Lung cancer continues to be the leading cause of cancer death in the U.S., killing more men and women than the other leading cancers combined. While smoking is clearly the main culprit, causing 85% of non-small cell lung cancer (NSCLC), the most common type of lung cancer, there are other important factors that work in synergy with smoking to elevate an individual’s risk of lung cancer. These factors include exposure to asbestos, diesel, Coal Tar Pitch Volatiles and other air pollutants; a history of obstructive lung disease (COPD or emphysema); and a family history of lung
The chance of surviving lung cancer remains poor: 80% of people diagnosed with lung cancer do not live 5 years. This is primarily because the majority of lung cancers are diagnosed at late stages when curative treatment options, like surgery, are not possible. This is in stark contrast with other major cancers, such as breast, prostate, colon and cervical cancers, which have long had established screening tests that have improved early detection.
The good news is that lung cancer screening will now be recommended, based on the results of a landmark study. The National Lung Screening Trial (NLST), published in 2011, reported that screening high-risk lung cancer patients with a low-dose CT (LDCT) significantly decreased lung cancer mortality more than screening with a routine chest x-ray (CXR). The NLST enrolled more than 50,000 asymptomatic adults between the ages of 55 to 74 years who had at least 30 pack-years of smoking exposure, including former smokers who had quit within the past 15 years. Subjects in the study could have lung disease such as emphysema, but could not be suspected of having lung cancer. Enrollees were randomized to receive three annual screening examinations using LDCT or annual CXR. During a median follow-up interval of 5.5 years, there was a 20% reduction in the mortality rate from lung cancer for the LDCT screened group.
For the first time, this study provided evidence that lung cancer screening can, in fact, detect lung cancer at earlier stages, and that treatment of earlier-stage lung cancer can improve the overall 5-year survival. This concept is a welcome finding for the millions of tobacco-exposed adults who have seen virtually no improvement in lung cancer survival rates in decades. Figure 1 above shows the impact that lung cancer screening will have on the stage of disease at the time of diagnosis, as compared to the current pattern. Earlier diagnosis translates into more treatment options and better survivability.
Since the NLST results were released, several professional organizations have developed screening recommendations utilizing LDCT. The most influential of these are recommendations from the US Preventive Services Task Force (USPSTF). The USPTF completed a comprehensive review of all the available information on lung cancer screening, including the NLST results, to provide recommendations meant to guide public health policy. The USPSTF recommended a Grade B to lung cancer screening with LDCT for lung cancer. This means that “there is moderate certainty that the net benefit is moderate to substantial.”
The specific recommendations from the USPSTF are for annual lung cancer screening with LDCT “in adults, ages 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years.” Furthermore, they recommend, “screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.” Individuals with additional exposures that increase their risk of lung cancer, as mentioned above, may see even more benefit from regular screening.
The USPTF also recommended that screening be done in clinical centers that have multidisciplinary teams, with the ability to perform and interpret the LDCT, to biopsy detected lesions and to treat diagnosed lung cancers, regardless of the stage of the cancer. In addition, lung cancer screening programs must include smoking cessation counseling because the best way to control the risk of lung cancer is to quit smoking.
Roswell Park Cancer Institute in Buffalo, New York, has an established lung cancer screening program that has been in operation for more than a decade. We have assembled a multidisciplinary team – experts in radiology, pulmonology, thoracic surgery and medical oncology – for the detection and treatment of lung cancer. We have also developed a smoking cessation service that provides personal counseling and the tools necessary to help high-risk individuals quit smoking.
What should be considered before being screened for lung cancer screening?
There are three main considerations to understand before undergoing lung cancer screening with LDCT. First, people at risk for lung cancer often have abnormal lesions, called nodules, detected on LDCT. The benefit of LDCT is that it detects these very small densities in the lungs, which may be cancerous. However, a main drawback is that it often detects lesions that are not cancerous. Unfortunately, it is difficult from the image to know if a lesion is cancerous or benign. Suspicious lesions must be followed closely by the clinician and at some point may require a biopsy. In the NLST trial, 96% of the nodules biopsied were benign; what is known as false positives. Additional analyses of the NLST data have also shown that individuals with multiple risk factors for lung cancer had the greatest reduction in lung cancer deaths and required fewer screenings to prevent a lung cancer death. They also had a significantly lower false-positive screening rate.
The second consideration for LDCT screening is that individuals with a 30 pack-year smoking history are recommended to receive yearly screening for 25 years upon their 55th birthday. While LDCT provides a low radiation dose, it can still confer some radiation exposure. Experts have determined that this cumulative exposure will not result in a significantly increased risk of cancer, but it remains a concern for patients and their advocates. Still, for people at high risk of lung cancer, the risk of cancer from smoking is greater than the risk of a radiation-induced cancer.
Finally, once deemed eligible, high-risk individuals must follow the screening schedule recommended by their provider. Whether a repeat LDCT is recommended in 3, 6 or 12 months, each person must take responsibility for adhering to the screening schedule. Missed appointments can mean that the benefits of early detection through screening are lost. Like other cancer screening procedures, such as prostate exams, breast mammography and colonoscopy, the recommended schedules are the best way to prevent advanced cancers.
Lung cancer is the greatest cause of cancer death in the US. A 20% reduction in 5-year mortality means that more than 30,000 lives could be saved each year with appropriate screening, adding valuable years of life. The recommendation by the USPTF supports insurance coverage for all eligible patients in the US under guidelines of the Affordable Care Act.
Remember, lung cancer screening requires a team of experienced clinicians to manage every phase of your care, and it requires your commitment to keep to your schedule to get the most out of screening. We invite you to call us at 1-877-ASK-RPCI (1-877-275-7724) for more information or to find out if you are eligible for lung cancer screening.
What to Expect When You Call Roswell Park for Lung Cancer Screening
When you first call 1-877-ASK-RPCI (1-877-275-7724) and tell the operator that you are interested in lung cancer screening, you will be asked a series of questions to make sure that you are eligible, including:
- Are you between the ages of 55 and 80?
- Have you smoked at least 30 pack-years of cigarettes (for example, 1 pack a day for 30 years OR 2 packs a day for 15 years)?
- If you have already quit smoking, have you smoked within the last 15 years?
If you answer YES to all three of these questions, then you are eligible for lung cancer screening with LDCT. The operator will transfer your information to our scheduling team and they will call you to schedule an appointment for an evaluation. After talking to a member of our clinical team, you will then be scheduled for the LDCT and possibly a lung function test if you need one. Our goal is to only test you as often as you need to be tested and to provide you with the best treatment options available.
If you cannot answer YES to all three questions, you are not eligible for lung cancer screening according to current guidelines. Additional resources may be offered based on your needs, including smoking cessation services.