Brain Imaging in Lung Cancer Staging

Recommendation Regarding Brain Imaging in Lung Cancer Staging.


Background:

Brain imaging is an important component of the accurate staging of newly diagnosed patients with non-small cell and small cell lung cancer. However, there is a paucity of robust evidence in the literature to give guidance as to the best imaging modality and those that should have brain imaging performed. Most recommendations come from large professional bodies such as NCCN, ESMO, NICE and the ACCP. Brain MRI is generally felt to be the most accurate modality. CT is an acceptable alternative if access to MRI is not possible or if there would be considerable delay in patient workup if waiting for an MRI to be completed.

Recommendation

Based on a review of the most recent guidelines from the organizations noted above:

  • Brain imaging is absolutely recommended for:
    • Patients with Clinical Stage III and IV NSCLC
    • Patients with symptoms (H/A, slurred speech etc…)
    • Patients with Small Cell Lung Cancer
  • Brain imaging for clinical Stage II NSCLC continues to be a matter of debate, however some national bodies have recommended it particularly NCCN.
  • MRI is the modality of choice over CT but depends on availability, wait time and cost.

Suggested Reading List

  • National Comprehensive Cancer Network (NCCN) – Clinical Practice Guidelines in Oncology, Non-Small Cell Lung Cancer v6.2018. http://www.nccn.org/default.aspx
  • National Institute for Health and Care Excellence (NICE) – Lung cancer: diagnosis and management (2011) NICE guideline CG121. https://pathways.nice.org.uk/pathways/ lung-cancer
  • Silvestri G. et. al., Methods for Staging Non-small Cell Lung Cancer.
  • Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2013; 143(5) (Suppl):e211S–e250S.
  • ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Early and locally advanced non-small-cell lung cancer (NSCLC). Ann Oncol (2017) 28 (suppl 4): iv1–iv21
  • Vernon J, Andruszkiewicz N, Schneider L, Schieman C, Finley CJ, Shargall Y, Fahim C, Farrokhyar F, Hanna WC. Comprehensive clinical staging for resectable lung cancer: Clinico-pathological correlations and the role of brain imaging. J Thorac Oncol. 2016 Nov;11(11):1970-1975

Follow-up and Surveillance Recommendations for Patients Treated Curatively for Lung Cancer.


Background:

Despite advances in the care of patients with NSCLC, the overall 5-year survival for patients treated with curative intent remains poor. The rationale for surveillance following the treatment of lung cancer is the detection of recurrent disease or a new primary lung cancer, no randomized data exist to support specific recommendations for surveillance modality and interval. Most recommendations are based on expert consensus and cohort studies, and the effect of surveillance on survival continues to be debated. Data extrapolated from screening trials does demonstrate a survival benefit to the detection of early stage cancers and most guideline-setting groups recommend a surveillance strategy involving regular clinical examinations and imaging. 1-8, 10-16

Recommendations

  • Surveillance for early recurrence or new primaries in patients treated with curative intent for NSCLC:
    • Low dose CT chest +/- contrast q6mo in years 1 and 2 1-5,9,17,18
    • Low dose CT chest +/- contrast q12mo years thereafter1-5,9,17,18
  • CT dose (i.e. Low dose vs Minimal dose) and the use of contrast is controversial. There are no data to suggest one dose over another. Extrapolation of data from the National Lung Cancer Screening Trial would suggest Low dose CT provides good sensitivity for the detection of early stage cancers.4,5,6
  • Surveillance for early recurrence or new primaries in patients treated with curative intent for SCLC:
  • Surveillance recommendations for surveillance post curative intent treatment of SCLC are based on expert consensus and parallel those for NSCLC.
  • Contrast enhanced CT chest may provide superior assessment of mediastinal nodal involvement18

