Chest
DIAGNOSIS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES (2ND EDITION)Screening for Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)
Section snippets
Materials and Methods
To update previous recommendations on lung cancer screening, we identified by a systematic review of the literature (see “Methodology for Lung Cancer Evidence Review and Guideline Development” chapter), the primary analysis of individuals who were screened for lung cancer between 2002 and May 2005, as well as studies that provided insights into the theoretical basis of screening or the clinical behavior of lung cancers found through screening. Supplemental material appropriate to this topic was
Results
Low-dose CT (LDCT) scanning remains the most promising of lung cancer screening techniques, but the results of ongoing randomized trials are not expected for at least another 2 to 3 years. In the meantime, researchers have pursued other approaches to evaluating the impact of CT screening on lung cancer outcomes and also focused on other issues that might affect how screening is used, such as investigating the hazard that smaller, early-stage, LDCT-detected nodules pose; the cost-effectiveness
Screening With LDCT
Using relatively low radiation exposure to create a low-resolution image of the entire thorax, LDCT screening is capable of detecting very small, early-stage cancers so that their shape and growth can be observed noninvasively. Previous research has demonstrated that compared with CXR, LDCT detects approximately three times as many small lung nodules; of those that are subsequently diagnosed as cancer, the overwhelming majority are stage I.4 For the additional early detection to benefit
Natural History of Clinically Apparent and CT-Detected Lung Cancers: Findings on Doubling Rates
Some research has explored use of the volume-doubling rate to predict the threat posed by smaller, screening-detected lung nodules, based on the hypothesis that nodules that are rapidly growing (ie, rapidly “doubling in size”) are more likely to cause significant disease. In other words, doubling times are examined on the basis of the assumption that the rate of doubling over a brief time period is at least crudely reflective of a tumor's past behavior and can be used as a proxy for the future
Cost-effectiveness of LDCT
Researchers have been eager to determine the cost-effectiveness of lung cancer screening, a task made difficult by the absence of efficacy data (Table 2).15, 17, 18, 41 Two studies have examined the cost of a single, “prevalence” screening compared with no screening on the basis of the apparent shift in stage distribution reported in the Early Lung Cancer Action Project (ELCAP) cohort (85% stage I in screening arm vs 21% stage I in the no-screening arm).15, 16 Both estimated the incremental
LDCT Ongoing and Future Studies
At least two randomized trials of LDCT are under way. The National Lung Screening Trial has randomly assigned 50,000 high-risk smokers, between 55 and 74 years of age, to annual screening with LDCT or CXR at 36 sites in the United States (http://www.cancer.gov/nlst/screeningcenters). The study is designed to have a 90% power to detect a mortality reduction of 20% by 2009. The NELSON trial,21 a collaboration between the Netherlands and Belgium, has randomly assigned 16,000 smokers to LDCT
Available Estimates of the Impact of LDCT Screening on Lung Cancer Mortality and Survival
Although there are not yet comparative data on the rate of lung cancer mortality among patients who are screened with LDCT compared with what might have happened had individuals not been screened, some preliminary analyses are pessimistic. In a study of 1,520 smokers and former smokers who received 5 years of annual LDCT scans at the Mayo Clinic, Swensen et al22 found that lung cancer incidence and mortality rates were comparable to those in the Mayo Lung Project, after adjusting subsets by age
LDCT
At present, the risks of LDCT are readily observable, but the impact on mortality remains unknown. Even if LDCT is ultimately shown to effect a mortality reduction, the legitimate concern about overdiagnosing cancers, the uncertainty about how to assess nodule growth rates, the influence of patient risk level on effectiveness and cost-effectiveness, and the high rates of benign nodule detection and subsequent treatment prompted by such detection all suggest that the cumulative consequences of
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