the new evidence on lung cancer screening with low dose computed tomography (LDCT) and the surgical implications. METHODS:A review of new literature was performed pertaining to lung cancer screening since implementation of UPSTF guidelines. Articles for inclusion were identified by both authors', then search of the Pubmed and Cochrane database was performed from January 1st, 2013 through February 4th, 2020 using the MeSH search terms: "lung cancer"; "screening"; "low dose CT". The results of these studies are summarized. RESULTS:We identified multiple prospective randomized control trials and meta-analysis since the NLST supporting lung cancer-specific mortality with screening. We identified new nodule classification systems and the development of risk-models which may reduce false positive rates and identify high risk patients not currently eligible for screening. Finally, we discussed the surgical implications of screening. CONCLUSION:New data supports NLST findings and show ongoing benefit to LDCT for lung cancer screening. Standardized LDCT screening classification has been shown to reduce harm and lower false positive rates. Further study is needed regarding use of risk-modeling. Screening will require an increase in the thoracic workforce to accommodate the amount of surgically operable cancers.
Current State of Shared Decision-Making for CT Lung Cancer Screening and Improvement Strategies.
Hill Paul Armstrong
Journal of patient experience
Introduction:Lung cancer remains the leading cause of oncologic mortality in the United States. Computed tomography (CT) screening has begun to combat this prevalent health problem. Prior to enrollment, a shared decision-making conversation is required to ensure a patient preference decision. This is the first and only imaging study to hold this requirement and compliance has been suspected to be low, but there is limited literature proving this. Methods:At a single academic institution, 30 patients who declined and 38 patients who enrolled in CT lung cancer screening were interviewed about their shared decision-making provider conversation. All referring providers were surveyed regarding their methods of shared decision-making for CT lung cancer screening. Clinical notes were evaluated 9 months prior to 2 interventions and 6 months following the first intervention to improve clinical documentation. Results:85% to 89% of the interviewed patients could not recall a decision aid used during the shared decision-making conversation. Zero percent of clinical notes met the Centers for Medicare/Medicaid Services (CMS) encounter requirements for shared decision-making despite interventions to improve knowledge and ease accessibility to decision aids and documentation templates. Discussion:Lack of compliance with CMS requirements has a low patient decision satisfaction. This also places the institution at risk for financial repercussions of reimbursement which may jeopardize the longevity of screening programs. Development of strategies to improve the patient experience and provider facilitation are nascent and require a dedicated leadership team with carefully constructed electronic health record support.
[Analysis of the efficacy of lung cancer screening in urban areas of Henan Province by low-dose computed tomography from 2013 to 2017].
Guo L W,Liu S Z,Zhang S K,Yang F N,Wu Y,Zheng L Y,Chen Q,Cao X Q,Sun X B
Zhonghua zhong liu za zhi [Chinese journal of oncology]
To evaluate the efficacy of lung cancer screening in urban areas of Henan province by low-dose computed tomography (LDCT) from 2013 to 2017. A cluster sampling method was used to select the residents of 40-74 years old in Henan province to investigate the risk factors and conduct lung cancer risk assessment. Subjects with high risk of lung cancer received LDCT for screening. A total of 179 002 residents completed the lung cancer risk assessment, and 35 672 subjects were identified as high risk of lung cancer, with a high risk rate of 19.93%. A total of 13 383 subjects with high risk received LDCT, and the screening rate was 37.52%. There were 786 cases diagnosed as positive nodules, and the detection rate was 5.87%. Among them, 755 cases of solid/partial solid nodule were ≥5 mm, 23 cases of non-solid nodules were ≥8 mm, 8 cases were intratracheal nodules, and 115 cases were diagnosed as suspicious lung cancer. The detection rate in males was 6.74%, which was higher than 5.02% in females. The detection rate was positively related with age (<0.05). The application of LDCT is a useful screening method which can elevate the early detection rate of positive nodules and other related diseases in lungs. In the future, males and older populations should be paid more attention to improve screening efficacy.
Potential Impact of Cessation Interventions at the Point of Lung Cancer Screening on Lung Cancer and Overall Mortality in the United States.
