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Kim: Lung Cancer Screening: Update
Chest Radiology

Journal of the Korean Society of Radiology 2015; 73(3): 137-146.

Published online: 1 September 2015

DOI: https://doi.org/10.3348/jksr.2015.73.3.137

Lung Cancer Screening: Update

Hyae Young Kim, MD

Department of Radiology, Center for Lung Cancer, National Cancer Center, Goyang, Korea.

Corresponding author: Hyae Young Kim, MD. Department of Radiology, Center for Lung Cancer, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang 10408, Korea. Tel. 82-31-920-2638, Fax. 82-31-920-2643, radhykim@ncc.re.kr

Received 3 June 2015       Revised 2 July 2015       Accepted 13 July 2015

Copyright © 2015 The Korean Society of Radiology

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Lung cancer is the leading cause of cancer deaths worldwide as well as in Korea. A recent National Lung Screening Trial in U.S. revealed that low-dose CT (LDCT) screening reduced lung cancer specific mortality by 20% in high risk individuals as compared to chest radiograph screening. Based on this evidence, several expert societies in U.S. and Korean multisociety collaborative committee developed guidelines for recommendation of lung cancer screening using annual LDCT in high risk populations. In most of the societies high risk groups are defined as persons aged 55 to 74 years, who are current smokers with history of smoking of more than 30 packs per year or ex-smokers, who quit smoking up to 15 or more years ago. The benefits of LDCT screening are modestly higher than the harms in high risk individuals. The harms included a high rate of false-positive findings, over-diagnosis and radiation-related deaths. Invasive diagnostic procedure due to false positive findings may lead to complications. LDCT should be performed in qualified hospitals and interpreted by expert radiologists. Recently, the American College of Radiology released the current version of Lung cancer CT screening Reporting and Data Systems. Education and actions to stop smoking must be offered to current smokers.

Keywords: Early Detection of Cancer, Lung Neoplasms, Mass Screening, Tomography, Spiral Computed

Figures and Tables

Table 1

Randomized Controlled Trials of Lung Cancer Screening with Low-Dose CT

jksr-73-137-i001
Study Years of Recruitment Sex Age Participants (Baseline) Smoking History Screening Schedule (Years)‡ Total Follow-Up Period Lung Cancer at Initial (Total in Follow-Up)
NLST (13)
USA		 2002-2004 Male 59% 55-74 LDCT arm: 26722 Current or Ex-smokers ≥ 30 PY, quit < 15 years 0, 1, 2 5 years 1.1% (2.4%)
Control arm (CXR): 26732
DANTE (24)
Italy		 2001-2006 Male 100% 60-74 LDCT arm: 1276 Current or Ex-smokers ≥ 20 PY 0, 1, 2, 3, 4 4 years 2.2% (4.7%)
Control arm (clinic)*: 1196
DLCST (25)
Denmark		 2004-2006 Male 55% 50-70 LDCT arm: 2052 Current or Ex-smokers ≥ 20 PY, quit < 15 years 0, 1, 2, 3, 4 10 years 0.8% (3.4%)
Control arm (usual care): 2052
MILD (26)
Italy		 2005-2011 Male 66% 49-75 LDCT arm: 1190 (A)/1186 (B) Current or Ex-smokers ≥ 20 PY, quit < 10 years 0, 1, 2, 3, 4 (A) 10 years 0.8% (2.4%)
Control arm (usual care): 1723 0, 2, 4 (B)
NELSON (27, 28)
Netherlands and Belgium		 2003-2006 Male 83.5% 50-74 LDCT arm: 7915 Current or Ex-smokers > 15 PY, quit < 10 years 0, 1, 3 10 years 0.9% (2.6%)
Control arm (usual care): 7907
ITALUNG (29, 30)
Italy		 2004- Male 64.7% 55-69 LDCT arm: 1613 Current or Ex-smokers ≥ 20 PY, quit < 10 years 0, 1, 2, 3, 4 4 years 1.5% (2.8%)
Control arm (usual care): 1593
LUSI (31)
Germany		 2007- Male 64.7% 50-69 LDCT arm: 2029 Current or Ex-smokers > 15 PY, quit < 10 years 0, 1, 2, 3, 4 5 years NA
Control arm (usual care): 2023
UKLS (32, 33)
United Kingdom		 2011- NA 50-75 LDCT arm: 2000† 5% risk of developing lung cancer in 5 years (Liverpool Lung Project risk model) 0 10 years NA
Control arm (usual care): 2000

*All participants received CXR + sputum cytology at baseline.

†Planned recruitment.

‡Screening schedule indicates which year the scans are performed with "0" indicating baseline scan.

