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Background: Lung cancer is by far the major cause of cancer deaths largely because in the
majority of patients it is at an advanced stage at the time it is discovered, when curative treatment
is no longer feasible. This article examines the data regarding the ability of screening to decrease
the number of lung cancer deaths.
Methods: A systematic review was conducted of controlled studies that address the effectiveness
of methods of screening for lung cancer.
Results: Several large randomized controlled trials (RCTs), including a recent one, have demon-
strated that screening for lung cancer using a chest radiograph does not reduce the number of
deaths from lung cancer. One large RCT involving low-dose CT (LDCT) screening demonstrated
a significant reduction in lung cancer deaths, with few harms to individuals at elevated risk when
done in the context of a structured program of selection, screening, evaluation, and management
of the relatively high number of benign abnormalities. Whether other RCTs involving LDCT
screening are consistent is unclear because data are limited or not yet mature.
Conclusions: Screening is a complex interplay of selection (a population with sufficient risk and
few serious comorbidities), the value of the screening test, the interval between screening tests,
the availability of effective treatment, the risk of complications or harms as a result of screening,
and the degree with which the screened individuals comply with screening and treatment recom-
mendations. Screening with LDCT of appropriate individuals in the context of a structured
process is associated with a significant reduction in the number of lung cancer deaths in the
screened population. Given the complex interplay of factors inherent in screening, many ques-
tions remain on how to effectively implement screening on a broader scale.
CHEST 2013; 143(5)(Suppl):e78S–e92S
Abbreviations: ACCP 5 American College of Chest Physicians; CXR 5 chest radiograph; DANTE 5 Detection and
Screening of Early Lung Cancer by Novel Imaging Technology and Molecular Essays Trial; DLCST 5 Danish Lung
Cancer Screening Trial; LDCT 5 low-dose CT; NCCN 5 National Comprehensive Cancer Network; NLST 5 National
Lung Screening Trial; NSCLC 5 non-small cell lung cancer; PLCO 5 Prostate, Lung, Colorectal and Ovarian Trial;
RCT 5 randomized controlled trial; RR 5 rate ratio; VATS 5 video-assisted thoracic surgery
3.2 Recommendations
Figure 2. [Section 3.3] Frequency of screening participants with a nodule detected on baseline
LDCT scan and percentage of nodules eventually proven to be benign in LDCT studies. A, Per-
centage of all participants screened with LDCT imaging who had a nodule detected at baseline
screening. B, Percentage of patients with a lesion identified at baseline LDCT screening that was
eventually found to be benign. Cohort 5 single-arm cohort studies of LDCT; DANTE 5 Detection
and Screening of Early Lung Cancer by Novel Imaging Technology and Molecular Essays Trial;
DLST 5 Danish Lung Cancer Screening Trial; LDCT 5 low-dose CT; LSS 5 Lung Screening Study;
NELSON 5 Dutch Belgian Randomised Lung Cancer Screening Trial; RCT 5 randomized controlled
trial. See Figure 1 legend for expansion of other abbreviation.
The most serious concern is the risk of death or the highly organized NLST setting, the rate of such
major complications as a result of screening. Of course, events was quite low.
this must be compared with the rate in nonscreened Another concern is the amount of radiation. An
patients and recognize that some deaths may be appropriately performed LDCT scan (about 1.5 mSv)
unrelated events that happened to occur after a screen- is less than the average annual background radiation
ing test. Limited data are available that carefully received in the United States (about 3-4 mSv). How-
assesses this concern; the NLST provides the best ever, nodules requiring further imaging rapidly drive
source of such data at this time. Overall, the frequency up the dose these patients receive. The average dose
of deaths in NLST that occurred within 2 months received per participant over 3 years in the NLST is
of a diagnostic evaluation of a detected finding was estimated at 8 mSv. Another study found an average
eight per 10,000 individuals screened by LDCT scan exposure of 6.2 to 6.8 mSv, with a maximum of 20 to
vs five per 10,000 individuals screened by CXR. Some 22 mSv over 4 years.49 For comparison, an average
deaths were presumably unrelated, as 1.9 and 1.5 per of 20 mSv per year and a maximum in any given year
10,000 occurred within 2 months when the diag- of 50 mSv is the limit allowed for at-risk workers. The
nostic evaluation involved only an imaging study. American Association of Physicists in Medicine recently
Focusing only on patients who had detected nodules stated, “Risks of medical imaging at effective doses
eventually found to be benign, the risk of death or below 50 mSv for single procedures or 100 mSv for
major complications following diagnostic events multiple procedures over short time periods are
(including imaging) was 4.1 and 4.5 in the LDCT too low to be detectable, and may be nonexistent.”50
screening arm vs 1.1 and 1.5 per 10,000 participants From estimates of several official bodies and commis-
in the CXR arm. In summary, there was an appre- sioned studies,51,52 which are based on dose extrap-
ciable increase in the rate of death or major com- olations from atomic bombings and many studies of
plications resulting from investigation of screening medical imaging,53,54 we estimate that the risk of a
findings from LDCT imaging and specifically in indi- radiation-induced cancer in the NLST is approximately
viduals who had only benign lesions. Nevertheless, in one cancer death in 2,500 screened participants.2
Figure 4. [Sections 4.2, 4.3] Components of a CT scan screening program as proposed by major organizations.
AATS 5 American Association of Thoracic Surgery; ACCP 5 American College of Chest Physicians; ACS 5 American Cancer Society; ASCO 5 American
Society of Clinical Oncologists; ATS 5 American Thoracic Society; IASLC 5 International Association for the Study of Lung Cancer; LC III 5 Lung
Cancer Guidelines (3rd ed); NCCN 5 National Comprehensive Cancer Network.
aACCP, ASCO, and ATS.