Cao Pianpian,Jeon Jihyoun,Levy David T,Jayasekera Jinani C,Cadham Christopher J,Mandelblatt Jeanne S,Taylor Kathryn L,Meza Rafael
Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer
INTRODUCTION:Annual lung cancer screening with low-dose computed tomography is recommended for adults aged 55 to 80 years with a greater than or equal to 30 pack-year smoking history who currently smoke or quit within the past 15 years. The 50% who are current smokers should be offered cessation interventions, but information about the impact of adding cessation to screening is limited. METHODS:We used an established lung cancer simulation model to compare the effects on mortality of a hypothetical one-time cessation intervention and annual screening versus annual screening only among screen-eligible individuals born in 1950 or 1960. Model inputs were derived from national data and included smoking history, probability of quitting with and without intervention, lung cancer risk and treatment effectiveness, and competing tobacco-related mortality. We tested the sensitivity of results under different assumptions about screening use and cessation efficacy. RESULTS:Smoking cessation reduces lung cancer mortality and delays overall deaths versus screening only across all assumptions. For example, if screening was used by 30% of screen-eligible individuals born in 1950, adding an intervention with a 10% quit probability reduces lung cancer deaths by 14% and increases life years gained by 81% compared with screening alone. The magnitude of cessation benefits varied under screening uptake rates, cessation effectiveness, and birth cohort. CONCLUSIONS:Smoking cessation interventions have the potential to greatly enhance the impact of lung cancer screening programs. Evaluation of specific interventions, including costs and feasibility of implementation and dissemination, is needed to determine the best possible strategies and realize the full promise of lung cancer screening.
Low-dose CT lung cancer screening in never-smokers and smokers: results of an eight-year observational study.
Kakinuma Ryutaro,Muramatsu Yukio,Asamura Hisao,Watanabe Shun-Ichi,Kusumoto Masahiko,Tsuchida Takaaki,Kaneko Masahiro,Tsuta Koji,Maeshima Akiko Miyagi,Ishii Genichiro,Nagai Kanji,Yamaji Taiki,Matsuda Takahisa,Moriyama Noriyuki
Translational lung cancer research
Background:This was an observational study of Japanese participants who underwent low-dose computed tomographic (LDCT) lung cancer screening between February 2004 and March 2012, to evaluate the lung cancers in never-smokers and smokers. Methods:The study population consisted of a total of 12,114 subjects [never-smokers, 6,021 (49.70%); smokers with <30 pack-years of smoking, 3,785 (31.24%); smokers with ≥30 pack-years of smoking, 2,305 (19.03%); unknown smoking status, 3 (0.02%)]. The odds ratio (OR) of lung cancer detection according to the smoking status adjusted for age and gender was evaluated. Results:A total of 152 lung cancers were diagnosed in 133 patients [never-smokers, 66 (49.6%); smokers with <30 pack-years of smoking, 31 (23.3%); smokers with ≥30 pack-years of smoking, 36 (27.1%)]; therefore, 72.9% of lung cancer patients did not meet the National Lung Screening Trial (NLST) criterion of smokers with ≥30 pack-years of smoking. The OR of lung cancer detection in smokers with ≥30 pack-years of smoking was higher than that in the never-smokers (OR =1.71, 95% CI: 1.04-2.82, P=0.03) and that in smokers with <30 pack-years of smoking (OR =1.71, 95% CI: 1.04-2.80, P=0.03), while the OR of lung cancer detection in smokers with <30 pack-years of smoking was the same as that in the never-smokers (OR =1.00, 95% CI: 0.62-1.61, P=0.99). Conclusions:Although the OR of lung cancer detection in smokers with ≥30 pack-years of smoking was higher than that in the never-smokers and smokers with <30 pack-years of smoking, approximately 70% of lung cancer patients might be missed if we only adopted the NLST criterion of smokers with ≥30 pack-years of smoking. Therefore, never-smokers and smokers with <30 pack-years of smoking should be included in the target population for LDCT lung cancer screening in Japan.
Favorable incremental cost-effectiveness ratio for lung cancer screening in Italy.
