Offer Smokers, Ex-Smokers CT Scans, Group Says

Older smokers and former long-time smokers should be offered annual low-dose CT screening for lung cancer, but only through organized screening programs that emphasize careful interpretation of findings and patient counseling, according to new guidelines from the American College of Chest Physicians.
They also call for the establishment of a lung cancer screening registry to capture data on follow-up testing, radiation exposure, patient experience and smoking behavior. Glamour cigarettes.
The guidelines recommend against the use of chest x-rays and sputum cytology for screening, and limit the low-dose CT screening to people between the ages of 55 and 74 who have smoked for three decades or more and either continue to smoke or have quit within the last 15 years.
For those who meet the criteria, the screening decision should be made on a case by case basis following counseling, according to the new guidelines, which were published Thursday in a supplemental issue of the journal CHEST.
"Counseling should include a complete description of potential benefits and harms, so the individual can decide whether to undergo low-dose CT screening," an ACCP committee wrote.
The guidelines are very similar to those published in January by the American Cancer Society. Both groups cited the inclusion criteria and findings from the National Lung Cancer Screening Trial (NLST) as the impetus for the recommendation to offer CT screening to some, but not all, smokers and former smokers.
The NLST found a statistically significant 20% reduction in lung cancer deaths associated with CT screening, but the scans also resulted in a high rate of false-positive findings. Low-dose scans identify small nodules in 10% to 50% of smokers and former smokers screened, but the vast majority of these lesions are benign.
Because the NLST and other screening trials had formal programs in place to evaluate scan results, unnecessary biopsies were kept to a minimum. But the guideline committee noted that the biopsy rate for benign lesions is much higher in general practice, and that complications and even rare deaths have been caused by surgical investigation of benign, CT-detected nodules.
"Lung cancer screening is a complex interplay of many things," ACCP guideline committee chairman Frank C. Detterbeck, MD, FCCP, of Yale University School of Medicine told MedPage Today. "How you do the scan makes a difference, and how it is interpreted makes a big difference. We find a lot of nodules when we screen and it takes judgement and expertise to know when to intervene."
Detterbeck said the new guidelines should help raise awareness among clinicians and the public that lung cancer screening involves more than just the scan. The hope is that it will also discourage those who consider screening merely an opportunity to make money, he added
"There are clearly programs out there getting it right, but there are also entrepreneurs who are driving mobile scanners up to malls to offer lung cancer screening to anyone," he says. "If you do a scan and find nodules, but just tell the patient 'It's probably OK,' they aren't going to believe you."
He added that the way radiologists interpret CT scans and how they write their reports also greatly influence patient anxiety and follow-up interventions.
"Radiologists tend to report on everything, so if a nodule is found the report is likely to say, 'Cannot rule out lung cancer,' even if the nodule is not all that suspicious," he said. "If those words are in the report, they are all the patient will focus on."
The guidelines call for low-dose CT scans to be conducted at centers similar to those that participated in the NLST, "with multidisciplinary coordinated care and a comprehensive process for screening, image interpretation, management of findings, and evaluation and treatment of potential cancers."
Although the ACCP and the ACS stop short of calling for all older, long-time smokers to be screened, that is the recommendation of the National Comprehensive Cancer Network (NCCN).
A consortium of major cancer centers across the U.S., NCCN published screening guidelines in 2011 that called for a baseline low-dose CT scan in people with a high risk of lung cancer.
If the baseline scan is normal, it should be followed up with a repeat scan annually for 3 years followed by periodic scans until age 74.
The NCCN defined high risk as:

• A current or former smokers between the ages of 55 and 74 who had smoked for at least 30 years, with former smokers quiting less than 15 years earlier
• Current smokers age 50 and older who had smoked for at least 20 years and had other lung cancer risk factors (besides second-hand smoke exposure)

All the groups agree chest x-ray screening should not be used to evaluate lung cancer risk in asymptomatic people.
ACS director of cancer screening Robert Smith, PhD, said surveys confirm that a growing number of physicians are aware of this, but he says chest x-rays are still being used for this purpose."
"Chest x-ray is not appropriate for lung cancer screening," he told MedPage Today.
And Smith and Detterbeck agree that no screening test is a substitute for smoking cessation.
"That is really the bottom line," Smith said. "If you are a smoker the most important thing you can do to prevent lung cancer is stop smoking."