Commentary: New US guidelines expand lung cancer screening

The United States Preventive Services Task Force has published updated recommendations addressing eligibility for lung cancer screening with a low-radiation dose chest CT scan. The current recommendations update those published at the end of 2013. The age limits have been expanded to age 50-80 years (previously age 55-80) and the smoking history criteria have expanded to included current and former smokers of at least 20 pack-years (previously 30 pack-years) who have been smokers in the past 15 years (unchanged). This change was informed by new evidence supporting the benefit of screening and more experience in managing the potential harms of screening. It is estimated to increase the pool of lung cancer screening eligible individuals by 80-90%. The translation of these recommendations into policy will take some time. Private insurers may change their coverage rules anytime between now and the end of 2022. CMS will take up a new net coverage determination with a decision expected in 9-12 months.

Though generally considered to be a positive move, those who believe there is a large difference between the benefit and harms of screening have suggested that the recommendations are still not broad enough. They note the relatively high risk of developing lung cancer in those who have quit smoking for more than 15 years and the absence of recommendations to use risk of developing lung cancer, or benefit of screening, calculators that incorporate other risk factors into eligibility calculations. They note that these tools would help to broaden the screening pool in a targeted manner with the potential to minimize disparities in care. Those who feel more sensitive towards the potential harms of screening point to the more restrictive criteria as being able to minimize the exposure to harms in those at low risk of developing lung cancer who are less likely to experience the benefit of screening. When there is well-intentioned debate on a topic it is likely that neither side is absolutely right or wrong.

As opposed to the eligibility criteria debate there is general consensus that implementation of high-quality lung cancer screening is necessary to maximize the value of screening. This means robust education and outreach programs aimed at reaching everyone eligible for screening; provision of clear education and decision support to those referred for screening; performance of high-quality low radiation dose chest CT imaging; expert interpretation of the imaging findings; expert management of the imaging findings to minimize testing in those without cancer and efficiently diagnose early-stage lung cancer when it is present; tracking and outreach to ensure compliance with annual screening and follow-up recommendations; and the provision of smoking cessation guidance or connection to a smoking cessation program.

We look forward to a time when the majority of lung cancers are screen-detected. The updated USPSTF recommendations are a step in that direction.

Peter Mazzone, MD
Director, Lung Cancer Program/Lung Cancer Screening Program, Respiratory Institute, Cleveland Clinic Taussig Cancer Institute
Member, Cancer Prevention, Control & Population Research Program, Case Comprehensive Cancer Center