Veronesi Giulia,Navone Niccolò,Novellis Pierluigi,Dieci Elisa,Toschi Luca,Velutti Laura,Solinas Michela,Vanni Elena,Alloisio Marco,Ghislandi Simone
Lung cancer (Amsterdam, Netherlands)
OBJECTIVES:Lung cancer detection by low-dose computed tomographic screening reduces mortality. However, it is essential to assess cost-effectiveness. We present a cost-effectiveness analysis of screening in Italians at high risk of lung cancer, from the point of view of the Italian tax-payer. MATERIALS AND METHODS:We used a decision model to estimate the cost-effectiveness of annual screening for 5 years in smokers (≥30 pack-years) of 55-79 years. Patients diagnosed in the COSMOS study were the screening arm; patients diagnosed and treated for lung cancer in the Lombardy Region, Italy, constituted the usual care arm. Treatment costs were extracted from our hospital database. Lung cancer survival in screened patients was adjusted for 2-year lead-time bias. Life-years and quality-adjusted life-years were estimated by stage at diagnosis, from which incremental cost-effectiveness ratios per life-year and quality-adjusted life-year gained were estimated. RESULTS:Base-case incremental cost-effectiveness ratios were 3297 and 2944 euro per quality-adjusted life-year and life-year gained, respectively. Deterministic sensitivity analysis indicated that these values were particularly sensitive to lung cancer prevalence, screening sensitivity and specificity, screening cost, and treatment costs for stage I and IV disease. From the probabilistic sensitivity analysis incremental cost-effectiveness ratios had a 98 % probability of being <25,000 euro (widely-accepted threshold) and a 55 % probability of being <5000 euro. CONCLUSIONS:Low-dose computed tomographic screening is associated with an incremental cost of 2944 euro per life-year gained in high risk population, implying that screening can be introduced in Italy at contained cost, saving the lives of many lung cancer patients.
Prognostic value of two geriatric screening tools in a cohort of older patients with early stage Non-Small Cell Lung Cancer treated with hypofractionated stereotactic radiotherapy.
Cuccia Francesco,Mortellaro Gianluca,Mazzola Rosario,Donofrio Alessandra,Valenti Vito,Tripoli Antonella,Matranga Domenica,Lo Casto Antonio,Failla Giuseppe,Di Miceli Giuseppe,Ferrera Giuseppe
Journal of geriatric oncology
OBJECTIVES:To investigate whether assessment with two geriatric screening tools shows a correlation with clinical outcomes of patients aged 65 years or more, with early-stage Non-Small Cell Lung Cancer (es-NSCLC) treated with hypofractionated stereotactic radiotherapy. METHODS:From March 2014 to June 2018 we retrospectively evaluated 42 patients with stage I and II lung tumors. Patients were assessed with Charlson Comorbidity Index (CCI) and G8 screening tool. Median age was 74 years (range, 65-91). Stereotactic radiotherapy was performed with Helical Tomotherapy delivering 50-70 Gray (Gy) in 8-10 fractions. Toxicity was evaluated using Common Terminology Criteria for Adverse Events v4.0 criteria. RESULTS:Median CCI and G8 scores were 6 (4-11) and 14 (12-17), respectively. With a median follow-up of 14 months (3-37), we observed: 3 cases of acute Grade 2 (G2) radiation pneumonitis, 1 late G2 non-cardiac chest pain, 1 late G2 dysphagia and 1 case of late G2 radiation pneumonitis. At statistical analysis, G8 scores ≤14 were significantly associated with late toxicity rates (p = .0073). Local failure was predictive of disease free survival and Overall Survival (p < .001 and p = .001). Death occurred in 12 patients, 6 for non-cancer related causes, with 1- and 2-yrs cancer specific survival rates of 94.8% and 90%, 1- and 2-yrs OS rates of 93% and 80%, respectively. CONCLUSIONS:Our experience shows a correlation between G8 scores and late toxicity in older patients treated with stereotactic radiotherapy for lung cancer, suggesting the need for prospective studies evaluating its use for the identification of patients at higher risk of adverse events.
Lung cancer mortality reduction by LDCT screening-Results from the randomized German LUSI trial.
