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Screening Ct

  •  “After the publication of the NLST (National Lung Screening Trial) results, physicians will be faced with whether to begin ordering low-dose computed tomography (LDCT) of the chest to screen for lung cancer in patients with a history of tobacco use. Despite the encouraging reduction in deaths observed by using LDCT in the NLST study population, recommending adoption of lung cancer screening in general practice is premature. Lessons learned from prostate and breast cancer screening should remind us that the reductions in deaths expected with screening are unfortunately not as readily achievable as initially believed. Furthermore, the potential harms of false-positive findings on chest computed tomography are very real.”
    Screening for lung cancer: it works, but does it really work?
    Silvestri GA
    Ann Intern Med 2011 Oct 18; 155(8):537-9
  •  “The morbidity and even mortality associated with invasive diagnostic testing and surgical resection due to false- and true-positive findings on computed tomography are likely to increase when the approach taken in the NLST is applied in non-specialty care settings and among the population at highest risk, namely, those with smoking-related comorbid conditions. Although the NLST results are perhaps encouraging, they do not tell us enough that we can be sure that patients who undergo LDCT in an attempt to find early-stage lung cancer will have more benefit than harm.”
    Screening for lung cancer: it works, but does it really work?
    Silvestri GA
    Ann Intern Med 2011 Oct 18; 155(8):537-9
  •  “ Although the NLST results are perhaps encouraging, they do not tell us enough that we can be sure that patients who undergo LDCT in an attempt to find early-stage lung cancer will have more benefit than harm.”
    Screening for lung cancer: it works, but does it really work?
    Silvestri GA
    Ann Intern Med 2011 Oct 18; 155(8):537-9
  • “Screening for lung cancer is not currently recommended, even in persons at high risk for this condition. Most patients with lung cancer present with symptomatic disease that is usually at an incurable, advanced stage. The recently reported NLST (National Lung Screening Trial) showed a 20% decrease in deaths from lung cancer in high-risk persons undergoing screening with low-dose computed tomography of the chest compared with chest radiography. The high-risk group included in the trial comprised asymptomatic persons aged 55 to 74 years, with smoking history of at least 30 pack-years. Screening with low-dose computed tomography detected more cases of early-stage lung cancer and fewer cases of advanced-stage cancer, confirming that screening has shifted the stage of cancer at diagnosis and provides more persons with the opportunity for curative treatment.”
    Screening for Lung Cancer: for patients at increased risk for lung cancer,it works
    Jett JR, Midthun DE
    Ann Intern Med 2011 Oct 18.155(8):540-2
  • “ Although computed tomography screening has risks and limitations, the 20% decrease in deaths is the single most dramatic decrease ever reported for deaths from lung cancer, with the possible exception of smoking cessation. Physicians should offer computed tomography screening for lung cancer to patients who fit the high-risk profile defined in the NLST.”
    Screening for Lung Cancer: for patients at increased risk for lung cancer,it works
    Jett JR, Midthun DE
    Ann Intern Med 2011 Oct 18.155(8):540-2
  • “Physicians should offer computed tomography screening for lung cancer to patients who fit the high-risk profile defined in the NLST.”
    Screening for Lung Cancer: for patients at increased risk for lung cancer,it works
    Jett JR, Midthun DE
    Ann Intern Med 2011 Oct 18.155(8):540-2
  • “On low-dose CT at baseline as compared to CXR, NCNs were detected three times as commonly (23% vs. 7%), malignancies four times as commonly (2.7% vs. 0.7%), Stage I malignancies six times as commonly (2.3% vs. 0.4%). Of the 27 CT-detected cancers, 96% (26/27) were resectable; 85% (23/27) were Stage I, 19 (83%) of the 23 were not seen on CXR. Following the ELCAP recommendations, biopsies were performed on 28 of the 233 subjects with NCNs; 27 had a malignant NCN and one had a benign one. Another three individuals underwent biopsy outside of the ELCAP recommendations, all had benign NCNs. No one had thoracotomy for a benign nodule.”