References

  1. Calman L, Beaver K, Hind D, Lorigan P, Roberts C, Lloyd-Jones M. Survival benefits from follow-up of patients with lung cancer: a systematic review and meta-analysis. J Thorac Oncol. 2011;6(12):1993-2004.
  2. Sugimura H, Yang P. Long-term survivorship in lung cancer: a review. Chest.2006;129(4):1088-97
  3. Srikantharajah D, Ghuman A, Nagendran M, Maruthappu M. Is computed tomography follow-up of patients after lobectomy for non-small cell lung cancer of benefit in terms of survival? Interact Cardiovasc Thorac Surg. 2012;15(5):893-8.
  4. Hanna WC, Paul NS, Darling GE, Moshonov H, Allison F, Waddell TK, et al. Minimal-dose computed tomography is superior to chest x-ray for the follow-up and treatment of patients with resected lung cancer. J Thorac Cardiovasc Surg. 2014;147(1):30-5.
  5. National Lung Screening Trial Research Team, Church TR, Black WC, Aberle DR, Berg CD, Clingan KL, et al. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med. 2013;368(21):1980-91.
  6. Crabtree TD, Puri V, Chen SB, et al. Does the method of radiologic surveillance affect survival after resection of stage I non-small cell lung cancer? J Thorac Cardiovasc Surg 2015;149:45-52, 53 e41-43.
  7. Aberle DR, DeMello S, Berg CD, Black WC, Brewer B, Church TR, et al. Results of the two incidence screenings in the National Lung Screening Trial. N Engl J Med. 2013;369(10):920-31.
  8. Erb CT, Su KW, Soulos PR, et al. Surveillance practice patterns after curative intent therapy for stage I non-small-cell lung cancer in the medicare population. Lung Cancer 2016;99:200-207. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27565940.
  9. Colt HG, Murgu SD, Korst RJ, et al. Follow-up and surveillance of the patient with lung cancer after curative-intent therapy: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e437S-454S. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23649451.
  10. Lou F, Huang J, Sima CS, et al. Patterns of recurrence and second primary lung cancer in early-stage lung cancer survivors followed with routine computed tomography surveillance. J Thorac Cardiovasc Surg 2013;145:75-81; discussion 81-72. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23127371.
  11. Srikantharajah D, Ghuman A, Nagendran M, Maruthappu M. Is computed tomography follow-up of patients after lobectomy for non-small cell lung cancer of benefit in terms of survival? Interact Cardiovasc Thorac Surg 2012;15:893-898. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22859511.
  12. Dane B, Grechushkin V, Plank A, et al. PET/CT vs. non-contrast CT alone for surveillance 1-year post lobectomy for stage I non-small-cell lung cancer. Am J Nucl Med Mol Imaging
  13. Nakamura R, Kurishima K, Kobayashi N, et al. Postoperative follow-up for patients with non-small cell lung cancer. Onkologie. 2010;33(1-2):14-18
  14. Johnson BE. Second lung cancers in patients after treatment for an initial lung cancer. J Natl Cancer Inst 1998; 90: 1335–1345.
  15. Demicheli R, Fornili M, Ambrogi F et al. Recurrence dynamics for non-small-cell lung cancer: effect of surgery on the development of metastases. J Thorac Oncol 2012; 7: 723–730.
  16. Toba H, Sakiyama S, Otsuka H et al. 18F-fluorodeoxyglucose positron emission tomography/computed tomography is useful in postoperative follow-up of asymptomatic non-small cell lung cancer patients. Interact Cardiovasc Thorac Surg 2012; 15: 859–864
  17. Vansteenkiste, et al. 2nd ESMO Consensus Conference on Lung Cancer: early-stage non-small-cell lung cancer consensus on diagnosis, treatment and follow-up. Annals of Oncology 25: 1462–1474, 2014
  18. Ung YC, Souter LH, Darling G, Dobranowski J, Donohue L, Leighl N, et al. Follow-up and surveillance of curatively treated lung cancer patients. Toronto (ON): Cancer Care Ontario; 2014 Aug 29. Program in Evidence-Based Care Evidence-Based Series No.: 26-3.

Recommendations for Invasive Mediastinal Staging for Potentially Resectable NSCLC – Choice of Invasive Modality

Indications for Invasive Mediastinal Staging for Potentially Resectable NSCLC

A. When is invasive mediastinal staging indicated?

Background:

As a general rule, invasive staging is typically held to be indicated when the risk of mediastinal lymph node involvement is 10% or greater. There is significant agreement in the existing published guidelines based on moderate to high quality evidence for the following recommendations.

Recommendation

Invasive mediastinal staging is indicated in patients with:

  • Primary tumour >/= 3cm 1-15
  • Central tumour* 1-3, 7, 13, 16-19
  • CT evidence of enlarged N1/N2/N3 nodes 1, 2, 5, 10, 16, 17, 20-23
  • PET evidence of avid N1/N2/N3 nodes 1, 2, 5, 16, 17, 22-25

Note:   Emerging evidence in smaller series has also identified other factors that are associated with an increased risk of mediastinal lymph node involvement. It is not well established if the risk is high enough to justify invasive staging on the basis of these risk factors alone in the absence of the above indications. These additional factors may supplement decision making on a case by case basis:

  • Adenocarcinoma histology 3, 8, 13, 20, 27-29
  • High SUVmax of the primary tumour** 5, 12, 13, 30-34
  • Elevated serum CEA***4, 10, 11, 15, 35

*“Central” is inconsistently defined in the literature26. At the minimum, tumours within the central 1/3 of the chest should undergo invasive staging.
**The threshold value of SUVmax associated with increased risk varies between studies and is poorly defined.
***This test is not a routine part of the work-up of lung cancer in North America

Suggested Reading

  1. Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143:e211S-50S.
  2. Ettinger DS, Wood DE, Aisner DL, et al. NCCN clinical practice guidelines in oncology. Non-small cell lung cancer. Version 4.2018. https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf Accessed June 4, 2018.
  3. de Leyn P, Dooms C, Kuzdzal J, et al. Revised ESTS guidelines for preoperative mediastinal staging for non-small-cell lung cancer. Eur J Cardiothorac Sur. 2014;45:787-98.
  4. Darling G, Dickie A, Malthaner R, Kennedy E, Tey R. Invasive mediastinal staging of non-small-cell lung cancer: A clinical practice guideline. Curr Oncol. 2011;18:e304-9.

References

  1. Ettinger DS, Wood DE, Aisner DL, et al. NCCN clinical practice guidelines in oncology. Non-small cell lung cancer. Version 4.2018. https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf Accessed June 4, 2018.
  2. Darling G, Dickie A, Malthaner R, Kennedy E, Tey R. Invasive mediastinal staging of non-small-cell lung cancer: A clinical practice guideline. Curr Oncol. 2011;18:e304-9.
  3. ­Chen K, Yang F, Jiang G, Li J, Wang J. Development and validation of a clinical prediction model for N2 lymph node metastasis in non-small cell lung cancer. Ann Thorac Surg. 2013;96:1761-8.
  4. Cho S, Song IH, Yang HC, Kim K, Jheon S. Predictive factors for node metastasis in patients with clinical stage I non-small cell lung cancer. Ann Thorac Surg. 2013;96:239-46.
  5. Farjah F, Lou F, SIma C, Rusch V, Rizk N. A prediction model for pathologic N2 disease in lung cancer patients with a negative mediastinum by positron emission tomorgraphy. J Thorac Oncol. 2013;8:1170-80.
  6. Fernandez FG, Kozower BD, Crabtree TD, et al. Utility of mediastinoscopy in clinical stage I lung cancers at risk for occult mediastinal nodal metastases. J Thorac Cardiovasc Surg. 2014;149:35-42.
  7. Gao SJ, Kim AW, Puchalski JT, et al. Indications for invasive mediastinal staging in patients with early non-small cell lung cancer staged with PET-CT. Lung Cancer. 2017;109:36-41.
  8. Gomez-Caro A, Boada M, Cabanas M, et al. False-negative rate after positron emission tomography/computer tomography scan for mediastinal staging in c) stage non-small-cell lung cancer. Eur J Cardiothorac Surg. 2012;42:93-100.
  9. Kanzaki R, Higashiyama M, Fujiwara A, et al. Occult mediastinal lymph node metastasis in NSCLC patients diagnosed as clinical N0-1 by preoperative integrated FDG-PET/CT and CT: Risk factors, pattern and histopathological study. Lung Cancer. 2011;71:333-7.
  10. Kimura H, Iwai N, Ando S, et al. A prospective study of indications for mediastinoscopy in lung cancer with CT findings, tumor size, and tumor markers. Ann Thorac Surg. 2003;75:1734-9.
  11. Koike T, Koike T, Yamato Y, Yoshia K, Tohabe SI. Predictive risk factors for mediastinal lymph node metastases in clinical stage IA non-small-cell lung cancer patients. J Thorac Oncol. 2012;7:1246-51.
  12. Li L, Ren S, Zhang Y, et al. Risk factors for predicting the occult nodal metastasis in T1-2N0M0 NSCLC patients staged by PET/CT: Potential value in the clinic. Lung Cancer. 2013;81:213-7.
  13. Lee PC, Port JL, Korst RJ, et al. Risk factors for occult mediastinal metastases in clinical stage I non-small cell lung cancer. Ann Thorac Surg. 2007;84:177-81.
  14. Park HK, Jeon K, Koh WJ, et al. Occult nodal metastasis in patients with non-small cell lung cancer at clinical stage IA by PET/CT. Respir. 2010;15:1179-84.
  15. Suzuki K, Nagai K, Yoshida J, et al. Clinical predictors of N2 disease in the setting of a negative computed tomographic scan in patients with lung cancer. J Thorac Cardiovasc Surg. 1999;117:593-8.
