EDITORIAL
Expert Opinion United States Preventive Services Task Force Recommendation on Screening for Lung Cancer Phillip M. Boiselle, MD, Caroline Chiles, MD, Edward Patz, MD, Martin Tammema¨gi, MD, and Douglas E. Wood, MD In December 2013, the U.S. Preventive Services Task Force (USPSTF) issued a Grade B recommendation in support of annual low-dose CT (LDCT) screening for lung cancer in adults aged 55 to 80 years who have at least a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. We asked 4 leading experts to share their expert opinions regarding the following question: “If you were given the opportunity to make one modification to the recent lung cancer screening recommendations from the U.S. Preventive Services Task Force, what would it be and why?” The date of publication. The National Lung Screening Trial (NLST) reported a mortality benefit from LDCT screening for lung cancer in the summer of 2011. The USPSTF guidelines were published approximately 2½ years later. If we use the conservative estimate that LDCT screening can avert 12,250 lung cancer deaths each year, that translates to more than 30,000 lives lost while we waited for this report. Lung cancer screening is an evolving field, and we can expect revisions to existing guidelines. As we learn more about risk factors for lung cancer development, we will need timely updates to recommendations and reimbursements if we are to ensure that those at risk have access to methods of early detection.
Caroline Chiles, MD Winston-Salem, North Carolina, USA The one modification would be to change the recommendation for an annual CT screen in every patient. Preliminary data from the NLST suggests that those individuals who have no pulmonary nodules on the prevalence study are at very low risk for developing lung cancer within the next several years. Increasing the interval between screening studies in these people to every other year would not appear to significantly impact outcomes, and it would reduce cost and radiation. As the NLST data are further explored, extending the interval between screens in select individuals may be possible to more efficiently implement a mass screening program.
Edward Patz, MD Durham, North Carolina, USA Individuals should be selected for lung cancer screening based on an accurate lung cancer risk prediction model estimate of individual risk. This approach has many benefits. Compared to using the USPSTF criteria for selecting screenees, it can lead to smaller samples being selected, more lung cancers being identified (greater sensitivity), and, because this approach has greater specificity, it will lead to fewer false positive screens. This approach should lead to greater screening program efficiency and cost effectiveness. It is also expected to reduce the numbers of low risk individuals who are screened who are more likely to be harmed by screening and less likely to benefit from screening. In addition, using the risk model approach can identify individuals who remain at substantially elevated risk and may benefit from screening after their smoking cessation period has exceeded 15 years. In the future, using spreadsheet calculators or smart phone apps should make application of sophisticated risk models easy.
Martin Tammema¨gi, MD St. Catharines, Ontario, Canada The USPSTF almost got it right, but they fell short in considering only age and smoking history as risk factors for lung cancer. Their choice in copying the inclusion criteria of the NLST demonstrates political correctness, yet it is naive and shortsighted to not also consider other risk factors for lung cancer, such as environmental exposure with agents like asbestos, or other diseases such as COPD or pulmonary fibrosis. I would modify the USPSTF recommendations to follow the National Comprehensive Cancer Network Guidelines that include a second tier of risk factors to be considered for patients to be eligible for lung cancer screening.
Douglas E. Wood, MD Seattle, Washington, USA
The authors declare no conflicts of interest. Copyright r 2014 by Lippincott Williams & Wilkins
J Thorac Imaging
Volume 29, Number 4, July 2014
www.thoracicimaging.com |
197
Expert Opinion United States Preventive Services Task Force Recommendation on Screening for Lung Cancer Phillip M. Boiselle, MD, Caroline Chiles, MD, Edward Patz, MD, Martin Tammema¨gi, MD, and Douglas E. Wood, MD In December 2013, the U.S. Preventive Services Task Force (USPSTF) issued a Grade B recommendation in support of annual low-dose CT (LDCT) screening for lung cancer in adults aged 55 to 80 years who have at least a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. We asked 4 leading experts to share their expert opinions regarding the following question: “If you were given the opportunity to make one modification to the recent lung cancer screening recommendations from the U.S. Preventive Services Task Force, what would it be and why?” The date of publication. The National Lung Screening Trial (NLST) reported a mortality benefit from LDCT screening for lung cancer in the summer of 2011. The USPSTF guidelines were published approximately 2½ years later. If we use the conservative estimate that LDCT screening can avert 12,250 lung cancer deaths each year, that translates to more than 30,000 lives lost while we waited for this report. Lung cancer screening is an evolving field, and we can expect revisions to existing guidelines. As we learn more about risk factors for lung cancer development, we will need timely updates to recommendations and reimbursements if we are to ensure that those at risk have access to methods of early detection.
Caroline Chiles, MD Winston-Salem, North Carolina, USA The one modification would be to change the recommendation for an annual CT screen in every patient. Preliminary data from the NLST suggests that those individuals who have no pulmonary nodules on the prevalence study are at very low risk for developing lung cancer within the next several years. Increasing the interval between screening studies in these people to every other year would not appear to significantly impact outcomes, and it would reduce cost and radiation. As the NLST data are further explored, extending the interval between screens in select individuals may be possible to more efficiently implement a mass screening program.
Edward Patz, MD Durham, North Carolina, USA Individuals should be selected for lung cancer screening based on an accurate lung cancer risk prediction model estimate of individual risk. This approach has many benefits. Compared to using the USPSTF criteria for selecting screenees, it can lead to smaller samples being selected, more lung cancers being identified (greater sensitivity), and, because this approach has greater specificity, it will lead to fewer false positive screens. This approach should lead to greater screening program efficiency and cost effectiveness. It is also expected to reduce the numbers of low risk individuals who are screened who are more likely to be harmed by screening and less likely to benefit from screening. In addition, using the risk model approach can identify individuals who remain at substantially elevated risk and may benefit from screening after their smoking cessation period has exceeded 15 years. In the future, using spreadsheet calculators or smart phone apps should make application of sophisticated risk models easy.
Martin Tammema¨gi, MD St. Catharines, Ontario, Canada The USPSTF almost got it right, but they fell short in considering only age and smoking history as risk factors for lung cancer. Their choice in copying the inclusion criteria of the NLST demonstrates political correctness, yet it is naive and shortsighted to not also consider other risk factors for lung cancer, such as environmental exposure with agents like asbestos, or other diseases such as COPD or pulmonary fibrosis. I would modify the USPSTF recommendations to follow the National Comprehensive Cancer Network Guidelines that include a second tier of risk factors to be considered for patients to be eligible for lung cancer screening.
Douglas E. Wood, MD Seattle, Washington, USA
The authors declare no conflicts of interest. Copyright r 2014 by Lippincott Williams & Wilkins
J Thorac Imaging
Volume 29, Number 4, July 2014
www.thoracicimaging.com |
197
