USPSTF Updated Guidance on Lung Cancer Screening With LDCT

The US Preventive Services Task Force (USPSTF) has released a new, updated recommendation statement on lung cancer screenings with low-dose computed tomography (LDCT). The full statement was published in a recent edition of JAMA.¹

A New, Updated Recommendation for Annual Lung Cancer Screening

The statement is an update to the 2013 recommendation also released by the USPSTF. In the development of the new recommendation, the Task Force commissioned a systematic review of research that evaluated the accuracy of LDCT for lung cancer screening. Additionally, the USPSTF performed a review of the literature regarding the benefits and harms associated with lung cancer screening.¹

A collaborative modeling study was also commissioned by the organization to provide further information regarding the ages at which screening should begin and end. In addition, the study examined the relative harms and benefits of different lung cancer screening modalities compared with modified multivariate risk prediction models.¹

Based on the reviewed evidence, the Task Force stated with “moderate certainty” that there appears to be a moderate net benefit associated with annual lung cancer screening using LDCT in persons considered at high risk for lung cancer. High-risk features that can determine or identify these patients include advanced age, total cumulative exposure to tobacco smoke, and years since smoking cessation.¹

Given this conclusion, the USPSTF stated that it recommends an annual lung cancer screening with LDCT in people between 50 to 80 years of age with a 20 pack-year smoking history who currently smoke or have quit smoking within the past 15 years.¹ Additionally, clinicians can consider discontinuing screening when a person has either not smoked for 15 years or has developed a health problem that significantly limits life expectancy or the ability or willingness to undergo curative long surgery.¹

The updated recommendation lowers the screening age from the previously recommended 55 to the now 50 and also reduces the minimum smoking history from 30 to 20 pack-years. In a separate commentary, a small team of US researchers suggested that expanding the criteria make more Americans, including high-risk women and racial minorities, eligible for screening.²

Overall, the new guidance makes 14.5 million US adults eligible for screening, which represents an increase of 6.5 million people compared with the time period before the update.² Researchers expect that this increase in screening could potentially save another 10,000 to 20,000 lives each year, given the documented mortality benefit associated with lung cancer screening with LDCT.²

How to Implement the Updated USPSTF Recommendation

The USPSTF provided several recommendations for how to implement the annual screening. First, clinicians should assess a person’s risk based on age (50-80 years) and pack-year smoking history (≥20 pack-years). The organization explained that 1 pack-year equals smoking a mean of 20 cigarettes, or 1 pack, each day for 1 year. People with a 20-pack year smoking history have smoked a pack a day for the last 20 years or 2 packs a day for the last 10 years.¹

In addition, the USPSTF recommends a shared decision-making approach to screening. Ideally, the clinician and patient should discuss the potential benefits, limitations, and possible harms associated with lung cancer screening prior to implementing screening. A person who chooses to undergo screening should then be referred for lung cancer screening with LDCT, with preference given to a center that has experience as well as expertise in such screening practices. Those who currently smoke should also be given or prescribed smoking cessation interventions prior to and during screening.¹

Limitations of the Recommendations

While the new guidance provides a welcome change by increasing the number of people eligible for screening, there are some limitations. For instance, setting the cutoff for screening at ≥80 years of age could be important, since there are many people in the United States in this age range who could derive benefit from screening.² Additionally, the updated recommendation does not include potentially important risk factors other than age and smoking history. These risk factors include exposure to air pollution, exposure to asbestos, inflammatory pulmonary diseases, and family clustering.²

References

1. US Preventive Services Task Force, Krist AH, Davidson KW, et al. Screening for lung cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(10):962-970. doi:10.1001/jama.2021.1117

2. Potter AL, Bajaj SS, Yang CJ. The 2021 USPSTF lung cancer screening guidelines: a new frontier. Lancet Respir Med. Published online May 6, 2021. doi:10.1016/S2213-2600(21)00210-1