Becker Nikolaus,Motsch Erna,Trotter Anke,Heussel Claus P,Dienemann Hendrik,Schnabel Philipp A,Kauczor Hans-Ulrich,Maldonado Sandra González,Miller Anthony B,Kaaks Rudolf,Delorme Stefan
International journal of cancer
In 2011, the U.S. National Lung Cancer Screening Trial (NLST) reported a 20% reduction of lung cancer mortality after regular screening by low-dose computed tomography (LDCT), as compared to X-ray screening. The introduction of lung cancer screening programs in Europe awaits confirmation of these first findings from European trials that started in parallel with the NLST. The German Lung cancer Screening Intervention (LUSI) is a randomized trial among 4,052 long-term smokers, 50-69 years of age, recruited from the general population, comparing five annual rounds of LDCT screening (screening arm; n = 2,029 participants) with a control arm (n = 2,023) followed by annual postal questionnaire inquiries. Data on lung cancer incidence and mortality and vital status were collected from hospitals or office-based physicians, cancer registries, population registers and health offices. Over an average observation time of 8.8 years after randomization, the hazard ratio for lung cancer mortality was 0.74 (95% CI: 0.46-1.19; p = 0.21) among men and women combined. Modeling by sex, however showed a statistically significant reduction in lung cancer mortality among women (HR = 0.31 [95% CI: 0.10-0.96], p = 0.04), but not among men (HR = 0.94 [95% CI: 0.54-1.61], p = 0.81) screened by LDCT (p = 0.09). Findings from LUSI are in line with those from other trials, including NLST, that suggest a stronger reduction of lung cancer mortality after LDCT screening among women as compared to men. This heterogeneity could be the result of different relative counts of lung tumor subtypes occurring in men and women.
Potential lung cancer screening outcomes using different age and smoking thresholds in the ANRS-CO4 French Hospital Database on HIV cohort.
Makinson A,Tron L,Grabar S,Milleron B,Reynes J,Le Moing V,Morquin D,Lert F,Costagliola D,Guiguet M
OBJECTIVES:In most lung screening programmes, only subjects ≥ 55 years old and smoking ≥ 30 pack-years are eligible to undergo chest low-dose computed tomography. Whether the same criteria should apply to people living with HIV (PLHIV) is uncertain, given the increased lung cancer risks associated with immunodeficiency and high rates of smoking. We assessed different outcomes obtained from simulating one round of lung cancer screening in PLHIV using different age and smoking thresholds for eligibility. METHODS:Data from the French Agence Nationale de Recherche sur le SIDA et les Hépatites Virales (ANRS)-CO4 French Hospital Database on HIV (FHDH) cohort of PLHIV and a national representative survey of PLHIV in care in 2011 (the ANRS-VESPA2 [enquête sur les personnes atteintes] study) were used to estimate the maximum proportion of incident lung cancers occurring between 2012 and 2016 that would have potentially been detected by screening in 2011. Secondary outcomes were numbers of eligible subjects in the cohort and numbers of subjects needed to screen (NNS) to detect one lung cancer. RESULTS:Among 77819 PLHIV in 2011 (median age 46 years; 66% men), 285 subjects subsequently developed lung cancer. Adoption of the US Preventive Services Task Force (USPSTF) recommendations (55-80 years; ≥ 30 pack-years) would have detected 31% of lung cancers at most. Lowering the minimum age to 50 and 45 years would have detected 49% and 60% of cancers, respectively, but would have greatly increased the number of eligible subjects and the NNS to detect one case of lung cancer. CONCLUSIONS:Use of the USPSTF criteria would have detected only a minority of lung cancers in a large French cohort of PLHIV in 2011. Screening PLHIV at younger ages (45 or 50 years) and/or the use of lower smoking thresholds (20 pack-years) may be beneficial, despite the consequently higher numbers of eligible subjects and NNS to detect one case of lung cancer, and should be evaluated in future studies.
Cost-effectiveness of lung MRI in lung cancer screening.
