Lung Cancer Screening: Updated Guidelines From CHEST

Performing annual low-dose computed tomography (CT) screening for lung cancer in individuals with high risk has been standard of care; however, a careful balance of benefits and harms may change the screening criteria based on findings, smoking cessation, and quality of imaging, according to updated guidelines published by Chest.

An approved panel of qualified experts was nominated to develop 12 key population, intervention, comparator, and outcome (PICO) questions related to the benefits and harms of low-dose CT screening, by reviewing the recent literature and evaluating the evidence. A total of 59 studies were included in the review. Studies were assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach and were subsequently classified as “strong” or “weak” corresponding with fulfilling the standards posed by the 12 PICO questions. The results were a total of 6 graded and 9 ungraded recommendations:

Annual screening with low-dose CT should be offered to

• Former (ie, quit within the past 15 years) and current asymptomatic smokers between the ages of 55 and 77 years, with a history of smoking ≥30 pack-years (weak recommendation, moderate-quality evidence)

Low-dose CT should not be routinely performed in

• Asymptomatic current and former smokers who are not between the ages of 55 and 77 years, and who have not smoked ≥30 pack-years, but who are at high risk for lung cancer based on clinical risk prediction calculators (weak recommendation, low-quality evidence)
• Individuals who have smoked <30 pack-years, are younger than 55 or older than 77 years, or who stopped smoking >15 years ago, and who are not at a high risk for lung cancer developing based on clinical risk prediction calculators (strong recommendation, moderate-quality evidence)
• Individuals who have limited ability to tolerate early stage treatment for detected lung cancer or those who have comorbidities that could adversely affect their ability to tolerate the evaluation of screen-detected findings or  substantially limit their life expectancy (strong recommendation, low-quality evidence)

Screening programs should

• Develop strategies that guide patients with symptoms suggestive of lung cancer to receive the appropriate diagnostic testing vs entering the screening process regardless of meeting screening criteria (ungraded consensus-based statement)
• Set predefined positive low-dose CT test results based on the detected size of solid or part-solid lung nodules, with a positive threshold of 4 mm, 5 mm, or 6 mm in diameter (weak recommendation, low-quality evidence)
• Develop effective strategies to maximize patient compliance with annual screening examinations (ungraded consensus-based statement)
• Develop a comprehensive and multidisciplinary approach to lung nodule management that includes pulmonology, radiology, thoracic surgery, and medical and radiation oncology specialties, with management algorithms developed for small solid, larger solid, and sub-solid nodules (ungraded consensus-based statement)
• Develop strategies to decrease the incidence of potentially indolent lung cancer treatment (ungraded consensus-based statement)
• Provide US Public Health Service-recommended evidence-based tobacco cessation treatment for current smokers receiving low-dose CT screening (strong recommendation, low-quality evidence)
• Provide effective counseling and shared decision making to individuals prior to receiving low-dose CT screening (ungraded consensus-based statement)
• Perform low-dose radiation chest CT based on American College of Radiology/Society of Thoracic Radiology protocols (ungraded consensus-based statement)
• Develop a structured examination result reporting system (ungraded consensus-based statement)
• Develop strategies for non-nodule findings to guide clinical management (ungraded consensus-based statement)
• Develop reporting and data collection tools that can be used to report data to the current National Registry and assist in quality improvement projects and goals (ungraded consensus-based statement)

The panel assembled and updated the above guidelines and recommendations for clinicians, administrators, and policy makers regarding lung cancer screening and low-dose CT screening programs based on the available published evidence. Furthermore, they and offered statements according to expert consensus where literature evidence was not sufficient for commentary in clinically relevant areas.

Reference

Mazzone PJ, Silvestri GA, Patel S, et al. Screening for lung cancer: CHEST guideline and expert panel report [published online January 25, 2018]. Chest. doi:10.1016/j.chest.2018.01.016