    Early lung cancer action project:overall design and findings from baseline screening
    Henschke CI
    Cancer 2000 Dec 1;89(11 Suppl) 2474-82
  • “On low-dose CT at baseline as compared to CXR, NCNs were detected three times as commonly (23% vs. 7%), malignancies four times as commonly (2.7% vs. 0.7%), Stage I malignancies six times as commonly (2.3% vs. 0.4%). Of the 27 CT-detected cancers, 96% (26/27) were resectable; 85% (23/27) were Stage I, 19 (83%) of the 23 were not seen on CXR.”
    Early lung cancer action project:overall design and findings from baseline screening
    Henschke CI
    Cancer 2000 Dec 1;89(11 Suppl) 2474-82
  • “The estimated five-year survival rate of baseline CT-detected malignancies of 60%-80% is a marked improvement over the current rate of 15%. Although false-positive CTs are common, they can be managed with minimal use of invasive diagnostic procedures.”
    Early lung cancer action project:overall design and findings from baseline screening
    Henschke CI
    Cancer 2000 Dec 1;89(11 Suppl) 2474-82
  •  “After the publication of the NLST (National Lung Screening Trial) results, physicians will be faced with whether to begin ordering low-dose computed tomography (LDCT) of the chest to screen for lung cancer in patients with a history of tobacco use. Despite the encouraging reduction in deaths observed by using LDCT in the NLST study population, recommending adoption of lung cancer screening in general practice is premature. Lessons learned from prostate and breast cancer screening should remind us that the reductions in deaths expected with screening are unfortunately not as readily achievable as initially believed. Furthermore, the potential harms of false-positive findings on chest computed tomography are very real.”
    Screening for lung cancer: it works, but does it really work?
    Silvestri GA
    Ann Intern Med 2011 Oct 18; 155(8):537-9
  •  “The morbidity and even mortality associated with invasive diagnostic testing and surgical resection due to false- and true-positive findings on computed tomography are likely to increase when the approach taken in the NLST is applied in non-specialty care settings and among the population at highest risk, namely, those with smoking-related comorbid conditions. Although the NLST results are perhaps encouraging, they do not tell us enough that we can be sure that patients who undergo LDCT in an attempt to find early-stage lung cancer will have more benefit than harm.”
    Screening for lung cancer: it works, but does it really work?
    Silvestri GA
    Ann Intern Med 2011 Oct 18; 155(8):537-9
  •  “ Although the NLST results are perhaps encouraging, they do not tell us enough that we can be sure that patients who undergo LDCT in an attempt to find early-stage lung cancer will have more benefit than harm.”
    Screening for lung cancer: it works, but does it really work?
    Silvestri GA
    Ann Intern Med 2011 Oct 18; 155(8):537-9
  • “Screening for lung cancer is not currently recommended, even in persons at high risk for this condition. Most patients with lung cancer present with symptomatic disease that is usually at an incurable, advanced stage. The recently reported NLST (National Lung Screening Trial) showed a 20% decrease in deaths from lung cancer in high-risk persons undergoing screening with low-dose computed tomography of the chest compared with chest radiography. The high-risk group included in the trial comprised asymptomatic persons aged 55 to 74 years, with smoking history of at least 30 pack-years. Screening with low-dose computed tomography detected more cases of early-stage lung cancer and fewer cases of advanced-stage cancer, confirming that screening has shifted the stage of cancer at diagnosis and provides more persons with the opportunity for curative treatment.”
    Screening for Lung Cancer: for patients at increased risk for lung cancer,it works
    Jett JR, Midthun DE
    Ann Intern Med 2011 Oct 18.155(8):540-2
  • “ Although computed tomography screening has risks and limitations, the 20% decrease in deaths is the single most dramatic decrease ever reported for deaths from lung cancer, with the possible exception of smoking cessation. Physicians should offer computed tomography screening for lung cancer to patients who fit the high-risk profile defined in the NLST.”
    Screening for Lung Cancer: for patients at increased risk for lung cancer,it works
    Jett JR, Midthun DE
    Ann Intern Med 2011 Oct 18.155(8):540-2
  • “Physicians should offer computed tomography screening for lung cancer to patients who fit the high-risk profile defined in the NLST.”
