Lung cancer screening: Clinical practice guidelines in oncology

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%.8 The NLST results indicate that to prevent one death from lung cancer, 320 high-risk individuals must be screened with LDCT. However, the NLST findings have not been replicated yet in a separate cohort. Further analysis of the NLST is underway, including comparative effectiveness modeling. The cost-effectiveness and true benefit-to-risk ratio for lung cancer screening still must be determined. At some point, an acceptable level of risk will have to be deemed appropriate for the benefits of screening. The NCCN Lung Cancer Screening Panel recommends helical LDCT screening for select patients at high risk for lung cancer based on the NLST results, nonrandomized studies, and observational data. These guidelines discuss in detail the criteria for determining which patients are at high risk, and the algorithm provides recommendations for evaluating and following-up nodules detected on LDCT screening (e.g., solid and part-solid nodules). Smokers should always be encouraged to quit smoking tobacco (http://www.smokefree.gov/). Programs using behavioral counseling combined with medications that promote smoking cessation (approved by the FDA) can be very useful (see Treating Tobacco Use and Dependence: Quick Reference Guide for Clinicians; http://www.surgeongeneral.gov/tobacco/tobaqrg.htm). When considering lung cancer screening, it is important to have a full understanding of all risks and benefits related to screening with LDCT. As policies for implementing lung screening programs are designed, a focus on multidisciplinary programs (incorporating primary care doctors, pulmonologists, radiologists, thoracic surgeons, medical oncologists, and pathologists) will be helpful to optimize decision-making and minimize interventions for patients with benign lung disease.