  16. Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143:e211S-50S.
  17. de Leyn P, Dooms C, Kuzdzal J, et al. Revised ESTS guidelines for preoperative mediastinal staging for non-small-cell lung cancer. Eur J Cardiothorac Sur. 2014;45:787-98.
  18. Al-Sarraf N, Aziz R, Gately K, et al. Pattern and predictors of occult mediastinal lymph node involvement in non-small cell lung cancer patients with negative mediastinal uptake on positron emission tomography. Eur J Cardiothorac Surg. 2012;144:1360-4.
  19. Zhang Y, Sun Y, Xiang J, et al. A prediction model for N2 disease in T1 non-small cell lung cancer. J Thorac Cardiovasc Surg. 2012;144:1360-4.
  20. Fibla JJ, Molins L, Simon C, Perez J, Vidal G. The yield of mediastinoscopy with respect to lymph node size, cell type, and the location of the primary tumor. J Thorac Oncol. 2006;1:430-3.
  21. Gurses A, Turna A, Bedirhan MA, et al. The value of mediastinoscopy in preoperative evaluation of mediastinal involvement in non-small-cell lung cancer patients with clinical N0 disease. J Thorac Cardiovasc Surg. 2002;50:174-7.
  22. Pozo-Rodriguez F, Martin de Nicolás JL, Sánchez-Nistal MA, et al. Accuracy of helical computed tomography at [18F] fluorodeoxyglucose positron emission tomography for identifying lymph node mediastinal metastases in potentially resectable non-small-cell lung cancer. J Clin Oncol. 2005;23:8348-56.
  23. Wang L, Jian W, Zhang C, et al. Lymph node metastasis in clinical stage IA peripheral lung cancer. Lung Cancer. 2015;90:41-6.
  24. Yap KK, Yap KS, Byrne AJ, et al. Positron emission tomography with selected mediastinoscopy compared to routine mediastinoscopy offers cost and clinical outcome benefits for pre-operative staging of non-small cell lung cancer. Eur J Nucl Med Mol Imaging. 2005;32:1033-40.
  25. Billé A, Pelosi E, Skanjeti A, et al. Preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer: accuracy of integrated positron emission tomography and computed tomography. Eur J Cardiothorac Surg. 2009:36:440-5.
  26. Casal RF, Vial MR, Miller R, et al. What exactly is a centrally located lung tumor? Results of an online survey. Ann Am Thorac Soc. 2017;14:118-23.
  27. Billé A, Okiror L, Skanjeti A, et al. Evaluation of integrated positron emission tomography and computed tomography accuracy in detecting lymph node metastasis in patients with adenocarcinoma vs squamous cell carcinoma. Eur J Cardiothorac Surg. 2013;43:574-9.
  28. Choi YS, Shim YM, Kim J, Kim K. Mediastinoscopy in patients with clinical stage I non-small cell lung cancer. Ann Thorac Surg. 2003;73-364-6.
  29. Mizuno T, Arimura T, Kuroda H, et al. Histological type predicts mediastinal metastasis and surgical outcome in resected cN1 non-small cell lung cancer. Gen Thorac Cardiovasc Surg. 20017;65:519-26.
  30. Cerfolio RJ, Bryant AS, Eloubeidi MA. Routine mediastinoscopy and esophageal ultrasound fine-needle aspiration in patients with non-small cell lung cancer who are clinically N2 negative: A prospective study. Chest. 2006;130:1791-5.
  31. Cerfolio RJ, Bryant AS, Ohja B, Bartolucci AA. The maximum standardized uptake values on positron emission tomography of a non-small cell lung cancer predict stage, recurrence, and survival. J Thorac Cardiovasc Surg. 2005;13-:151-9
  32. Li M, Liu N, Hu M, et al. Relationship between primary tumor fluorodeoxyglucose uptake and nodal or distant metastases at presentation in T1 stage non-small cell lung cancer. Lung Cancer. 2009;63:383-6.
  33. Lin JT, Yang XN, Zhing WZ, et al. Association of maximum standardized uptake value with mediastinal lymph node metastases in cN0 non-small cell lung cancer. Eur J Cardiothorac Surg. 2016;50:914-9.
  34. Miyasaka Y, Suzuki K, Tamakochi K, Matsunaga T, Oh S. The maximum standardized uptake value of fluorodeoxyglucose positron emission tomography of the primary tumour is a good predictor of pathological nodal involvement in clinical N0 non-small-cell lung cancer. Eur J Cardiothorac Surg. 2013;44:83-7.
  35. Ye B, Cheng M, Li W, et al. Predictive factors for lymph node metastasis in clinical stage IA lung adenocarcinoma. Ann Thorac Surg. 2014;98:217-23.
Choice of Invasive Modality

