Lung Cancer Screening: A Need for Adjunctive Testing

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Eric S. Edell, MD, FCCP

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References
  1. Naidch DP et al. Radiology. 1990;175(3):729-731. doi:10.1148/radiology.175.3.2343122
  2. Kaneko M et al. Radiology. 1996;201(3):798-802. doi:10.1148/radiology.201.3.8939234
  3. National Lung Screening Trial Research Team. Radiology. 2011;258(1):243-253. doi:10.1148/radiol.10091808
  4. National Lung Screening Trial Research Team. J Thorac Oncol. 2019;14(10):1732-1742. doi:10.1016/j.jtho.2019.05.044
  5. Mazzone PJ et al. Chest. 2021;160(5):e427-e494. doi:10.1016/j.chest.2021.06.063
  6. Tanner NT et al. Chest. 2023;S0012-3692(23)00175-7. doi:10.1016/j.chest.2023.02.003
  7. National Lung Screening Trial Research Team. N Engl J Med. 2011;365(5):395- 409. doi:10.1056/NEJMoa1102873
  8. Marmor HN et al. Curr Chall Thorac Surg. 2023;5:5. doi:10.21037/ccts-20-171
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Eric S. Edell, MD, FCCP
Internist and Pulmonologist
Mayo Clinic
Rochester, MN

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Eric S. Edell, MD, FCCP
Internist and Pulmonologist
Mayo Clinic
Rochester, MN

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Eric S. Edell, MD, FCCP
Internist and Pulmonologist
Mayo Clinic
Rochester, MN

Click to read more from Pulmonology Data Trends 2023.

Click to read more from Pulmonology Data Trends 2023.

References
  1. Naidch DP et al. Radiology. 1990;175(3):729-731. doi:10.1148/radiology.175.3.2343122
  2. Kaneko M et al. Radiology. 1996;201(3):798-802. doi:10.1148/radiology.201.3.8939234
  3. National Lung Screening Trial Research Team. Radiology. 2011;258(1):243-253. doi:10.1148/radiol.10091808
  4. National Lung Screening Trial Research Team. J Thorac Oncol. 2019;14(10):1732-1742. doi:10.1016/j.jtho.2019.05.044
  5. Mazzone PJ et al. Chest. 2021;160(5):e427-e494. doi:10.1016/j.chest.2021.06.063
  6. Tanner NT et al. Chest. 2023;S0012-3692(23)00175-7. doi:10.1016/j.chest.2023.02.003
  7. National Lung Screening Trial Research Team. N Engl J Med. 2011;365(5):395- 409. doi:10.1056/NEJMoa1102873
  8. Marmor HN et al. Curr Chall Thorac Surg. 2023;5:5. doi:10.21037/ccts-20-171
References
  1. Naidch DP et al. Radiology. 1990;175(3):729-731. doi:10.1148/radiology.175.3.2343122
  2. Kaneko M et al. Radiology. 1996;201(3):798-802. doi:10.1148/radiology.201.3.8939234
  3. National Lung Screening Trial Research Team. Radiology. 2011;258(1):243-253. doi:10.1148/radiol.10091808
  4. National Lung Screening Trial Research Team. J Thorac Oncol. 2019;14(10):1732-1742. doi:10.1016/j.jtho.2019.05.044
  5. Mazzone PJ et al. Chest. 2021;160(5):e427-e494. doi:10.1016/j.chest.2021.06.063
  6. Tanner NT et al. Chest. 2023;S0012-3692(23)00175-7. doi:10.1016/j.chest.2023.02.003
  7. National Lung Screening Trial Research Team. N Engl J Med. 2011;365(5):395- 409. doi:10.1056/NEJMoa1102873
  8. Marmor HN et al. Curr Chall Thorac Surg. 2023;5:5. doi:10.21037/ccts-20-171
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Early detection of lung cancer by screening with low dose computed tomography (LDCT) scanning has long been investigated as a potential means of reducing related deaths.1,2 The 2011 National Lung Screening Trial (NLST) compared LDCT scanning with standard chest radiograph (CXR). Results showed a significant reduction in mortality in high-risk current and former smokers who were screened annually (3×) with LDCT scan vs CXR.3

LDCT scanning for lung cancer is currently a standard of care, partially due to the results of the NLST.4,5 In 2013, LDCT scanning was recommended by the US Preventive Services Task Force (USPSTF), making about 8 million Americans eligible for screening.6 In 2019, an extended NLST cohort follow-up study showed that earlier detection with LDCT scanning not only delayed lung cancer death, but also prevented it—or at least delayed it by a decade or more.4,7 This sparked another change in eligibility criteria in the 2021 USPSTF guidelines, allowing an additional 6.5 million people to be eligible for screening.6

Unfortunately, LDCT scanning has some negative aspects to its use, such as high false-positive rates, repeated radiation exposure, and the lack of ability to distinguish between nodules that are benign or malignant.8 There is a need for adjunctive testing for screening. Some current research is focusing on the development of liquid biomarkers intended to be complementary to imaging as a method of using noninvasive lung cancer diagnostics.