Allen Bradley D,Schiebler Mark L,Sommer Gregor,Kauczor Hans-Ulrich,Biederer Juergen,Kruser Timothy J,Carr James C,Hazen Gordon
OBJECTIVES:Recent studies with lung MRI (MRI) have shown high sensitivity (Sn) and specificity (Sp) for lung nodule detection and characterization relative to low-dose CT (LDCT). Using this background data, we sought to compare the potential screening performance of MRI vs. LDCT using a Markov model of lung cancer screening. METHODS:We created a Markov cohort model of lung cancer screening which incorporated lung cancer incidence, progression, and mortality based on gender, age, and smoking burden. Sensitivity (Sn) and Sp for LDCT were taken from the MISCAN Lung Microsimulation and Sn/Sp for MRI was estimated from a published substudy of the German Lung Cancer Screening and Intervention Trial. Screening, work-up, and treatment costs were estimated from published data. Screening with MRI and LDCT was simulated for a cohort of male and female smokers (2 packs per day; 36 pack/years of smoking history) starting at age 60. We calculated the screening performance and cost-effectiveness of MRI screening and performed a sensitivity analysis on MRI Sn/Sp and cost. RESULTS:There was no difference in life expectancy between MRI and LDCT screening (males 13.28 vs. 13.29 life-years; females 14.22 vs. 14.22 life-years). MRI had a favorable cost-effectiveness ratio of $258,169 in men and $403,888 in women driven by fewer false-positive screens. On sensitivity analysis, MRI remained cost effective at screening costs < $396 dollars and Sp > 81%. CONCLUSIONS:In this Markov model of lung cancer screening, MRI has a near-equivalent life expectancy benefit and has superior cost-effectiveness relative to LDCT. KEY POINTS:• In this Markov model of lung cancer screening, there is no difference in mortality between yearly screening with MRI and low-dose CT. • Compared to low-dose CT, screening with MRI led to a reduction in false-positive studies from 26 to 2.8% in men and 26 to 2.6% in women. • Due to similar life-expectancy and reduced false-positive rate, we found a favorable cost-effectiveness ratio of $258,169 in men and $403,888 in women of MRI relative to low-dose CT.
Screening and topical decolonization of preoperative nasal Staphylococcus aureus carriers to reduce the incidence of postoperative infections after lung cancer surgery: a propensity matched study.
Fourdrain Alex,Bouabdallah Ilies,Gust Lucile,Cassir Nadim,Brioude Geoffrey,Falcoz Pierre-Emmanuel,Alifano Marco,Le Rochais Jean-Philippe,D'Annoville Thomas,Trousse Delphine,Loundou Anderson,Leone Marc,Papazian Laurent,Thomas Pascal Alexandre,D'Journo Xavier Benoit
Interactive cardiovascular and thoracic surgery
OBJECTIVES:Health care-associated infections (HAIs) are serious issues following lung cancer surgery, leading to an increased risk of morbidity and hospital cost burden. The aim of this study was to evaluate the impact on postoperative outcomes of a preoperative screening and decolonization strategy of nasal carriers for Staphylococcus aureus prior to lung cancer surgery. METHODS:We performed a retrospective study comparing 2 cohorts of patients undergoing major lung resection: a control group of patients from the placebo arm of the randomized Clinical Study to Evaluate the Efficacy of Chlorhexidine Mouthwashes operated on between July 2012 and April 2015 without any nasopharyngeal screening (N = 224); an experimental group, with preoperative screening for S. aureus of nasal carriers and selective 5-day decolonization in positive carriers using mupirocin ointment between January 2017 and December 2017 (N = 310). The 2 groups were matched according to a propensity score analysis with 1:1 matching. The primary outcome was the rate of postoperative HAIs, and the secondary outcome was the need for postoperative mechanical ventilation after surgery. RESULTS:After matching, 2 similar groups of 108 patients each were obtained. In the experimental group, 26 patients had positive results for nasal carriage, and a significant decrease was observed in the rate of overall postoperative HAIs [control n = 19, 17.6%; experimental group n = 9, 8.3%; P = 0.043; relative risk 0.47 (0.22-1)] and in the rate of postoperative mechanical ventilation [control n = 12, 11.1%; experimental group n = 4, 3.7%; P = 0.038; relative risk 0.33 (0.11-1)]. After logistic regression and multivariable analysis, screening of S. aureus nasal carriers reduced the rate of HAIs [odds ratio (OR) 0.29, 95% confidence interval (CI) 0.11-0.76; P = 0.01] and reduced the risk of the need for postoperative mechanical ventilation (OR 0.19, 95% CI 0.05-0.74; P = 0.02). There was no significant statistical difference between the 2 groups regarding the rate of postoperative S. aureus-associated infection (control group n = 6, 5.6%; experimental group n = 2, 1.9%; P = 0.28). CONCLUSIONS:Identification of nasal carriers of S. aureus and selective decontamination using mupirocin appeared to have a beneficial effect on postoperative infectious events after lung resection surgery.