B. Choice of invasive modality

Background

When invasive mediastinal staging is required. Various modalities maybe utilized including, but not limited to cervical mediastinoscopy (CM), endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS). This set of recommendations will compare these techniques and attempt to set some parameters regarding required nodal stations. In doing so, we are very cognizant of the variation in the technology and expertise available at the various Thoracic Surgery centres across the country.

Recommendations

  1. Both cervical mediastinoscopy (CM) and needle (FNA) techniques (EBUS with or without EUS) have excellent reported sensitivity, negative predictive value and accuracy.

Initial reports on the accuracy of EBUS and EUS in lung cancer staging yielded disappointing results with unacceptably high false negative rates. However, more contemporary reports have shown equivalence. Indeed, with wider access to mediastinal lymph node staging, needle techniques may prove to be superior to conventional surgical staging. Combined EBUS and EUS, for example, affords access at lymph nodes from station 2R, 2L, 3p, 4R, 4L, 5, 6, 7, 8R, 8L, 9R, 9L, 10R, 10L, 11R and 11L.

  1. We recommend that invasive mediastinal staging, whether with mediastinoscopy or needle techniques should include sampling of at least the right paratracheal lymph node station (station 4R), left paratracheal lymph node station (station 4L) and subcarinal lymph node (station 7), as well as any other suspicious lymph node station by CT or PET criteria

Conventional reports of adequate mediastinoscopy in invasive staging of the mediastinum stipulate that both lower paratracheal lymph node stations and the subcarinal lymph node station should be sampled. While there may not be a lot of evidence that support this convention, it does seem like a reasonable and valid recommendation. This same rule should apply to needle techniques for the same reasons. Therefore, regardless of procedure, an invasive mediastinal staging procedure should only be considered adequate if it samples lymphoid tissue from both lower paratracheal lymph nodes and subcarinal lymph node, and any lymph nodes that are considered suspicions by CT or PET. For example, in a patient with a right upper lobe tumor and a suspicious high paratracheal lymph node by PET, and adequate mediastinoscopy or EBUS would include lymphoid tissue sampled from at least stations 4R, 4L, 7 and 2R.

  1. If both procedures are readily available at an institution, then needle techniques (preferably under sedation in an endoscopy suite) should preferentially be selected to cervical mediastinoscopy

The most important factors in selecting which procedure to use is whether the selected procedure is performed adequately with good results, and whether the target lymph nodes are within reach of that procedure. For example, using mediastinoscopy alone in a patient with left lower lobe tumor and a suspicious lower paraesophageal lymph node (station 8L) would not be considered adequate even if lymph node tissue is adequately obtained from stations 4R, 4L and 7. However, in situations where both procedures can be used safely and adequately, the panel recommends a needle technique. This is because of the lower incidence of devastating complications and the lower cost associated with needle techniques. One should note, that the cost advantage of needle techniques is more pronounced when they are performed in an endoscopy suite.

  1. In an institution where needle techniques are available with high quality, there is no need to confirm negative results with a more invasive procedure.

Given the equivalent results obtained by both procedures in the right setting, the practice of routinely confirming negative EBUS or EUS resulted is not supported by the current literature and is not necessary. There are situations where a negative EBUS or EUS result may require confirmation with a more invasive technique, such as CM or thoracoscopy. This includes inadequate samples or highly suspicious lymph nodes by imaging criteria that are unexpectedly negative.

Suggested reading

  1. Silvestri GA, Gonzalez AV, Jantz MA, Margolis ML, Gould MK, Tanoue LT, Harris LJ, Detterbeck FC. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e211S-e250S
  2. Yasufuku K, Pierre A, Darling G, de Perrot M, Waddell T, Johnston M, da Cunha Santos G, Geddie W, Boerner S, Le LW, Keshavjee S. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg. 2011 Dec;142(6): 1393-400
  3. Liberman M, Sampalis J, Duranceau A, Thiffault V, Hadjeres R, Ferraro P. Endosonographic mediastinal lymph node staging of lung cancer. Chest. 2014 Aug;146(2):389-397
  4. Czarnecka-Kujawa K, Rochau U, Siebert U, Atenafu E, Darling G, Waddell TK, Pierre A, De Perrot M, Cypel M, Keshavjee S, Yasufuku K. Cost-effectiveness of mediastinal lymph node staging in non-small cell lung cancer. J Thorac Cardiovasc Surg. 2017 Jun;153(6):1567-1578
  5. Nasir BS, Yasufuku K, Liberman M. When should negative endobronchial ultrasound findings be confirmed by a more invasive procedure? Ann Surg Oncol. 2018 Jan;25(1):68-75

Lung Cancer Screening.