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Advances in Lung Cancer Diagnostics and Treatment

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References

1. Cancer facts and figures 2022. American Cancer Society. Accessed June 14, 2022. https://www.cancer.org/content/dam/ cancer-org/research/cancer-facts-and-statistics/annual-cancerfacts-and-figures/2022/2022-cancer-facts-and-figures

2. Novellis P, Maisonneuve P, Dieci E, et al. Quality of life, postoperative pain, and lymph node dissection in a robotic approach compared to VATS and OPEN for early stage lung cancer. J Clin Med. 2021;10(8):1687. doi:10.3390/jcm10081687

3. Chen AC, Pastis NJ Jr, Mahajan AK, et al. Robotic bronchoscopy for peripheral pulmonary lesions: a multicenter pilot and feasibility study (BENEFIT). Chest. 2021;159(2):845-852. doi:10.1016/j. chest.2020.08.2047

4. Current cigarette smoking among adults in the United States. Centers for Disease Control and Prevention. Updated March 17, 2022. Accessed June 15, 2022. https://www.cdc.gov/tobacco/ data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

5. Haddad DN, Sandler KL, Henderson LM, Rivera MP, Aldrich MC. Disparities in lung cancer screening: a review. Ann Am Thorac Soc. 2020;17(4):399-405. doi:10.1513/AnnalsATS.201907- 556CME

6. US Preventive Services Task Force issues final recommendation statement on screening for lung cancer. USPSTF Bulletin. Published March 9, 2021. Accessed June 15, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/lung-cancer-newsbulletin.pdf

7. Mazzone PJ, Silvestri GA, Souter LH, et al. Screening for lung cancer: CHEST guideline and expert panel report. Chest. 2021;160(5):e427-e494. doi:10.1016/j.chest.2021.06.063

8. Lung cancer screening report. National Cancer Institute Cancer Trends Progress Report. Updated April 2022. Accessed June 15, 2022. https://progressreport.cancer.gov/detection/lung_cancer

9. Huang L, Li L, Zhou Y, et al. Clinical characteristics correlate with outcomes of immunotherapy in advanced non-small cell lung cancer. J Cancer. 2020;11(24):7137-7145. doi:10.7150/ jca.49213

10. Forde PM, Spicer J, Lu S, et al. Neoadjuvant nivolumab plus chemotherapy in resectable lung cancer. N Engl J Med. 2022;386(21):1973-1985. doi:10.1056/NEJMoa2202170

11. Wu YL, Tsuboi M, He J, et al. Osimertinib in Resected EGFR-Mutated Non-Small-Cell Lung Cancer. N Engl J Med. 2020;383(18):1711-1723. doi:10.1056/NEJMoa2027071

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CHEST Physician
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Eric S. Edell, MD, FCCP
Author(s)
Eric S. Edell, MD, FCCP

Click to view more from Pulmonology Data Trends 2022.

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References

1. Cancer facts and figures 2022. American Cancer Society. Accessed June 14, 2022. https://www.cancer.org/content/dam/ cancer-org/research/cancer-facts-and-statistics/annual-cancerfacts-and-figures/2022/2022-cancer-facts-and-figures

2. Novellis P, Maisonneuve P, Dieci E, et al. Quality of life, postoperative pain, and lymph node dissection in a robotic approach compared to VATS and OPEN for early stage lung cancer. J Clin Med. 2021;10(8):1687. doi:10.3390/jcm10081687

3. Chen AC, Pastis NJ Jr, Mahajan AK, et al. Robotic bronchoscopy for peripheral pulmonary lesions: a multicenter pilot and feasibility study (BENEFIT). Chest. 2021;159(2):845-852. doi:10.1016/j. chest.2020.08.2047

4. Current cigarette smoking among adults in the United States. Centers for Disease Control and Prevention. Updated March 17, 2022. Accessed June 15, 2022. https://www.cdc.gov/tobacco/ data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

5. Haddad DN, Sandler KL, Henderson LM, Rivera MP, Aldrich MC. Disparities in lung cancer screening: a review. Ann Am Thorac Soc. 2020;17(4):399-405. doi:10.1513/AnnalsATS.201907- 556CME

6. US Preventive Services Task Force issues final recommendation statement on screening for lung cancer. USPSTF Bulletin. Published March 9, 2021. Accessed June 15, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/lung-cancer-newsbulletin.pdf

7. Mazzone PJ, Silvestri GA, Souter LH, et al. Screening for lung cancer: CHEST guideline and expert panel report. Chest. 2021;160(5):e427-e494. doi:10.1016/j.chest.2021.06.063

