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CT Lung Screening Still Needs Some Tweaks

September 20, 2013
Written by: , Filed in: Chest Radiology
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Lung cancer screening via low-dose CT is moving forward, but awkwardly. The latest recommendations for improvement come from a British veteran of lung screening trials who suggests adjusting the screening criteria to include nonsmokers.

John K. Field, PhD, a professor in the department of molecular and clinical cancer medicine at the University of Liverpool in Liverpool, England, said during the European Respiratory Society Annual Congress last week in Barcelona, Spain, “Maybe the Americans need to go back and re-look at the NLST [National Lung Screening Trial] screening criteria for future screening programs.”

Dr. Field was quoted by Crystal Phend of MedPage Today

The NLST, a U.S. study that compared low-dose helical CT to standard chest X-ray as a screening method for lung cancer, ended in November 2010, earlier than planned, because of its dramatic finding that the participants who received CT scans had a 20 percent lower risk of dying from lung cancer.

Since then, the news has been mixed. WellPoint now covers CT lung screening, but most other insurers don’t. Last summer, a task force recommended broad screening criteria, and this summer, the U.S. Preventive Services Task Force (USPSTF) tentatively went along. Two studies published September 5 in the New England Journal of Medicine looked at a model for predicting which CT-detected lung nodules are malignant and found that X-ray screening actually has some advantages over CT.

CT lung screening has a high rate of false positives, leading to invasive follow-up procedures that are often unnecessary or even harmful. So instead of the USPSTF’s tentative guidelines—basically, screen 55- to 79-year-olds with a 30 pack-year history of smoking, either current or within the past 15 years—Dr. Field prefers the National Comprehensive Cancer Network’s more nuanced criteria, which include those as young as 50 who have at least 20 pack-years of smoking and one other risk factor.

But he also said:

It’s very important that we find a way to include the very high-risk nonsmoker.

The Liverpool Lung Project (for which he was primary investigator) used a risk model that identified individuals with a 5 percent risk of developing lung cancer over five years, using smoking history, family history, pneumonia as a surrogate for respiratory disease, prior malignancy, and asbestos exposure.

About 30 percent of the population met those criteria, but they account for about two thirds of lung cancers, he said.

“I really feel the USPSTF need to rethink,” Dr. Field said, “and that’s what we told them.”

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