The American College of Chest Physicians (CHEST) recently released a new clinical guideline, Screening for Lung Cancer: CHEST Guideline and Expert Panel Report. The guideline contains 16 evidence-based recommendations and an update of the evidence base for the benefits, harms, and implementation of low-dose chest computed tomography (CT) screening. It appears in the journal CHEST®.
Lung cancer is by far the leading cause of cancer death among both men and women, making up almost 25 percent of all cancer deaths. Evidence suggests that low-dose CT screening for lung cancer can reduce cancer-related deaths in the group that is screened. The new guidelines provide recommendations on the selection of screen-eligible individuals, the quality of imaging and image interpretation, the management of screen detected findings and the effectiveness of smoking cessation interventions.
"The goal of these guidelines is to assist stakeholders with the development of high-quality screening programs and arm clinical providers with the information necessary to engage at-risk individuals in order to increase the number of screenings," says lead author Peter Mazzone, MD, MPH, FCCP. "Outlined in the recommendations is who should be screened and what that screening process should look like from the clinical side. For an individual patient, these guidelines highlight the importance of education to foster informed, value-based decisions about whether to be screened."
Of the 16 recommendations, the guidelines presented in the report include the following:
1. For asymptomatic individuals age 55 to 77 who have smoked 30 pack years or more and either continue to smoke or have quit within the past 15 years, we recommend that annual screening with low-dose CT should be offered (Strong Recommendation, Moderate-Quality Evidence).
2. For asymptomatic individuals who do not meet the smoking and/or age criteria in Recommendation #1, are age 50 to 80, have smoked 20 pack years or more and either continue to smoke or have quit within the past 15 years, we suggest that annual screening with low-dose CT should be offered (Weak Recommendation, Moderate-Quality Evidence).
3. For asymptomatic individuals who do not meet the smoking and/or age criteria in Recommendations #1 and 2 but are projected to have a high net benefit from lung cancer screening based on the results of validated clinical risk prediction calculations and life expectancy estimates, or based on life-year gained calculations, we suggest that annual screening with low-dose CT should be offered (Weak Recommendation, Moderate-Quality Evidence).
4. For individuals who have accumulated fewer than 20 pack years of smoking or are younger than age 50 or older than 80, or have quit smoking more than 15 years ago, and are not projected to have a high net benefit from lung cancer screening based on clinical risk prediction or life-year gained calculators, we recommend that low dose CT screening should not be performed (Strong Recommendation, Moderate-Quality Evidence).
5. For individuals with comorbidities that substantially limit their life expectancy and adversely influence their ability to tolerate the evaluation of screen detected findings, or tolerate treatment of an early stage screen detected lung cancer, we recommend that low-dose CT screening should not be performed (Strong Recommendation, Low-Quality Evidence).
6. We suggest that low-dose CT screening programs develop strategies to determine whether patients have symptoms that suggest the presence of lung cancer, so that symptomatic patients do not enter screening programs but instead receive appropriate diagnostic testing, regardless of whether the symptomatic patient meets screening eligibility criteria (Ungraded Consensus-Based Statement).
7. We suggest that low-dose CT screening programs develop strategies to provide effective counseling and shared decision-making visits prior to the performance of the LDCT screening exam (Ungraded Consensus-Based Statement).
8. We suggest that screening programs define what constitutes a positive test on the low-dose CT based on the size of a detected solid or part-solid lung nodule, with a threshold for a positive test that is either 4 mm, 5 mm, or 6 mm in diameter (Weak Recommendation, Low-Quality Evidence).
9. We suggest that low-dose CT screening programs develop strategies to maximize compliance with annual screening exams and evaluation of screen-detected findings (Ungraded Consensus-Based Statement).
10. We suggest that low-dose CT screening programs develop a comprehensive approach to lung nodule management that includes access to multi-disciplinary expertise (Pulmonary, Radiology, Thoracic Surgery, Medical and Radiation Oncology), and algorithms for the management of small solid nodules, larger solid nodules, and sub-solid nodules (Ungraded Consensus-Based Statement).
11. We suggest that low-dose CT screening programs develop strategies to minimize overtreatment of potentially indolent lung cancers (Ungraded Consensus-Based Statement).
12. For individuals who currently smoke and are undergoing low-dose CT screening, we recommend that screening programs provide evidence-based tobacco cessation treatment as recommended by the US Public Health Service (Strong Recommendation, Low-Quality Evidence).
13. We suggest that low-dose CT screening programs follow the ACR/STR protocols for performing low radiation dose chest CT scans (Ungraded Consensus-Based Statement).
14. We suggest that low-dose CT screening programs use a structured reporting system to report the exam results (Ungraded Consensus-Based Statement).
15. We suggest that low-dose CT screening programs develop strategies to guide the management of non-lung nodule findings (Ungraded Consensus-Based Statement).
16. We suggest that low-dose CT screening programs develop data collection and reporting tools capable of assisting with quality improvement initiatives and reporting to the current National Registry (Ungraded Consensus-Based Statement)
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