Patient-centered Radiology Reporting for Lung Cancer Screening.
Vitzthum von Eckstaedt Hans,Kitts Andrea B,Swanson Christina,Hanley Michael,Krishnaraj Arun
Journal of thoracic imaging
Medicine is slowly transitioning toward a more patient-centered approach, with patients taking a more central role in their own care. A key part of this movement has involved giving patients increased access to their medical record and imaging results via electronic health portals. However, most patients lack the knowledge to fully understand medical documents, which are generally written above their comprehension level. Radiology reports, in particular, utilize complex terminology due to radiologists' historic function as consultants to other physicians, with little direct communication to patients. As a result, typical radiology reports lack standardized formatting, and they are often inscrutable to patients. Numerous studies examining patient preference also point to a trend for more accessible radiology reports geared toward patients. Reports designed with an infographic format, combining simple pictures and standardized text, may be an ideal format that radiologists can pursue to provide patient-centered care. Our team, through feedback from patient advisory groups, developed a patient-friendly low-dose computed tomography lung cancer screening report with an infographic format that is both visually attractive and comprehensible to the average patient. The report is designed with sections including a description of low-dose computed tomography, a section on individualized patient results, the meaning of the results, and a list of the next steps in their care. We believe that this form of the report has the potential to serve as a bridge between radiologists and patients, allowing for a better patient understanding of their health and empowering patients to participate in their health and health care.
Lung Cancer Screening: Patient Selection and Implementation.
Thomas Nina A,Tanner Nichole T
Clinics in chest medicine
Robust evidence exists in support of lung cancer (LC) screening with low-dose computed tomography in patients at high risk of developing LC; however, judicious patient selection is necessary to obtain optimal benefit while minimizing harm. Several professional societies have published recommendations regarding patient selection criteria for screening. Multiple risk prediction models that include additional patient-specific risk factors have since been developed to more accurately predict risk of developing LC. Implementation of a new screening program requires thorough multidisciplinary planning and maintenance. Multisociety guidelines highlight 9 principal components to implement and maintain a successful program.
Implementation of targeted screening for lung cancer in a high-risk population within routine NHS practice using low-dose computed tomography.
Grover Helen,Ross Thomas,Fuller Elizabeth
We report a primary care-based lung cancer targeted screening programme using low-dose CT (LDCT) in South Tyneside and Sunderland. Ever smokers with ≥10 pack-years aged 55-74 years were identified at annual COPD review. 925 individuals attended for LDCT. 2% (n=19/925) had lung cancer diagnosed. 66.7% (n=14/21) had early stage disease and 78.9% (n=15/19) were offered treatment with curative intent. 79.3% of individuals attending for LDCT were ranked in the lowest deprivation quintiles. This approach has been successfully established in routine NHS practice; it is effective with improvements in stage of disease and engages individuals in deprived areas.
Computed Tomography Screening for Early Lung Cancer, COPD and Cardiovascular Disease in Shanghai: Rationale and Design of a Population-based Comparative Study.
