Obstacles to and Solutions for a Successful Lung Cancer Screening Program

Peter J. Mazzone, MD, MPH, FCCP

Disclosures

Semin Respir Crit Care Med. 2016;37(5):659-669. 

In This Article

Abstract and Introduction

Abstract

Lung cancer screening with a low radiation dose chest CT scan has been shown to reduce the number of people, in a well-defined very high-risk cohort, who die from lung cancer. Many potential screening-related harms have been identified, including anxiety and morbidity related to the evaluation of screen-detected findings. A favorable balance of the benefit and harms of lung cancer screening requires careful implementation of a screening program, with a focus on several obstacles to the success of the program. In this review, evidence to support the benefit and harms of lung cancer screening is provided, followed by a discussion of 11 obstacles to the development of a high-quality program. For each obstacle, an approach is suggested, based on evidence and mandates as well as practicality and lessons learned. The approach to each of these obstacles highlights the multi-disciplinary nature of lung cancer screening, and the value of considering lung cancer screening a program rather than a test.

Introduction

A cursory review of lung cancer as a disease would lead one to anticipate substantial clinical utility from lung cancer screening. Lung cancer meets the traditional metrics for a disease that could benefit from a successful screening program; it is the second most common cause of cancer in both men and women,[1] it is the leading cause of cancer-related mortality in both men and women,[1] early detection leads to improved outcomes,[2] and there is an identifiable group at risk for developing the disease. Despite this, it has taken decades of research to demonstrate that lung cancer screening, when correctly implemented, can provide more benefit than harm to the population screened.

Screening is a unique balance of benefit and harms. Unlike most diagnostic or treatment decisions, a decision to screen someone must consider that only a small minority of those who are screened will benefit from being screened, while all who are screened are exposed to the potential harms of screening. In addition, screening, by definition, is applied to individuals who are otherwise well, without symptoms or signs of the presence of the disease in question. The harms of screening must be considered in this context.

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