COMMENTARY

Expanding Lung Cancer Screening: New Guidelines

Neil Skolnik, MD

Disclosures

May 05, 2021

This transcript has been edited for clarity.

Neil Skolnik, MD: Today we are going to talk about the new US Preventive Services Task Force (USPSTF) guidelines on lung cancer screening; there have been some big, important changes.

I'm Neil Skolnick, and joining me today is Dr John Russell, chair of the Department of Family Medicine at Abington – Jefferson Health. Welcome, John.

John Russell, MD: It's great to be with you today.

Skolnik: Can you tell us about the changes in lung cancer screening guidelines?

Russell: The new USPSTF guidelines recommend an annual low-dose CT scan for patients 50-80 years of age who have a 20 pack-year history of smoking — meaning they smoked one pack a day for 20 years or two packs daily for 10 years — plus those who currently smoke or who quit within the past 15 years.

The previous guidelines recommended screening only those ages 55 and older with a 30 pack-year history of smoking.

Skolnik: Can you address the prevalence of lung cancer as well as the benefits to patients from screening?

Russell: Lung cancer is the malignancy that causes the most deaths in the United States — about 228,000 cases and 35,000 deaths annually.

Before screening, most lung cancers were found in the late stages, and the 5-year survival was about 20%. If you can find it in an early stage, that number goes up to 59%. The purpose of screening is to find more lung cancers at an earlier stage. Smoking, the number-one risk factor for lung cancer, increases the risk 20-fold. But there is also an increased risk with advancing age.

Skolnik: What led to the expansion of the screening criteria?

Russell: The previous guidelines started in 2014. We now have 7 years of experience and more data. The NELSON trial, published in The New England Journal of Medicine, looked at screening starting at age 50 and had really positive results. That led to the earlier age recommendation. Also, post hoc analysis of the previous paradigms for screening found that African Americans — who in general smoke fewer cigarettes per day — were more likely to be excluded as well as some other populations. The old guidelines caught 58% of Whites who smoked but only 32% of African Americans who smoked. Expanding screening will lead to more people undergoing lung cancer screening.

Skolnik: We start at age 50 with annual CT lung screening among eligible patients. When do we discontinue screening?

Russell: You should screen until the patient's 81st birthday or when they reach 15 years as an ex-smoker. You might start the screening process and someone has reached 10 years as an ex-smoker, but when they reach 15 years, you can stop. You can also stop if the patient reaches a point in their health that makes it difficult to participate in screening or any interventions that screening results might lead to.

Skolnik: To date we haven't done a great job. Only about 15% of eligible people have been screened. Any sense of why we haven't done better?

Russell: It's our newest guideline, and it can take a while for information to get out to doctors. It's not like other screening programs. It's not age based. It's easy to say we're going to start colon cancer or mammogram screening at a certain age. Hearing more success stories helps — when patients say, "My lung cancer was found early." The most successful screening programs are patient driven: "I need my mammogram"; "I'm here for my Pap smear."

There were also some worries about false positives when the studies first came out, but these are decreasing as we gain more experience with screening and use programs such as the Lung CT Screening Reporting and Data System (Lung-RADS), which is like the Breast Imaging – Reporting and Data System (BI-RADS) for breast cancer screening.

Skolnik: In summary, what are the current guidelines?

Russell: We're going to screen patients with an annual low-dose CT scan beginning at the age of 50, and ending at the age of 80 in patients with 20 pack-years of smoking, current smokers, and those who quit within the past 15 years.

Skolnik: John, thank you for joining us. These are big, important changes. I'm Dr Neil Skolnick and this is Medscape.

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