Du Yihui,Li Qiong,Sidorenkov Grigory,Vonder Marleen,Cai Jiali,de Bock Geertruida H,Guan Yu,Xia Yi,Zhou Xiuxiu,Zhang Di,Rook Mieneke,Vliegenthart Rozemarijn,Heuvelmans Marjolein A,Dorrius Monique D,van Ooijen P M A,Groen Harry J M,van der Harst Pim,Xiao Yi,Ye Zhaoxiang,Xie Xueqian,Wang Wenjing,Oudkerk Matthijs,Fan Li,Liu Shiyuan
RATIONALE AND OBJECTIVES:To describe the rational and design of a population-based comparative study. The objective of the study is to assess the screening performance of volume-based management of CT-detected lung nodule in comparison to diameter-based management, and to improve the effectiveness of CT screening for chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD), in addition to lung cancer, based on quantitative measurement of CT imaging biomarkers in a Chinese screening setting. MATERIALS AND METHODS:A population-based comparative study is being performed, including 10,000 asymptomatic participants between 40 and 74 years old from Shanghai urban population. Participants in the intervention group undergo a low-dose chest and cardiac CT scan at baseline and 1 year later, and are managed according to NELCIN-B3 protocol. Participants in the control group undergo a low-dose chest CT scan according to the routine CT protocol and are managed according to the clinical practice. Epidemiological data are collected through questionnaires. In the fourth year from baseline, the diagnosis of the three diseases will be collected. RESULTS:The unnecessary referral rate will be compared between NELCIN-B3 and standard protocol for managing early-detected lung nodules. The effectiveness of quantitative measurement of CT imaging biomarkers for early detection of lung cancer, COPD and CVD will be evaluated. CONCLUSION:We expect that the quantitative assessment of the CT imaging biomarkers will reduce the number of unnecessary referrals for early detected lung nodules, and will improve the early detection of COPD and CVD in a Chinese urban population. TRIAL REGISTRATION:ClinicalTrials.gov, NCT03988322. Registered on 14 June 2019.
Overdiagnosis of lung cancer with low-dose computed tomography screening: meta-analysis of the randomised clinical trials.
Brodersen John,Voss Theis,Martiny Frederik,Siersma Volkert,Barratt Alexandra,Heleno Bruno
Breathe (Sheffield, England)
In low-dose computed tomography (LDCT) screening for lung cancer, all three main conditions for overdiagnosis in cancer screening are present: 1) a reservoir of slowly or nongrowing lung cancer exists; 2) LDCT is a high-resolution imaging technology with the potential to identify this reservoir; and 3) eligible screening participants have a high risk of dying from causes other than lung cancer. The degree of overdiagnosis in cancer screening is most validly estimated in high-quality randomised controlled trials (RCTs), with enough follow-up time after the end of screening to avoid lead-time bias and without contamination of the control group. Nine RCTs investigating LDCT screening were identified. Two RCTs were excluded because lung cancer incidence after the end of screening was not published. Two other RCTs using active comparators were also excluded. Therefore, five RCTs were included: two trials were at low risk of bias, two of some concern and one at high risk of bias. In a meta-analysis of the two low risk of bias RCTs including 8156 healthy current or former smokers, 49% of the screen-detected cancers were overdiagnosed. There is uncertainty about this substantial degree of overdiagnosis due to unexplained heterogeneity and low precision of the summed estimate across the two trials. Key points:Nine randomised controlled trials (RCTs) on low-dose computed tomography screening were identified; five were included for meta-analysis but only two of those were at low risk of bias.In a meta-analysis of recent low risk of bias RCTs including 8156 healthy current or former smokers from developed countries, we found that 49% of the screen-detected cancers may be overdiagnosed.There is uncertainty about the degree of overdiagnosis in lung cancer screening due to unexplained heterogeneity and low precision of the point estimate.If only high-quality RCTs are included in the meta-analysis, the degree of overdiagnosis is substantial. Educational aims:To appreciate that low-dose computed tomography screening for lung cancer meets all three main conditions for overdiagnosis in cancer screening: a reservoir of indolent cancers exists in the population; the screening test is able to "tap" this reservoir by detecting biologically indolent cancers as well as biologically important cancers; and the population being screened is characterised by a relatively high competing risk of death from other causesTo learn about biases that might affect the estimates of overdiagnosis in randomised controlled trials in cancer screening.
Performance of lung cancer screening with low-dose CT in Gejiu, Yunnan: A population-based, screening cohort study.