    Screening for Lung Cancer: for patients at increased risk for lung cancer,it works
    Jett JR, Midthun DE
    Ann Intern Med 2011 Oct 18.155(8):540-2
  • “There remain unresolved issues with respect to CT screening for lung cancer. These include its feasibility, psychosocial and cost-effectiveness in the UK, harmonisation of CT acquisition techniques, management of suspicious screening findings, the choice of screening frequency and the selection of an appropriate risk group for the intervention. UKLS is aimed at resolving these issues.”
    CT screening for lung cancer in the UK: position statement by UKLS investigators following the NLST report
    Field JK et al.
    Thorax 2011 Aug 66(8):736-7
  • NLST (National Lung Screening Trial)
    “The aggressive and heterogeneous nature of lung cancer has thwarted efforts to reduce mortality from this cancer through the use of screening. The advent of low-dose helical computed tomography (CT) altered the landscape of lung-cancer screening, with studies indicating that low-dose CT detects many tumors at early stages. The National Lung Screening Trial (NLST) was conducted to determine whether screening with low-dose CT could reduce mortality from lung cancer.”
  • NLST (National Lung Screening Trial)
    “The National Lung Screening Trial (NLST) was conducted to determine whether screening with low-dose CT could reduce mortality from lung cancer.
  • “ From August 2002 through April 2004, we enrolled 53,454 persons at high risk for lung cancer at 33 U.S. medical centers. Participants were randomly assigned to undergo three annual screenings with either low-dose CT (26,722 participants) or single-view posteroanterior chest radiography (26,732). Data were collected on cases of lung cancer and deaths from lung cancer that occurred through December 31, 2009.”
    “ The rate of adherence to screening was more than 90%. The rate of positive screening tests was 24.2% with low-dose CT and 6.9% with radiography over all three rounds. A total of 96.4% of the positive screening results in the low-dose CT group and 94.5% in the radiography group were false positive results. The incidence of lung cancer was 645 cases per 100,000 person-years (1060 cancers) in the low-dose CT group, as compared with 572 cases per 100,000 person-years (941 cancers) in the radiography group (rate ratio, 1.13; 95% confidence interval [CI], 1.03 to 1.23).”
    Reduced lung-cancer mortality with low-dose computed tomographic screening
    Aberle DR et al.
    N Engl J Med 2011 Aug 4;365(5):395-409
  • “There were 247 deaths from lung cancer per 100,000 person-years in the low-dose CT group and 309 deaths per 100,000 person-years in the radiography group, representing a relative reduction in mortality from lung cancer with low-dose CT screening of 20.0% (95% CI, 6.8 to 26.7; P=0.004). The rate of death from any cause was reduced in the low-dose CT group, as compared with the radiography group, by 6.7% (95% CI, 1.2 to 13.6; P=0.02).”
    Reduced lung-cancer mortality with low-dose computed tomographic screening
    Aberle DR et al.
    N Engl J Med 2011 Aug 4;365(5):395-409
  • “In the NLST, a 20.0% decrease in mortality from lung cancer was observed in the low-dose CT group as compared with the radiography group. The rate of positive results was higher with low-dose CT screening than with radiographic screening by a factor of more than 3, and low-dose CT screening was associated with a high rate of false positive results.”
    Reduced lung-cancer mortality with low-dose computed tomographic screening
    Aberle DR et al.
    N Engl J Med 2011 Aug 4;365(5):395-409
  • “Screening with the use of low-dose CT reduces mortality from lung cancer.”
    Reduced lung-cancer mortality with low-dose computed tomographic screening
    Aberle DR et al.
    N Engl J Med 2011 Aug 4;365(5):395-409
  • NLST Eligibility for Screening CT/CXR
    - Age 55-74 years at time of randomization
    - Minimum of 30 pack years, and if former smoker had quit within the 15 prior years
    - Prior history of lung cancer, chest CT within 18 months prior to enrollment, had hemoptysis or weight loss over 15 lbs were excluded
    - 53,454 enrolled, 26,722 had low dose chest CT, 26733 had radiography at 33 sites nationwide
    - Three screenings at 1 yr intervals
  • CT Screening: Downside
    - High false positive rate
    - Overdiagnosis (detect lesions which may never have become sympptomatic)
    - Potential risk of radiation on f/u screenings
    - Risk to patient with workup (i.e. bx) of incidental lesion that is benign
  •  “Although some agencies and organizations are contemplating the establishment of lung-cancer screening recommendations on the basis of the findings of the NLST, the current NLST data alone are, in our opinion, insufficient to fully inform such important decisions.”