8. Lung cancer screening report. National Cancer Institute Cancer Trends Progress Report. Updated April 2022. Accessed June 15, 2022. https://progressreport.cancer.gov/detection/lung_cancer

9. Huang L, Li L, Zhou Y, et al. Clinical characteristics correlate with outcomes of immunotherapy in advanced non-small cell lung cancer. J Cancer. 2020;11(24):7137-7145. doi:10.7150/ jca.49213

10. Forde PM, Spicer J, Lu S, et al. Neoadjuvant nivolumab plus chemotherapy in resectable lung cancer. N Engl J Med. 2022;386(21):1973-1985. doi:10.1056/NEJMoa2202170

11. Wu YL, Tsuboi M, He J, et al. Osimertinib in Resected EGFR-Mutated Non-Small-Cell Lung Cancer. N Engl J Med. 2020;383(18):1711-1723. doi:10.1056/NEJMoa2027071

References

1. Cancer facts and figures 2022. American Cancer Society. Accessed June 14, 2022. https://www.cancer.org/content/dam/ cancer-org/research/cancer-facts-and-statistics/annual-cancerfacts-and-figures/2022/2022-cancer-facts-and-figures

2. Novellis P, Maisonneuve P, Dieci E, et al. Quality of life, postoperative pain, and lymph node dissection in a robotic approach compared to VATS and OPEN for early stage lung cancer. J Clin Med. 2021;10(8):1687. doi:10.3390/jcm10081687

3. Chen AC, Pastis NJ Jr, Mahajan AK, et al. Robotic bronchoscopy for peripheral pulmonary lesions: a multicenter pilot and feasibility study (BENEFIT). Chest. 2021;159(2):845-852. doi:10.1016/j. chest.2020.08.2047

4. Current cigarette smoking among adults in the United States. Centers for Disease Control and Prevention. Updated March 17, 2022. Accessed June 15, 2022. https://www.cdc.gov/tobacco/ data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

5. Haddad DN, Sandler KL, Henderson LM, Rivera MP, Aldrich MC. Disparities in lung cancer screening: a review. Ann Am Thorac Soc. 2020;17(4):399-405. doi:10.1513/AnnalsATS.201907- 556CME

6. US Preventive Services Task Force issues final recommendation statement on screening for lung cancer. USPSTF Bulletin. Published March 9, 2021. Accessed June 15, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/lung-cancer-newsbulletin.pdf

7. Mazzone PJ, Silvestri GA, Souter LH, et al. Screening for lung cancer: CHEST guideline and expert panel report. Chest. 2021;160(5):e427-e494. doi:10.1016/j.chest.2021.06.063

8. Lung cancer screening report. National Cancer Institute Cancer Trends Progress Report. Updated April 2022. Accessed June 15, 2022. https://progressreport.cancer.gov/detection/lung_cancer

9. Huang L, Li L, Zhou Y, et al. Clinical characteristics correlate with outcomes of immunotherapy in advanced non-small cell lung cancer. J Cancer. 2020;11(24):7137-7145. doi:10.7150/ jca.49213

10. Forde PM, Spicer J, Lu S, et al. Neoadjuvant nivolumab plus chemotherapy in resectable lung cancer. N Engl J Med. 2022;386(21):1973-1985. doi:10.1056/NEJMoa2202170

11. Wu YL, Tsuboi M, He J, et al. Osimertinib in Resected EGFR-Mutated Non-Small-Cell Lung Cancer. N Engl J Med. 2020;383(18):1711-1723. doi:10.1056/NEJMoa2027071

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Lung cancer remains the leading cause of cancer death worldwide, killing about three times as many men and women as prostate and breast cancer, respectively. The introduction of targeted therapy and immunotherapy has markedly increased survival rates over the last decade.1 Robotic technologies at both the diagnostic and treatment stages have shown promise for the management of lung cancer in these patients.2,3 Smoking rates have also been steadily declining in the United States—from 20.9% in 2005 to 12.5% in 2020.4

Based on these combined factors, the fact that lung cancer continues to outpace others in terms of cancer incidence and mortality may not be entirely due to a lack of innovation or improvement in health behaviors. A remaining piece of the puzzle might be sufficient uptake in screening among high-risk adults. Identifying lung cancer before it progresses beyond stage I significantly improves 5-year survival rates, but few patients are diagnosed that early.5 The US Preventive Services Task Force, CHEST, and other organizations updated screening recommendations in 2021 to include earlier low-dose computed tomography (CT) scan screening (age 50 instead of 55) and to include people with even less smoking history (from 30 pack-years to 20).6,7 Before these updates were made, it was estimated that about 4.5% of at-risk adults (aged 55-80 years) received a CT scan within the last year.8

We have yet to see what impact these guidelines will have in practice. Without physician awareness and patient education, it is likely that screening rates and the number of cases caught in early stages will stay low—despite the growing number of tools at our disposal.

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