Wei Meng-Na,Su Zheng,Wang Jian-Ning,Gonzalez Mendez Maria J,Yu Xiao-Yun,Liang Hao,Zhou Qing-Hua,Fan Ya-Guang,Qiao You-Lin
BACKGROUND:The performance of lung cancer screening with low-dose computed tomography (CT) (LDCT) in China is uncertain. This study aimed to evaluate the performance of LDCT lung cancer screening in the Chinese setting. METHODS:In 2014, a screening cohort of lung cancer with LDCT was established in Gejiu, Yunnan Province, a screening center of the Lung Cancer Screening Program in Rural China (LungSPRC). Participants received a baseline screening and four rounds of annual screening with LDCT in two local hospitals until June 2019. We analyzed the rates of participation, detection, early detection, and the clinical characteristics of lung cancer. RESULTS:A total of 2006 participants had complete baseline screening results with a compliance rate of 98.4%. Of these, 1411 were high-risk and 558 were nonhigh-risk participants. During this period, 40 lung cancer cases were confirmed, of these, 35 were screen-detected, four were post-screening and one was an interval case. The positive rate of baseline and annual screening was 9.7% and 9.0%, while the lung cancer detection rate was 0.4% and 0.6%, respectively. The proportion of early lung cancer increased from 37.5% in T0 to 75.0% in T4. Adenocarcinoma was the most common histological subtype. Lung cancer incidence according to the criteria of LungSPRC and National Lung Cancer Screening Trial (NLST) was 513.31 and 877.41 per 100 000 person-years, respectively. CONCLUSIONS:The program of lung cancer screening with LDCT showed a successful performance in Gejiu, Yunnan. However, further studies are warranted to refine a high-risk population who will benefit most from LDCT screening and reduce the high false positive results. KEY POINTS:This study reports the results of lung cancer screening with LDCT in Gejiu, Yunnan, a high-risk area of lung cancer, and it demonstrates that lung cancer screening with LDCT is effective in detecting early-stage lung cancer. Our program provides an opportunity to explore the performance of LDCT lung cancer screening in the Chinese context.
Lung Cancer Screening by Low-Dose CT Scan: Baseline Results of a French Prospective Study.
Leleu Olivier,Basille Damien,Auquier Marianne,Clarot Caroline,Hoguet Estelle,Pétigny Valérie,Addi Amale Aït,Milleron Bernard,Chauffert Bruno,Berna Pascal,Jounieaux Vincent
Clinical lung cancer
BACKGROUND:Lung cancer mortality has been found to decrease significantly with low-dose (LD) computed tomographic (CT) screening among current or former smokers. However, such a screening program is not implemented in France. This study assessed the feasibility of a lung cancer screening program using LD CT scan in a French administrative territory. We report here the results of the first screening round. PATIENTS AND METHODS:DEP KP80 was a single-arm prospective study initiated in May 2016. Participants aged 55 to 74 years, current or former smokers of ≥ 30 pack-years, were recruited. An annual LD CT scan was scheduled. Our algorithms considered nodules < 5 mm as negative findings and nodules > 10 mm as positive; for intermediate nodules between 5 and 10 mm, 3-month CT scan with doubling time measurement was recommended. All general practitioners, pulmonologists, and radiologists from the Somme department were solicited to participate. Subjects were selected by general practitioners or pulmonologists who checked the inclusion criteria and prescribed the CT scan. RESULTS:Over a 2.5-year period, 1307 subjects were recruited. Screening was negative in 733 cases (77.2%), positive in 54 (5.7%), and indeterminate in 162 (17.1%). After the 3-month scans, 57 subjects screened positive: 26 patients exhibited 31 lung cancers (67.7% of stage 0 to I), of whom 76.9% underwent surgical resection, and 29 had no cancer (false-positive rate = 3.1%). The prevalence of lung cancer was 2.7%. CONCLUSION:This study demonstrated the feasibility of organized lung cancer screening using LD CT scan within a real-life context in the general population.
Disparities in Lung Cancer Screening: A Review.
Haddad Diane N,Sandler Kim L,Henderson Louise M,Rivera M Patricia,Aldrich Melinda C
Annals of the American Thoracic Society
Lung cancer is the leading cause of cancer mortality in the United States. Certain groups are at increased risk of developing lung cancer and experience greater morbidity and mortality than the general population. Lung cancer screening provides an opportunity to detect lung cancer at an early stage when surgical intervention can be curative; however, current screening guidelines may overlook vulnerable populations with disproportionate lung cancer burden. This review aims to characterize disparities in lung cancer screening eligibility, as well as access to lung cancer screening, focusing on underrepresented racial/ethnic minorities and high-risk populations, such as individuals with human immunodeficiency virus. We also explore potential system- and patient-level barriers that may influence smoking patterns and healthcare access. Improving access to high-quality health care with a focus on smoking cessation is essential to reduce the burden of lung cancer experienced by vulnerable populations.