    Reduced lung-cancer mortality with low-dose computed tomographic screening
    Aberle DR et al.
    N Engl J Med 2011 Aug 4;365(5):395-409
  •  “Before public policy recommendations are crafted, the cost-effectiveness of low-dose CT screening must be rigorously analyzed. The reduction in lung-cancer mortality must be weighed against the harms from positive screening results and overdiagnosis, as well as the costs. The cost component of low-dose CT screening includes not only the screening examination itself but also the diagnostic follow-up and treatment.”
    Reduced lung-cancer mortality with low-dose computed tomographic screening
    Aberle DR et al.
    N Engl J Med 2011 Aug 4;365(5):395-409
  • October 26,2011
    NCCN Guidelines (National Comprehensive Cancer Network)
    “Perhaps the most difficult aspect of lung cancer screening is addressing the moral obligation. As part of the Hippocratic oath, physicians promise to first “do no harm.” The dilemma is that if lung cancer screening is beneficial but physicians do not use it, they are denying patients effective care. However, if lung cancer screening is not effective, then patients may be harmed by overdiagnosis, increased testing, invasive testing or procedures, and the anxiety of a potential cancer diagnosis
  • “Lung cancer screening with CT should be part of a program of care and should not be performed in isolation as a free standing test. Given the high percentage of false-positive results and the downstream management that ensues for many patients, the risks and benefits of lung cancer screening should be discussed with the individual before doing a screening LDCT scan. It is recommended that institutions performing lung cancer screening use a multidisciplinary approach that may include specialties such as radiology, pulmonary medicine, internal medicine, thoracic oncology, and thoracic surgery. Management of downstream testing and follow-up of small nodules are imperative and may require establishment of administrative processes to ensure the adequacy of follow-up.”
  • “Lung cancer screening with CT should be part of a program of care and should not be performed in isolation as a free standing test. Given the high percentage of false-positive results and the downstream management that ensues for many patients, the risks and benefits of lung cancer screening should be discussed with the individual before doing a screening LDCT scan.”
  • “It is recommended that institutions performing lung cancer screening use a multidisciplinary approach that may include specialties such as radiology, pulmonary medicine, internal medicine, thoracic oncology, and thoracic surgery. Management of downstream testing and follow-up of small nodules are imperative and may require establishment of administrative processes to ensure the adequacy of follow-up.”
  • “Screening is recommended (category 1) for high-risk individuals: age 55-74 years; ≥30 pack-year history of smoking tobacco; and if former smoker, have quit within 15 years.7,8 Some high-risk individuals in the NLST also had COPD and other risk factors. This is a category 1 recommendation, because these individuals are selected based on the NLST inclusion criteria.”
  • “Annual screening is recommended for these high-risk individuals until they are 74 years old based on the NLST. However, there is uncertainty about the appropriate duration of screening and the age at which screening is no longer appropriate.”
  • Screening is also recommended (category 2B) for high-risk individuals: age ≥50 years, ≥20 pack-year history of smoking tobacco, and one additional risk factor. This is a category 2B recommendation from the NCCN panel, because these individuals are selected based on non-randomized studies and observational data. These additional risk factors were previously described and include: cancer history, lung disease history, family history of lung cancer, radon exposure, and occupational exposure.
  • Moderate-Risk Individuals
    NCCN defines moderate-risk individuals as those: age ≥50 years and ≥20 pack-year history of smoking tobacco or second-hand smoke exposure, but no additional lung cancer risk factors. The NCCN Lung Cancer Screening panel does not recommend lung cancer screening for these moderate-risk individuals. This is a category 2A recommendation, based on non-randomized studies and observational data.
  • Low-Risk Individuals
    NCCN defines low-risk individuals as those: age <50 years and/or smoking history <20 pack-years. The NCCN Lung Cancer Screening panel does not recommend lung cancer screening for these low-risk
    individuals. This is a category 2A recommendation, based on non-randomized studies and observational data.