Background:

The positions and recommendations herein should be regarded as the product of a non-systematic literature review. They are however in accordance (with some specific societal variations) with the positions advocated by the Canadian Task Force on Preventive Health Care, the US Preventive Services Task Force, the American College of Chest Physicians, The American Cancer Society, the American Association of Thoracic Surgery and the National Comprehensive Cancer Network. Our hope is that this recommendation is of utility to CATS members and other stakeholders including our patient community.

Notes:

  1. There is one large-scale, well powered RCT, several smaller RCTs and a number of institutional series to consider.
  2. The existing randomized trials produce conflicting conclusions regarding the benefit or absence of benefit to lung cancer screening.
  3. A large number of professional societies, task-forces and governing bodies have published formal position statements on lung cancer screening, and in particular the Canadian Task Force on Preventive Health has adopted a stance on this issue and is in favor of lung cancer screening.
  4. The primary study, which drives the general support in favor of lung cancer screening from most societies and task forces, is the National Lung Screening Trial (NLST)
  5. The NLST was a randomized trial comparing annual screening low-dose CT (LDCT) vs CXR for 3-years in >53,000 patients in the US. The study targeted “high-risk” patients with inclusion criteria being: i) men and women 55-74 years of age ii) history of at least 30 pack-years smoking (current or those who quit within 15 years of enrollment)
    1. Key Findings:
      1. A positive finding was that of a non-calcified nodule >4mm. 39% of LDCT screened patients had at least one positive scan
      2. 96.4% of positive scans were false-positive scans, and follow up was at discretion of the institution
      3. 90% of positive scans led to a further investigation
      4. The rate of adverse events from interventions for positive scans was low at 1.4% of LDCT patients
      5. There were 247 lung cancer deaths per 100,000 person-years in the LDCT group and 309 lung cancer deaths per 100,000 person-years in the CXR group
      6. This translates into a relative reduction in lung cancer mortality of 20%, and a relative reduction in all-cause mortality of 6.7%
      7. This translates to the need to screen 320 persons annually for 3-years to prevent one lung cancer death over six years.
  6. CXR alone does not reduce mortality for lung cancer and is not recommended as a screening modality
  7. LDCT is more sensitive than CXR in detecting small asymptomatic lung cancers
  8. Screening has a high false positive rate, and leads to a large volume of additional investigations including further imaging and some invasive procedures
  9. Participation in a screen trial was associated with a favorable reduction in smoking cessation
  10. The concern of cost-effectiveness associated with screening is a major issue. Modelling studies suggest LDCT screening may reduce lung cancer mortality over 10 years at a cost of $81,0002 – 269,0003 per quality-adjusted life years.
  11. Screening for lung cancer cannot be thought of as a single intervention and requires a dedicated program that involves knowledgeable counselling, discussion of potential risks, expert radiology, thoracic surgery and pathology, and resources to ensure follow up and management of incidental findings
  12. Smoking cessation is a more effective and more cost-effective intervention to reduce lung cancer mortality than is screening.

Recommendation

CATS acknowledges that the provision of clinical care, and the associated resources required to implement a potential lung cancer screening program are considerable, and ultimately may not be possible in each jurisdiction.

It is Only within the confines of a dedicated lung cancer screening program, CATS recommends screening asymptomatic adults aged 55 to 74 years, who are in good health, with at least a 30 pack-year smoking history who smoke or have quit smoking within 15 years, with low-dose, non-contrast CT scanning of the chest, every year for three consecutive years. At this time CATS cannot provide a recommendation of subsequent screening following this 3-year interval.

Key References

1.Reduced lung-cancer mortality with low-dose computed tomography screening. NEJM. 2011;365(5):395.
2.Cost-effectivenes of CT screening in the National Lung Screening Trial. NEJM 2014 Nov;371(19):1793-802
3.Cost-effectiveness of computed tomography screening for lung cancer in the United States. J Thorac Oncol. 2011;6(11):1841.