A = annual, B = biennial, CXR = chest radiograph, DANTE = Detection and Screening of Early Lung Cancer by Novel Imaging Technology and Molecular Essays, DLCST = Danish Lung Cancer Screening Trials, ITALUNG = Italian Lung, LUSI = German Lung Cancer Screening Intervention Trial, MILD = Multicentric Italian Lung Detection, NA = not available, NELSON = Dutch-Belgian randomized lung cancer screening trial, NLST = National Lung Screening Trial, PY = pack-years, UKLS = United Kingdom Lung Screen

Table 2

Effects of Lung Cancer Screening with LDCT

jksr-73-137-i002
Study Screen Methods Participants Persons-Year Lung Cancer Deaths Relative Risk (95% CI) Overall Deaths Relative Risk (95% CI)
NLST (14) LDCT arm 26722 144103 356 0.80 (0.70-0.92) 1877 0.93 (0.88-0.99)
Control arm 26732 143368 443 2000
DANTE (24) LDCT arm 1276 3796 20 0.83 (0.45-1.53) 46 0.85 (0.56-1.27)
Control arm 1196 3140 20 45
DLCST (25) LDCT arm 2052 9769 15 1.37 (0.63-2.97) 61 1.46 (0.98-2.15)
Control arm 2052 9794 11 42
MILD (26) LDCT arm 2376 11073 18 1.50 (0.63-3.58) 51 1.49 (0.89-2.49)
1190 (annual)
1186 (biennial)
Control arm 1723 6450 7 20

CI = confidence interval, DANTE = Detection and Screening of Early Lung Cancer by Novel Imaging Technology and Molecular Essays, DLCST = Danish Lung Cancer Screening Trials, LDCT = low-dose computed tomography, MILD = Multicentric Italian Lung Detection, NLST = National Lung Screening Trial

Table 3

Lung CT Screening Reporting and Data System (39)

jksr-73-137-i003
Category Findings Description Management
0. Incomplete Incomplete exam Additional LDCT or comparisons
1. Negative No nodules/specific calcification No nodules and definitely benign nodules Annual LDCT
2. Benign appearance or behavior Solid < 6 mm, new 4 mm Very low likelihood of becoming clinically active cancer due to size or lack of growth (stable > 3 mo) Annual LDCT
Part solid < 6 mm
Non solid < 20 mm OR ≥ 20 mm unchanged or slow growing
3. Probably benign Solid 6-8 mm at baseline OR new 4-6 mm Low likelihood of becoming clinically active cancer suggesting short term follow-up 6 month LDCT
Part solid ≥ 6 mm with solid < 6 mm OR new < 6 mm total
Nonsolid ≥ 20 mm
4A. Suspicious Solid 8-15 mm at baseline OR growing Additional diagnostic testing and/or tissue sampling is advised Tissue sampling OR 3 month LDCT, PET/CT when ≥ 8 mm solid
Part solid ≥ 6 mm with solid 6-8 mm OR new growing < 4 mm total
4B. Suspicious Solid ≥ 15 mm at baseline OR new or growing > 8 mm Tissue sampling OR chest CT, PET/CT
Part solid with solid ≥ 8 mm OR new or growing ≥ 4 mm solid

Modifier S, potentially clinically significant (non-lung cancer related); modifier C, diagnosed lung cancer.

LDCT = low-dose computed tomography, PET/CT = positron emission tomography/CT

Table 4

Lung Cancer Stage Detected in NLST According to Screening Rounds (3743)

jksr-73-137-i004
Stage First Round, % Second Round, % Third Round, %
IA or IB 54.6 59.1 63.9
IIIA, IIIB, or IV 37.8 31.2 30.4

NLST = National Lung Screening Trial

Table 5

Populations Recommended Lung Cancer Screening with Low-Dose CT

jksr-73-137-i005
Society Primary Population Other Populations
ACCP, ACS, KSTR, KMCC (15, 16, 22, 23) Aged 55-74 years
≥ 30 pack-year smoking
Former smokers quit within past 15 years		 Not applicable
USPSTF, ESR/ERS (19, 21) Aged 55-80 years
≥ 30 pack-year smoking
Former smokers quit within past 15 years		 Not applicable
NCCN (49) Aged 55-74 years
≥ 30 pack-year smoking
Former smokers quit within past 15 years		 Aged ≥ 50 years
≥ 20 pack-year smoking
Additional risk factors*
AATS (18) Aged 55-79 years
≥ 30 pack-year smoking		 Aged ≥ 50 years
≥ 20 pack-year smoking
Additional risk factors† or lung cancer survivors ≥ 5 years
CMS (20) Aged 55-77 years
≥ 30 pack-year smoking
Former smokers quit within past 15 years		 Not applicable

*Cancer history, lung disease history, family history of lung cancer, radon exposure, and occupational exposure.

†Chronic obstructive pulmonary disease, environmental and occupational exposures, any prior cancer or thoracic radiation, and genetic or family history.

AATS = American Association for Thoracic Surgery, ACCP = American College of Chest Physicians, ACS = American Cancer Society, CMS = Centers for Medicare & Medicaid Service, ESR/ERS = European Society of Radiology/European Respiratory Society, KMCC = Korean multisociety collaborative committee, KSTR = Korean Society of Thoracic Radiology, NCCN = National Comprehensive Cancer Network, USPSTF = U.S. Preventive Service Task Services

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