  • “The NCCN Lung Cancer Screening panel recommends helical LDCT screening for select patients at high risk for lung cancer based on the NLST results, non-randomized studies, and observational data.”
    NCCN Guidelines Version 1.2012 Lung Cancer Screening
    10-26-2011
  • “Lung cancer screening with LDCT is a complex and controversial topic with inherent risks and benefits. Results from the large, prospective, randomized NLST show that lung cancer screening with LDCT can decrease lung cancer specific mortality by 20% and even decrease all-cause mortality by 7%. The NLST results indicate that to prevent one death from lung cancer, 320 high-risk individuals need to be screened with LDCT.”
    NCCN Guidelines Version 1.2012 Lung Cancer Screening
    10-26-2011
  • - 1326 consecutive patients underwent EBCT coronary artery scoring exams
    - 25 % former or current smokers
    - 2 Board -certified CT radiologists reviewed examinations on a workstation using mediastinal windows, lung windows and bone windows
    - Significant extra-cardiac abnormalities were noted
    - Horton, Circulation 2002;106:532-534.
  • - Findings
    - 103/1326 patients had extracardiac pathology requiring clinical or imaging follow-up
    - 53 patients with noncalcified nodules < 1 cm
    - 12 patients with noncalcified nodules > 1 cm
    - 24 patients with infiltrates
    - 7 patients with indeterminate liver lesions
    - 2 patients with sclerotic bone lesions
    - 2 patients with breast findings
    - 1 patient with polycystic liver disease
    - 1 patient with esophageal thickening
    - 1 patient with ascites
    - Horton, Circulation 2002;106:532-534
  • - 503 patients underwent cardiac imaging with 16 or 64 MDCT
    - 53% current or former smokers
    - Contrast enhanced scans
    - Cardiologists assessed the heart
    - Radiologists reviewed the other organs
    - Reconstructed both large FOV and small FOV
    - Onuma JACC 2006;48:402-406.
  • - Findings
    - 346 noncardiac findings were identified in 292 patients (58.1%)
    - 114 patients (22.7%) had clinically significant findings
    - 3.5% had therapeutic consequences
    - 4 cases of malignancy (0.8%)- 2 lung cancers, 1 breast
    - 49 patients with noncalcified nodules < 1 cm
    - 12 patients with noncalcified nodules > 1 cm
    - 16 patients with infiltrates
    - 17 patients with pleural effusions
    - 7 patients with aortic aneurysms
    - Onuma JACC 2006;48:402-406
  • - Findings
    - 32/ 201 patients in whom coronary disease was ruled out, non cardiac findings by CT were considered sufficient to explain the symptoms
    - Onuma JACC 2006;48:402-406.
  • - 166 patients for contrast enhanced CTA
    - Prospective Study
    - 16 slice MDCT
    - 1mm slices
    - Radiologist reviewed soft tissue, lung, and bone windows
    - Haller AJR 2006; 187:105-110.
  • "Extracardiac findings were detected in 41 patients (24.7%). Findings were classified as minor (19.9%) or major (4.8%). Among the major findings, which had an immediate impact on patient management and treatment, were bronchial carcinoma and pulmonary emboli."

    Haller
    AJR 2006; 187:105-110.
  • Budoff Cardiovasc Interv 2006; 68:965-73.

    - High risk of nodule detection in this population
    - Concern with the cost of following these nodules, the radiation dose to the patient, as well as the potential risk of biopsy, etc
    - Concern for potential increased cancer risk in patients undergoing follow-up CT scans.
    - Concern about unnecessary anxiety for both the patients and physician regarding the follow-up of insignificant findings
  • "At reduced radiation exposure, low kilovoltage scanning increases the percentage of central and peripheral pulmonary arteries that can be evaluated with CT angiography without a substantial decrease in image quality."

    CT Angiography of pulmonary Arteries to Detect Pulmonary Embolism: Improvement of Vascular Enhancement with Low Kilovoltage Settings
    Schueller-Weidekamm C et al.
    Radiology 2006; 241:899-907.
All images on this site are © 2012 Elliot K. Fishman, MD.